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 17th, 2026
QUESTION 4, Question ID: CVMCQ24122
A 65-year-old man is evaluated during routine follow-up. He is asymptomatic. He has aortic regurgitation that has been monitored with serial echocardiography. Medical history is significant for hypertension and dyslipidemia. Medications are lisinopril and atorvastatin.
On physical examination, blood pressure is 128/45 mm Hg and pulse rate is 70/min. Cardiac examination reveals prominent carotid and radial pulses bilaterally, a soft systolic murmur heard at the right upper sternal border, and a holodiastolic murmur heard at the left sternal border.
Transthoracic echocardiogram shows a dilated left ventricle (left ventricular end systolic diameter [LVESD] of 54 mm), an ejection fraction of 58%, severe aortic regurgitation, and a normal aortic root. Previous echocardiogram showed an LVESD of 48 mm.
Which of the following is the most appropriate next step in management?
A. Aortic valve replacement
B. Cardiac magnetic resonance imaging
C. Lisinopril dosage increase
D. Repeat echocardiography in 6 to 12 months
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: A. Aortic valve replacement
Educational Objective: Manage severe aortic regurgitation.
The most appropriate next step in management for this patient with severe aortic regurgitation and a dilated left ventricle is aortic valve replacement (Option A). In chronic aortic regurgitation, surgical aortic valve replacement is advised for patients with symptoms (typically dyspnea or angina) or left ventricular (LV) dysfunction (ejection fraction ≤55%) thought to be caused by aortic regurgitation. It is also recommended for patients with severe aortic regurgitation who are undergoing other cardiac surgery. In addition, surgical treatment is reasonable in asymptomatic patients with severe aortic regurgitation and normal LV function with significant LV dilatation (LV end systolic diameter >50 mm or indexed end-systolic dimension >25 mm/m2). Transcatheter aortic valve implantation is not currently indicated for aortic regurgitation. The patient's physical examination findings, including the wide pulse pressure and prominent pulses, are consistent with severe aortic regurgitation, which is confirmed on echocardiography. Although this patient is asymptomatic and has normal LV function, the left ventricle has dilated since the last echocardiogram to greater than 50 mm, meeting the criteria for surgical replacement. He should undergo aortic valve replacement.
Cardiac magnetic resonance (CMR) imaging (Option B) can quantitatively assess the severity of aortic regurgitation, assess the aorta for aneurysmal dilation, and assess ventricular function and dimensions. In this patient, however, echocardiography has provided the necessary information, and CMR imaging is not necessary.
Patients with chronic aortic regurgitation and concomitant hypertension should undergo medical therapy, preferably with dihydropyridine calcium channel blockers, ACE inhibitors, or angiotensin receptor blockers, but this does not obviate the need for surgery when indicated. This patient with a dilated left ventricle should undergo surgery; increasing the lisinopril dosage (Option C) is not the most appropriate next step. Monitoring of valve and LV status with clinical evaluation and echocardiography every 6 to 12 months (Option D) is an appropriate strategy in asymptomatic patients with severe aortic regurgitation and a nondilated and normally functioning left ventricle. This patient, however, has a dilated left ventricle and should undergo surgery.
Key Points
- In chronic severe aortic regurgitation, aortic valve replacement is advised for patients with symptoms, most typically dyspnea or angina.
- Surgical treatment of chronic severe aortic regurgitation is reasonable in asymptomatic patients with left ventricular (LV) dysfunction without another cause or those with normal LV function and significant LV dilatation.
Reference
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021;143:e72-e227. PMID:
33332150 doi:10.1161/CIR.0000000000000923
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.
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 (676 Responses):
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.