Cardiometabolic IQ Challenge

Learn about a variety of cardiometabolic risk factors and prevention methods through our interactive challenge quizzes, with corresponding clinical explanations and correct answers.

  1. Eating foods rich in omega-3 fatty acids is recommended to prevent cardiovascular disease in people with diabetes

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    Answer: True

    Explanation: According to the American Diabetes Association 2018 Standards of Care, “Eating foods rich in long-chain n-3 fatty acids, such as fatty fish (EPA and DHA) and nuts and seeds (ALA), is recommended to prevent or treat CVD; however, evidence does not support a beneficial role for the routine use of n-3 dietary supplements.” For more information, please see:

    American Diabetes Association. "4. Lifestyle Management: Standards of Medical Care in Diabetes—2018." Diabetes Care 41.Supplement 1 (2018): S38-S50.

  2. A recent study in type 2 diabetics reported that a higher BMI was associated with:

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    Answer: A

    Explanation: AStudy found that eating breakfast at a later time is independently associated with higher BMI in a cohort of non-shift workers with type 2 diabetes. For more information, please see:

    Nimitphong, H., et al. "The relationship among breakfast time, morningness–eveningness preference and body mass index in Type 2 diabetes." Diabetic Medicine (2018).

  3. According to the American Diabetes Association, artificial sweeteners are safe to use and can substitute sugar sweeteners in people with type 2 diabetes

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    Answer: True

    Explanation: According to the American Diabetes Association 2018 Standards of Care, “nonnutritive sweeteners (containing few or no calories) may be an acceptable substitute for nutritive sweeteners (those containing calories such as sugar, honey, agave syrup) when consumed in moderation. For more information, please see:

    American Diabetes Association. "4. Lifestyle Management: Standards of Medical Care in Diabetes—2018." Diabetes Care 41.Supplement 1 (2018): S38-S50.

  4. High protein diets are recommended for type 2 diabetics with a history of hypoglycemia

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    Answer: False

    Explanation: According to the According to the American Diabetes Association 2018 Standards of Care, “In individuals with type 2 diabetes, protein intake may enhance or increase the insulin response to dietary carbohydrates. Therefore, carbohydrate sources high in protein should not be used to treat or prevent hypoglycemia due to the potential concurrent rise in endogenous insulin.” For more information, please see:

    American Diabetes Association. "4. Lifestyle Management: Standards of Medical Care in Diabetes—2018." Diabetes Care 41.Supplement 1 (2018): S38-S50.

  5. People with type 2 diabetes and hypertension should not consume more 2300 mg/day of sodium

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    Answer: False

    Explanation: Although consuming <2300 mg/day of sodium is recommended for people with type 2 diabetes, further restriction may be indicated for people with both diabetes and hypertension. For more information, please see:

    American Diabetes Association. "4. Lifestyle Management: Standards of Medical Care in Diabetes—2018." Diabetes Care 41.Supplement 1 (2018): S38-S50.

  1. According to the 2013 ACC/AHA Guideline for the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk, which of the following statin benefit groups is not identified correctly?

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    Answer: B

    Explanation: "Patients with baseline elevation of LDL-C ≥ 190 mg/dL not due to secondary modifiable causes are at very high risk of first and recurrent ASCVD events because of their lifetime exposure to markedly elevated LDL-C levels, and therefore, 10-year ASCVD risk assessment is not indicated in this high-risk population." Thus, the guideline indicates that "Adults aged ≥ 21 years with LDL-C ≥ 190 mg/dL" is a statin benefit group.

    Reference: Stone, Neil J., et al. "2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines." Journal of the American College of Cardiology 63.25 Part B (2014): 2889-2934.

  2. The 2017 update now recommends the use of PCSK9 inhibitors or ezetimibe for primary prevention in patients with diabetes and LDL-C < 190 mg/dL

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    Answer: B

    Explanation: According to the update, "The ECDP writing committee judged that the new data did not warrant changes to the decision pathways and algorithms regarding the use of ezetimibe or PCSK9 inhibitors in primary prevention patients with LDL-C <190 mg/dL with or without diabetes mellitus."

    Reference: Lloyd-Jones, Donald M., et al. "2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways." Journal of the American College of Cardiology 70.14 (2017): 1785-1822.

