Preparing for the American Board of Internal Medicine Maintenance of Certification

The following cardiology focused cases and questions should assist in fostering the continuing scholarship required for professional excellence in the practice of medicine. This section appears every other month; we hope you find it useful.

Questions 1. An 83-year-old woman is seen in your office for an initial visit. She states that she has been healthy all her life, that she feels well, and that she remains active. She is not currently taking any medications except for a multivitamin. Her physical examination is unremarkable except for a blood pressure of 150/70 mm Hg in both arms that remains unchanged on repeat assessment 4 weeks later. All of the following statements about this patient’s blood pressure are true EXCEPT: a) The most likely explanation for her elevated blood pressure reading is increased arterial stiffness.

b) Isolated systolic hypertension (ie, elevated systolic blood pressure with normal diastolic blood pressure) is the most common form of hypertension in both men and women over 80 years of age.

c) Elevated systolic blood pressure in this age group places the patient at increased risk for stroke and heart disease.

d) Clinical trials have shown that lowering this patient’s systolic blood pressure to less than 140 mm Hg will reduce the risk of stroke.

e) Dietary sodium restriction is effective in lowering systolic blood pressure in older adults.

2. A 77-year-old man presents to your office for an initial visit. He has a history of hypertension and coronary artery disease, but he has not seen a doctor in several years. His only medication is aspirin. Physical examination is notable only for a blood pressure of 190/80 mm Hg. Serum electrolytes are normal and the serum creatinine level is 1.1 mg/dL. Which of the following is the LEAST likely factor contributing to this patient’s high blood pressure reading? a) Primary (“essential”) hypertension

b) White coat hypertension

c) Pseudohypertension

d) Renal artery stenosis

e) Primary hyperaldosteronism (Conn’s syndrome)

3. During a routine office visit, a 73-year-old man requests information about his cholesterol level. He has high blood pressure that is well-controlled with medications (120/80 mm Hg). He has no history of coronary artery disease, peripheral arterial disease, or diabetes, and he has never smoked. There is no history of premature vascular disease in his family. Nonfasting lipid levels include a total cholesterol of 187 mg/dL and a high-density lipoprotein (HDL) cholesterol of 51 mg/dL. According to National Cholesterol Education Program Adult Treatment Panel (ATP) III guidelines, the treatment goal for this patient is an low-density lipoprotein (LDL) cholesterol level of _________.a) < 70 mg/dL

b) < 100 mg/dL

c) 130 mg/dL

d) 160 mg/dL

e) Insufficient information to determine

4. In the National Cholesterol Education Program ATP III guidelines, all of the following are considered “coronary risk equivalents” EXCEPT: a) Diabetes mellitus

b) Chronic kidney disease

c) Abdominal aortic aneurysm

d) Symptomatic cerebrovascular disease

e) Atherosclerotic lower extremity arterial disease

5. All of the following are criteria for diagnosing metabolic syndrome EXCEPT: a) Insulin resistance

b) Abdominal obesity

c) Triglyceride level > 150 mg/dL

d) Low HDL cholesterol

e) Blood pressure > 130/85 mm Hg

6. Which of the following best describes blood pressure trends in the United States after age 60? a) Systolic and diastolic blood pressure both increase

b) Systolic blood pressure increases, diastolic blood pressure remains unchanged

c) Systolic blood pressure increases, diastolic blood pressure decreases

d) Systolic blood pressure remains unchanged, diastolic blood pressure increases

e) Systolic and diastolic blood pressure both remain unchanged

7. Among individuals 65 years of age or older, which of the following is the strongest risk factor for a new coronary heart disease event? a) Systolic blood pressure

b) Diastolic blood pressure

c) Total cholesterol level

d) Ratio of total cholesterol to HDL cholesterol

e) Cigarette smoking

8. A 79-year-old woman with known coronary artery disease is referred to your office for further evaluation and management. As part of her assessment, a fasting lipid profile is obtained, which reveals a total cholesterol of 186 mg/dL, HDL 44 mg/dL, triglycerides 110 mg/dL, and calculated LDL 120 mg/dL. The most appropriate initial management of this patient’s lipid profile is:

