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.

The landmark PREDIMED study was originally published in 2013, but it was retracted and republished in June 2018 after some statistical errors were corrected from the original publication. This generated a lot of controversy about the role of the Mediterranean Diet for the primary prevention of cardiovascular disease. What do the ultimate results tell us? Test your knowledge with this quick quiz.

  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.

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