  3. Which of the following is not true of the recommended cholesterol thresholds to achieve a net benefit for patients with clinical ASCVD?

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    Answer: C

    Explanation: "Thresholds for consideration of net ASCVD risk-reduction benefit are LDL-C reduction ? 50% and may consider LDL-C <70 mg/dL or non-HDL-C <100 mg/dL for all patients with clinical ASCVD and baseline LDL-C 70-189 mg/dL."

    Reference: Lloyd-Jones, Donald M., et al. "2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways." Journal of the American College of Cardiology 70.14 (2017): 1785-1822.

  4. For a 40-year old patient with clinical ASCVD and coronary artery disease that has not achieved an LDL-C reduction of ≥ 50% despite maximally tolerated statin therapy, which of the following may be considered:

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    Answer: D

    Explanation: "For patients ≥ 21 years of age, With Clinical ASCVD, With comorbidities, on Statin for Secondary Prevention, Baseline LDL-C 70-189 mg/dL, adding ezetimibe (in patients who require <25% additional LDL-C lowering) or a PCSK9 inhibitor (in patients who require >25% additional LDL-C lowering) may be added as initial non-statin agents in case of an inadequate response (LDL-C reduction of <50% from baseline) to maximally tolerated statin therapy; additionally, LDL-C <70 mg/dL or non-HDL-C <100 mg/dL may be considered -- Figure 2B."

    Reference: Lloyd-Jones, Donald M., et al. "2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways." Journal of the American College of Cardiology 70.14 (2017): 1785-1822.

  5. Which of the following is an acceptable therapy for managing LDL-C in special population groups with ASCVD:

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    Answer: B

    Explanation: According to the update, there is limited information available, which does not support initiation of high-intensity statin therapy for secondary prevention in individuals >75 years of age, and PCSK9 inhibitor (alirocumab or evolocumab) therapy for patients with NYHA functional class II to III heart failure. Statin and ezetimibe therapy may only be resumed after completion of breastfeeding. Pregnant women with ASCVD or high ASCVD risk with significant elevations in LDL-C (recognizing that a progressive rise in both LDL-C and triglycerides is physiologic during pregnancy) may be managed with a bile acid sequestrant.

    Reference: Lloyd-Jones, Donald M., et al. "2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways." Journal of the American College of Cardiology 70.14 (2017): 1785-1822.

  1. The recently re-published PREDIMED trial showed that the incidence of major cardiovascular events was lower in individuals:

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    Answer: B

    Explanation: "Individuals assigned a Mediterranean diet supplemented with nuts had a total of 83 cardiovascular events compared to 96 events in the group assigned to a Mediterranean diet supplemented with extra-virgin olive oil, and 109 events in the low-fat diet group."

    Reference: Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts." New England Journal of Medicine (2018).

  2. Participants in the PREDIMED study had which of the following major CVD risk factors:

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    Answer: E

    Explanation: "Eligible participants were men (55 to 80 years of age) or women (60 to 80 years of age) with no cardiovascular disease at enrollment, who had either type 2 diabetes mellitus or at least three of the following major risk factors: smoking, hypertension, elevated low-density lipoprotein cholesterol levels, low high-density lipoprotein cholesterol levels, overweight or obesity, or a family history of premature coronary heart disease."

    Reference: Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts." New England Journal of Medicine (2018).

  3. After the study design correction, there was no statistical difference in the primary endpoint between the Mediterranean diets and control diet.

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    Answer: B

    Explanation: "Analyses that excluded participants whose assignment to an intervention group was known or suspected not to have followed the randomization protocol (participants from Sites D and B and second household members) yielded results consistent with the results of our primary analysis."

    Reference: Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts." New England Journal of Medicine (2018).

  4. The effects of the Mediterranean diets on the rate of CV events were more pronounced in participants with:

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    Answer: A

    Explanation: "Our analysis, which incorporated information about adherence to the diets, suggests that the difference in rates of cardiovascular events between those assigned to the Mediterranean diets and those assigned the control diet was greater among participants with better adherence. We found little difference in changes in physical activity among the three groups."

    Reference: Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts." New England Journal of Medicine (2018).

  5. The PREDIMED study enrolled subjects from which country:

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    Answer: C

    Explanation: PREDIMED was a multicenter trial in Spain.

