Exam 2 - Random Multiple Choice

Question 1

A white patient with HFrEF (LVEF 30% [0.3]) has mild fatigue and dyspnea on exertion. Serum electrolytes, creatinine clearance, and other labs are within normal limits and the serum digoxin concentration collected 18 hours after the previous dose is 0.8 ng/mL (µg/L; 1 nmol/L). The blood pressure is 125/75 mm Hg and heart rate is 60 bpm. The patient’s cardiovascular drug regimen is unchanged over the previous 3 months and includes:

lisinopril 10 mg daily
carvedilol 25 mg BID
furosemide 40 mg BID
digoxin 0.125 mg daily
spironolactone 25 mg daily
atorvastatin 40 mg daily at bedtime

Which of the following is the most appropriate change to the patient’s pharmacotherapy?

a. Initiate amlodipine
b. Increase the digoxin dose to 0.25 mg/day
c. Initiate ivabradine
d. Change lisinopril to sacubitril/valsartan

Answer 1

d. Change lisinopril to sacubitril/valsartan

Question 2

A white patient with HFrEF (LVEF 30% [0.3]) has mild fatigue and dyspnea on exertion. Serum electrolytes, creatinine clearance, and other labs are within normal limits and the serum digoxin concentration collected 18 hours after the previous dose is 0.8 ng/mL (µg/L; 1 nmol/L). The blood pressure is 125/75 mm Hg and heart rate is 60 bpm. The patient’s cardiovascular drug regimen is unchanged over the previous 3 months and includes:

lisinopril 10 mg daily
carvedilol 25 mg BID
furosemide 40 mg BID
digoxin 0.125 mg daily
spironolactone 25 mg daily
atorvastatin 40 mg daily at bedtime

Which should be added to reduce the risk of death and hospitalization in this pt?

a. BiDil
b. dapagliflozin
c. diltiazem
d. metformin

Answer 2

b. dapagliflozin

Question 3

Sacubitril/valsartan is contraindicated in patients with which of the following?

a. Hypokalemia
b. Concomitant therapy with bumetanide
c. Angioedema with ramipril
d. Blood pressure >130/80 mm Hg

Answer 3

c. Angioedema with ramipril

Question 4

Which of the following medications may exacerbate HFrEF?

a. Naproxen
b. Amlodipine
c. Rosuvastatin
d. Empagliflozin

Answer 4

a. Naproxen

Question 5

Which of the following medication can increase wheezing and shortness of breath in a patient with HFrEF and COPD?

a. Carvedilol
b. Spironolactone
c. Bumetanide
d. Dapagliflozin

Answer 5

a. Carvedilol

(non-selective BB can inc wheezing and SOB. Use a selective one such as metoprolol succinate)

Question 6

Which of the following adverse effects associated with ramipril can be managed by switching to valsartan?

a. Cough
b. Hypotension
c. Hyperkalemia
d. Fetal toxicity

Answer 6

a. Cough

Question 7

Patients receiving empagliflozin for HFrEF should be counseled about which of the following?

a. The risk of pulmonary toxicity when used with carvedilol
b. Signs and symptoms of urinary tract infections
c. The risk of seizures when used with ACE inhibitors
d. Signs and symptoms of volume overload

Answer 7

b. Signs and symptoms of urinary tract infections

Question 8

The risk of hyperkalemia is increased when spironolactone is used concurrently with which of the following medications?

a. Ivabradine
b. Furosemide
c. Ibuprofen
d. Metolazone

Answer 8

c. Ibuprofen

(risk increases when MRA used with any NSAID)

Question 9

Which of the following should be used to monitor loop diuretic therapy in patients with heart failure?

a. Daily weights, serum potassium, serum creatinine
b. Thyroid-stimulating hormone (TSH) and free T4
c. Fasting blood sugar and hemoglobin A1C
d. Fasting lipid profile

Answer 9

a. Daily weights, serum potassium, serum creatinine

Question 10

Which of the following best describes the use of sacubitril/valsartan in patients with heart failure?

a. It is contraindicated in patients with type 2 diabetes
b. ACE inhibitors should be discontinued at least 36 hours before starting sacubitril/valsartan
c. Hypokalemia is a common adverse effect
d. It causes less hypotension than an ACE inhibitor or ARB

