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Pre Study Toets - Accredidatie ACCSAP-7

6 Accreditatiepunten voor internisten.

ACCSAP-7 2009: Focus on Hypertension and Risk Factor Management.

Internisten kunnen via de Pre Study en Post Study toetsvragen beantwoorden van de deelmodule Hypertension and Risk Factor Management.

U heeft recht op 6 accreditatiepunten indien u beide toetsen volledig beantwoordt.

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ACCSAP-7 voor Internisten is mede mogelijk gemaakt door financiële ondersteuning van
Sanofi-Aventis en Bristol Myers Squibb

1. Features associated with endothelial dysfunction include which of the following?

A. Increased oxygen free radical production, reduced growth factors, increased thrombosis, decreased thrombolysis.
B. Increased expression of cellular adhesion molecules, increased platelet aggregation and activation, decreased matrix metalloproteinases, increased growth factors.
C. Increased platelet aggregation and activation, increased matrix metalloproteinases, decreased thrombosis, and increased thrombolysis. 
D. Vasoconstriction, increased cytokines and inflammation, increased monocyte production into macrophages, increased growth factors.
E. Vasoconstriction, decreased cytokines and inflammation, increased thrombosis, decreased thrombolysis. 

2. Which of the following risk factors were included among the nine factors found by the INTERHEART study to account for over 90% of the risk for MI?

A. Cigarette smoking, abnormal lipids, family history, high consumption of trans fat in the diet.
B. Hypertension, low daily fruit and vegetable consumption, high psychosocial stress, small stature
C. Abdominal obesity, diabetes, low psychosocial stress, low physical activity. 
D. Diabetes, abdominal obesity, low fish consumption, high psychosocial stress.
E. Depression, financial stress, low locus of control, high fruit and vegetable consumption.

3. You provided care for a 62-year-old man during his MI 1 year ago. You are seeing him now for an annual follow-up in your office. Lipid values prior to the MI, while not on any specific lipid lowering treatment, were:

Total cholesterol 266 mg/dl

LDL-C 175 mg/dl

HDL-C 28 mg/dl

Triglycerides 315 mg/dl

He had smoked cigarettes in the past, but has quit. He currently exercises three times per week, follows a Step II diet carefully, and takes simvastatin 20 mg/day, prescribed by his internist. He is on a beta-blocker and aspirin. His present lipoprotein profile is:

Total cholesterol 232 mg/dl

LDL-C 140 mg/dl

HDL-C 32 mg/dl

Triglycerides 300 mg/dl

Which of the following is the most appropriate course of action at this time?

A. Switch from simvastatin, 20 mg/day, to atorvastatin 40 or 80 mg/day.
B. Switch from simvastatin to gemfibrozil. 
C. Add ezetimibe 10 mg per day. 
D. Add niacin to simvastatin. 
E. Change to mevacor/long-acting niacin combination formulation. 

4. A 47-year-old African-American female presents to your office with intermittent chest pain, with exertion and shortness of breath. She has a strong history of heart disease in her family. She is currently smoking and has been since she was 12 years old. She averages 12 cigarettes per day. She has a history of IV drug abuse, but claims she is not currently using drugs. The patient has government-assisted insurance. Your recommendation would be to initiate which of the following?

A. Varenicline; it has the best effect on smoking cessation. 
B. Nicotine gum; she can purchase it over the counter. 
C. Bupropion; it is economical and effective.
D. Combination therapy, using nicotine gum and bupropion.

5. You are completing a cardiac clearance for knee surgery on a 44-year-old Caucasian male. When taking down his vital signs, you ask the patient if he uses tobacco. He states that he enjoys smoking, but his wife does not like it and he has thought of quitting. You discuss the importance of being smoke free for the surgery.

The best treatment for this patient would be which of the following?

A. Nicotine gum and nicotine patch with a quit day in 2 weeks.
B. Bupropion and nicotine patch with no quit date necessary.
C. Varenicline and a quit date on day 8 of treatment.
D. The patient is not ready for treatment at this time.

6. A 55-year-old diabetic male is referred for management of hypertension, diabetes, and hyperlipidemia. On his initial visit, his BP was 148/94 mm Hg, heart rate 78 bpm, height 71 inches, and weight 210 lb (BMI 29 kg/m2). Laboratory values were: total cholesterol 246 mg/dl, LDL 140 mg/dl, HDL 32 mg/dl, and triglycerides of 360 mg/dl, potassium of 4.1 mg/dl, creatinine of 0.9 mg/dl, and HgA1c of 7.4%. You started him on 5 mg of ramipril and 20 mg of simvastatin daily, and counseled him regarding diet and exercise. After 2 months of diet and exercise, he returns for repeat evaluation. He has lost 14 lb and his BP is now 132/78 mm Hg. Repeat labs reveal a total cholesterol of 200 mg/dl, LDL of 100 mg/dl, HDL of 34 mg/dl, triglycerides of 330 mg/dl, and HgA1c of 6.9%.