    Reference: Estruch, Ramón, et al. "Primary prevention of cardiovascular disease with a mediterranean diet supplemented with extra-virgin olive oil or nuts." New England Journal of Medicine (2018).

  1. Thiazolidinediones are safe to use for glycemic control in patients with HF and T2D

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    Answer: B

    Explanation: According to the American Diabetes Association guidelines, thiazolidinediones are associated with an increased risk of heart failure, and should be avoided in patients with asymptomatic heart failure.

    Reference: American Diabetes Association. "9. Cardiovascular disease and risk management: standards of medical care in diabetes-2018." Diabetes care 41.Supplement 1 (2018): S86-S104.

  2. Which of the following antidiabetic drugs has demonstrated the greatest benefits in patients with T2D and HF?

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    Answer: C

    Explanation: According to the American Diabetes Association 2018 Standards of Care, SGLT-2 inhibitors have shown the most HF-related benefits in patients with T2D in clinical trials.

    Reference: American Diabetes Association. "9. Cardiovascular disease and risk management: standards of medical care in diabetes-2018." Diabetes care 41.Supplement 1 (2018): S86-S104.

  3. Patients with T2D and ischemic cardiomyopathy are at a greater risk for HF progression and mortality compared to patients with T2D and non-ischemic cardiomyopathy

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    Answer: A

    Explanation: According to the American Heart Association Scientific Statement on the management of patients with HF and cardiometabolic comorbidities, "The association of increased mortality with diabetes mellitus in patients with HF appears to be limited to or more apparent in patients with an ischemic than in those with a nonischemic pathogenesis."

    Reference: Bozkurt, Biykem, et al. "Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the American Heart Association." Circulation 134.23 (2016): e535-e578.

  4. In patients with stage A HF and T2D, which drugs are useful to prevent the development of HF?

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    Answer: E

    Explanation: "ACE inhibitors and ARBs can be useful to prevent HF in patients at high risk for developing HF who have a history of atherosclerotic vascular disease, diabetes mellitus, of hypertension associated with cardiovascular risk factors."

    Reference: Bozkurt, Biykem, et al. "Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the American Heart Association." Circulation 134.23 (2016): e535-e578.

  5. In patients with T2D and HF, which of the following HbA1c levels is associated with the lowest risk of mortality?

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    Answer: B

    Explanation: Based on observational studies, there is a U-shaped association between HbA1c levels and mortality risk in patients with T2D and HF, with the lowest risk of death in those patients with modest glucose control (HbA1c >7.1-7.8%); however, the relationship between glycemic control and outcomes in patients with HF and T2D has not clearly been defined.

    Reference: Bozkurt, Biykem, et al. "Contributory risk and management of comorbidities of hypertension, obesity, diabetes mellitus, hyperlipidemia, and metabolic syndrome in chronic heart failure: a scientific statement from the American Heart Association." Circulation 134.23 (2016): e535-e578.

  1. The 2018 ADA/EASD consensus report emphasizes individualized T2D management based on the presence of which comorbidities

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    Answer: A

    Explanation: The new suggested algorithm from ADA/EASD emphasizes the individualization of therapy based on the presence of ASCVD, HF, or CKD in patients with T2D.

    Reference: Davies, Melanie J., et al. "Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)." Diabetologia (2018): 1-38.

  2. If a patient with T2D has co-existing HF or CKD, the first choice to intensify antihyperglycemic therapy after lifestyle and metformin if patient is not at target HbA1c is:

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    Answer: B

    Explanation: According to the 2018 ADA/EASD algorithm, if HF or CKD predominates in a patient with T2D, an SGLT2i with evidence of reducing HD and/or CKD progression is preferred to intensify therapy if patient is not at goal after metformin and lifestyle therapy.

    Reference: Davies, Melanie J., et al. "Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)." Diabetologia (2018): 1-38.

  3. If ASCVD predominates in a patient with T2D, which agent should be the first choice to intensify therapy beyond metformin and lifestyle if not at HbA1c goal?

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    Answer: C

    Explanation: If ASCVD predominates, either a GLP-1 RA with proven CVD benefit or an SGLT-2i with proven CVD benefit (if eGFR is adequate) can be added to the existing regimen in this setting.

    Reference: Davies, Melanie J., et al. "Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)." Diabetologia (2018): 1-38.