Answer 10

b. ACE inhibitors should be discontinued at least 36 hours before starting

Question 11

Hypokalemia is a potential complication of which of the following medications?

a. Carvedilol
b. Eplerenone
c. Losartan
d. Torsemide

Answer 11

d. Torsemide

Question 12

What is the most appropriate therapy for a patient with HFrEF that develops lisinopril-induced angioedema?

a. Change to ramipril
b. Change to sacubitril/valsartan
c. Change to hydralazine/isosorbide dinitrate
d. Change to amlodipine

Answer 12

c. Change to hydralazine/isosorbide dinitrate

(a and b are CI)

Question 13

A patient with Stage C HFrEF is taking sacubitril/valsartan 49/51 mg orally twice daily, dapagliflozin 10 mg orally daily, furosemide 40 mg orally twice daily, digoxin 0.125 mg orally daily, and metoprolol succinate 25 mg orally daily. The patient presents with increasing shortness of breath, fatigue, ankle swelling, and an 8-pound (3.6 kg) weight gain over the past 2 weeks. Labs are significant for serum potassium of 5.2 mEq/L (mmol/L), serum creatinine 1.0 mg/dL (88 µmol/L), and serum digoxin concentration 0.8 ng/mL (mcg/L; 1 nmol/L) collected 18 hours after the last dose. Vital signs are BP 125/75 mm Hg and heart rate 75 BPM. Which is the most appropriate immediate intervention?

a. inc furosemide to 80 mg twice daily
b. inc metoprolol to 50 mg daily
c. initiate spironolactone 12.5 mg daily
d. inc digoxin dose to 0.25 mg daily

Answer 13

a. inc furosemide to 80 mg twice daily

(pt has volume overload; b. is wrong bc they are having worsening HF symptoms, c. is wrong bc K > 5, d. is already in range)

Question 14

A patient with HFrEF (LVEF 30-35% [0.3-0.35]) is in normal sinus rhythm and is receiving sacubitril/valsartan 97/103 mg orally twice daily, dapagliflozin 10 mg orally daily, carvedilol 50 mg orally twice daily, digoxin 0.125 mg orally daily, spironolactone 25 mg orally daily, and furosemide 40 mg orally twice daily. Vital signs are BP 110/75 mm Hg and pulse 85 bpm. All labs are within normal limits. Which would be the most appropriate medication to add to reduce hospitalization?

a. potassium chloride
b. ivabradine
c. diltiazem
d. vericiguat

Answer 14

b. ivabradine

(pt is on max BB and HR is > 70)

Question 15

A patient with HFpEF (LVEF 50-55% [0.5-0.55]) also has diabetes, hypertension, hyperlipidemia, asthma, and A Fib. Current vital signs are: HR 85 bpm and BP 128/85 mm Hg. Current labs include serum creatinine 1.0 mg/dL (88 µmol/L), serum potassium 4.3 mEq/L (mmol/L), and HgbA1c 6.8% (51 mmol/mol). Current medications include hydrochlorothiazide 25 mg orally daily, lisinopril 10 mg orally daily, atorvastatin 20 mg orally daily, aspirin 81 mg orally daily, metformin 1000 mg orally twice daily, fluticasone 250/50 inhale 1 puff twice daily, and albuterol PRN. Which of the following medications will most likely improve health outcomes in this patient with HFpEF?

a. metoprolol succinate
b. ivabradine
c. empagliflozin
d. amlodipine

Answer 15

c. empagliflozin

Question 16

Which of the following best describes the primary ion channel inhibited by sotalol, the corresponding action potential phase affected, and its effects on the ECG?

a. Sodium; phase 4 causing a prolongation of the QTc
b. Sodium; phase 1 causing a widening the QRS
c. Potassium; phase 2 causing a widening the QRS
d. Potassium; phase 3 causing a prolongation of the QTc

Answer 16

d. Potassium; phase 3 causing a prolongation of the QTc

Question 17

Which of the following antibiotic classes should be avoided in combination with dofetilide?

