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(BQ) Part 2 book Braunwald''s heart disease - Review and assessment presents the following contents: Preventive cardiology; atherosclerotic cardiovascular disease; diseases of the heart, pericardium, and pulmonary vascular bed; cardiovascular disease in special populations; cardiovascular disease and disorders of other organs.
SECTION III (CHAPTERS 41 TO 61) 3â•… Preventive Cardiology; Atherosclerotic Cardiovascular Disease Neal K Lakdawala, Neil Wimmer, and Leonard S Lilly Directions: For each below, select the ONE BEST response QUESTION 295 A 48-year-old man with elevated low-density lipoprotein (LDL) cholesterol, hypertension, and a family history of premature coronary disease presents to his physician’s office for routine evaluation He does not have diabetes He smokes pack of cigarettes per day and is exploring means to quit His 10-year risk of atherosclerotic cardiovascular disease using the 2013 ACC/AHA Pooled Cohort Equations was recently calculated to be 18.8%, compared with a 1.7% risk in a similarly aged man with optimal risk factors He also has a history of supraventricular tachycardia that has been successfully suppressed by verapamil, after not tolerating a beta-blocker He is currently taking simvastatin 20╯mg daily, verapamil sustained-release 180╯mg daily, and aspirin 81╯mg daily His blood pressure is 138/70╯mm╯Hg Laboratory studies include total cholesterol, 250╯mg/dL; HDL cholesterol, 42╯mg/dL; LDL cholesterol, 166╯mg╯dL; and triglycerides, 210╯mg/dL The hepatic transaminase levels are normal Which of the following is the most appropriate recommendation regarding lipid-altering therapy? A He does not have active coronary artery disease—no further adjustment in medication is required B Simvastatin should be increased to 40╯mg daily C Simvastatin should be increased to 80╯mg daily D Replace simvastatin with atorvastatin 20╯mg daily or rosuvastatin 10╯mg daily E Gemfibrozil 150╯mg twice daily should be added QUESTION 297 With respect to renovascular hypertension, which of the following statements is correct? A Worsening renal function with angiotensin-converting enzyme inhibitor therapy suggests unilateral renovascular disease B Atherosclerotic disease most commonly involves the distal third of the main renal artery C Fibromuscular renovascular disease arises primarily in women aged 20-60 D When atherosclerotic renal artery stenosis is found, mechanical revascularization is the treatment of choice E Patients with severe, accelerated hypertension are unlikely to have renovascular disease as the cause QUESTION 298 Which of the following statements regarding hypertension is true? A Pure “white coat” hypertension is found in 5% of patients B Renal parenchymal disease is the most common cause of secondary hypertension C Inaccurately-low blood pressure is typically recorded in patients with sclerotic brachial arteries D When measuring the blood pressure, an inappropriately small cuff size results in a spuriously low systolic measurement E Coarctation of the aorta, Cushing disease, and pheochromocytoma together account for ~10% of hypertensive patients QUESTION 296 QUESTION 299 All of the following interventions have a blood pressure– lowering effect EXCEPT A A diet that reduces caloric intake by 1000 calories per day B Reduction of dietary sodium C Daily magnesium and calcium supplements D Reduction of ethanol consumption to less than 1╯oz (30╯mL)/d An asymptomatic 68-year-old man presents with newly diagnosed hypertension The electrocardiogram (ECG) demonstrates left ventricular hypertrophy (LVH) with “strain” pattern Which of the following statements is TRUE? A Electrocardiography is more sensitive than echocardiography for the detection of LVH B Hypertensive patients with LVH are more likely to develop heart failure than those without LVH 141 142 CHAPTERS 41 TO 61 III C The presence of LVH is expected in hypertension and has no bearing on mortality rates D A beta-blocker such as atenolol reduces cardiovascular morbidity and mortality more than other pharmacologic agents in hypertensive patients with LVH E LVH is a compensatory protective mechanism that prevents further hypertensive damage to the heart QUESTION 300 Each of the following statements regarding the association of oral contraceptives (OCs) and hypertension is correct EXCEPT A Among oral contraceptive users, the likelihood of developing hypertension is increased by alcohol consumption B The likelihood of developing hypertension is independent on the age of the user C Elevated blood pressure normalizes within months of initiating OC therapy in 50% of patients D The mechanism for contraceptive-induced hypertension likely involves renin-aldosterone–mediated volume expansion QUESTION 304 Which of the following statements regarding the effects of HMG-CoA reductase inhibitors (“statins”) is correct? A Expression of hepatic low-density lipoprotein receptors is decreased B Hepatic production of very-low-density lipoprotein is increased C Myonecrosis