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NBME 20 Answers

nbme20/Block 2/Question#48

A sedentary 50-year-old man with hypertension comes ...

Antidepressant therapy

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Most of the pts values were normal. Drinking wasn't outrageous, LDL was mild, BMI has fine. He did have HTN though. The biggest risk factors are the fact that he had suffered an MI and started suffering severe depression (weight loss/anxiety). Thus, he is more at risk for suicide.

sohaib111  Won't having an MI be a very big risk factor for another one ? And also if they wanted this answer (the anti-depressant), why would they just add that his LDL is inreasing in the last sentence... +6  
dbg  bc they're SOBs and DOBs +6  
doodimoodi  Yeah, recommended LDL in people with previous heart problem is < 100 jeez +  
asingh  It is because of the timeframe of mortality is 2 yrs, everything else will affect later +1  
benny  mdd increase MI +  
benny  Type 2 diabetes and major depressive disorder (MDD) are independent contributors to cardiovascular disease and to an increased risk of myocardial infarction (MI). +  

 +0  upvote downvote
submitted by mbourne(8),

I think that if they had something like "statin therapy" as an answer choice, we would have an argument for that as it would decrease mortality by helping prevent ANOTHER heart attack. However, I think that anti-depressant therapy will do a LOT to prevent suicide, while omega-3 fatty acids (healthy as they are) wouldn't do AS MUCH to prevent a heart attack.

The question is basically asking, "You can only prescribe one of these to keep this dude alive as long as possible. Which one will have the best chance at accomplishing that?"

Therefore, the answer should be anti-depressant therapy.

bharatpillai  why antidepressant therapy though? there are not enough features given to suggest MDD. He's 56 years old, not an elderly single male so not at the highest "classical" population at risk of suicide? the question is so ambiguous... Given MI, wouldn't chronic alcoholic intake predispose him to dilated cardiomyopathy? +  
neovanilla  I don't believe it's that he has MDD by the clinical definition. It's more that his QoL has probably changed drastically since the MI and MIs are strongly associated with decreased outlook on life, especially considering how common it is to get a second MI soon after the first. I don't know the stats on suicide post-MI, but helping the patient's depression to make him more pro-active to help himself prevent another MI would be better than "a diet high in omega 3 FAs" (at least, this was my justification, as mbourne was saying) +