a. Fluoroquinolones
b. Cephalosporins
c. Penicillins
d. Sulfonamides

Answer 17

a. Fluoroquinolones

(both cause QTc prolongation)

Question 18

A 57-year-old hospitalized patient develops atrial fibrillation in the past 24 hours with a rapid ventricular response (heart rate = 179 beats/min). Past medical history is significant for hypertension, angina, and thyrotoxicosis. Symptoms include fatigue and palpitations. Which of the following intravenous medications do you recommend as INITIAL management of the patient’s atrial fibrillation?

a. Digoxin to control his ventricular rate
b. Esmolol to control his ventricular rate
c. Ibutilide to restore sinus rhythm
d. Amiodarone to restore sinus rhythm

Answer 18

c. Ibutilide to restore sinus rhythm

Question 19

In which of the following patients would it be the SAFEST to initiate flecainide?

a. Thyrotoxicosis and obesity
b. Asthma and heart failure
c. Myocardial infarction and hyperlipidemia
d. Coronary artery disease and severe left ventricular hypertrophy

Answer 19

a. Thyrotoxicosis and obesity

Question 20

A 54-year-old patient presents to the ER complaining of worsening palpitations, shortness of breath, and fatigue. Past medical history includes MI (5 months ago), HF (LVEF = 25% [0.25]), paroxysmal AF, and pulmonary fibrosis secondary to amiodarone (one year ago). Current medications include aspirin, enalapril, furosemide, carvedilol, atorvastatin, and rivaroxaban. Vital signs include BP 115/70 mm Hg, HR 72 beats/min. Pertinent labs include K+ 4.2 mEq/L (mmol/L), Mg 2.1 mEq/L (1.05 mmol/L), CrCl 32 mL/min (0.53 mL/s). ECG reveals: AF, HR 70 beats/min, QT interval 400 msec, QRS 94 msec. Successful electrical cardioversion is performed and the patient is now in sinus rhythm. The plan is to start chronic antiarrhythmic therapy to maintain him in sinus rhythm. Which of the following antiarrhythmic medication would be most appropriate to maintain him in sinus rhythm?

a. Amiodarone
b. Dofetilide
c. Flecainide
d. Sotalol

Answer 20

b. Dofetilide

(pt has HF, so amiodarone or dofetilide are options, but they have developed pulmonary fibrosis from amiodarone before; flecainide should not be used in pts with prior MI or HFrEF)

Question 21

For the acute management of AV nodal reentry and orthodromic AV reentry, which medication would be used first to restore normal sinus rhythm?

a. Adenosine
b. Procainamide
c. Lidocaine
d. Digoxin

Answer 21

a. Adenosine

Question 22

A 19-year-old female with a history of WPW (Wolff-Parkinson-White) syndrome is seen in the ER. No other medical problems nor known heart disease is present. ECG shows atrial fibrillation (heart rate = 178 beats/min). The patient is hemodynamically stable. Which is the best intravenous medication to administer at this time?

a. Adenosine
b. Verapamil
c. Procainamide
d. Lidocaine

Answer 22

c. Procainamide

(Idk the reasoning for this one)

Question 23

A 54-year-old man with a past medical history of asthma and migraines presents to the clinic complaining of dizziness and palpitations that have been occurring for the past 2 to 3 days. An ECG reveals that he is in atrial fibrillation (HR = 90 beats/min). Which option would be the most appropriate stroke prevention strategy for this patient?

a. Aspirin
b. Apixaban
c. Clopidogrel
d. No antithrombotic therapy is needed

Answer 23

d. No antithrombotic therapy is needed

(CHADsVASc is 0)

Question 24

Which patient will be at the highest risk of developing medication-induced torsades de pointes?

a. Male with a history of stroke and taking amiodarone
b. Male with a history of heart failure and taking flecainide
c. Female with a history of hyponatremia and taking diltiazem
d. Female with a history of myocardial infarction and taking dofetilide

Answer 24

d. Female with a history of myocardial infarction and taking dofetilide

(class Ia or III antiarrhythmic has risk of torsades, more common in women and those with structural heart disease i.e. CAD, HF, LV hypertrophy)