a) Reassurance

b) Low-fat, low-cholesterol diet

c) Cholestyramine

d) 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor

e) Sustained-release niacin

9. An 87-year-old woman is referred to your office for evaluation and management of persistent systolic hypertension. She is otherwise healthy and remains active in her church. She is not taking any medications. On physical examination, her resting heart rate is 70 beats per minute. The seated blood pressure, repeated twice in both arms, is 170/80 mm Hg. The remainder of her examination is normal except for an S₄ gallop. What is the most appropriate management of this patient?a) Return appointment in 1 month to recheck the blood pressure

b) Schedule a 24-hour ambulatory blood pressure recording

c) A thiazide diuretic

d) An angiotensin-converting enzyme inhibitor

e) A beta blocker

10. Which of the following statements about cigarette smoking in persons over age 65 is TRUE? a) Life-long smokers who continue to smoke at age 65 are very unlikely to quit thereafter.

b) Physician advice to quit smoking has less impact in smokers over age 65 than in middle-aged adults.

c) Most smoking-related cardiovascular deaths occur prematurely, ie, in persons under 65 years of age.

d) In patients over 65 years of age with established coronary artery disease, smoking cessation reduces the risk of future coronary events.

e) Nicotine replacement therapy should be avoided in older smokers with known coronary artery disease.

Answers 1: d

Aging of the large arteries results in increased arterial stiffness and an associated rise in systolic blood pressure with increasing age. Diastolic blood pressure tends to peak and plateau in late middle-age, declining modestly thereafter. As a result, isolated systolic hypertension is the most common form of hypertension in both men and women after age 80 years. Moreover, data from the Framingham Heart Study and other sources implicate systolic hypertension as a potent risk factor for cardiovascular disease and stroke in older adults. Medications, as well as dietary sodium restriction, have been shown to lower systolic blood pressure in older adults. However, although several randomized clinical trials have demonstrated that treatment of systolic hypertension reduces the risk of stroke and cardiovascular events in older adults, including those over 80 years of age, none of these studies have enrolled patients with systolic blood pressures in the range of 140 to 159 mm Hg, and none have attempted to lower systolic blood pressure to less than 140 mm Hg. None&shy;theless, based on compelling epidemiologic data, current guidelines recommend that systolic blood pressure be reduced to less than 140 mm Hg in patients of all ages.

JAMA

Chaudhry SI, Krumholz HM, Foody JM. Systolic hypertension in older persons. . 2004;292:1074-1080.

Arch Intern Med

Appel LJ, Espeland MA, Easter L, Wilson AC, Folmar S, Lacy CR. Effects of reduced sodium intake on hypertension control in older individuals: results from the Trial of Nonpharmacologic Interventions in the Elderly (TONE). . 2001;161:685-693.

2: e Although the prevalence of “secondary” causes of hypertension, especially renal and renovascular hypertension, increases with age, in the majority of cases, hypertension in older adults is primary or “essential” (ie, not attributable to another identifiable disease process). White coat hypertension refers to the phenomenon of higher blood pressure readings in the physician’s office than at other times. White coat hypertension is relatively common among older adults, and patients seeing a new physician for the first time may be particularly prone to this condition. Pseudohypertension occurs when stiff, atherosclerotic peripheral arteries lead to an overestimation of central aortic blood pressure by conventional sphygmomanometry. Pseudohypertension has been reported to occur in 5% to 10% of elderly patients with marked systolic hypertension, widened pulse pressure, and absence of evidence for hypertensive end-organ disease (eg, hypertensive retinopathy). Atherosclerotic renal artery stenosis increases in prevalence with increasing age, usually as a manifestation of systemic atherosclerosis; the presence of coronary artery disease in this patient places him at increased risk for renal artery stenosis. Primary hyperaldosteronism is an important cause of secondary hypertension, but it is less common in older adults than the other choices. The presence of a normal serum potassium level also makes primary hyperaldo&shy;steronism less likely, although it does not completely exclude this possibility.