  4. The 2018 ADA/EASD consensus report does not give additional recommendations for patients with T2D and without established ASCVD, CKD, or HF

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    Answer: B

    Explanation: The consensus statement gives extended recommendations in T2D patients without established ASCVD, CKD, or HF, and recommends the individualization of therapy based on several patient-level factors, including the need to minimize side effects such as hypoglycemia and weight gain, and cost considerations.

    Reference: Davies, Melanie J., et al. "Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)." Diabetologia (2018): 1-38.

  5. In T2D patients that have a need to minimize weight gain or promote weight loss and without established ASCVD or DKD, which GLP-1 RA should be added first based on the evidence?

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    Answer: D

    Explanation: According to the ADA/EASD 2018 consensus statement, when a GLP-1 RA is considered to be added to existing antihyperglycemic therapy in T2D patients who have excess weight and without ASCVD or CKD, semaglutide should be considered first, followed by liraglutide, dulaglutide, exenatide, and lixisenatide.

    Reference: Davies, Melanie J., et al. "Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)." Diabetologia (2018): 1-38.

  1. A patient with exertional dyspnea has a H2FPEP score of 4. What is the probability of this patient being diagnosed with HFpEF?

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    Answer: C

    Explanation: According to the authors that developed the H2FPEP score, a score of 4 corresponds with a 0.7-0.8 probability of being diagnosed with HFpEF.

    Reference: Reddy, Yogesh NV, et al. "A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure with Preserved Ejection Fraction." Circulation (2018): CIRCULATION AHA-118.

  2. Which of the following statements regarding the diagnosis of HFpEF is TRUE?

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    Answer: D

    Explanation: Right-sided heart catherization with exercise is the gold standard for confirming or ruling out HFpEF in patients with normal resting filling pressures.

    Reference: Reddy, Yogesh NV, et al. "A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure with Preserved Ejection Fraction." Circulation (2018): CIRCULATION AHA-118.

  3. Which of the following treatments have shown positive results regarding composite all-cause mortality for the treatment of HFpEF?

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    Answer: A

    Explanation: Unlike in patients with heart failure with reduced ejection fraction, no treatment has yet been shown to reduce all-cause mortality in HFpEF patients.

    Reference: Ponikowski, Piotr, et al. "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC." European journal of heart failure 18.8 (2016): 891-975.

  4. Which of the treatments has demonstrated decreases in NT-proBNP levels in patients with HFpEF in randomized-controlled trials?

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    Answer: B

    Explanation: In the PARAMOUNT trial, sacubitril/valsartan significantly reduced NT-proBNP levels in HFpEF patients; studies with hydralazine, ivabradine, and vericiguat have shown no effect on NT-proBNP in HFpEF.

    Reference: Gladden, James D., Antoine H. Chaanine, and Margaret M. Redfield. "Heart failure with preserved ejection fraction." Annual review of medicine 69 (2018): 65-79.

  5. Routine use of nitrates or phosphodiesterase-5 inhibitors to reduce symptoms and increase quality of life is recommended in HFpEF patients

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    Answer: B

    Explanation: According to the 2017 ACC/AHA/HFSA updated heart failure guidelines, the routine use of nitrates or PDE-5 inhibitors to increase activity or quality of life in HFpEF is ineffective and not recommended.

    Reference: Yancy, Clyde W., et al. "2017 ACC/AHA/HFSA focused update of the 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America." Journal of the American College of Cardiology 70.6 (2017): 776-803.

  1. The overweight insulin-resistant individual demonstrates an improvement in cardiometabolic risk profile after modest dietary weight loss. This statement is:

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    Answer: A

    Explanation: A recent study has revealed that "Insulin-resistant overweight individuals demonstrate significant improvement in cardiometabolic risk profile in response to modest dietary weight loss."

    Reference: McLaughlin, T. et al. "Dietary weight loss in insulin-resistant non-obese humans: Metabolic benefits and relationship to adipose cell size." Nutrition, Metabolism and Cardiovascular Diseases 29.1 (2019): 62-68.

  2. The risk of obesity-associated diseases such as CVD is predicted by:

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    Answer: C

    Explanation: Studies have found that both excess BMI and waist circumference-years better-predicted risk of CVD than BMI or waist circumference alone.

