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: According to the latest American College of Cardiology and American Heart Association dyslipidemia guidance, in which of the following patients is it most appropriate to obtain a lipoprotein A level?
A. A twenty-eight-year-old woman with obesity and polyendocrine metabolic ovarian syndrome, formerly known as PCOS, whose father had a myocardial infarction at age 48.
B. A 47-year-old man with well-controlled hypertension for the past five years, without a family history of early cardiovascular disease and an LDL cholesterol of 92
C. A 35-year-old woman with episodic migraine since age 12 and an LDL of 72 who exercises regularly.
D. A 52-year-old man with triglycerides of 320 related to uncontrolled type 2 diabetes.
The correct answer is A, a 28-year-old woman with obesity and polyendocrine metabolic ovarian syndrome, formerly known as PCOS, or polycystic ovary syndrome, whose father had a myocardial infarction at age 48.
Where should we start with this question? First, let's figure out what kind of a question it is. Given that we are being asked what test to order and who is eligible for this test, this is an assessment question.
So let's do a little bit of background information first. lipoprotein A, sometimes called lipoprotein small a and abbreviated LP(a), is an inherited LDL-like cholesterol particle with an added protein called apolipoprotein A. Elevated LP(a), which is what I'm going to call it just because it's a lot to say the word out, is a cardiovascular risk enhancer because it promotes atherosclerosis, inflammation, and thrombus, increasing the risk for ASCVD, stroke, peripheral arterial disease, and aortic stenosis.
Levels are largely genetically determined, remain stable over life, and are not meaningfully lowered by diet and exercise like we see with other forms of cholesterol. A commonly used elevated threshold is 50 mg/dL or greater. High LP(a) helps explain premature or really unexpected ASCVD, particularly with a strong family history of ASCVD, even when the LDL cholesterol is not markedly elevated.
This podcast focuses on who should be screened for LP(a), and in a future podcast I'll focus on intervention for this condition.
Current ACC/AHA dyslipidemia guidelines support obtaining a once-in-a-lifetime LP(a) level in individuals at increased risk for atherosclerotic cardiovascular disease. This, of course, includes a wide range of individuals with what ACC/AHA call risk enhancers. What are these? Here's a list:
Premature ASCVD in a first-degree relative, such as a parent, sibling, or child. Now, premature ASCVD is defined as an event prior to age 65 in individuals assigned female at birth and age 55 in those assigned male at birth. The recommendations include a strong family history of cardiovascular disease.
Another risk enhancer: suspected or known familial hypercholesterolemia. This would include people with known familial hypercholesterolemia or its gene variant, and what we will notice in these people is that they very often have LDLs of 190 or greater. Not total cholesterol, folks, LDL of 190 or greater in the adult and 160 or greater in the child. Sometimes these people will also have select physical exam findings, including tendon xanthomas, which are cholesterol deposits, or early corneal arcus.
Recurrent or unexplained ASCVD risk despite otherwise acceptable lipid levels is also considered to be one of these risk enhancers, as is a personal history of premature or recurrent ASCVD, and borderline or intermittent ASCVD risk where further risk clarification may help guide therapeutic decisions.
With this information in mind, which I will grant you is a lot, but let's boil it down and take another look at the question.
According to the latest ACC/AHA dyslipidemia guidance, in which patient is it most appropriate to obtain a lipoprotein small a, or LP(a), level?
A. A 28-year-old woman with obesity and polyendocrine metabolic ovarian syndrome, aka PCOS, whose father had an MI at age 48. This is the best answer. Given her dad's age when he had his MI, he clearly qualifies as premature ASCVD. In addition, PEMOS, or polyendocrine metabolic ovarian syndrome, is also known to increase risk for elevated lipoprotein(a) and overall ASCVD risk.
Let's take a look at the rest of the answers.
B. A 47-year-old man with well-controlled hypertension for the past 5 years, without a family history of early cardiovascular disease. His LDL cholesterol is 92. This is obviously incorrect. The patient has no strong family history, no premature ASCVD himself, and an otherwise stable cardiovascular risk assessment. Routine repeat lipid monitoring is certainly appropriate, but this scenario does not specifically highlight an indication for targeted LP(a) testing. Of course, he does have very strong cardiovascular risk here with his hypertension, and this will be greatly mitigated by continued hypertension control as well as watching that LDL cholesterol. General rule: LDL in this patient would need to be less than 100. He's in the low 90s, and applying the PREVENT ASCVD calculator might tip you over to offering him statin therapy.
C. A 35-year-old woman with episodic migraine since age 12 and an HDL of 72 who exercises regularly. Personal or family history of migraines does not warrant specialized lipid testing. She has two characteristics that are in favor of reduced ASCVD risk. One is her rather admirable HDL, it's high, and we like that, and the fact that she exercises on a regular basis. And when I'm teaching NP students about dyslipidemia, I like to remind them that you want your highs high and your lows low. In other words, you want your HDL high, you want your LDL low. At the same time, in the absence of other ASCVD risk enhancers, she does not qualify for specialized dyslipidemia testing.
D. A 52-year-old man with triglycerides of 320 related to his uncontrolled type 2 diabetes. Recommended or ideal triglyceride levels are below 150 mg/dL, and this patient obviously has very high triglycerides. Likely this is a secondary hypertriglyceridemia related to his poor type 2 diabetes control. Triglycerides do tend to follow blood sugar, and when blood sugars are up, triglycerides are up as well. One of the most important points is what do you do to address the hypertriglyceridemia, and through the first point here would be improved glycemic control. But this factor alone should not be considered a reason to check a lipoprotein small a on this man.
Key takeaway: practice is dynamic. LP(a) testing and its role in ASCVD has been evolving over years, but it was only recently added to the recommendations on screening in select individuals. Practice will humble you like this, and you need to keep your eyes open and appreciate that the NP boards will be up to date on screening guidelines.
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