JAMA

Chaudhry SI, Krumholz HM, Foody JM. Systolic hypertension in older persons. . 2004;292:1074-1080.

N Engl J Med

Messerli FH, Ventura HO, Amodeo C. Osler’s maneuver and pseudohypertension. . 1985;312:1548-1551.

JAMA

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. . 2003;289:2560-2572.

3: c

Apart from his age, this patient has only 1 other cardiovascular risk factor—hypertension&mdash;which is well controlled. His 10-year risk for a new coronary event is 10% to 20%. Accordingly, his target LDL cholesterol level, based on ATP III guidelines, is < 130 mg/dL. Therapeutic lifestyle changes are recommended as initial treatment for such patients with LDL cholesterol levels ranging from 130 to 159 mg/dL, and drug therapy should be considered in patients with LDL cholesterol levels of 160 mg/dL or higher.

JAMA

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). . 2001;285:2486-2497.

4: b

Although chronic kidney disease and proteinuria have been associated with an increased risk of cardiovascular events, current ATP III guidelines have not identified these markers as coronary risk equivalents. In contrast, diabetes mellitus, abdominal aortic aneurysm, symptomatic cerebrovascular disease, and atherosclerotic peripheral arterial disease are all associated with a 10-year risk of new coronary heart disease events in excess of 20%—equivalent to the risk in patients with established coronary artery disease.

JAMA

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). . 2001;285:2486-2497.

5: a

Insulin resistance is a hallmark of metabolic syndrome, but it is not easily measured clinically, and therefore it is not a criterion for diagnosis. In order to establish a clinical diagnosis of metabolic syndrome, patients must fulfill at least 3 of the following 5 criteria: abdominal obesity (waist circumference > 35 inches in women, > 40 inches in men); serum triglyceride level > 150 mg/dL; low HDL cholesterol level (< 50 mg/dL in women, < 40 mg/dL in men); blood pressure > 130/85 mm Hg; fasting plasma glucose > 110 mg/dL.

JAMA

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). . 2001;285:2486-2497.

6: c

Due to arterial stiffening, the systolic blood pressure tends to rise with advancing age, whereas the diastolic blood pressure tends to plateau in late middle age and decline thereafter. These divergent trends in the systolic and diastolic blood pressure result in a widening of the pulse pressure, a hallmark of aging and a marker of the degree of arterial stiffness.

Arch Intern Med

Stamler J, Stamler R. Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. . 1993;153:598-615.

Hypertension

Burt VL, Cutler JA, Higgins M, et al. Trends in the prevalence, awareness, treatment, and control of hypertension in the adult US population. Data from the health examination surveys, 1960 to 1991. . 1995;26:60-69.

Circulation

Franklin SS, Gustin W 4th, Wong ND, et al. Hemodynamic patterns of age-related changes in blood pressure. The Framingham Heart Study. . 1997;96:308-315.

7: a

In the Framingham Heart Study, as well as other large epidemiologic studies, systolic blood pressure has been found to correlate most strongly with incident coronary heart disease events in persons over 65 years of age. The relative importance of diastolic blood pressure, total cholesterol, and smoking decline with age. Diabetes mellitus and the ratio of total cholesterol to HDL cholesterol are independent risk factors for coronary events in older adults, but less potent than systolic blood pressure.

Hypertension

Stokes J 3rd, Kannel, WB, Wolf PA, D’Agostino RB, Cupples LA. Blood pressure as a risk factor for cardiovascular disease. The Framingham Study—30 years of follow-up. . 1989;13(5 suppl):I13-I18.

Arch Intern Med.

Stamler J, Stamler R, Neaton JD. Blood pressure, systolic and diastolic, and cardiovascular risks. US population data. 1993;153:598-615.