    Reference: Reis, Jared P., et al. "Excess body mass index-and waist circumference-years and incident cardiovascular disease: the CARDIA study." Obesity 23.4 (2015): 879-885.

  3. According to the most recent AACE Guidelines, which one of the following patient BMI profiles indicates an appropriate scenario for bariatric surgery?

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    Answer: D

    Explanation: The AACE guidelines recommend that patients with a BMI of ≥40 can be recommended for bariatric surgery.

    Reference: Garvey, W. Timothy, et al. "American Association of Clinical Endocrinologists and American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity." Endocrine Practice 22.s3 (2016): 1-203.

  4. Which of the following types of bariatric surgeries is most efficacious in promoting weight loss?

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    Answer: B

    Explanation: An article states that "In general, gastric bypass patients will lose around 70 percent of their excess weight, sleeve gastrectomy patients will lose around 60 percent."

    Reference: https://www.obesityaction.org/community/article-library/choosing-the-right-weight-loss-surgery-procedure/

  5. Liraglutide 3.0 mg can be considered for individuals:

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    Answer: C

    Explanation: A recent study found that "The analysis did not indicate any differences in the treatment effects, or safety profile, of liraglutide 3.0 mg for individuals with BMI 27 to <35 or ≥35 kg/m². Liraglutide 3.0 mg can, therefore, be considered for individuals with a BMI of ≥35 as well as for those with a BMI of 27 to <35 kg/m².

    Reference: le Roux, Carel, et al. "Comparison of Efficacy and Safety of Liraglutide 3.0 mg in Individuals with BMI above and below 35 kg/m²: A Post-hoc Analysis." Obesity facts 10.6 (2017): 531-544.

  1. The mechanism of action for GLP-1 RAs in reducing the risk of ASCVD is:

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    Answer: D

    For more information please visit: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5902002/

  2. Which of the following statements is true about CVOT trials with GLP-1 RA and SGLT-2is

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    Answer: A

    For more information please visit: https://cardiab.biomedcentral.com/articles/10.1186/s12933-019-0822-4

  3. According to recent guideline updates and consensus statements, which agents are preferred based on current evidence for T2DM patients with ASCVD?

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    Answer: B

    For more information please visit:
    http://www.onlinejacc.org/content/72/24/3200?_ga=2.119672392.1323584427.1543254460-%20%201928984987.1540233298
    https://care.diabetesjournals.org/content/43/Supplement_1/S111

  4. The PIONEER-6 trial showed which of the following:

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    Answer: B

    For more information please visit: https://www.nejm.org/doi/full/10.1056/NEJMoa1901118

Clinical Case Challenges

  1. Clinical Case Challenge!

    A 62-year-old male with a medical history of hypertension and Type 2 Diabetes for last 10 years with an HbA1c of 7.6% presents to the clinic. During patient interview he told that he exercises 5 days/week and takes his medicines regularly.

    Medical History

    - T2D for 10 years
    - Hypertension
    - Prior Stroke
    - EF >55%

    Physical Examination and Lab Results:

    - Blood pressure: 146/92 mmHg
    - Pulse rate: 68 bpm
    - Body mass index: 28.7 kg/m2
    - Cr: 1.8 (CrCl 40 ml/min)
    - TC: 162 mg/dL
    - LDL-C: 70 mg/dL
    - TG: 180 mg/dL
    - HDL-C: 32 mg/dL

    Medications:

    - Lisinopril/HCTZ
    - Rosuvastatin
    - Metformin
    - Insulin

    Question: What would you do for his medical therapy?

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    Both C. and D. are the correct answers

    Expert Commentary on the Case Conclusion

  1. Management of Heart Failure with Preserved Ejection Fraction

    A 73-year-old female with a medical history of paroxysmal atrial fibrillation and hypertension visits for an annual exam. She is presented with dyspnea on exertion that has been progressive for the last 18 months and have been hospitalized for pneumonia three months ago. Her dyspnea has been worse since her last hospitalization. She also has two pillow orthopnea and occasional PND.

