A 38-year-old woman comes to the physician for a routine checkup. She has no current complaints. The patient's past medical history is significant for hypertension and type 2 diabetes mellitus. Her medications include low-dose hydrochlorothiazide, lisinopril, metformin, and glyburide. She smokes 1/2 pack of cigarettes daily and drinks alcohol occasionally. Her last menstrual period was 2 weeks ago. Blood pressure is 130/85 mm Hg and pulse is 85/min. The patient's body mass index is 32 kg/m². The remainder of the physical examination is within normal limits. Her fasting blood glucose is 120 mg/dL and HbA1C level is 6.7%. Which of the following factors is the most significant predictor of future cardiovascular events in this patient?

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Explanation: 11ec2b69_be27_c3b7_8f63_1b929a065f14_MD0005_00 Diabetes mellitus is the most significant predictor of adverse cardiovascular outcomes for this patient. Patients with diabetes have a significant risk of atherosclerotic vascular disease and future cardiovascular events, with all-cause mortality equal to patients with established coronary heart disease (CHD) and prior myocardial infarction. As a result, diabetes is considered a CHD risk equivalent. Diabetes has even more prognostic significance for women. In addition, other CHD risk factors (eg, hypertension, smoking, obesity) have a synergistic effect with diabetes and greatly increase the risk. This patient has well-controlled diabetes according to her HbA1C level of 6.7%. Strict glycemic control significantly lowers microvascular complications (eg, retinopathy, nephropathy, neuropathy) but does not consistently reduce macrovascular complications (eg, CHD, stroke). As a result, diabetes mellitus remains the most significant CHD risk factor in this patient. (Choices A and D) Advanced age and male gender are associated with a higher risk of CHD. Until menopause, women generally have a lower CHD risk than men of the same age. (Choice B) Moderate alcohol consumption is associated with a reduced risk of adverse cardiovascular outcomes. (Choice E) Hypertension is a well-established risk factor. Blood pressure should be kept <140/90 mm Hg in diabetics. However, many guidelines recommend a blood pressure <130/80 mm Hg in diabetics with nephropathy and proteinuria >500 mg/day. This patient's blood pressure is within the recommended range. (Choice F) Obesity is associated with other CHD risk factors (eg, hypertension, dyslipidemia). The Framingham Heart Study also showed that obesity is an independent CHD risk factor but is not as significant as diabetes. (Choice G) Smoking is an important modifiable CHD risk factor. However, most studies have shown that the most significant increase in CHD risk is in patients smoking >1 packs daily. The risk of cardiovascular events declines rapidly after smoking cessation and approaches that of nonsmokers in 2-3 years. This patient would benefit from smoking cessation, but her diabetes carries a higher CHD risk. Educational objective: Diabetes mellitus is a significant predictor of adverse cardiovascular outcomes, especially in women. It is considered to be a coronary heart disease risk equivalent. The role of glycemic control in the development of macrovascular disease in patients with type 2 diabetes is not firmly established. References: The independent effect of type 2 diabetes mellitus on ischemic heart disease, stroke, and death: a population-based study of 13,000 men and women with 20 years of follow-up. (http://www.ncbi.nlm.nih.gov/pubmed/15249351) Impact of diabetes and previous myocardial infarction on long-term survival: 25-year mortality follow-up of primary screenees of the Multiple Risk Factor Intervention Trial. (http://www.ncbi.nlm.nih.gov/pubmed/15249353)

A 38-Year-Old Woman Comes to the Physician for a Routine