CMC Risk Assessment & Management 5 — Questions and Answers
Question 1: A patient with stable angina has a fractional flow reserve (FFR) of 0.78 during coronary angiography. What is the clinical implication?
- Non-hemodynamically significant lesion; defer revascularization
- Hemodynamically significant ischemia; revascularization is indicated (Correct answer)
- Borderline result requiring repeat angiography in 6 months
- Normal coronary physiology; discharge without further evaluation
Correct answer: Hemodynamically significant ischemia; revascularization is indicated
An FFR ≤ 0.80 indicates hemodynamically significant ischemia, and revascularization has been shown to improve outcomes compared to medical therapy alone.
Question 2: Which lipid parameter, beyond LDL-C, is most useful for residual cardiovascular risk assessment in a patient with elevated triglycerides and low HDL?
- Total cholesterol
- Non-HDL cholesterol (Correct answer)
- VLDL cholesterol only
- LDL particle number measured by electrophoresis
Correct answer: Non-HDL cholesterol
Non-HDL cholesterol (total cholesterol minus HDL-C) captures all atherogenic lipoproteins including VLDL remnants and is superior to LDL-C alone in hypertriglyceridemia.
Question 3: In a patient with aortic stenosis being evaluated for transcatheter aortic valve replacement (TAVR), the STS-PROM score is 8%. How is this risk categorized?
- Low surgical risk (< 4% STS-PROM)
- Intermediate surgical risk (4–8% STS-PROM)
- High surgical risk (> 8% STS-PROM) (Correct answer)
- Prohibitive surgical risk (> 15% STS-PROM)
Correct answer: High surgical risk (> 8% STS-PROM)
An STS-PROM of > 8% is classified as high surgical risk, supporting TAVR over SAVR in eligible patients with severe symptomatic aortic stenosis.
Question 4: Which medication class, when added to maximally tolerated statin therapy in patients with atherosclerotic cardiovascular disease and LDL > 70 mg/dL, has demonstrated reduction in cardiovascular events?
- Bile acid sequestrants as monotherapy
- PCSK9 inhibitors (evolocumab or alirocumab) (Correct answer)
- Niacin extended-release
- Omega-3 fatty acids at low dose (1 g/day)
Correct answer: PCSK9 inhibitors (evolocumab or alirocumab)
PCSK9 inhibitors reduce LDL-C by 50–60% and have demonstrated significant reductions in cardiovascular events in patients with established ASCVD on maximally tolerated statins (FOURIER and ODYSSEY OUTCOMES trials).
Question 5: A patient with a mechanical mitral valve replacement has an INR of 1.8. What is the most appropriate next step?
- No change; INR 1.8 is acceptable for mechanical mitral valves
- Increase warfarin dose; target INR is 2.5–3.5 for mechanical mitral valves (Correct answer)
- Switch to a direct oral anticoagulant (DOAC)
- Bridge with unfractionated heparin while continuing current warfarin dose
Correct answer: Increase warfarin dose; target INR is 2.5–3.5 for mechanical mitral valves
Mechanical mitral valves require a higher INR target of 2.5–3.5 due to higher thrombogenicity; an INR of 1.8 is subtherapeutic and warfarin dose should be increased.
Question 6: In a patient with STEMI, which feature on admission identifies highest 30-day mortality risk according to the Killip classification?
- Killip Class I (no CHF signs)
- Killip Class II (S3 or basilar rales)
- Killip Class III (pulmonary edema)
- Killip Class IV (cardiogenic shock) (Correct answer)
Correct answer: Killip Class IV (cardiogenic shock)
Killip Class IV (cardiogenic shock) carries 30-day mortality approaching 50–80% and is the highest-risk category in the Killip classification of acute MI.
Question 7: A 48-year-old woman with no traditional risk factors has an elevated Lp(a) level of 95 mg/dL. What is the clinical significance of this finding?
- Lp(a) > 50 mg/dL is a risk-enhancing factor for ASCVD (Correct answer)
- Elevated Lp(a) has no impact on cardiovascular risk without other risk factors
- Lp(a) > 100 mg/dL is required to influence clinical management
- Lp(a) elevation is only relevant in familial hypercholesterolemia
Correct answer: Lp(a) > 50 mg/dL is a risk-enhancing factor for ASCVD
Lp(a) ≥ 50 mg/dL is a recognized risk-enhancing factor per 2018 ACC/AHA guidelines and can tip borderline-risk patients toward initiating or intensifying statin therapy.
CMC Risk Assessment & Management 5
A patient with stable angina has a fractional flow reserve (FFR) of 0.78 during coronary angiography.
What is the clinical implication?