    MEDICAL HISTORY

    - Paroxysmal atrial fibrillation
    - Hypertension

    PHYSICAL EXAMINATION:

    - Height: 5'2''
    - Weight: 90kg
    - BMI: 36.2 kg/m2
    - BP: 154/79 mmHg - regular 18 - RR
    - HR: 94
    - Afebrile
    - JVP - difficult but appears to be 3 cm above clavicle sitting
    - Chest - clear to P & A
    - Cor - regular rhythm S4
    - Abd - normal
    - Ext - 1+ edema

    MEDICATIONS:

    - Lisinopril 5mg qd
    - Chlorthalidone 25 mg qd
    - Apixaban 5 mg bid

    LAB RESULTS:

    - Sodium - 138 mmol/L;
    - Potassium - 4.3 mmol/L;
    - Bicarbonate - 24 mmol/L
    - BUN - 33 mg/dL;

    - Creatinine - 1.4 mg/dl
    - eGFR - 39ml/min/1.73/m2
    - Hemoglobin - 11.9 g/dL
    - HbA1c - 5.8%
    - NT pro BNP - 297 pg/mL (age-specific and sex-specific normal range, 10 to 218 pg per milliliter)
    - Fasting lipids:
    - Cholesterol total = 210 mg/dL,
    - HDL = 54 mg/dL,
    - LDL = 150 mg/dL,
    - TGs = 120 mg/dL
    - ECG normal sinus rhythm, otherwise unremarkable

    ECHO IN HOSPITAL DEMONSTRATED

    - LVEF 50% Pulmonary artery systolic pressure = 45 mm Hg
    - Evidence of moderate diastolic dysfunction
    - Normal left ventricular wall thickness
    - Moderately enlarged left atrium
    - Mild aortic sclerosis with no stenosis
    - Mild to moderate tricuspid regurgitation with mildly reduced right ventricular function

    Question: What would you do for his medical therapy?

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    Expert Commentary on the Case Conclusion

  1. Mastering the Prior Authorization Process to Meet Patient Needs

    A 61-year old African-American male with a history of ASCVD, hypertension and myocardial infarction visits for an annual exam. Physician is considering a PCSK9 inhibitor option as this patient needs further LDL-C lowering medication options. This patients has been referred to a pharmacist in the lipid clinic to fill out prior authorization paperwork.

    MEDICAL HISTORY:

    - ST-segment elevation myocardial infarction – 12/1/16
    - Hypertension
    - Ischemic cardiomyopathy
    - LVEF 20-24% s/p implantation of automatic cardioverter/defibrillator
    - Statin intolerance

    MEDICATIONS:

    - Aspirin 81 mg P.O daily
    - Lisinopril 2.5 mg P.O daily
    - Metoprolol 25 mg P.O daily
    - Spironolactone 12.5 mg P.O daily
    - Ezetimibe 10 mg P.O daily

    LABORATORY RESULTS:

    - Current LDL-C = 145 mg/dL

    Question: What should the pharmacist do next?

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    Expert Commentary on the Case Conclusion

  1. A Case of Resistant Hypertension

    A 67 year-old male with a history of hypertension, CAD (s/p PCI with stenting of RCA), hyperlipidemia, GERD, BPH, and DKD visits for an annual exam. He reports measuring home BP infrequently, but reports it is usually around 140-150/70-80 mmHg. At his visit, the following are measured:

    PHYSICAL EXAM:

    - BMI: 33 kg/m2
    - BP: 188/94 mm Hg
    - HR: 72 bpm
    - Cardiac exam: regular rhythm, normal S1S2
    - Lungs: clear; peripheral pulses symmetrical
    - Absent carotid or abdominal bruits

    LABORATORY RESULTS:

    - eGFR: >60 ml/min/1.73 m2
    - Serum K+: 3.6 mEq/L
    - HbA1c: 6.1%
    - Serum Na+: 142 mEq/L

    MEDICATIONS:

    - Losartan HCT: 100/25 mg qday
    - Carvedilol: 12.5 mg bid
    - Amlodipine: 5mg qday
    - Clonidine: 0.1 mg qhs
    - Atorvastatin: 10 mg qday
    - ASA: 81 mg qday

    After ordering an aldosterone-to-renin ratio (ARR) and 24-hour urine test for aldosterone, cortisol, sodium, and protein, it is decided to stop losartan hct and substitute it with lisinopril 40 mg qday and chlorthalidone 25 mg qam. Clonidine is also stopped and amlodipine is increased to 10 mg qday. At the patient?s 1 month follow up, his office BP (automated, 5-serial readings, unattended) is 165/92 mmHg. And the following is found during his exam:

    LABORATORY RESULTS:

    - Aldosterone/PRA: 11 ng/dL 0.6 ng/ml/hr
    - 24-hr urinary aldosterone: 14 mcg
    - 24-hr urinary sodium: 218 meq

    Patient Case Question: Which medication change should be recommended?

