INCORRECT (Correct answer: 7% or lower)

The ADA recommends an A1c goal of less than 7% as reasonable for many nonpregnant adults. While more stringent goals such as <6.5% might be appropriate for select patients, a more stringent goal is less likely to be helpful here. Marco does not have T2DM that is being treated with lifestyle or metformin only and does have significant ASCVD disease and risk factors, including a recent MI, obesity, hypertension, hyperlipidemia and a family history of both T2DM and CVD.

(Recommendation 6.4, Glycemic Targets: Standards of Medical Care in Diabetes—2019, American Diabetes Association Diabetes Care 2019 Jan; 42(Supplement 1): S61-S70. https://doi.org/10.2337/dc19-S006)

INCORRECT (Correct answer: DASH or Mediterranean-style diet)

Reduced sodium (DASH-type) and Mediterranean-style diets have been shown to decrease ASCVD risk factors. Physical activity has also been shown to reduce ASCVD risks, but Marco needs to be evaluated for new cardiovascular disease symptoms following his recent MI before making any significant changes to his level of physical activity. He also requires cardiac rehab.

(Recommendation 3.1 & 3.2, 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines)

INCORRECT - Correct answer: Rosuvastatin 5 mg once weekly to be doubled every two weeks (twice a week then every other day, etc.) up to 40 mg daily as tolerated.

Most patients who have experienced a statin-associated side effect are able to tolerate statin rechallenge with an alternative statin. The typical strategy is to rechallenge with an alternative statin at a low dose, then slowly increase dosing as tolerated.

(Recommendation 3.2.1, 2018 AHA/ACC/AACVPR/ AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, https://doi.org/10.1161/CIR.0000000000000625) Depending on Marco’s health plan, coverage for rosuvastatin in primary care may require a retrial and failure of atorvastatin.

INCORRECT - Correct answer: Metformin + GLP-1RA

Once metformin is started, it should be continued unless there is a contraindication. For individuals who do not improve on metformin and have ASCVD, the best choice for an add-on agent is GLP-1 receptor agonist or SGLT2 inhibitor with demonstrated cardiovascular risk reduction. Of the choices here, metformin + GLP-1RA is the most appropriate. However, the cost can be prohibitive for patients without insurance.

(Recommendation 9.11,Table 9.1, Figure 9.2. 9, combination therapy text at pg S97. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes—2019. Diabetes Care 2019 Jan; 42(Supplement 1): S90-S102. https://doi.org/10.2337/ dc19-S009)

INCORRECT - Correct answer: Yes, Marco should be referred to a cardiologist as well as a diabetes educator

Because he has palpitations and shortness of breath, and most morbidity and mortality in T2DM is associated with macrovascular events, the cardiologist plays a central role in optimizing care for this patient.

(Section 1.1, 2018 ACC Expert Consensus Decision Pathway on Novel Therapies for Cardiovascular Risk Reduction in Patients With Type 2 Diabetes and Atherosclerotic Cardiovascular Disease: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. Journal of the American College of Cardiology. Volume 72, Issue 24, December 2018 DOI: 10.1016/j.jacc.2018.09.020 and American Diabetes Association. 4. Comprehensive medical evaluation and assessment of comorbidities: Standards of Medical Care in Diabetes—2019. Diabetes Care 2019;42(Suppl. 1):S34–S45)