Question 25

A 52-year-old man, who has a history of skipping heartbeats, comes to the emergency department as the skipped beats are now accompanied with shortness of breath. Past medical history is insignificant. The ECG monitoring in the emergency department identifies non-sustained monomorphic outflow tract VT. Which of the following is the MOST APPROPRIATE treatment?

a. metoprolol
b. amiodarone
c. mexiletine
d. nifedipine

Answer 25

a. metoprolol

(pt has minimal symptoms, so best to go conservative with metoprolol)

Question 26

A 65-year-old man has a history of MI (6 months ago; current EF = 25%) and recurrent ventricular tachycardia. During an electrophysiologic study, the patient experienced inducible ventricular tachycardia (rate = 240 beats/min), causing syncope. Which is the best treatment option for this patient’s arrhythmia to prevent recurrence?

a. Radiofrequency ablation of the accessory pathway
b. Implantable cardioverter-defibrillator
c. Initiate amiodarone therapy
d. Increase the patient’s β-blocker to the max dose

Answer 26

b. Implantable cardioverter-defibrillator

(pt has had MI over 40 days ago, EF is less than 40, they also experienced inducible VT; amiodarone is recommended for pts with ICDs with significant sx)

Question 27

Which of the following comorbidities can be associated with the development of atrial fibrillation?

a. Hypocalcemia
b. Obstructive sleep apnea
c. Asthma
d. Hypothyroidism

Answer 27

b. Obstructive sleep apnea

Question 28

Propafenone may cause which of the following ECG changes?

a. Prolonged QRS interval
b. Prolonged ST segment
c. Shortened PR interval
d. Shortened QT interval

Answer 28

a. Prolonged QRS interval

(Class 1C; Drug’s primary action is on sodium channels and also beta receptors)

Question 29

A 78-year-old female is referred to the Electrophysiology clinic by their primary care doctor for atrial fibrillation. Past medical history is significant for HTN, asthma, and diabetes. The patient denies dizziness, fatigue, shortness of breath, palpitations, or chest pain. ECG demonstrates atrial fibrillation, HR 110 bpm, QTc 465ms, QRS 122ms. What would be the BEST treatment option for this patient?

a. diltiazem
b. flecainide
c. sotalol
d. amiodarone

Answer 29

a. diltiazem

(no symptoms, QTc is too long for sotalol, amiodarone would not be first option due to side effect profile)

Question 30

Myocardial fibers that discharge spontaneously have which of the following present?

a. Accelerated AV conduction
b. Circus movement
c. Abnormal automaticity
d. Sinus arrhythmia

Answer 30

c. Abnormal automaticity

Question 31

A 58-year-old male with a history of ischemic cardiomyopathy presents to clinic with orthopnea, dyspnea with minimal exertion, 3+ pitting edema, fatigue, anorexia, nausea, and early satiety.

These signs and symptoms are consistent with:

a. Volume overload only
b. Low cardiac output only
c. Both volume overload and low cardiac output
d. Neither volume overload or low cardiac output

Answer 31

c. Both volume overload and low cardiac output

(pt has edema, orthopnea, fatigue is sign of low CO, etc)

Question 32

All of the following strategies would be reasonable for overcoming diuretic resistance in a patient currently receiving furosemide 120 mg IV twice daily, EXCEPT:

a. Adding spironolactone 25 mg orally once daily
b. Increasing the dose of furosemide to 240 mg IV twice daily
c. Increasing the frequency of furosemide to 120 mg IV three times daily
d. Adding metolazone 2.5 mg orally once daily

Answer 32

a. Adding spironolactone 25 mg orally once daily

Question 33

Which of the following laboratory values should be monitored to assess the safety of furosemide? SELECT ALL THAT APPLY.
a. Brain natriuretic peptide
b. Serum creatinine
c. Potassium
d. Liver transaminases

Answer 33

b. Serum creatinine
c. Potassium

Question 34

A patient is admitted with acute decompensated heart failure and evidence of low cardiac output. The patient’s current medications include sacubitril/valsartan 49/51 mg twice daily, furosemide 40 mg twice daily, metoprolol succinate (CR/XL) 200 mg daily, and digoxin 0.125 mg daily. The patient has been stable on these doses for the previous 4 months. The team decides that inotropic therapy is indicated. Which of the following would be an appropriate agent to initiate at this time?

