Voiceover: Welcome to NP Certification Q&A, presented by Fitzgerald Health Education Associates. This podcast is for NP students studying to pass their NP certification exam. Getting to the correct test answers means breaking down the exam questions themselves. Leading NP expert Dr. Margaret Fitzgerald shares her knowledge and experience to help you dissect the anatomy of a test question so you can better understand how to arrive at the correct test answer. So, if you're ready, let's jump right in.
Margaret Fitzgerald: A 55-year-old man is seen in follow-up 6 weeks post hospitalization for acute coronary syndrome with drug-eluting stent placement. He has a 40 pack-year cigarette smoking history and currently smokes two packs of cigarettes per day. His medical history is also significant for stage 3-A CKD, with a current estimated GFR of 52. His medications include high-intensity statin therapy and ezetimibe (Zetia), along with standard post-ACS and CKD therapies. He states he's feeling well and taking all his medications as advised without adverse effects.
Laboratory results today reveal an LDL cholesterol of 98, HDL of 35, triglycerides of 154. Which of the following is the most appropriate next step in lipid management?
A. As he is feeling well, an LDL cholesterol is post ACS goal. Continue current therapy.
B. Due to his GFR, discontinue Zetia and substitute with bempedoic acid.
C. Add a PCSK9 inhibitor to current regimen.
D. Advise that moderate intensity statin therapy is preferred in stage 3-A CKD.
The correct answer is C, add a PCSK9 inhibitor to the current regimen.
Where should you start with a question like this? First, determine what kind of a question it is. Given that we are provided with information that he has recent ACS and what the intervention was, this is an evaluation question. Just a reminder, evaluation questions are focused on looking at response to care.
Some background information here. ASCVD, or atherosclerotic cardiovascular disease, secondary prevention means preventing another cardiovascular event in a patient who already has clinical ASCVD. What health challenges would qualify as clinical ASCVD? The list includes prior ACS, which we have in this patient, MI, angina, whether stable or not, and a history of coronary or other arterial revascularization, which he also has with the stent. Additional history can include ischemic stroke, TIA, or atherosclerotic peripheral vascular disease, and those are also all considered to be part of clinical ASCVD.
Why this variety of diseases that include both cardiac and non-cardiac disease? The commonality in all of these, of course, is atherosclerosis.
In primary prevention of ASCVD, the most recent ACC/AHA dyslipidemia guidelines recommend using the PREVENT ASCVD equations to help guide the patient and clinician in maintaining the best cardiac outcomes by minimizing the development of atherosclerotic disease. Secondary prevention of ASCVD aims at preventing recurrent cardiovascular disease, such as recurrent MI, stroke, cardiovascular death, the need for additional revascularizations, and complications of peripheral arterial disease, by aggressively treating modifiable risk factors.
The risk calculators we use for primary prevention do not apply to secondary prevention, but many of the therapeutic principles overlap. In other words, once a person has established ASCVD in any form, they are not in that 10-to-30-year risk calculator territory that we get from the primary prevention information. The reason is they always qualify for aggressive risk reduction.
With this information in mind, let's take another look at the question and possible responses.
A 55-year-old male is seen for follow-up 6 weeks post hospitalization for ACS with drug-eluting stent placement. He has a 40 pack-year cigarette smoking history and currently is smoking two packs of cigarettes per day. His medical history is also significant for stage 3A CKD, with a current estimated GFR around 52.
So, I'm going to stop here for a moment and make a comment about what we know about this patient. As you've heard me say many times in these podcasts, always look for what is special about a given patient. And here we have a middle-aged man who continues to smoke heavily, has a very significant tobacco use history, and has stage 3-A CKD in addition to his ACS history. In other words, he has a good deal of comorbidity and is likely on a number of post-ACS meds that include, but are not limited to, an ACE inhibitor or ARB, a beta blocker, and antiplatelet therapy.
Back to the question. His current medications include high-intensity statin therapy, ezetimibe, along with standard post-ACS and CKD therapies. He states he's feeling well and taking all of his medications as advised without adverse effect. Laboratory results today reveal LDL cholesterol of 98, HDL of 35, triglycerides 154. Which of the following is the most appropriate next step in lipid management?
Again, as an aside, you'll notice that his meds are not all listed out. This is a question that is focused on his dyslipidemia therapy, and this can make this question quite challenging, because what you probably want to do is say, "Yeah, but I want to know about all of his meds." In real life, absolutely. But often on the boards the question will steer you to focusing on just one issue.
So let's look at the responses here.
A. As he is feeling well and LDL cholesterol is at post-ACS goal, continue current therapy. This is, of course, incorrect. He had ACS. He's considered to be very high risk for another event. Complicating this whole scenario, of course, is that he's continuing to smoke, which just reinforces that he's at very high risk status. His goal LDL should be less than 70, and some sources would even say lower than that, like lower than 60. The fact that he's feeling well, I'm happy to hear that. But at the same time, do not let a comment like "feeling well" on the NP boards mislead you into thinking there's nothing else that needs to be done for the patient. His LDL does need to be lower.
Now, I do want to make one comment here. Remember, he's on high-intensity statin therapy, which brings his LDL down by 50% or more, and the ezetimibe brings it down by probably another 20%. So his LDL is 98. Prior to being on these meds, his LDL was probably around 220 or higher, and that, coupled with his smoking, no doubt dramatically contributed to his ACS.
Option B, due to his GFR, discontinue the ezetimibe and substitute with bempedoic acid. This is incorrect. It's really easy to be on high alert during boards when there's a comment about CKD, thinking automatically some meds need to be adjusted or discontinued, whatever it would be. But in reality, and remember, this is a general rule, few meds need dose adjustment or discontinuation when the GFR is above 50. Of course, prudent practice dictates checking each and every med. Ezetimibe use has been studied in stage 4 and even stage 5 CKD with no adjustment required. One reason is very little of this drug is systemically absorbed. With bempedoic acid, there is increased adverse effects when the GFR is less than 30.
C. Add a PCSK9 inhibitor to the current regimen. This is, of course, our correct answer. The use of this drug will likely result in another 50%-ish LDL reduction. So his LDL currently is almost 100, let's just round it up and call it 100. Adding the PCSK9 inhibitor will bring him down, in all likelihood, to less than 50, and that would be in alignment with the ACC/AHA secondary prevention recommendations. Suffice it to say, he also needs advice on smoking cessation. Cardiac rehab would be a great idea for him as well. So it's not the only thing that would be advised, but it is one of the main things at this point.
Option D, advise that moderate-intensity statin is preferred in stage 3A CKD. This is also incorrect. At the same time, since we're on the subject, at what point would you consider lowering the statin dose in CKD? The general rule is, as long as the statin therapy is being tolerated, once GFR is less than 30, which is stage 4 CKD, or obviously if it was less than 15, that's stage 5 CKD, there is consideration for reduction in statin dose because there's increased risk for statin adverse effects, including things like rhabdomyolysis and myositis. Even then, though, every clinical situation deserves careful thought. Statin use is associated with positive outcomes in atherosclerotic disease. And please remember: kidney health, brain health, heart health, it's all vascular health. The same blood vessels that feed the heart feed the brain and feed the kidney.
Key takeaway: secondary prevention ASCVD goals are different from the primary prevention of ASCVD. What would likely be acceptable for primary prevention would be considered undertreatment in secondary prevention.
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