with muscle symptoms and elevated serum CK >10 times normal occurs in 5% of patients D Concurrent administration of erythromycin increases the risk of myositis QUESTION 305 Which statement regarding the effect of medications on the serum lipid profile is correct? A Nonselective beta-blockers increase high-density lipoprotein (HDL) levels B Thiazide diuretics decrease triglyceride levels C Estrogen replacement therapy decreases HDL and triglyceride levels D Protease inhibitors raise total cholesterol and triglyceride levels E Corticosteroids reduce triglyceride levels QUESTION 301 QUESTION 306 Which of the following statements regarding pheochromocytoma is correct? A Approximately 1% of pheochromocytomas are extraadrenal B Fifty percent of pheochromocytomas are malignant C Fifty percent of adrenal pheochromocytomas are bilateral D Hypertension related to pheochromocytoma only rarely causes chronic persistent hypertension E Multiple adrenal tumors are common in familial forms of pheochromocytoma Which of the following statements regarding genetic lipoprotein disorders is correct? A Familial hypercholesterolemia results from mutations in the gene that encodes the enzyme HMG-CoA reductase B Mutations in the apo B gene results in a form of hypercholesterolemia that is indistinguishable from familial hypercholesterolemia C Patients with familial hypertriglyceridemia typically develop xanthomas or xanthelasmas D Gain-of-function mutations in the PCSK9 gene result in decreased LDL cholesterol levels and a reduction in coronary events E Patients with familial combined hyperlipidemia have elevations of both LDL and HDL cholesterol levels and a rate of coronary events similar to populations with normal lipid levels QUESTION 302 Which of the following statements regarding adverse effects of antihypertensive agents is correct? A Cough resulting from angiotensin-converting enzyme (ACE) inhibitors arises more commonly in Caucasians than in Asians B ACE inhibitor–induced cough reliably resolves within days after discontinuation of the drug C Gingival hyperplasia is a recognized adverse effect of calcium channel blockers D Bradycardia is a common side effect of hydralazine E Volume depletion and alopecia are established side effects of minoxidil therapy QUESTION 303 Thiazide diuretics can contribute to each of the following metabolic effects EXCEPT A Hypomagnesemia B Hypouricemia C Hypercalcemia D Hypertriglyceridemia E Hyponatremia QUESTION 307 Which of the following statements regarding niacin is correct? A It acts primarily via upregulation of the hepatic LDL receptor B It raises plasma HDL cholesterol levels but has no effect on LDL levels C It reduces the circulating level of lipoprotein (a) D Niacin added to statin therapy reduces coronary event rates QUESTION 308 Which of the following statements about apolipoproteins is correct? A Apo AI is a major component of LDL cholesterol B Apo B48, synthesized by the small intestine, and apo B100, secreted by the liver, are synthesized by two distinct genes 143 QUESTION 309 Each of the following statements regarding hypertriglyceridemia is true EXCEPT A Hypertriglyceridemia is associated with diabetes mellitus, chronic renal failure, and obesity B Cigarette smoking and excessive alcohol consumption are associated with secondary hypertriglyceridemia C In epidemiologic studies, adjustment for high-density lipoprotein levels and other factors diminishes the role of hypertriglyceridemia as an independent predictor of coronary artery disease D There is a stronger relationship between hypertriglyceridemia and cardiovascular risk in women than in men E The addition of fenofibrate to simvastatin lowers triglyceride levels and has been shown to reduce coronary events in type diabetic patients, compared with simvastatin alone QUESTION 310 Each of the following statements regarding lipoprotein (a) [Lp(a)] is true EXCEPT A One component of Lp(a) is structurally identical to low-density lipoprotein and another is similar to plasminogen B Lp(a) levels not vary significantly between racial groups C Lp(a) levels vary little with changes in dietary fat intake D Observational studies have associated elevated Lp(a) levels with cardiovascular events QUESTION 311 True statements regarding lipid-lowering medications include each of the following EXCEPT A Fibric acid derivatives lower triglycerides, raise highdensity lipoprotein (HDL) levels, and may increase LDL cholesterol levels B Fish oil therapy raises triglyceride levels C Other medications should not be taken within hour before or within hours after taking a bile acid–binding resin D Ezetimibe added to statin therapy in patients with a recent acute coronary syndrome reduces subsequent coronary event rates more than statin therapy alone QUESTION 312 A 70-year-old businessman presented to the emergency department (ED) of a university medical center with multiple episodes of anterior substernal chest discomfort over the prior days, each lasting 5-10 minutes in duration He has a history of