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 72-year-old woman with a 20-year history of hypertension and dyslipidemia, both at evidence-based practice goals with appropriate drug therapy, as well as a remote history of peptic ulcer disease presents for follow-up. She is a non-smoker, drinks about 1-2 glasses of wine per week and denies the use of other substances. Her daily routine includes a 2-3 mile walk and she denies history of acute coronary syndrome or other ASCVD related conditions. She mentions that one of her friends takes an aspirin a day to "prevent a heart attack or a stroke” and further states, “I live alone and I need to maintain my independence.” According to the latest recommendations from US Preventative Services Task Force, which of the following is the most appropriate advice regarding low dose aspirin use in this patient? 

A: Start low-dose aspirin therapy 81 milligrams daily as the vascular benefits outweigh the risk. 

B: Best evidence for primary prevention of ASCVD event is with higher dose aspirin at 325 milligrams a day. 

C: The risks associated with aspirin therapy in this patient outweigh the potential benefits. 

D: Start aspirin therapy only if the patient has a family history of heart disease and 1st degree relatives. 

And the correct answer is C: The risks associated with aspirin therapy in this patient outweighs the potential benefits. Let's take a look at what kind of a question this is. 

This is clearly a plan or intervention question because it's asking if there's a medication that we should add to this patient's regimen. 

First, some background information. According to US Preventative Services Task Force, cardiovascular disease, or CVD, is the leading cause of mortality in the United States, accounting for more than one in four deaths. Each year in this country, approximately 605,000 people have a first myocardial infarction and an estimated 610,000 experience the first stroke. Given this information, efforts to reduce ASCVD risk, particularly in older adults with known risk factors as we have in this scenario. At the same time, practicing by best evidence while we balance the benefits versus risk of treatment is key to safe clinical practice and, of course, NP board success outcomes. 

Well, not that many years ago the advice for the routine use of low-dose aspirin in adults, particularly if they were over the age of 60, for primary prevention of cardiac and stroke events was pretty much what we did. 

But now we have additional studies that raise concerns. What is known now is the potential benefits of aspirin therapy, even low-dose at 81 milligrams a day, and preventing heart attacks or strokes needs to be weighed against the increased risk of GI bleed and hemorrhagic stroke, both of which rise with age. 

This risk increases significantly in patients with a history of peptic ulcer disease, as is mentioned in this scenario. And I've said this before in these podcasts, since it says remote history of peptic ulcer disease, you might be inclined to go like, ‘Yeah, yeah, yeah. 

You know, hypertension, dyslipidemia, that's what I'm concentrating on. And yeah, she's had PUD in the past. It's not significant to the scenario.’ It actually is quite significant to this scenario. 

So, what should we be doing instead of putting everybody on low-dose aspirin? What we should focus our care on is managing modifiable risk factors such as hypertension, hyperlipidemia, with an emphasis on meeting treatment goals with pharmacologic and lifestyle modification, including diet and exercise. 

This will be our best effort towards primary prevention of ASCVD. You are given the information in the scenario that she does have a decent program of physical activity, she's at goal with her medications that she's taking for her high blood pressure and dyslipidemia, and therefore she's doing a lot to modify her ASCVD risk. 

Please be advised though, the guidelines for low-dose aspirin therapy for ASCVD prevention are more nuanced than what I might be leading you to believe. 

There are certain circumstances where there is evidence to at least consider the benefit versus risk of low dose aspirin therapy, particularly in adults under the age of 60 who have diabetes. 

But as with all interventions, guidelines need to be applied by looking at case by case review. I'll often say this to NPs who I'm counseling as they enter practice, is to remember we practice both art and science. 

So, let's take a look at the question again and the offered responses. A 72-year-old woman with a 20-year history of hypertension and dyslipidemia, both at EBP goals with appropriate drug therapy as well as a remote history of peptic ulcer disease presents for follow-up. She is a non-smoker, drinks about 1-2 glasses of wine per week and denies the use of other substances. Her daily routine includes a 2-3 mile walk. She denies history of ACS or other ASCVD-related conditions. She mentions that one of her friends takes an aspirin a day to help "prevent a heart attack or a stroke” and further mentions, “I live alone and I need to maintain my independence.” According to the latest recommendations from the US Preventative Services Task Force, which of the following is the most appropriate advice in starting low-dose aspirin therapy in this patient? 

A: Start low-dose aspirin therapy at 81 milligrams a day as the vascular benefit outweighs the risk. This is incorrect. As was mentioned, the use of aspirin for primary prevention of a ASCVD events and older adults without a history of heart disease is not recommended due to increase bleeding risk and in particular with this patient the peptic ulcer disease ratchets that risk up. 

B: Best evidence for primary prevention of ASCVD event is with higher dose 325 milligrams per day of aspirin therapy. Once again, this is incorrect. In addition, higher dose aspirin therapy is usually associated with a greater risk of GI irritation, but interestingly not with increased bleeding risks. 

C: The risks associated with aspirin therapy in this patient outweighs the potential benefits. This is, of course, the correct answer. Even without the history of peptic ulcer disease, this answer would be correct. Now we're adding in the PUD history and the bleeding risk goes that much higher. ASCVD risk is best managed as noted in this patient, with taking a look at hypertension and dyslipidemia control also continuing to encourage her to maintain what sounds like a healthy lifestyle, taking her meds, and achieving those evidence-based practice goals. 

D: Start aspirin therapy only if the patient has a family history of heart disease and 1st degree relatives. 

Again, option D is incorrect. I also want you to know the word “only” in the answer. That is a problematic word, and few things in our line of work are either ‘always’ or ‘never,’ ‘only’ something along those lines. Those are what I call the absolute words that everybody gets this or no one gets it. We only use it in these scenarios. There just are so few things that we would apply an absolute word like “only” so steer clear of choosing responses that contain those absolutes. 

Key takeaway: practice is dynamic and as a nurse practitioner you must be familiar and up to date with the latest recommendations. Whereas you'll run into a fair number of patients who are still taking aspirin for primary prevention of ASCVD, few actually qualify for this intervention. Knowledge of this information is critical to safe practice as well as NP board success. 

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