a. dopamine
b. dobutamine
c. milrinone
d. either b or c

Answer 34

c. milrinone

(they are on BB)

Question 35

A 57-year-old African American patient with ischemic cardiomyopathy (EF 25%) presents to the ED with acute decompensated HF. His vital signs include blood pressure 103/77 mmHg (negative for orthostasis), heart rate 92 bpm, respiratory rate 23 rpm, and oxygen saturation 91% on 4 L by nasal cannula. Physical examination reveals JVD, crackles at the bases bilaterally, ascites, and trace bilateral lower extremity edema. Pt reports a 10 lb (4.5 kg) weight gain in the past 2 weeks since his metoprolol dose was increased despite strict adherence to both dietary restrictions and medications. In the ED, he already received furosemide 160 mg IV once with minimal response in urine output. Labs: potassium 5.1 mEq/L, B-type natriuretic peptide 950 pg/mL (ng/L; 275 pmol/L), BUN 32 mg/dL, and SCr 2.2 mg/dL (baseline). The patient’s medications on admission include lisinopril 10 mg daily, metoprolol succinate (CR/XL) 150 mg daily, and furosemide 120 mg twice daily.

How should their BB be managed at this time?

a. continue at the current dose
b. d/c immediately
c. reduce to the last tolerated dose
d. change to atenolol

Answer 35

c. reduce to the last tolerated dose

(Metoprolol’s negative inotropic effect is likely the cause of his acute decompensation. Don’t d/c BB, this would make things worse. Atenolol would not help with HF.)

Question 36

A 57-year-old African American patient with ischemic cardiomyopathy (EF 25%) presents to the ED with acute decompensated HF. His vital signs include blood pressure 103/77 mmHg (negative for orthostasis), heart rate 92 bpm, respiratory rate 23 rpm, and oxygen saturation 91% on 4 L by nasal cannula. Physical examination reveals JVD, crackles at the bases bilaterally, ascites, and trace bilateral lower extremity edema. Pt reports a 10 lb (4.5 kg) weight gain in the past 2 weeks since his metoprolol dose was increased despite strict adherence to both dietary restrictions and medications. In the ED, he already received furosemide 160 mg IV once with minimal response in urine output. Labs: potassium 5.1 mEq/L, B-type natriuretic peptide 950 pg/mL (ng/L; 275 pmol/L), BUN 32 mg/dL, and SCr 2.2 mg/dL (baseline). The patient’s medications on admission include lisinopril 10 mg daily, metoprolol succinate (CR/XL) 150 mg daily, and furosemide 120 mg twice daily.

Which of the following would be appropriate for managing this patient’s volume overload?

a. Initiate furosemide 160 mg IV twice daily
b. Change to bumetanide 2 mg IV twice daily
c. Initiate furosemide 20 mg/h IV continuous infusion plus metolazone 5 mg by mouth daily
d. Initiate furosemide 5 mg/h IV continuous infusion

Answer 36

c. Initiate furosemide 20 mg/h IV continuous infusion plus metolazone 5 mg by mouth daily

(A. pt had minimal response to furosemide 160 mg once daily, so likely that the threshold for diuresis has not been reached; B. is a decreased dose from dose received in ED; D. is also a dose decrease

Question 37

A 57-year-old African American patient with ischemic cardiomyopathy (EF 25%) presents to the ED with acute decompensated HF. His vital signs include blood pressure 103/77 mmHg (negative for orthostasis), heart rate 92 bpm, respiratory rate 23 rpm, and oxygen saturation 91% on 4 L by nasal cannula. Physical examination reveals JVD, crackles at the bases bilaterally, ascites, and trace bilateral lower extremity edema. Pt reports a 10 lb (4.5 kg) weight gain in the past 2 weeks since his metoprolol dose was increased despite strict adherence to both dietary restrictions and medications. In the ED, he already received furosemide 160 mg IV once with minimal response in urine output. Labs: potassium 5.1 mEq/L, B-type natriuretic peptide 950 pg/mL (ng/L; 275 pmol/L), BUN 32 mg/dL, and SCr 2.2 mg/dL (baseline). The patient’s medications on admission include lisinopril 10 mg daily, metoprolol succinate (CR/XL) 150 mg daily, and furosemide 120 mg twice daily.

