Master Chronic Care
for MCCQE Part 1

What the MCCQE Part 1 Tests in Chronic Care

Chronic Care on the MCCQE Part 1 tests the management of long-term conditions across primary and secondary care settings, with emphasis on evidence-based pharmacotherapy, monitoring targets, and complication prevention. Candidates must demonstrate decision-making for common chronic diseases: hypertension (target BP <140/90 mmHg; <130/80 if diabetic or CKD), type 2 diabetes (HbA1c target ≤7% for most, individualised), COPD (GOLD criteria, LAMA/LABA first-line), heart failure (HFrEF: ACEi/ARNI, beta-blocker, MRA, SGLT2i), chronic kidney disease (eGFR staging, ACEi/ARB for proteinuria), osteoporosis (FRAX, bisphosphonates), and hypothyroidism (levothyroxine, TSH target 0.5–2.5 mIU/L). Exam questions present clinical scenarios requiring stepwise treatment intensification, recognition of adverse effects (e.g., metformin lactic acidosis risk if eGFR <30), and guideline-based screening (e.g., annual albuminuria in diabetes).

High-Yield Concepts

• Hypertension – Target Organ Protection: First-line monotherapy: ACEi/ARB (if <55 years or Black patients on CCB), amlodipine, or thiazide-like diuretic (indapamide). Target clinic BP <140/90; <130/80 if diabetes, CKD, or established CVD. Resistant hypertension: confirm adherence, exclude secondary causes, add spironolactone 12.5–25 mg daily.
• Type 2 Diabetes – Glycaemic Control and CVD Risk: HbA1c target 48–53 mmol/mol (6.5–7.0%) for most, less stringent if frail or high hypoglycaemia risk. Metformin first-line (stop if eGFR <30). If ASCVD, HF, or CKD: add SGLT2i (empagliflozin, dapagliflozin) or GLP-1 RA (liraglutide, semaglutide) independent of HbA1c. Annual foot exam, retinal screening, and urine ACR.
• Heart Failure with Reduced Ejection Fraction (HFrEF): Diagnosis: LVEF ≤40% on echo. Quadruple therapy: ACEi (or ARNI if symptomatic), beta-blocker (bisoprolol, carvedilol), MRA (spironolactone, eplerenone), SGLT2i (dapagliflozin, empagliflozin). Loop diuretics for congestion. Avoid NSAIDs, verapamil, diltiazem.
• Chronic Obstructive Pulmonary Disease (COPD) – GOLD Groups: Group A: bronchodilator PRN (SABA or LAMA). Group B: LAMA + LABA. Group E (exacerbations ≥2/year or 1 hospitalisation): LAMA+LABA+ICS (e.g., beclometasone/formoterol/glycopyrronium). Annual influenza vaccine, pneumococcal vaccine. LTOT if PaO₂ ≤7.3 kPa at rest.
• Chronic Kidney Disease (CKD) – Staging and Renoprotection: eGFR categories G1–G5; albuminuria A1–A3. ACEi/ARB for ACR >3 mg/mmol or hypertension. SGLT2i (dapagliflozin) for eGFR ≥25 and ACR >3. Avoid metformin if eGFR <30; adjust drug doses (e.g., gabapentin, digoxin). Refer if eGFR <30 or progressive decline >5 mL/min/year.
• Osteoporosis – FRAX and Treatment: FRAX score ≥20% major fracture or ≥3% hip fracture: start bisphosphonate (alendronate 70 mg weekly, risedronate 35 mg weekly). Ensure calcium (1000–1200 mg/day) and vitamin D (800 IU/day). Denosumab if intolerance or severe renal impairment. Monitor DEXA every 2 years.
• Hypothyroidism – Levothyroxine Dosing: Initial dose 1.6 mcg/kg/day (typically 50–100 mcg). Target TSH 0.5–2.5 mIU/L. Recheck TSH 6–8 weeks after dose change. Caution in elderly or IHD: start 25 mcg daily, increase by 25 mcg every 4 weeks. Avoid concomitant iron, calcium, or PPIs within 4 hours.
• Chronic Pain – Opioid Safety: Not first-line for chronic non-cancer pain. Use paracetamol, NSAIDs (short-term), or topical agents. If opioids considered: trial of 4 weeks, assess function, prescribe naloxone if ≥50 MME/day. Avoid concurrent benzodiazepines. Monitor for opioid use disorder (screening tool: SOAPP-R).

Common Traps in Chronic Care Questions

• Confusing first-line antihypertensive in Black patients: CCB (amlodipine) or thiazide, not ACEi/ARB due to lower renin levels.
• Assuming all type 2 diabetes patients need strict HbA1c <7% – frail elderly or those with limited life expectancy may have target <8.5%.
• Starting a beta-blocker in acute decompensated HF – only initiate when euvolemic and stable; bisoprolol/carvedilol should be uptitrated slowly.
• Forgetting to check U+E and eGFR before starting SGLT2i or ACEi – risk of hyperkalaemia or acute kidney injury.
• Prescribing alendronate without counselling on proper administration (fasting, upright, 30 min wait) – risk of oesophagitis.
• Interpreting a normal TSH in a patient on levothyroxine as optimal – always check FT4 if TSH low-normal to avoid overtreatment.

How to Revise Chronic Care for the MCCQE Part 1

Prioritise memorising guideline-driven step-up algorithms for hypertension, diabetes, and HFrEF, as these appear in multi-step management questions. Focus on drug contraindications and monitoring (e.g., eGFR thresholds for metformin, SGLT2i, and ACEi). Practice interpreting clinical vignettes that combine comorbidities (e.g., diabetic nephropathy with HF) to choose the safest combination therapy. Review the GOLD ABCD/E grouping for COPD and FRAX thresholds for osteoporosis. Questions often test 'what to do next' after first-line failure or adverse effect. Use the Canadian Hypertension Society and Diabetes Canada guidelines as reference. Simulate timed questions to improve speed in selecting the correct escalation or deprescribing step.

Practise it: MedLumen has 50 Chronic Care questions for the MCCQE Part 1, each with a full explanation and references.