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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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).

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).

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).

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).

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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/

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.