Which of the following GDMT would be appropriate to initiate prior to discharge? (Assume discharge laboratory values are identical to the admission values provided above.)

a. Spironolactone 25 mg by mouth once daily
b. Digoxin 0.125 mg by mouth once daily
c. Candesartan 4 mg by mouth once daily
d. Isosorbide dinitrate 20 mg and hydralazine 37.5 mg by mouth three times daily

Answer 37

d. Isosorbide dinitrate 20 mg and hydralazine 37.5 mg by mouth three times daily

(BiDil reduces mortality in African American pts)

Question 38

A 63-year-old female with hypertensive cardiomyopathy (EF 30%–35%) presents with a chief complaint of “always feeling tired.” Her daughter reports that the patient’s exercise tolerance has significantly declined recently despite strict adherence to a low-sodium diet and medications that include sacubitril/valsartan 24/26 mg BID, carvedilol 12.5 mg BID, furosemide 80 mg BID, and digoxin 0.125 mg daily. Vital signs include BP 92/57 mm Hg (mild orthostasis), HR 95 bpm, and RR 16 rpm. On physical examination, she has no findings consistent with volume overload. Laboratory analysis reveals sodium 135 mEq/L, potassium 4.9 mEq/L, BUN 45 mg/dL, and serum creatinine (SCr) 2.2 mg/dL (baseline BUN 27 mg/dL/ SCr 1.1 mg/dL). Upon further questioning, the patient admits to occasional dizziness.

In which of the following hemodynamic subsets should this patient be placed?

a. Subset I (warm and dry)
b. Subset II (warm and wet)
c. Subset III (cold and dry)
d. Subset IV (cold and wet)

Answer 38

c. Subset III (cold and dry)

Question 39

A 63-year-old female with hypertensive cardiomyopathy (EF 30%–35%) presents with a chief complaint of “always feeling tired.” Her daughter reports that the patient’s exercise tolerance has significantly declined recently despite strict adherence to a low-sodium diet and medications that include sacubitril/valsartan 24/26 mg BID, carvedilol 12.5 mg BID, furosemide 80 mg BID, and digoxin 0.125 mg daily. Vital signs include BP 92/57 mm Hg (mild orthostasis), HR 95 bpm, and RR 16 rpm. On physical examination, she has no findings consistent with volume overload. Laboratory analysis reveals sodium 135 mEq/L, potassium 4.9 mEq/L, BUN 45 mg/dL, and serum creatinine (SCr) 2.2 mg/dL (baseline BUN 27 mg/dL/ SCr 1.1 mg/dL). Upon further questioning, the patient admits to occasional dizziness.

Which of the following laboratory parameters would assist in confirming the volume status of this patient?

a. C-reactive protein
b. B-type natriuretic peptide
c. Serum albumin
d. Hemoglobin

Answer 39

b. B-type natriuretic peptide

Question 40

A 63-year-old female with hypertensive cardiomyopathy (EF 30%–35%) presents with a chief complaint of “always feeling tired.” Her daughter reports that the patient’s exercise tolerance has significantly declined recently despite strict adherence to a low-sodium diet and medications that include sacubitril/valsartan 24/26 mg BID, carvedilol 12.5 mg BID, furosemide 80 mg BID, and digoxin 0.125 mg daily. Vital signs include BP 92/57 mm Hg (mild orthostasis), HR 95 bpm, and RR 16 rpm. On physical examination, she has no findings consistent with volume overload. Laboratory analysis reveals sodium 135 mEq/L, potassium 4.9 mEq/L, BUN 45 mg/dL, and serum creatinine (SCr) 2.2 mg/dL (baseline BUN 27 mg/dL/ SCr 1.1 mg/dL). Upon further questioning, the patient admits to occasional dizziness.

