NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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November 3rd, 2026
MKSAP Set D: Question 3, Question ID: CVQQQ24003
A 68-year-old woman is evaluated before discharge after undergoing percutaneous coronary intervention with drug-eluting stent placement for non–ST-elevation acute coronary syndrome. She is asymptomatic. Her medical history is notable for hypertension. Medications are aspirin, ticagrelor, carvedilol, lisinopril, hydrochlorothiazide, atorvastatin, and sublingual nitroglycerin as needed.
Physical examination, including vital signs, is normal. Left ventricular ejection fraction is normal.
Which of the following medication changes is indicated?
A. Start spironolactone
B. Switch hydrochlorothiazide to diltiazem
C. Switch ticagrelor to clopidogrel
D. Make no medication changes
Responses Received from Members (Responses uploaded on Thursday):
The Correct Answer is: D. Make no medication changes
Educational Objective: Select appropriate medications following percutaneous coronary intervention for acute coronary syndrome.
Following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS), this patient is taking optimal pharmacologic therapy, including dual antiplatelet therapy and a statin; thus, no medication changes are indicated (Option D). All patients with ACS should be given high-intensity statin therapy; when patients are at very high risk for recurrent events, additional lipid-lowering agents may be required to achieve target LDL cholesterol levels (<55 mg/dL [1.42 mmol/L]). Unless there are strong contraindications, all patients who have undergone PCI also require dual antiplatelet therapy for 1 year, followed by lifelong aspirin therapy. Oral β-blockers are most strongly indicated for patients with residual angina and those with left ventricular dysfunction. ACE inhibitors or angiotensin receptor blockers are recommended for people with diabetes mellitus, hypertension, ST-elevation myocardial infarction, and/or reduced left ventricular function. This patient is asymptomatic and normotensive, and her medication regimen includes the most highly indicated pharmacotherapy: aspirin, ticagrelor, and atorvastatin. No adjustment to her medical therapy is required.
American College of Cardiology/American Heart Association guidelines recommend administration of a mineralocorticoid receptor antagonist to all patients with non–ST-elevation acute coronary syndrome who are receiving an ACE inhibitor and β-blocker, have a left ventricular ejection fraction of 40% or less, and have heart failure or diabetes. In this patient with an ACS and preserved left ventricular function, no evidence supports the use of a mineralocorticoid receptor antagonist, such as spironolactone (Option A) or eplerenone.
Calcium channel blockers, such as amlodipine and diltiazem (Option B), can be used in patients with contraindications to β-blockers and in those with continued angina despite optimal doses of β-blockers and nitrates. Immediate-release nifedipine has been associated with increased mortality in patients with coronary heart disease, so it should be avoided. This patient has no residual angina and is normotensive; therefore, there is no indication for a calcium channel blocker.
A P2Y12 inhibitor should be continued for at least 1 year after myocardial infarction in most patients, regardless of stent placement or type of stent; however, no evidence supports clopidogrel over ticagrelor (Option C). In fact, the PLATO trial showed a modest benefit of ticagrelor over clopidogrel. Prasugrel may be equally effective to ticagrelor and superior to clopidogrel but is associated with more severe bleeding. There is no indication to replace ticagrelor with clopidogrel in this patient.
Key Point
- Following percutaneous coronary intervention for acute coronary syndrome, all patients should receive aspirin, a P2Y12 inhibitor, and a high-intensity statin; select patients also benefit from ACE inhibitors or angiotensin receptor blockers, mineralocorticoid receptor antagonists, β-blockers, and/or other antianginal agents.
Reference
Bhatt DL, Lopes RD, Harrington RA. Diagnosis and treatment of acute coronary syndromes: a review. JAMA. 2022;327:662-675. PMID: 35166796 doi:10.1001/jama.2022.0358
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2025 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.