hypertension, elevated LDL-cholesterol and had been a regular cigarette smoker until stopping months ago He experienced a single transient ischemic attack year ago His home medications included aspirin 81╯mg daily, atorvastatin 10╯mg daily, and lisinopril 10╯mg daily The initial ECG was unremarkable, but while being evaluated in the ED he experienced another 5-minute episode of chest discomfort, during which the ECG demonstrated transient 1-mm ST depression in leads II, III, aVF, V5, and V6 The initial cardiac troponin T was 0.06╯ng/mL (reference range 140╯mg/dL E Hypertension QUESTION 319 A 52-year-old woman presents for routine outpatient management She is interested in nonpharmacologic approaches QUESTION 321 Each of the following statements about pharmacologic therapy for secondary prevention of coronary artery disease is correct EXCEPT A Long-term aspirin use after myocardial infarction (MI) reduces cardiovascular mortality, re-infarction, and stroke rates B After MI, beta-blocker therapy significantly reduces mortality over the next to years C Angiotensin-converting enzyme inhibitors administered after MI confer an early mortality reduction only in patients with left ventricular dysfunction D Administration of HMG-CoA reductase inhibitors reduces cardiovascular deaths after MI in patients with average cholesterol levels E After an acute MI, intensive lipid lowering with a high-dose statin confers improved clinical outcomes compared with only moderate lipid lowering QUESTION 322 Which of the following statements regarding heterozygous familial hypercholesterolemia (FH) is correct? A It is a relatively common disorder with a gene frequency of at least in 500 persons in the population B Tendon xanthomas are rare C It is inherited as a recessive trait D Cutaneous planar xanthomas are common E The fundamental defect is the presence of only one quarter of the normal number of low-density lipoprotein surface receptors QUESTION 323 Which of the following is characteristic of familial hypertriglyceridemia? A Plasma low-density lipoprotein is usually high B Plasma triglyceride levels can rise as high as 1000╯mg/ dL after a meal 145 QUESTION 324 Each of the following statements about coronary stent thrombosis is correct EXCEPT A The strongest predictor of late stent thrombosis is premature discontinuation of dual antiplatelet therapy B Stent thrombosis has been reported to occur more than a year after the placement of drug-eluting stents C Implantation of a drug-eluting stent should be avoided in a patient for whom noncardiac surgery is planned within 12 months D Stent thrombosis is associated with a mortality rate of 5% to 10% E Late stent thrombosis is more likely to occur in individuals with diabetes or renal failure than in patients without these conditions QUESTION 325 A 60-year-old man was admitted to the hospital with an acute anterior myocardial infarction (MI) He underwent urgent cardiac catheterization and successful reperfusion was achieved after a complex coronary angioplasty with stent placement His hospital course was complicated by rising serum creatinine and urea nitrogen levels In addition, a purple, net-like discoloration developed on his lower extremities (Figure 3-1) Which of the following statements is correct? A These findings likely resulted from the presenting MI rather than from the catheterization procedure B The urinalysis likely reveals an active sediment with cells and casts C A high serum complement level is likely D Transient eosinophilia is often part of this syndrome E Progression to end-stage renal failure does not occur QUESTION 326 Correct statements with respect to low-density lipoprotein (LDL) include all the following EXCEPT A LDL is the major cholesterol-carrying component of plasma B Apo AI comprises 25% of LDL mass C LDL is formed mainly from metabolism of very-lowdensity lipoprotein (VLDL) D The major lipid components of LDL are triglyceride and esterified cholesterol E The minority of patients with elevated LDL levels have familial hypercholesterolemia QUESTION 327 Which of the following statements regarding high-sensitivity C-reactive protein (hsCRP) is NOT correct? A Statins reduce hsCRP in a manner directly related to their low-density lipoprotein–lowering effect B An hsCRP level >3╯mg/L in a patient with unstable angina is associated with an increased risk of recurrent coronary events C An elevated level of hsCRP is predictive of the onset of type diabetes mellitus D Statin therapy has been shown to reduce cardiovascular events in apparently healthy individuals with elevated hsCRP even if the baseline LDL-C is 90% bioavailability when administered by subcutaneous injection Other advantages of LMWH include a prolonged half-life and predictable anticoagulant responses (Table 5-6) Patients receiving LMWH not require serial laboratory monitoring to monitor the anticoagulant effect, except those with renal failure, extreme obesity, or pregnancy Heparin-induced thrombocytopenia can occur with LMWH but is less common than with UFH