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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December 16, 2025
MKSAP 19 Cardiovascular Medicine, Question 111
A 78-year-old woman is evaluated during follow-up of nonischemic heart failure with reduced ejection fraction diagnosed 6 months ago. She has New York Heart Association functional class III symptoms. She is receiving optimal guideline-directed medical therapy consisting of valsartan- sacubitril, carvedilol, spironolactone, and furosemide.
On physical examination, blood pressure is 104/62 mm Hg and pulse rate is 58/min. A grade 2/6 holosystolic murmur is heard at the apex, and a grade 1/6 crescendo-decrescendo systolic murmur is heard at the base. There is no jugular venous distention or peripheral edema.
ECG shows sinus rhythm and left bundle branch block with QRS duration of 155 ms. Echocardiogram shows an ejection fraction of 30%, left ventricular end-systolic dimension of 53 mm, mild to moderate mitral regurgitation, and mild aortic stenosis.
Which of the following is the most appropriate treatment?
A. Cardiac resynchronization therapy
B. Ivabradine
C. Mitral valve clip placement
D. Transcatheter aortic valve implantation
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. Cardiac resynchronization therapy
Educational Objective:
Treat heart failure with cardiac resynchronization therapy.
Cardiac resynchronization therapy (CRT) (Option A) is the most appropriate treatment. This patient with heart failure with reduced ejection fraction is on optimal guideline-directed medical therapy. CRT is indicated in patients with a left ventricular ejection fraction (LVEF) of 35% or less, New York Heart Association (NYHA) functional class II to IV symptoms despite guideline-directed medical therapy, sinus rhythm, and left bundle branch block with a QRS complex of 150 ms or longer (class 1 recommendation). In such patients, CRT is associated with improved LVEF, reduced symptoms, and improved survival rates. Many patients who meet the indication for CRT also meet indications for implantable cardioverter-defibrillator (ICD) therapy. ICD therapy reduces mortality in patients with NYHA class I to III heart failure symptoms and LVEF less than 35% on optimal medical therapy. This patient meets the criteria for ICD placement, but she may experience substantial improvement in ejection fraction with CRT and may not require or benefit from ICD insertion.
In patients with LVEF of 35% or less who are in sinus rhythm with a heart rate of at least 70/min and taking maximally tolerated doses of a β-blocker, the sinoatrial node modulator ivabradine (Option B) reduces heart failure–associated hospitalizations and the combined end point of mortality and heart failure hospitalization. Ivabradine is not indicated in this patient with a heart rate of 58/min.
The mitral valve clip (Option C) is designed to approximate mitral valve leaflets and reduce mitral regurgitation. Mitral valve clip placement is reasonable for patients with severe secondary mitral regurgitation with heart failure symptoms and a left ventricular end-systolic dimension less than 70 mm and pulmonary artery pressure less than 70 mm Hg. CRT is more likely to improve symptoms and is the most appropriate step for this patient before considering a mitral valve clip.
Transcatheter aortic valve implantation (TAVI) (Option D) is usually reserved for patients with symptomatic severe aortic stenosis. Factors that increase procedural risk include reduced ejection fraction, another reason not to proceed with TAVI in this patient.
Key Point
Cardiac resynchronization therapy is indicated for patients with ejection fraction of 35% or less with left bundle branch block, QRS duration of 150 ms or greater, and New York Heart Association functional class II to IV symptoms despite guideline-directed medical therapy.
Bibliography
Wu A. Heart failure. Ann Intern Med. 2018;168:ITC81-ITC96. PMID: 29868816
Copyright 2019, American College of Physicians.
December 2, 2025
MKSAP 19 Pulmonary/Critical Care Medicine, Question 24
A 50-year-old man is referred for poorly controlled asthma. Triggers include exercise and exposure to dust, pollen, and fumes. He has allergic rhinitis. He has been treated with several courses of glucocorticoids, but symptoms recurred after he stopped treatment despite regular use of his fluticasone-salmeterol and tiotropium inhalers. His only other medication is albuterol. He has good inhaler technique.
On physical examination, vital signs are normal. BMI is 23. Pulmonary examination reveals few expiratory wheezes. The remainder of the examination is unremarkable.
Laboratory studies reveal a normal total IgE level and complete blood count.
Chest radiograph is normal. Spirometry demonstrates moderate airflow obstruction that improves with bronchodilators.
Which of the following is the most appropriate diagnostic test to perform next?
A. Absolute blood eosinophil count
B. α1-Antitrypsin level
C. Aspergillus-specific IgE level
D. Measurement of common allergen-specific IgE levels
Responses Received from Members (609 Responses):
The Correct Answer is: A. Absolute blood eosinophil count
Educational Objective:
Diagnose allergic asthma phenotype.
The most appropriate diagnostic test for this patient is measurement of the absolute blood eosinophil count (Option A). The patient presents with symptoms suggestive of allergic asthma; establishing this asthma phenotype can help direct therapy. Clinical characteristics suggesting a type 2 asthma phenotype include atopy, seasonal exacerbations, hay fever, and allergen sensitization. Biomarker evaluation in these patients often demonstrates serum or sputum eosinophilia and/or high IgE levels. This patient has a normal IgE level, but this does not preclude type 2 asthma. Obtaining a blood absolute eosinophil count will help establish the phenotype. In patients with severe disease, elevated levels of IgE and eosinophils are therapeutic targets for biologic therapies. Several types of biologic therapies are available that are directed against type 2 inflammation, targeting pathways involved in activation of eosinophils and IgE production. Use of antibody therapies in eligible patients with severe persistent allergic asthma despite standard therapy reduces symptoms, exacerbations, and need for oral glucocorticoids.
An α1-antitrypsin level (Option B) should be obtained once in all patients with chronic obstructive pulmonary disease. A pattern of basilar emphysema, associated liver disease or panniculitis, or a strong family history of emphysema in patients with COPD suggests possible α-1 antitrypsin deficiency, but none of these features is sufficiently sensitive for the condition. Routine testing is not indicated in patients with asthma.
Patients with allergic bronchopulmonary aspergillosis (ABPA) present with difficult-to-control asthma, productive cough, and expectoration of mucus plugs. Commonly accepted diagnostic criteria include elevated IgE levels, positive skin tests to Aspergillus antigens, increased Aspergillus-specific IgE and IgG levels, and either central bronchiectasis or infiltrates. This patient does not have the clinical phenotype of ABPA, radiographic findings, or elevated IgE level suggesting ABPA.
Measuring Aspergillus-specific IgE level (Option C) is not indicated.
Identifying the presence of atopy can identify an allergic asthma phenotype in a patient with respiratory symptoms. Atopic status can be measured by skin prick testing or measurement of allergen-specific IgE testing (Option D). Skin prick testing is rapid, simple, and relatively inexpensive. Measurement of immunoglobulin-specific IgE is more expensive but not more accurate. However, the first management step for this patient is to measure the total blood eosinophil count to determine his asthma phenotype.
Key Point
Clinical characteristics suggesting a type 2 asthma phenotype include atopy, seasonal exacerbations, hay fever, and allergen sensitization.
For patients with symptoms suggestive of type 2 asthma phenotype, measurement of IgE levels and total eosinophil count can be used to confirm this asthma phenotype and direct therapy.
Bibliography
McGregor MC, Krings JG, Nair P, et al. Role of biologics in asthma. Am J Respir Crit Care Med. 2019;199:433-445. PMID: 30525902 doi:10.1164/rccm.201810-1944CI
Copyright 2019, American College of Physicians.