Which of the following would be the optimal initial intervention for this patient?

a. Change furosemide to 80 mg IV twice daily
b. Hold furosemide and initiate cautious hydration with IV fluids
c. Hold carvedilol and initiate dobutamine at 2 mcg/kg/min IV
d. Increase carvedilol to 25 mg by mouth twice daily

Answer 40

b. Hold furosemide and initiate cautious hydration with IV fluids

(pt is volume depleted so we should hold furosemide; A. would make things worse; D. is wrong bc negative inotropic effects, carvedilol should be maintained until hypoperfusion has resolved)

Question 41

Compared to dobutamine, which of the following is true regarding milrinone?

a. Lower risk of hypotension
b. Greater dependence on hepatic clearance
c. Longer elimination half-life
d. Increased risk of arrhythmias

Answer 41

c. Longer elimination half-life

Question 42

An 84-year-old white male with ischemic cardiomyopathy (EF 20%-25%) presents to the hospital with acute decompensated HF. Vital signs include BP 89/55 mm Hg, HR 93 bpm (no orthostasis present), and RR 20 rpm. Physical examination reveals JVD, positive S3 sound, bilateral crackles throughout on lung auscultation, and 3+ bilateral edema to the thighs. Chest radiograph reveals pulmonary edema and pleural effusions. Hemodynamic measurements obtained by pulmonary artery catheter include pulmonary capillary wedge pressure 28 mm Hg, cardiac index 1.7 L/min/m2 (0.028 L/s/m2), and systemic vascular resistance 1,000 dyne·s·cm−5 (12.5 Wood units; 100 MPa·s/m3). The patient’s laboratory values are all normal, except BUN 34 mg/dL (12.1 mmol/L), and SCr 1.5 mg/dL (baseline BUN 32 mg/dL and 0.9 mg/dL). Medications on admission include lisinopril 10 mg daily, bisoprolol 10 mg daily, bumetanide 2 mg BID, atorvastatin 40 mg daily, and aspirin 81 mg daily.

Which of the following would be an appropriate initial strategy for managing this patient’s volume overload?

a. Furosemide 80 mg IV twice daily
b. Furosemide 80 mg IV twice daily plus metolazone 10 mg by mouth once daily
c. Furosemide 20 mg/h IV continuous infusion
d. Nitroglycerin 25 mcg/min IV continuous infusion

Answer 42

a. Furosemide 80 mg IV twice daily

(B. is wrong bc combo therapy would be reserved for pts who failed loop first; C. is wrong bc this is F 480 mg IV over a 24 hr period and would exceed initial dose for acute decomp HF; D. is wrong bc they have hypotension)

Question 43

An 84-year-old white male with ischemic cardiomyopathy (EF 20%-25%) presents to the hospital with acute decompensated HF. Vital signs include BP 89/55 mm Hg, HR 93 bpm (no orthostasis present), and RR 20 rpm. Physical examination reveals JVD, positive S3 sound, bilateral crackles throughout on lung auscultation, and 3+ bilateral edema to the thighs. Chest radiograph reveals pulmonary edema and pleural effusions. Hemodynamic measurements obtained by pulmonary artery catheter include pulmonary capillary wedge pressure 28 mm Hg, cardiac index 1.7 L/min/m2 (0.028 L/s/m2), and systemic vascular resistance 1,000 dyne·s·cm−5 (12.5 Wood units; 100 MPa·s/m3). The patient’s laboratory values are all normal, except BUN 34 mg/dL (12.1 mmol/L), and SCr 1.5 mg/dL (baseline BUN 32 mg/dL and 0.9 mg/dL). Medications on admission include lisinopril 10 mg daily, bisoprolol 10 mg daily, bumetanide 2 mg BID, atorvastatin 40 mg daily, and aspirin 81 mg daily.

Which of the following therapies would be appropriate for managing this patient’s low output?

a. Sodium nitroprusside 0.1 mcg/kg/min IV continuous infusion
b. Nitroglycerin 25 mcg/min IV continuous infusion
c. Dopamine 10 mcg/kg/min IV continuous infusion
d. Dobutamine 2 mcg/kg/min IV continuous infusion

Answer 43

d. Dobutamine 2 mcg/kg/min IV continuous infusion

(positive inotropic therapy is best)