A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 41-year-old man presents to his primary care provider because of chest pain with activity for the past 6 months. Past medical history is significant for appendectomy at age 12 and, hypertension, and diabetes mellitus type 2 that is poorly controlled. He takes metformin and lisinopril but admits that he is bad at remembering to take them everyday. His father had a heart attack at 41 and 2 stents were placed in his heart. His mother is healthy. He drinks alcohol occasionally and smokes a half of a pack of cigarettes a day. He is a sales executive and describes his work as stressful. Today, the blood pressure is 142/85 and the body mass index (BMI) is 28.5 kg/m2. A coronary angiogram shows > 75% narrowing of the left anterior descending coronary artery. Which of the following is most significant in this patient?
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A
Diabetes mellitusCorrect. Diabetes mellitus is a CAD risk equivalent, conferring among the highest single-factor risks for premature coronary disease, especially when poorly controlled as in this patient.
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B
HypertensionIncorrect. Hypertension is a major CAD risk factor but is generally considered to confer less relative risk than diabetes, especially when controlled (this patient is on lisinopril and BP is 142/85).
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C
ObesityIncorrect. Obesity (BMI 28.5 is overweight, not obese) is a contributor but mediates risk largely through diabetes, hypertension, and dyslipidemia.
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D
SmokingIncorrect. Smoking is a major modifiable risk factor, but half-pack/day quantifies modest exposure; diabetes ranks higher overall in this patient's risk profile.
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E
Family history of premature CADIncorrect. Premature paternal MI is a major genetic risk factor for CAD, but diabetes mellitus is the most significant single contributor in this patient as a coronary artery disease risk equivalent.
↑ Tap an answer to reveal the reasoning
Answer: A. Among classical cardiovascular risk factors, diabetes mellitus is considered a coronary artery disease (CAD) equivalent and carries the greatest relative risk for accelerating atherosclerosis and producing coronary events in middle-aged adults. Diabetic patients have CAD prevalence and mortality similar to non-diabetics who have already had a myocardial infarction, which is why aggressive risk-factor reduction (LDL targets, BP control, antiplatelets) is recommended.
The pathophysiology involves hyperglycemia-induced endothelial dysfunction, increased oxidative stress, accelerated formation of advanced glycation end-products (AGEs), prothrombotic state (increased PAI-1, fibrinogen), and dyslipidemia (small dense LDL, hypertriglyceridemia, low HDL). Poor glycemic control compounds this, and this patient's poor adherence makes his diabetes a particularly potent risk factor.
While smoking, hypertension, and family history (father with MI at 41) are all major risk factors, in standardized risk equations diabetes confers the largest single-factor increase in CAD risk among the choices listed. Tight glycemic control, statin therapy regardless of LDL, ACE inhibitors, and aspirin (for secondary prevention) are the cornerstones of management.
**Why each option:**
**A.** Correct. Diabetes mellitus is a CAD risk equivalent, conferring among the highest single-factor risks for premature coronary disease, especially when poorly controlled as in this patient.
**B.** Hypertension is a major CAD risk factor but is generally considered to confer less relative risk than diabetes, especially when controlled (this patient is on lisinopril and BP is 142/85).
**C.** Obesity (BMI 28.5 is overweight, not obese) is a contributor but mediates risk largely through diabetes, hypertension, and dyslipidemia.
**D.** Smoking is a major modifiable risk factor, but half-pack/day quantifies modest exposure; diabetes ranks higher overall in this patient's risk profile.