BIBLIOGRAPHY Garcia DA, Baglin TP, Weitz JL, et╯al: Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis, ed 9: American College of Chest Physicians Evidence-based Clinical Practie Guidelines Chest 141:e24S, 2012 TABLE 5-6╇ Advantages of Low-Molecular-Weight Heparin and Fondaparinux over Heparin ADVANTAGE CONSEQUENCE Better bioavailability and longer half-life after subcutaneous injection Can be given subcutaneously once or twice daily for both prophylaxis and treatment Dose-independent clearance Simplified dosing Predictable anticoagulant response Monitoring of coagulation is unnecessary in most patients BIBLIOGRAPHY Lower risk for HIT Longstaff C, William S, Thelwell C: Fibrin binding and the regulation of plasminogen activators during thrombolytic therapy Cardiovasc Hematol Agents Med Chem 6:212, 2008 Safer than heparin for short- or long-term administration Lower risk for osteoporosis Safer than heparin for long-term administration Cardiovascular Disease in Special Populations; Cardiovascular Disease and Disorders of Other Organs Vezzosi D, Vignaux O, Dupin N, et╯al: Carney complex: clinical and genetic 2010 update Ann Endocrinol 6:486, 2010 Stowasser M: Primary aldosteronism in 2011: towards a better understanding of causation and consequences Nat Rev Endocrinol 8:70, 2011 Andersson P, Rydberg E, Willenheimer R: Primary hyperparathyroidism and heart disease: a review Eur Heart J 25:1776, 2004 296 ANSWERS TO QUESTIONS 703 TO 706 CHAPTERS 76 TO 89 V 703–D, 704–B, 705–A, 706–C (Braunwald, pp 1844-1845, 1846-1847, 1853, 1854, 1856, 1858-1859; see also Answers to Questions 670 to 674) Rheumatologic disorders often involve the cardiovascular system and can result in pericardial, myocardial, valvular, or arterial abnormalities Aortic involvement is estimated to occur in 15% of patients with giant cell arteritis Inflammation often involves the proximal aorta and aortic valve cusps, resulting in dilatation of the vessel and aortic regurgitation.1 Other rheumatologic diseases that prominently involve the aorta include ankylosing spondylitis and psoriatic arthritis Valvular abnormalities are found by transesophageal echocardiography in 50% of patients with systemic lupus erythematosus.2 The most common involvement, termed Libman-Sacks endocarditis, represents noninfectious valve thickening, usually on the atrial side of the mitral valve and the arterial side of the aortic valve Over time, fibrosis may result in valvular insufficiency Much less commonly, the vegetations may occlude the valve orifice, causing stenosis Clinical manifestations of Libman-Sacks lesions, such as infective endocarditis or peripheral embolism, are rare.2 Although pulmonary hypertension can develop in many rheumatologic disorders, it is a particularly prominent feature of scleroderma and is one of the leading causes of morbidity and mortality in that condition.3 Behỗet disease typically results in inflammation of the thoracic aorta and branch vessels, leading to stenoses and aneurysmal dilatation of the subclavian and carotid arteries.4 Thoracic and abdominal aortic aneurysms may also result REFERENCES Weyand CM, Goronzy JJ: Medium and large vessel vasculitis N Engl J Med 349:160, 2003 Perez-Villa F, Font J, Azqueta M, et╯al: Severe valvular regurgitation and antiphospholipid antibodies in systemic lupus erythematosus: a prospective, long-term follow-up study Arthritis Rheum 53:460, 2005 McMahan ZH, Hummers LK: Systemic sclerosis—challenges for clinical practice Nat Rev Rheumatol 9:90, 2013 Ambrose NL, Haskard DO: Differential diagnosis and management of Behỗet syndrome Nat Rev Rheumatol 9:79, 2013 This page intentionally left blank This page intentionally left blank This page intentionally left blank This page intentionally left blank Smarter search Faster answers Smarter, Faster Search for Better Patient Care Unlike a conventional search engine, ClinicalKey is specifically designed to serve doctors by providing three core components: Comprehensive Content The most current, evidence-based answers available for every medical and surgical specialty Trusted Answers Content supplied by Elsevier, the world’s leading provider of health and science information Unrivaled Speed to Answer Faster, more relevant clinical answers, so you can spend less time searching and more time caring for patients Start searching with ClinicalKey today! Visit ClinicalKey.com for more information and subscription options ... 10:316, 20 10 Nordestgaard BG, Benn M, Schnohr P, et╯al: Nonfasting triglycerides and risk of myocardial infarction, ischemic heart disease, and death in men and women JAMA 29 8 :29 9, 20 07 The... systematic review and meta-analysis J Hypertens 30:8 52, 20 12 Flachskampf FA, Gallasch J, Gefeller O, et╯al: Randomized trial of acupuncture to lower blood pressure Circulation 115:3 121 , 20 07 ANSWER... 1997 to 20 07 Am J Med 122 :85, 20 09 Yu R, Nissen NN, Bannykh SI: Cardiac complications as initial manifestation of pheochromocytoma: frequency, outcome, and predictors Endocr Pract 18:483, 20 12 ANSWER