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    Expert Commentary on the Case Conclusion

  1. Balancing Glucose Control and Weight Gain

    A 52 year old woman who was diagnosed with T2DM in 2001 is seen in consultation to improve glucose control. She has no hypoglycemic symptoms and her finger stick glucoses are 132-187 mg/dl AC and 156-398 mg/dl hs. She is frustrated by weight gain (17 lbs in past 11 months) and acknowledges stress eating due to financial concerns. She mentions that she is ?too busy? to exercise and per her husband she snores and wakes up tired. She has previously declined a sleep study since she is ?sure she doesn?t have sleep apnea.? Upon examination the following is documented:

    MEDICAL HISTORY:

    - Background diabetic retinopathy
    - Diabetic polyneuropathy
    - Diabetic nephropathy with microalbuminuria
    - Obesity
    - Hypertension
    - Dyslipidemia
    - Depression

    FAMILY HISTORY:

    - T2DM in mother and 3/5 siblings

    SOCIAL HISTORY:

    - She and husband own struggling business
    - No tobacco, alcohol or illicit drug use

    PHYSICAL EXAM:

    - Tearful when discussing problems
    - Generally and truncally obese
    - Does not appear acromegalic or cushingoid
    - BP: 128/82 mmHg
    - HR: 78 bpm
    - BMI: 43.4 kg/m2
    - Feet: loss distal cold sensation; normal vibration and monofilament sensation

    LABORATORY RESULTS:

    - HbA1c: 9.7%
    - Creatinine: 0.8 mg/dl
    - GFR>60 mL/m/1.73m2
    - K+: 4.5mM

    CURRENT MEDICATIONS

    - Lispro insulin 80 unit base dose with sliding scale AC
    - Basaglar insulin 135 units bid
    - Lisinopril 40 mg qd
    - Atorvastatin 40 mg qd
    - Sertraline 100 mg qd

    PRIOR MEDICATIONS

    - Metformin (GI upset)
    - Liraglutide (dizziness)
    - Empagliflozin (3 time/night urination)
    - Pioglitazone (prior refusal due to concerns about bone fractures and weight gain)

    Patient Case Question: How do you improve glucose control in this patient?

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    Expert Commentary on the Case Conclusion

  1. Severe Hypertriglyceridemia

    A 45 year old man with known CHD S/P multiple PCIs/stents, T2DM since 1994, and hypertension for >20 years is hospitalized 5 months previously for chest pain. During his admission, the following is found:

    LABORATORY RESULTS:

    - TG: 2509 mg/dl
    - HbA1c: 10.2%

    MEDICATIONS:

    - Gemfibrozil 600 mg BID
    - DHA + EPA 2.5 g
    - Atorvastatin 20 mg
    - Glipizide 10 mg
    - Metformin 850 mg BID

    The patient was discharged on same medications plus a low fat diet and insulin glargine 10 units daily. His home glucose monitoring recordings have been in the 100-150 mg/dL range during several months of increasing insulin dosage. At his next clinic visit:

    MEDICATIONS:

    - Glargine 72 units daily
    - Metformin 1 g BID
    - Glipizide 10 mg BID
    - Rosuvastatin 20 mg
    - Gemfibrozil 600 mg BID
    - Fish oils 1.6 g BID
    - Clopidogrel 75 mg
    - Aspirin 81 mg

    PHYSICAL EXAM:

    - Weight: maximum 280 lbs; patient had lost 14lbs since his hospitalization on a low fat diet
    - BP: 140/68 mmHg
    - BMI: 34.7 kg/m2
    - Eruptive xanthomata on back and arms

    LABORATORY RESULTS:

    - TC: 259 mg/dL
    - TG: 1965 mg/dL
    - HDL-C: 35 mg/dL
    - HbA1c: 7.8%
    - AST, ALT: normal
    - Creatinine: 1.0 mg/dL
    - TSH: 1.6 mIU/L
    - U/A albumin: ? 789 mg/g

    SOCIAL HISTORY:

    - Eats fish approximately 1-2 times per month, whole grains approximately 1 serving a day, fruits and vegetables 4-5 servings a day; occasionally he eats out, but when he does, he eats salads
    - No EtOH
    - No tobacco
    - Walks approximately 30 minutes daily, but this is difficult due to symptoms of peripheral neuropathy

    Patient Case Question: What is the next best step in the management of this patient to reduce his triglyceride level?

