chap 36: HF

Question 1

1. Angiotensin-converting-enzyme (ACE) inhibitors are a central part of the treatment of heart failure because they have more than one action to address the pathological changes in this disorder. Which of the following pathological changes in heart failure is NOT addressed by ACE inhibitors?
2. Changes in the structure of the left ventricle so that it dilates, hypertrophies, and uses energy less efficiently.
3. Reduced formation of cross-bridges so that contractile force decreases.
4. Activation of the sympathetic nervous system that increases heart rate and preload.
5. Decreased renal blood flow that decreases oxygen supply to the kidneys.

Answer 1

3. Activation of the sympathetic nervous system that increases heart rate and preload.

Question 2

2. One of the three types of heart failure involves systolic dysfunction. Potential causes of this most common form of heart failure include:
3. Myocardial ischemia and injury secondary to myocardial infarction
4. Inadequate relaxation and loss of muscle fiber secondary to valvular dysfunction
5. Increased demands of the heart beyond its ability to adapt secondary to anemia
6. Slower filling rate and elevated systolic pressures secondary to uncontrolled hypertension

Answer 2

1. Myocardial ischemia and injury secondary to myocardial infarction

Question 3

3. The American Heart Association and the American College of Cardiology have devised a classification system for heart failure that can be used to direct treatment. Patients with symptoms and underlying disease are classified as stage:
4. A
5. B
6. C
7. D

Answer 3

3. C

Question 4

4. Diagnosis of heart failure cannot be made by symptoms alone because many disorders share the same symptoms. The most specific and sensitive diagnostic test for heart failure is:
5. Chest x-rays that show cephalization and measure heart size
6. Two-dimensional echocardiograms that identify structural anomalies and cardiac dysfunction
7. Complete blood count, blood urea nitrogen, and serum electrolytes that facilitate staging for end-organ damage
8. Measurement of brain natriuretic peptide to distinguish between systolic and diastolic dysfunction

Answer 4

2. Two-dimensional echocardiograms that identify structural anomalies and cardiac dysfunction

Question 5

5. Treatments for heart failure, including drug therapy, are based on the stages developed by the ACC/AHA. Stage A patients are treated with:
6. Drugs for hypertension and hyperlipidemia, if they exist
7. Lifestyle management including diet, exercise, and smoking cessation only
8. Angiotensin-converting enzyme (ACE) inhibitors to directly affect the heart failure only
9. No drugs are used in this early stage

Answer 5

1. Drugs for hypertension and hyperlipidemia, if they exist

Question 6

6. Class I recommendations for stage A heart failure include:
7. Aerobic exercise within tolerance levels to prevent the development of heart failure
8. Reduction of sodium intake to less than 2,000 mg/day to prevent fluid retention
9. Beta blockers for all patients regardless of cardiac history
10. Treatment of thyroid disorders, especially if they are associated with tachyarrhythmias

Answer 6

4. Treatment of thyroid disorders, especially if they are associated with tachyarrhythmias

Question 7

7. Stage B patients should have beta blockers added to their heart failure treatment regimen when:
8. They have an ejection fraction less than 40%
9. They have had a recent MI
10. Both 1 and 2
11. Neither 1 nor 2

Answer 7

3. Both 1 and 2

Question 8

8. Increased life expectancy for patients with heart failure has been associated with the use of:
9. ACE inhibitors, especially when started early in the disease process
10. All beta blockers regardless of selectivity
11. Thiazide and loop diuretics
12. Cardiac glycosides

Answer 8

1. ACE inhibitors, especially when started early in the disease process

Question 9

9. Stage C patients usually require a combination of three to four drugs to manage their heart failure. In addition to ACE inhibitors and beta blockers, diuretics may be added. Which of the following statements about diuretics is NOT true?
10. Diuretics reduce preload associated with fluid retention.
11. Diuretics can be used earlier than stage C when the goal is control of hypertension.
12. Diuretics may produce problems with electrolyte imbalances and abnormal glucose and lipid metabolism.
13. Diuretics from the potassium-sparing class should be used when using an angiotensin receptor blocker (ARB).

Answer 9

4. Diuretics from the potassium-sparing class should be used when using an angiotensin receptor blocker (ARB).

Question 10

10. Digoxin has a very limited role in treatment of heart failure. It is used mainly for patients with:
11. Ejection fractions above 40%
12. An audible S3
13. Mitral stenosis as a primary cause for heart failure
14. Renal insufficiency

Answer 10

2. An audible S3

Question 11

11. Which of the following classes of drugs is contraindicated in heart failure?
12. Nitrates
13. Long-acting dihydropyridines
14. Calcium channel blockers
15. Alpha-beta blockers

Answer 11

3. Calcium channel blockers

Question 12

12. Heart failure is a leading cause of death and hospitalization in older adults (greater than 65 years old). The drug of choice for this population is:
13. Aldosterone antagonists
14. Eplerenone
15. ACE inhibitors
16. ARBs

Answer 12

3. ACE inhibitors

Question 13

13. ACE inhibitors are contraindicated in pregnancy. While treatment of heart failure during pregnancy is best done by a specialist, which of the following drug classes is considered to be safe, at least in the later parts of pregnancy?
14. Diuretics
15. ARBs
16. Beta blockers
17. Nitrates

Answer 13

3. Beta blockers

Question 14

14. Heart failure is a chronic condition that can be adequately managed in primary care. However, consultation with or referral to a cardiologist is appropriate when:
15. Symptoms markedly worsen or the patient becomes hypotensive and has syncope
16. There is evidence of progressive renal insufficiency or failure
17. The patient remains symptomatic on optimal doses of an ACE inhibitor, a beta blocker, and a diuretic
18. Any of the above

Answer 14

4. Any of the above

Question 15

15. ACE inhibitors are a foundational medication in HF. Which group of patients cannot take them safely?
16. Elderly patients with reduced renal clearance
17. Pregnant women
18. Women under age 30
19. 1 and 2

Answer 15

4. 1 and 2

Question 16

16. What assessment that can be done at home is the most reliable for making decisions to change HF medications?
17. Weight
18. BP
19. Heart rate
20. Serum Glucose

Answer 16

1. Weight

Question 17

17. Evidence is strong that the timing of HF interventions are best initiated when:
18. The person enters stage C
19. The person has functional disabilities
20. At the earliest indication
21. When stage IV is determined

Answer 17

3. At the earliest indication

Question 18

18. HF patients frequently take more than one drug. When are anticoagulants typically used?
19. When the patient enters stage III
20. Only in cases of diastolic failure
21. When there is concurrent A Fib
22. In all cases

Answer 18

3. When there is concurrent A Fib

Question 19

19. What can chest x-rays contribute to the diagnosis and management of HF?
20. They have no role.
21. They can give very precise pictures of pulmonary fluid status.
22. They provide an idea of general cardiac size and pulmonary great vessel distribution.
23. They can confirm the diagnosis.

Answer 19

3. They provide an idea of general cardiac size and pulmonary great vessel distribution.