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CDE Diabetes

Practice Exam: Cardiovascular Protection in People with Diabetes (Chapter 23)

Cardiovascular disease (CVD) remains the leading cause of death for people living with diabetes. The 2018 Clinical Practice Guidelines emphasize that diabetes significantly accelerates the natural history of CVD, making aggressive risk reduction a cornerstone of management.

This practice exam tests your ability to implement the comprehensive “ABCDEs” of cardiovascular protection, ranging from lifestyle interventions to the use of cardioprotective pharmacotherapy.

Key Concepts Covered in This Exam:

  • Risk Assessment: Differentiating between proximate (<10 years) and lifetime risk, especially in younger patients who may have low short-term risk but high relative risk.

  • Lipid Management: Identifying the indications for statin therapy and the specific targets for Low-Density Lipoprotein Cholesterol (LDL-C).

  • Blood Pressure Control: Applying the correct targets and selecting preferred pharmacological agents (e.g., ACE inhibitors or ARBs) for renal and cardiovascular protection.

  • Cardioprotective Agents: Recognizing the specific roles of SGLT2 inhibitors and GLP-1 receptor agonists in reducing cardiovascular events independent of glycemic control.

  • Antiplatelet Therapy: Understanding when aspirin therapy is indicated for secondary prevention versus the nuances of primary prevention.

1. In the EMPA-REG OUTCOME trial, what was the primary driver of CVD risk reduction with empagliflozin?

2. Which diabetes complication is described as an emerging recognition of a nonatherothrombotic cause of morbidity and mortality?

3. A 62-year-old woman with type 2 diabetes and a history of myocardial infarction is not achieving glycemic targets on metformin. Her eGFR is 45 mL/min/1.73 m². Which class of antihyperglycemic agent should be considered to reduce her CV risk?

4. The ACCORD trial examined intensive glycemic control (A1C 6.4-6.9%) vs. standard control in people with established type 2 diabetes and CVD or multiple CV risk factors. What was the concerning finding that led to early termination of the ACCORD trial?

5. Diabetes confers a cardiovascular disease (CVD) event risk equivalent to aging approximately how many years?

6. In the CANVAS study with canagliflozin, what safety concerns were identified?

7. Which observation from the ADVANCE trial has been linked to future CV events, microvascular events, and all-cause mortality?

8. A 45-year-old man with type 2 diabetes and clinical CVD is on statin therapy but his LDL-C remains significantly elevated. He has familial hypercholesterolemia. Which class of medication may be considered for this patient to further reduce MACE?

9. In the STENO-2 trial, what was the number needed to treat (NNT) for mortality reduction?

10. At what age does diabetes transition from intermediate to high CVD risk in men?

11. A clinician is considering the evidence regarding ACE inhibitors for CV protection in diabetes. In the meta-analysis of ACE inhibitors

12. What A1C target is generally recommended as part of the comprehensive CV risk reduction approach?

13. In the ABCDES framework for cardiovascular risk reduction, what does the “C” represent?

14. In the Nurses’ Health Study, women with type 2 diabetes who performed at least 4 hours per week of moderate or vigorous exercise had what percent lower risk of developing CVD?

15. A meta-analysis compared the CV safety of sulfonylureas with active comparators in people with type 2 diabetes. What did the meta-analysis of 115 trials find regarding sulfonylureas?

16. A 55-year-old man with type 2 diabetes has no history of cardiovascular disease and an LDL-C=1.8 mmol/L.  He asks about starting statin therapy. According to the guidelines, should this patient receive statin therapy?

17. A 35-year-old man with type 1 diabetes of 18 years duration has microalbuminuria but no clinical CVD. He asks about statin therapy. According to the guidelines, should he receive statin therapy?

18. A 50-year-old woman with type 2 diabetes and no history of CVD asks whether she should take ASA daily for heart attack prevention. What is the guideline recommendation regarding ASA for primary prevention of CVD in diabetes?

19. What is the key point regarding the elimination of the 2013 guideline recommendation to start ACE inhibitor or ARB in all people with diabetes ≥55 years without CV risk factors or end organ damage?

20. According to the guidelines, at what age should people with diabetes and an additional CV risk factor or end organ damage be considered for ACE inhibitor or ARB therapy for vascular protection?

21. A 52-year-old woman with type 2 diabetes currently smokes 1 pack per day. She has no other CV risk factors. How does smoking affect CV risk in people with diabetes?

22. What was the relative risk reduction in major adverse cardiac events (MACE) in the STENO-2 trial after 13 years of follow-up?

23. A 60-year-old man with type 2 diabetes and established CVD is allergic to ASA. He needs antiplatelet therapy for secondary prevention. What alternative antiplatelet agent can be used?

24. For secondary prevention of CVD events in people with diabetes, what dose of ASA is recommended?

25. Why do pooled estimates suggest that ASA should not be used routinely for primary CVD prevention in people with diabetes?

26. A 58-year-old man with type 2 diabetes and established coronary artery disease is on a statin but has not reached his LDL-C target of <1.8 mmol/L. What second-line agent should generally be considered to help achieve LDL-C goals?

27. What is the recommended blood pressure target for people with diabetes according to the guidelines?

28. What does “vascular age” refer to in the context of CVD risk assessment?

29. What is the eGFR threshold below which SGLT2 inhibitors with demonstrated CV outcome benefit are not recommended according to these guidelines?