MKSAP Quiz: Cardiovascular risk reduction
A 45-year-old man is seen for cardiovascular risk reduction. Hyperlipidemia was diagnosed 4 years ago and is treated with atorvastatin. He has a 35-pack-year history of cigarette smoking and is a current smoker. Following a physical exam, what is the most appropriate management?
A 45-year-old man is seen for cardiovascular risk reduction. Hyperlipidemia was diagnosed 4 years ago and is treated with atorvastatin. He has a 35-pack-year history of cigarette smoking and is a current smoker. Six months ago, prediabetes was diagnosed. He occasionally has a depressed mood. He does not take aspirin on a regular basis.
On physical examination, vital signs are normal. BMI is 29. The remainder of the examination is unremarkable.
Which of the following is the most appropriate management?
A. Depression screening and treatment
B. Low-dose aspirin
C. Smoking cessation counseling and varenicline
D. Weight loss
MKSAP Answer and Critique
The correct answer is C. Smoking cessation counseling and varenicline. This content is available to MKSAP subscribers as Question 39 in the Cardiovascular Medicine section. More information about MKSAP is available online.
Smoking cessation counseling and varenicline (Option C) is the most appropriate management for this patient. Tobacco use is the leading preventable cause of disease, disability, and death in the United States. Almost one third of cardiovascular disease deaths are attributable to smoking and exposure to secondhand smoke. Even low levels of smoking increase risks for acute myocardial infarction; thus, reducing the number of cigarettes per day does not eliminate risk completely. Smoking cessation substantially reduces cardiovascular risk within 2 years, with risk returning to the level of a nonsmoker after approximately 15 years. Smoking status should be assessed at every visit, and cessation counseling and pharmacologic therapy should be offered to active smokers. Of all the recommended pharmacologic agents approved for smoking cessation, varenicline is the most effective monotherapy. Combination pharmacologic therapy is probably more effective.
Psychosocial factors, including depression, anger, and anxiety, are associated with worse cardiovascular outcomes. Depression has been linked to a higher risk for cardiovascular events. Psychosocial stressors also affect the course of treatment and adherence to healthy lifestyles after a cardiovascular event. Although it is important to detect and treat these disorders if present, there is no evidence that detection and treatment (Option A) affect cardiovascular risk itself.
The U.S. Preventive Services Task Force recommends low-dose aspirin (Option B) for the primary prevention of atherosclerotic cardiovascular disease (ASCVD) and colorectal cancer in adults aged 40 to 59 years with a 10-year ASCVD risk of 10% or greater who do not have an increased risk for bleeding, have a life expectancy of at least 10 years, and are willing to take low-dose aspirin daily for at least 10 years. The American College of Cardiology/American Heart Association guideline recommends that aspirin be used infrequently in the routine primary prevention of ASCVD because of lack of net benefit.
The National Diabetes Prevention Program found that in persons at high risk for diabetes, interventions such as changes in diet, exercise, and weight loss (Option D) of 5% to 7% reduced the risk for developing diabetes by 58% but did not reduce CVD events.
Key Points
- Smoking cessation substantially reduces cardiovascular risk within 2 years, with risk returning to the level of a nonsmoker after approximately 15 years.
- Smoking status should be assessed at every visit, and cessation counseling and pharmacologic therapy should be offered to active smokers.