October 20th, 2026
MKSAP Set D: Question 2, Question ID: CVMCQ24005
A 69-year-old man is evaluated in the emergency department after 2 hours of severe substernal chest pressure that began while at rest. He received aspirin in the ambulance and arrived in the emergency department with minimal residual chest discomfort. Initial ECG was normal. Shortly after arrival, recurrent chest discomfort develops and radiates to the back with associated diaphoresis and shortness of breath. Medical history is unremarkable, and he takes no medications.
On physical examination, blood pressure is 100/52 mm Hg, pulse rate is 54/min, and oxygen saturation is 92% with the patient breathing ambient air; other vital signs are normal. There is a soft diastolic murmur at the left sternal border. Faint bibasilar crackles are present. There is no lower extremity edema.
ECG and chest radiograph are shown.
Which of the following is the most appropriate next step in management?
A. Emergent CT angiography
B. Emergent percutaneous coronary intervention
C. Intravenous fluids
D. Intravenous unfractionated heparin
E. Thrombolytic therapy
Responses Received from Members (606 Responses):
The Correct Answer is: A. Emergent CT angiography
Educational Objective: Diagnose acute ascending aortic dissection.
The most appropriate next step in management is emergent CT angiography (CTA) (Option A) to establish the likely diagnosis of an acute ascending aortic dissection. Although the presentation of ST-elevation myocardial infarction (STEMI) is often clear, several diagnoses can mimic STEMI. Acute aortic syndromes may cause ST-segment elevation if the dissection involves the right coronary artery ostium, resulting in myocardial ischemia. Diagnostic clues to the presence of aortic dissection include a tearing quality of pain with radiation to the back, differential blood pressures and pulses in the upper extremities, aortic insufficiency, pulsus paradoxus, and mediastinal widening on chest radiograph. Invasive aortic angiography, magnetic resonance angiography, and transesophageal echocardiography have sensitivity and specificity similar to CTA (shown; intimal flap indicated by arrow) in diagnosing acute thoracic aortic disease; however, CTA is most often performed because of speed and widespread availability. Acute thoracic aortic dissection is a surgical emergency requiring emergent thoracic surgery. This patient has findings that suggest acute ascending aortic dissection, including chest pain radiating to the back, evidence of aortic insufficiency (diastolic murmur, wide pulse pressure, hypotension, and pulmonary edema), and a widened mediastinum on chest radiograph. He should undergo immediate CTA and likely emergency surgery.
Although this patient is having an acute myocardial infarction, primary percutaneous coronary intervention (Option B) and the associated need for anticoagulation and dual antiplatelet therapy would delay and complicate the surgical intervention that is needed emergently for this patient.
Although inferior myocardial infarction may be associated with right ventricular infarction requiring intravenous fluids (Option C), this patient has pulmonary edema and aortic valvular insufficiency without evidence of active bleeding. Fluid resuscitation is not indicated.
Neither intravenous anticoagulation, such as unfractionated heparin (Option D), nor thrombolytic therapy Option E) is an appropriate treatment for acute aortic dissection, as they both would increase the risk of bleeding and complicate the pending surgery. Other than blood pressure control, usually with intravenous β-blockers, medical therapy is not effective in type A aortic dissection, and immediate surgery is indicated.
Key Points
- Acute aortic syndromes may cause ST-segment elevation if the dissection involves the coronary artery with resultant myocardial ischemia.
- CT angiography (CTA), magnetic resonance angiography, and transesophageal echocardiography have similar sensitivity and specificity in diagnosing acute thoracic aortic disease; however, CTA is most often performed because of speed and widespread availability.
Reference
Kayali F, Jubouri M, Al-Tawil M, et al. Coronary artery involvement in type A aortic dissection: fate of the coronaries. J Card Surg. 2022;37:5233-5242. PMID: 36177668 doi:10.1111/jocs.16981
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2025 American College of Physicians.
ACP MKSAP. © Copyright 2026 American College of Physicians. All Rights Reserved All Rights Reserved.