CMC Risk Assessment & Management 3 — Questions and Answers
Question 1: A 55-year-old woman with type 2 diabetes has an LDL of 105 mg/dL and no prior cardiovascular events. Per 2018 ACC/AHA guidelines, what is her statin therapy indication?
- No statin needed if LDL < 130 mg/dL
- High-intensity statin due to diabetes alone
- Moderate- to high-intensity statin given diabetes as a risk-enhancing condition (Correct answer)
- Defer decision until coronary calcium score obtained
Correct answer: Moderate- to high-intensity statin given diabetes as a risk-enhancing condition
Adults aged 40–75 with diabetes are candidates for moderate- to high-intensity statin; high-intensity is preferred when multiple risk factors or 10-year ASCVD risk ≥ 20% is present.
Question 2: Which hemodynamic parameter measured during right heart catheterization most directly quantifies pulmonary vascular resistance (PVR)?
- Mean pulmonary artery pressure alone
- (Mean PAP − PCWP) / cardiac output (Correct answer)
- Central venous pressure / heart rate
- Systemic vascular resistance / cardiac index
Correct answer: (Mean PAP − PCWP) / cardiac output
PVR = (mean PAP − PCWP) / cardiac output, expressed in Wood units, and differentiates pre-capillary from post-capillary pulmonary hypertension.
Question 3: In a patient with stable ischemic heart disease, which non-invasive test result best identifies high-risk findings that mandate prompt coronary angiography?
- Exercise stress echo showing lateral wall hypokinesis at 9 METs
- Nuclear stress test with ≥ 10% ischemic myocardium at low workload (Correct answer)
- Stress echo with normal wall motion at 8 METs
- ECG stress test with 0.5 mm ST depression at 10 METs
Correct answer: Nuclear stress test with ≥ 10% ischemic myocardium at low workload
Ischemic myocardium ≥ 10% on nuclear perfusion imaging at low workload is a high-risk feature that warrants referral for coronary angiography.
Question 4: Which scoring system is used to estimate the operative mortality risk of patients undergoing cardiac surgery, and is commonly used in pre-operative cardiac risk stratification?
- CHADS2-VASc
- STS Risk Score (Correct answer)
- HEART Score
- Revised Cardiac Risk Index
Correct answer: STS Risk Score
The Society of Thoracic Surgeons (STS) Risk Score estimates operative mortality and morbidity for cardiac surgical procedures and guides surgical candidacy decisions.
Question 5: In a patient with peripheral artery disease (PAD) and an ankle-brachial index (ABI) of 0.65, what is the most appropriate first-line cardiovascular risk-reduction therapy?
- Warfarin anticoagulation
- High-intensity statin therapy plus antiplatelet therapy (Correct answer)
- Beta-blocker monotherapy
- Immediate surgical revascularization
Correct answer: High-intensity statin therapy plus antiplatelet therapy
Patients with PAD (ABI < 0.9) have high ASCVD risk; high-intensity statin plus antiplatelet therapy (aspirin or clopidogrel) is the guideline-recommended medical management.
Question 6: A 70-year-old man with hypertension and paroxysmal AF has a CHA₂DS₂-VASc score of 3. What is the most appropriate anticoagulation recommendation?
- No anticoagulation needed below score of 4
- Antiplatelet therapy with aspirin only
- Oral anticoagulation is recommended (Correct answer)
- Anticoagulation only if AF episodes exceed 24 hours
Correct answer: Oral anticoagulation is recommended
A CHA₂DS₂-VASc score ≥ 2 in men (≥ 3 in women) indicates sufficient stroke risk to recommend oral anticoagulation per ACC/AHA AF guidelines.
Question 7: Which pre-operative evaluation tool is most appropriate for estimating cardiac risk before a major non-cardiac surgical procedure?
- HEART Score
- Revised Cardiac Risk Index (RCRI) (Correct answer)
- GRACE Score
- TIMI Risk Score
Correct answer: Revised Cardiac Risk Index (RCRI)
The Revised Cardiac Risk Index (RCRI) estimates risk of major adverse cardiac events (MACE) after non-cardiac surgery using six clinical predictors.
CMC Risk Assessment & Management 3
A 55-year-old woman with type 2 diabetes has an LDL of 105 mg/dL and no prior cardiovascular events.
Per 2018 ACC/AHA guidelines, what is her statin therapy indication?