Which of the following is the best next step to take?

A. Add a beta-blocker. 
B. Begin titration of short-acting niacin with a goal of 3 g/day.
C. Add 150 mg/day of fenofibrate.
D. Double the statin dose.

7. A 47-year-old premenopausal woman comes to you for evaluation because she is concerned about her risk for diabetes and heart disease. Multiple firstdegree relatives have diabetes and CHD, and you managed her husband’s care post-MI. Her past medical history is significant only for gestational diabetes with her second child. Her exam is remarkable for height of 66 inches, 165 lb (BMI 26.5 kg/m2), waist circumference of 36 inches, BP of 128/82 mm Hg, and a heart rate of 80 bpm. CV exam is unremarkable and ECG shows borderline LV hypertrophy. Laboratory testing reveals total cholesterol of 210 mg/dl,LDL of 120 mg/dl, HDL of 422 mg/dl, and triglycerides of 230 mg/dl. Fasting blood glucose is 136 mg/dl,Thyroid stimulating hormone is 2.0 mg/dl, and urinalysis is within normal limits.

Your next step is to do which of the following?

A. Order an HgA1c.
B. Obtain an OGTT.
C. Encourage her to lose 10 lb to reduce her risk for diabetes.
D. Repeat a fasting glucose.

8. Which of the following is the best answer to this question: Should inflammatory markers be used to assess CV risk and responses to risk factor management

A. Yes, in all patients.
B. Yes, predominantly in intermediate-risk patients. 
C. No. 

9. Of the identifiable genetic causes of human hypertension, most encode genes that do which of the following?

A. Set the level of sympathetic nervous system activity. 
B. Govern insulin resistance.
C. Regulate renal handling of sodium and chloride.
D. Regulate plasma renin activity.
E. Encode the gene for endothelin.

10. Which of the following is a target organ consequence of chronically elevated BP?

A. Slowed pulse wave velocity.
B. Increased EF.
C. Impaired sodium reabsorption by the proximal renal tubules.
D. Atrophy of mesangial cells of the kidney.

11. A 74-year-old woman, BG, is admitted to the CCU with constricting chest pain for 8 hours, which has subsided in the last hour. Her ECG shows a 3 mm ST-segment depression and T-wave inversion in leads V4-V6, and the troponin I value is clearly elevated. She is hemodynamically stable, but the BP is 182/104 mm Hg. There is no clinical evidence of LV dysfunction.

The elevated BP should be treated initially with which of the following?

A. IV sodium nitroprusside or nitroglycerin.
B. Oral ACE inhibitor and thiazide diuretic. 
C. IV BB (esmolol). 
D. Rest in a quiet room. 
E. Oral nondihydropyridine CCB (diltiazem or verapamil). 

12. Randomized controlled trials have shown that the benefit of antihypertensive treatment in preventing CVD outcomes such as heart attack, stroke, and CV mortality depends principally on which of the following?

A. Reduction in diastolic BP. 
B. Reduction in systolic BP.
C. Effects on plasma renin activity. 
D. Effects on sympathetic neural function and circulating catecholamines.
E. All of the above. 

13. Which of the following is the drug of first choice for hypertensive type 2 diabetic patients without micro or macroalbuminuria and with normal renal function?

A. A diuretic.
B. An angiotensin II receptor blocker.
C. A BB.
E. All of the above.

14. A new patient, Ms. H.E., age 56 years, is found to have a BP of 162/88 mm Hg. She is 5’8” and weighs 174 lb. Lab data include: white blood cell count 7,300/cm, hemoglobin 14.1 g/dl, hematocrit 43%, serum fasting glucose 122 mg/dl, glycated hemoglobin 6.2%, sodium 141 mEq/L, potassium 3.4 mEq/L, creatinine 1.1 mg/dl, BUN 26 mg/dl, estimated GFR 84 ml/min, PRA 0.5 ng/ml/h, and plasma aldosterone 18 ng/dl. A spot urine had a concentration of creatinine of 250 mg/dl, and a protein concentration of 4.3 mg/dl.

Which of the following is the most likely diagnosis?

A. Hypertension due to diabetic nephropathy.
B. Renovascular hypertension.
C. Primary hypertension with no evidence of target-organ damage.
D. Primary hypertension with hypertensive nephropathy.
E. Hypertension due to primary aldosteronism. 

15. The patient, T.M., returns after 1 month, with a BP of 138/86 mm Hg and a serum creatinine of 2.0.

Which of the following is your next step in his management?

A. Stop the ARB and substitute a CCB plus beta-blocker.
B. Add a CCB to the ARB-DIU combination.
C. Continue current treatment
D. Switch to a loop diuretic. 
E. Refer the patient to a nephrologist in preparation for dialysis.