9 Questions on Primary CV Disease Prevention

Question 1. The AHA/ACC atherosclerotic cardiovascular disease (ASCVD) risk estimator does not take into account which of the above factors?

Answer: D. CAC is not included in the AHA/ACC risk estimator. The AHA/ACC risk estimator takes into account age, diabetes, sex, race, smoking, total cholesterol, HDL-cholesterol, systolic blood pressure, and treatment for hypertension (HTN). However, the Multi-Ethnic Study of Atherosclerosis risk estimator does take CAC into account.

Question 2. The new guidelines lay out several factors that enhance 10-year ASCVD risk. Which of the above is not included?

Answer: B. Eastern European ancestry (not identified). The new guidelines identify South Asian ancestry as a risk factor for ASCVD, not Eastern European ancestry. Other risk enhancers listed include family history of premature ASCVD, primary hypercholesterolemia, premature menopause, and chronic inflammatory disease (eg, rheumatoid arthritis and HIV). 

Question 3. What level of CAC is considered the threshold for elevating risk estimation for ASCVD?

Answer: B. 100 AU. CAC measurement reclassifies ASCVD risk upwards when scores are ≥100 AU. If uncertainty still exists about whether a patient found to have a borderline or intermediate 10-year ASCVD risk should be started on a statin, obtaining a CAC score can be helpful.

Question 4. The guidelines recommend that patients engage in approximately how many minutes of moderate-intensity exercise per week?

Answer: E. 150 minutes. Adults who are able should be encouraged to engage in at least 150 minutes per week of moderate-intensity exercise or 75 minutes per week of vigorous-intensity exercise to reduce ASCVD risk. Patients unable to achieve these levels should still be encouraged to be as active as possible.

Question 5. Which of the above agent/s should be considered if a patient with T2DM on metformin needs further glucose lowering? 

Answer: E. A and C. SGLT-2 inhibitors have been shown in 3 large randomized controlled trials (EMPA-REG OUTCOME, CANVAS, DECLARE-TIMI 58) to significantly reduce ASCVD risk, HF admissions and exacerbations, A1c, body weight, and blood pressure. Three GLP-1 RAs have been shown to reduce ASCVD events, although the majority of patients studied had established CVD.

Question 6. The new guidelines diminish the recommendation to initiate which of the above drugs for primary ASCVD prevention?

Answer: C. Aspirin. Findings from recent large trials (ASCEND, ASPREE, ARRIVE) have diminished the role of aspirin for primary prevention in the era of statins and better control of CV risk factors. The decision to start aspirin should be based on overall ASCVD risk estimate and the patient’s risk of bleeding. Obtaining CAC score may be useful in making this decision.

Question 7. What is the minimum LDL-C level at which a patient should be automatically considered for a high-intensity statin?

Answer: E. 190 mg/dL. It is recommended (class 1) that in patients aged 20-75 years with an LDL-C of ≥190 mg/dL, maximally tolerated statin therapy should be started. 

Question 8. Potential barriers to following therapeutic recommendations should be considered how frequently?

Answer: A. Every time a clinical decision is made. Failing to consider non-health-related factors influencing a patient’s ability to follow recommendations may lead to ineffective care. Risk calculators do not consider these challenges and can lead to underestimating a patient’s risk for ASCVD and related events; clinicians must routinely explore barriers to following therapy recommendations and tailor advice to the patient’s circumstances.

Question 9. True or false? E-cigarettes should be recommended to help patients quit smoking.