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    Expert Commentary on the Case Conclusion

  1. Challenges with High LDL-C Levels

    A 50 year old woman who is a busy mom working and going to school part time is referred for treatment of high cholesterol. Her weight has never been a problem but can vary by approximately 5 pounds; however, her weight is currently higher than her ?goal weight.? The patient tries to eat healthy, but is not sure what diet changes to make. She likes desserts and has switched to portioned ice cream bars but eats 2 per day. The patient also does not enjoy exercise, but will occasionally walk on a treadmill. Her exam reveals:

    MEDICAL HISTORY:

    - High cholesterol over the last ?few? years
    - Depression and anxiety
    - Not menopausal

    FAMILY HISTORY:

    - Mother has elevated cholesterol levels

    PHYSICAL EXAM:

    - BMI: 24.5 kg/m2
    - Waist circumference: 83 cm
    - BP: 132/85 mmHg

    LABORATORY RESULTS:

    - Cholesterol: 321 mg/dL
    - TG: 115 mg/dL
    - HDL-C: 73 mg/dL
    - LDL-C: 223 mg/dL

    MEDICATIONS:

    - Alprazolam- 0.75 mg daily

    Patient Case Question: How would you manage this patient?

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    Expert Commentary on the Case Conclusion

  1. Developments in Type 2 Diabetes treatment to decrease the risk of hypoglycemia

    A 53-year old male with a past history of diabetes for 7 years is referred to you by his cardiologist. He was 100 pounds heavier at the diagnosis and this weight loss is unintentional. At his visit, the following are measured:

    Medical history:

    • Severe hypertriglyceridemia
    • Hypertension
    • CKD (eGFR 49 ml/min)
    • 3-vessel CHD
    • S/P PCI,
    • LVEF ? 43%
    • Claudication
    • Hyperkalemia
    • increased LFTs
    • macular edema
    • proliferative retinopathy

    Social and Family history:

    • Minimal alcohol
    • S/P tobacco- 8 packs-years,
    • Works as roofer
    • Father- T2DM, CHD

    Review of symptoms:

    • Dyspnea on exertion
    • Erectile dysfunction
    • Peripheral sensory neuropathy

    Physical Exam:

    • Pulse -70
    • BP 160/88
    • Weight 89 kg
    • BMI 26.6 kg /m2
    • Thyroid ? upper limit of normal (ULN)
    • Gr 2/6 SEM LLSB and apex
    • Reduced pedal pulses
    • 2+ lower extremity edema
    • Charcot left foot

    Labs:

    • HbA1c ? 10.5%
    • BUN ? 32 mg/dL
    • Creatinine ? 1.27 mg/dL
    • eGFR ? 59 mL/min
    • Potassium ? 4.1 mmol/L
    • Cholesterol ? 166 mg/dL
    • Triglycerides ? 209 mg/dL
    • HDL-C ? 31 mg/dL
    • LDL-C ? 93 mg/dL
    • Non-HDL-C ? 135 mg/dL
    • ALT ? 42 U/L, AST 25 U/L

    Current Medications:

    • Metformin 1000 mg BID
    • Acetylsalicylic acid (ASA) 81 mg
    • Lisinopril
    • Spironolactone 25 BID
    • Nitroglycerin (NTG) 0.4 SL PRN

    Additional information about patient:

    • Patient is fearful of hypoglycemia, as he has seen his father be hospitalized for this condition multiple times
    • Based on patient?s medical profile and HbA1c of 10.5%, treatment intensification may be necessary; however, he is hesitant to intensify his treatment

    Based on your patient?s profile, laboratory results, and discussion with him, what will be your next step in treating this patient?

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    Expert Commentary on the Case Conclusion

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