8: d

In the Heart Protection Study, simvastatin 40 mg daily was associated with substantial reductions in mortality and vascular events in patients 40 to 80 years of age with known vascular disease (coronary artery disease, peripheral arterial disease, cerebrovascular disease) or diabetes mellitus. More recently, similar findings have been reported with atorvastatin. These data provide strong evidence supporting the use of statins for secondary prevention in a broad range of high-risk patients, including those with relatively mild abnormalities in the lipid profile. Statin therapy should be initiated along with appropriate dietary modifications, including a low-fat, low-cholesterol diet, but diet alone is insufficient in this population. Cholestyramine and niacin are possible alternatives in patients intolerant to statins but are not recommended as first-line therapy.

Lancet

Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial. . 2002;360:7-22.

Lancet

Shepherd J, Blauw GJ, Murphy MB, et al. PROspective Study of Pravastatin in the Elderly at Risk. Pravastatin in elderly individuals at risk of vascular disease (PROSPER): a randomised controlled trial. . 2002;360:1623-1630.

Circulation

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. . 2002;106:3143-3421.

9: c

The Systolic Hypertension in the Elderly Program (SHEP) study documented the effectiveness of a thiazide diuretic (chlorthalidone) in reducing the risk of cardiovascular events and stroke in patients up to 90 years of age with isolated systolic hypertension. More recently, the 40,000 patient Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) confirmed that diuretic therapy was associated with superior outcomes overall compared to an alpha blocker, ACE inhibitor, and calcium channel antagonist. In addition, conventional thiazide diuretics are substantially cheaper than most other antihypertensive drugs. This patient has “persistent” stage II hypertension; therefore, additional evaluation or treatment delays are not appropriate.

JAMA

Chobanian AV, Bakris GL, Black HR, et al. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. . 2003;289:2560-2572.

JAMA

SHEP Cooperative Research Group. Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). . 1991;265:3255-3264.

The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-2997.

10: d

Data from the Coronary Artery Surgery Study Registry indicate that among smokers 70 years of age or older with established coronary artery disease, those who continue to smoke have a 3-fold higher risk of myocardial infarction or cardiovascular death than those who quit smoking. In another study, men who quit smoking at age 65 gained 1.4 to 2.0 years of additional life compared to those who continued to smoke, while women who quit gained an additional 2.7 to 3.7 years of life. Although older persons who smoke may claim that they are “too old to quit,” cessation rates are actually higher among the elderly than in younger adults, and physician advice to quit smoking is more likely to motivate an older patient to quit smoking than a younger one. Also, although smoking is the single most important cause of preventable premature deaths in the United States, well over half of all smoking-related cardiovascular deaths occur among persons over 65 years of age. Nicotine replacement therapy improves smoking cessation rates, and has been shown to be safe in patients with coronary artery disease, including those recently hospitalized with acute coronary syndromes.

MMWR Morb Mortal Wkly Rep

Centers for Disease Control and Prevention (CDC). Cigarette smoking among adults—United States, 2001. . 2003;52:953-956.

MMWR Morb Mortal Wkly Rep

Annual smoking-attributable mortality, years of potential life lost, and economic costs—United States, 1995-1999. . 2002;51:300-303.

N Engl J Med.

LaCroix AZ, Lang J, Scherr P, et al. Smoking and mortality among older men and women in 3 communities. 1991;324:1619-1625.

N Engl J Med.

Hermanson B, Omenn GS, Kronmal RA, Gersh BJ. Beneficial 6-year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS registry. 1988;319:1365-1369.

Am J Public Health.

Taylor DH Jr, Hasselblad V, Henley SJ, et al. Benefits of smoking cessation for longevity. 2002;92:990-996.

J Am Geriatr Soc

Whitson HE, Heflin MT, Burchett BM. Patterns and predictors of smoking cessation in an elderly cohort. . 2006;54:466-471.

MMWR Morb Mortal Wkly Rep.

Arday D. Receipt of advice to quit smoking in Medicare managed care. 2000;49:797-801.

N Engl J Med.

Joseph AM, Norman SM, Ferry LH, et al. The safety of transdermal nicotine as an aid to smoking cessation in patients with cardiac disease. 1996;335(24):1792-1798.