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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September 23, 2025
MKSAP 19 Nephrology, Question 32
A 46-year-old man is evaluated for confirmed primary hypertension. The patient is asymptomatic and takes no medications. He is a current smoker with a 20-pack-year history. Family history is significant for hypertension in his mother and father; his father had a stroke at age 55 years.
On physical examination, blood pressure is 154/96 mm Hg in both arms, pulse rate is 74/min, and respiration rate is 18/min. BMI is 30. The remainder of the examination is normal.
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A 12-lead ECG is normal.
The patient is instructed in lifestyle modifications, including smoking cessation, exercise, and a low sodium diet. Moderate-intensity atorvastatin is initiated.
Which of the following is the most appropriate additional therapy?
A. Amlodipine
B. Amlodipine-valsartan
C. Chlorthalidone
D. Valsartan
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: B. Amlodipine-valsartan
Educational Objective:
Treat stage 2 hypertension with combination drug therapy.
The most appropriate additional therapy is amlodipine-valsartan (Option B). This patient has stage 2 hypertension (systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg). For patients with stage 2 hypertension with or without cardiovascular risk or disease, pharmacologic management in addition to therapeutic lifestyle interventions is recommended. The 2017 American College of Cardiology/American Heart Association blood pressure (BP) guideline recommends combination therapy with two first-line antihypertensive drugs of different classes for adults with stage 2 hypertension and an average BP that is 20/10 mm Hg above their BP target. Based on the presence of hypertension, dyslipidemia, and cigarette smoking, this patient has a calculated 10-year atherosclerotic cardiovascular disease (ASCVD) event risk of 10%. The target BP for patients with established cardiovascular disease or for patients with an estimated ASCVD event risk ≥10% is 130/80 mm Hg. This patient has an elevated 10-year ASCVD event risk and his BP is >20/10 mm Hg above target; therefore, combination drug therapy is indicated. To maximize adherence, using a fixed-dose combination agent may be more effective than adding two separate antihypertensive agents.
Starting chlorthalidone, amlodipine, or valsartan (Options A, C, D) as single-agent therapy would each be appropriate as first-line therapy for patients with stage 1 hypertension (systolic BP of 130-139 mm Hg or diastolic BP of 80–89 mm Hg). Combination therapy is recommended for patients with stage 2 hypertension and an average BP that is 20/10 mm Hg above their BP target.
Key Point
A blood pressure <130/80 mm Hg is recommended for adults with hypertension and cardiovascular disease or a 10-year atherosclerotic cardiovascular disease event risk ≥10%.
Combination therapy with two first-line antihypertensive medications of different classes is recommended for adults with stage 2 hypertension and an average blood pressure (BP)
of >20/10 mm Hg above BP target.
Bibliography
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018;71:e127-e248. PMID: 29146535
Copyright 2019, American College of Physicians.
September 9, 2025
MKSAP 19 Endocrinology & Metabolism, Question 68
A 67-year-old man is evaluated in the hospital for hyperglycemia 3 days after admission for a COPD exacerbation. Appropriate treatment was initiated with antibiotics, bronchodilators, supplemental oxygen, and systemic glucocorticoids. The patient's oral intake remains good. Since the initiation of systemic glucocorticoids, fasting blood glucose levels have been consistently greater than 180 mg/dL (10.0 mmol/L) and postprandial levels occasionally greater than 250 mg/dL (13.9 mmol/L).
On admission, hemoglobin A1c was 5.3%.
Which of the following is the most appropriate management of this patient's hyperglycemia?
A. Basal and correctional insulin
B. Basal, prandial, and correctional insulin
C. Correctional insulin
D. Metformin
Responses Received from Members (667 Responses):
The Correct Answer is: B. Basal, prandial, and correctional insulin
Educational Objective:
Treat hyperglycemia in a hospitalized patient who has good oral intake.
Point-of-care glucose measurement is important to identify hyperglycemia in hospitalized patients prescribed glucocorticoids. The most appropriate management of this patient's hyperglycemia is the initiation of basal, prandial, and correctional insulin (Option B). The American Diabetes Association (ADA) recommends initiation of insulin therapy for treatment for persistent hyperglycemia starting at a threshold of 180 mg/dL (10.0 mmol/L). After insulin therapy is started, a target glucose range of 140 to 180 mg/dL (7.8-10.0 mmol/L) is recommended for most critically ill and non-critically ill patients.
Basal insulin is long-acting insulin given once daily; prandial insulin is scheduled short-acting insulin given three times daily with each meal; and correctional insulin is dosing in response to continued elevated glucose rather than preemptively. A correctional dose of short-acting insulin should be given in addition to the scheduled prandial insulin to correct for hyperglycemia before eating. This approach leads to improved outcomes and avoids large fluctuations in glucose values through the day. A randomized controlled trial has shown that basal-prandial insulin treatment improved glycemic control and reduced hospital complications compared with use of only correctional insulin (“sliding scale insulin”) regimens in general surgery patients with type 2 diabetes mellitus.
The ADA notes that basal insulin, or a basal plus correction regimen (Option A), is the preferred treatment for non-critically ill hospitalized patients with poor oral intake or those with oral intake restriction. Because this patient's oral intake is good, the preferred management of hyperglycemia is basal, prandial, and correctional insulin.
The sole use of correctional insulin (Option C) for the management of inpatient hyperglycemia is not recommended. This approach to hyperglycemia is reactive and can cause large fluctuations in glucose values and lag times between measurement and insulin injection. The use of correctional insulin in hospitalized patients as the only means to control hyperglycemia is strongly discouraged by the ADA.
Research on the safety of oral hypoglycemic drugs in the hospital setting is ongoing, and conclusive findings have not yet been established. Harm is also a concern, particularly in patients who may experience changes in volume status, exposure to contrast agents, and unpredictable meals because of testing or clinical status changes. Initiating metformin (Option D) is not the best choice for this patient.
Key Point
Basal, prandial, and correctional insulin is the recommended treatment for hyperglycemia in non-critically ill hospitalized patients who have good oral intake.
The use of correctional insulin in hospitalized patients as the only means to control hyperglycemia is strongly discouraged by the American Diabetes Association.
Bibliography
American Diabetes Association. 15. Diabetes care in the hospital: standards of medical care in diabetes-2021. Diabetes Care. 2021;44:S211-S220. PMID: 33298426 doi:10.2337/dc21-S015
Copyright 2019, American College of Physicians.