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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January 27th, 2026
MKSAP 19 Cardiovascular Medicine, Question 11
A 70-year-old man is evaluated for recently diagnosed paroxysmal atrial fibrillation that is mildly symptomatic. Medical history is significant for hypertension and previous stroke. Medications are rivaroxaban and metoprolol. He has experienced no episodes of bleeding on anticoagulation therapy. On physical examination, blood pressure is 128/74 mm Hg and pulse rate is 72/min and regular. The remainder of the examination is unremarkable.
An echocardiogram reveals an enlarged left atrium and normal left ventricle. Forty-eight–hour ambulatory ECG monitoring shows atrial fibrillation prevalence of 10% with a controlled ventricular rate less than 90/min and no other abnormalities.
Which of the following is the most appropriate treatment?
- Left atrial appendage occlusion
- Pacemaker implantation
- Rhythm control
- Switch rivaroxaban to warfarin
- No additional therapy
Responses Received from Members (Graph is uploaded on Thursday afternoon):
The Correct Answer is: C. Rhythm control
Educational Objective: Manage atrial fibrillation with early rhythm control.
Rhythm control (Option C) is the most appropriate treatment for this patient who presents with paroxysmal atrial fibrillation. This patient is reflective of those included in the EAST-AFNET 4 randomized clinical trial, which evaluated a rhythm control strategy versus usual care (typically including rate control) in patients with a recent diagnosis (within 12 months) of atrial fibrillation and coexisting cardiovascular conditions. The inclusion criteria were age older than 75 years or previous transient ischemic attack or stroke, or two of the following: age older than 65 years, female sex, heart failure, hypertension, diabetes mellitus, severe coronary artery disease, chronic kidney disease, and left ventricular hypertrophy. The trial demonstrated improved clinical outcomes, including a reduction in the primary composite end point of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome, among patients randomly assigned to an early rhythm control strategy, including asymptomatic patients. The intervention included either antiarrhythmic drugs or catheter ablation, but importantly, it included aggressive concomitant medical therapy (e.g., oral anticoagulation when indicated, hypertension treatment) in both the intervention and the control groups. Based on the trial results, this patient is mostly likely to benefit from early rhythm control for atrial fibrillation.
This patient is appropriately receiving stroke prevention therapy with a direct oral anticoagulant (DOAC), and he has had no recurrent stroke or significant bleeding episodes on the current therapy. Therefore, left atrial appendage occlusion (Option A) is not indicated.
Among the common indications for permanent pacemaker implantation (Option B) are symptomatic bradycardia without reversible cause; permanent atrial fibrillation with symptomatic bradycardia; alternating bundle branch block; and complete heart block, high-degree atrioventricular (AV) block, or Mobitz type 2 second-degree AV block, irrespective of symptoms. This patient has no indications for pacemaker implantation.
Oral anticoagulation in patients with atrial fibrillation can be accomplished with a vitamin K antagonist (warfarin) or DOAC, such as rivaroxaban. Rivaroxaban is noninferior to warfarin in the prevention of stroke or systemic embolism and is associated with less intracranial and fatal bleeding. The 2019 American College of Cardiology/American Heart Association atrial fibrillation guideline recommends DOACs in preference to warfarin in DOAC-eligible patients. Thus, there is no suggestion that switching to warfarin (Option D) would improve outcomes in this patient.
Offering no additional therapy (Option E) would be inappropriate because early rhythm control is associated with improved clinical outcomes in patients such as this one.
Key Point
- In patients with recently diagnosed atrial fibrillation and concomitant cardiovascular conditions, early rhythm control (antiarrhythmic drugs or ablation) reduces the primary composite end point of cardiovascular death, stroke, or hospitalization for heart failure or acute coronary syndrome compared with usual care.
Bibliography
Kirchhof P, Camm AJ, Goette A, et al; EAST-AFNET 4 Trial Investigators. Early rhythm-control therapy in patients with atrial fibrillation. N Engl J Med. 2020;383:1305-1316. PMID:
32865375 doi:10.1056/NEJMoa2019422
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
All Rights Reserved.
January 13th, 2026
MKSAP 19 Pulmonary & Critical Care Medicine, Question 102
A 32-year-old woman is evaluated for an asthma exacerbation. She previously had well-controlled asthma. She has increased the use of her maintenance inhaler and is using her rescue medication four times daily, but her symptoms persist. She reports no fever, chills, chest pain, or purulent sputum. She has no history of intubation, emergency department visits, or hospitalizations for asthma and has adhered to her medication regimen. She is a nonsmoker. His only medication is inhaled budesonide-formoterol.
On physical examination, respiration rate is 25/min; the remainder of vital signs are normal. Oxygen saturation is 96% with the patient breathing ambient air. The patient is not using accessory muscles of respiration and is able to speak in full sentences. There is scattered expiratory wheezing.
Which of the following is the most appropriate treatment?
- Doxycycline, 5-day course
- Intravenous methylprednisone, followed by a 5-day prednisone course
- Prednisone, 5-day course
- Prednisone, 14-day course
Responses Received from Members (670 Responses):
The Correct Answer is: C. Prednisone, 5-day course
Educational Objective: Treat an asthma exacerbation.
The most appropriate management for this patient with an asthma exacerbation is to start a 5-day course of prednisone (Option C). Asthma exacerbation is an acute worsening of symptoms or lung function from baseline that necessitates a step up in therapy. Prompt recognition and treatment of asthma exacerbations are needed to relieve symptoms and prevent hospitalizations. All patients with asthma should have a written asthma management plan that helps them recognize the symptoms of an exacerbation and begin self-treatment. If symptoms do not improve with self-treatment, evaluation is appropriate. Clinicians should screen for patient factors that contribute to an increased risk of death from asthma and should counsel patients appropriately. Important risk factors include a history of near-fatal asthma attack or intubation; an emergency department or hospital visit in the last 12 months; poor asthma medication adherence or not using inhaled glucocorticoid; current or recent treatment with an oral glucocorticoid; psychosocial stressors or psychiatric disease; food allergy; and overuse of a short-acting β2-agonist. On physical examination, signs of a severe asthma exacerbation that should prompt aggressive intervention and hospitalization include being unable to speak in full sentences; use of accessory muscles of respiration; respiration rate greater than 30/min, heart rate greater than 120/min; oxygen saturation less than 90% with the patient breathing ambient air; and agitation, confusion, or drowsiness. This patient does not have any signs of or risk factors for a severe asthma exacerbation; therefore, she can be safely managed as an outpatient. The best next step is to begin an oral glucocorticoid such as prednisone for a period of 5 to 7 days.
Asthma exacerbations do not require antibiotics (Option A) unless other signs suggestive of infection, such as fever, are present.
Patients such as this one with low risk for a severe asthma exacerbation can be treated with a 5- to 7- day course of prednisone. A 14-day course of prednisone (Option D) is unnecessarily long, and intravenous glucocorticoids, such as methylprednisone, followed by a course of prednisone (Option B) is also excessive and unnecessary.
Key Point
- All patients with asthma should have a written asthma management plan that helps them recognize the symptoms of an exacerbation and begin self-treatment.
- Patients with an asthma exacerbation who continue to have symptoms after self-treatment should be treated with an oral glucocorticoid.
Bibliography
Fergeson JE, Patel SS, Lockey RF. Acute asthma, prognosis, and treatment. J Allergy Clin Immunol. 2017;139:438-447. PMID: 27554811 doi:10.1016/j.jaci.2016.06.054
Multiple-choice questions reprinted with permission from the American College of Physicians.
MKSAP 19. © Copyright 2021 American College of Physicians.
All Rights Reserved.