Heart Failure Flashcards
- Which of the following finding, when reduced, indicates impaired systolic function in a patient with heart failure?
A. BNP
B. SCr
C. LVEF
D. LVH
E. Troponin
C
- What is the most common etiology of heart failure?
A. Ischemic
B. Idiopathic, unknown cause
C. Viral cardiomyopathy
D. Drug-induced
E. Hypertension
A
A 58-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months
prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years,
dyslipidemia, and is status post myocardial infarction 2 years ago.
Physical exam reveals the following: BP 148/96 mmHg, pulse 98 beats/min, Ht: 5’11’’ (18cm), Wt: 189 lb (86 kg; usual = 178 lb [ (+) JVD, (−) HJR or hepatomegaly
(+) S3, (+) S4
ECG: regular rate/rhythm, evidence of old infarct
ECHO: EF 33% (0.33)
CXR: Crackles bilaterally and cardiomegaly (enlarged heart)
Labs:
Sodium: 142 mE/L (142 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Magnesium: 1.8 mEq/L (0.90 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 μmol/L)
BNP: 322 pg/mL (322 ng/L; 93 pmol/L)
Current medications:
Aspirin 81 mg daily
Diltiazem 180 mg daily
Glipizide 10 mg twice daily for diabetes
Simvastatin 20 mg nightly at bedtime
Acetaminophen 500 mg twice daily
- Which of the patient’s medications can exacerbate systolic dysfunction heart failure?
A. Glipizide
B. Diltiazem
C. Acetaminophen
D. b and c
E. All of the above
B
A 58-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months
prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years,
dyslipidemia, and is status post myocardial infarction 2 years ago.
Physical exam reveals the following: BP 148/96 mmHg, pulse 98 beats/min, Ht: 5’11’’ (18cm), Wt: 189 lb (86 kg; usual = 178 lb [ (+) JVD, (−) HJR or hepatomegaly
(+) S3, (+) S4
ECG: regular rate/rhythm, evidence of old infarct
ECHO: EF 33% (0.33)
CXR: Crackles bilaterally and cardiomegaly (enlarged heart)
Labs:
Sodium: 142 mE/L (142 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Magnesium: 1.8 mEq/L (0.90 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 μmol/L)
BNP: 322 pg/mL (322 ng/L; 93 pmol/L)
Current medications:
Aspirin 81 mg daily
Diltiazem 180 mg daily
Glipizide 10 mg twice daily for diabetes
Simvastatin 20 mg nightly at bedtime
Acetaminophen 500 mg twice daily
- Which of the following is TRUE regarding the patient’s current NYHA functional class
and stage of heart failure?
A. Class III, Stage B
B. Class III, Stage C
C. Class II, Stage B
D. Class II, Stage C
E. Class IV, Stage C
B
A 58-year-old man presents to the clinic today with complaints of increasing shortness of breath while dressing and carrying groceries and a 10 lb (4.5 kg) weight gain. A few months
prior, he noticed episodes of waking in the middle of the night with shortness of breath, difficulty breathing after walking two flights of stairs, as well as ankle edema. The patient has a history of osteoarthritis × 10 years, hypertension × 4 years, diabetes mellitus × 5 years,
dyslipidemia, and is status post myocardial infarction 2 years ago.
Physical exam reveals the following: BP 148/96 mmHg, pulse 98 beats/min, Ht: 5’11’’ (18cm), Wt: 189 lb (86 kg; usual = 178 lb [ (+) JVD, (−) HJR or hepatomegaly
(+) S3, (+) S4
ECG: regular rate/rhythm, evidence of old infarct
ECHO: EF 33% (0.33)
CXR: Crackles bilaterally and cardiomegaly (enlarged heart)
Labs:
Sodium: 142 mE/L (142 mmol/L)
Potassium: 3.7 mEq/L (3.7 mmol/L)
Magnesium: 1.8 mEq/L (0.90 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 μmol/L)
BNP: 322 pg/mL (322 ng/L; 93 pmol/L)
Current medications:
Aspirin 81 mg daily
Diltiazem 180 mg daily
Glipizide 10 mg twice daily for diabetes
Simvastatin 20 mg nightly at bedtime
Acetaminophen 500 mg twice daily
- Which of the following is the MOST appropriate ACUTE treatment plan for the patient’s heart failure?
A. Add HCTZ 12.5 mg Qday, since creatinine clearance is above 30 mL/min (0.5 mL/s)
B. Add HCTZ 25 mg Qday, increase dose of diltiazem to 240 mg Qday
C. Add furosemide 20 mg BID and nesiritide infusion since BNP is elevated
D. Add furosemide 20 mg BID and lisinopril 10 mg Qday, discontinue diltiazem
E. Add furosemide
D
- What is the medical term for the symptom of “feels short of breath when she lies down at night”?
A. Orthopnea
B. Hepatojugular reflux
C. Paroxysmal nocturnal dyspnea
D. Pulmonary congestion
E. Peripheral edema
A
- Which of the following is TRUE regarding ACE inhibitors in heart failure?
A. Should be used mainly in severe heart failure, NYHA functional class IV
B. Efficacy of ACE inhibitors is a class effect
C. May be used in place of hydralazine and isosorbide dinitrate in cases of renal
dysfunction
D. Can be replaced by angiotensin receptor blockers if the patient has hyperkalemia
E. Should be discontinued if creatinine clearance decreases by more than 10%
B
- Which of the following is TRUE regarding β-blockers in heart failure?
A. Ideally should be started in setting of congestion to aid in diuresis
B. FDA-approved agents include carvedilol and metoprolol succinate
C. Metoprolol tartrate is more efficacious than carvedilol for heart failure
D. Chronic β-blockade increases ventricular mass
E. Metoprolol has more potent blood pressure lowering effects compared to
carvedilol
B
- A 74-year-old woman presents to clinic for heart failure follow-up. She is classified as NYHA FC II. Her blood pressure is 144/82 mm Hg, and most recent EF is 26% (0.26).
Her current medication regimen includes lisinopril 20 mg Qday, carvedilol 25 mg BID,
digoxin 0.125 mg Qday, and furosemide 20 mg BID. Which of the following would be
the BEST choice to add at this time?
A. Metolazone
B. Hydralazine and isosorbide
C. Spironolactone
D. Hydrochlorothiazide
E. Valsartan
C
- Mineralocorticoid receptor antagonists (or aldosterone receptor antagonists) have been shown to reduce mortality in patients with heart failure. Which of the following is TRUE about MRAs?
A. Spironolactone leads more frequently to gynecomastia compared to eplerenone
B. Associated with hypokalemia
C. Can only be used in NYHA functional class IV
D. Used after maximizing ACE inhibitors, β-blockers, and digoxin
E. Added to loop diuretic when a patient is resistant to its effects to enhance removal
of fluid
A
- A 76-year-old man is admitted to the hospital presenting with peripheral and pulmonary edema, decreased urinary output, hypotension, and altered mental status. Pertinent values:
PCWP = 32 mm Hg (4.3 kPa), Cardiac index (CI) = 1.8 L/min/m2. Based on his
presentation, what hemodynamic subset is he in?
A. I
B. II
C. III
D. IV
E. II and IV
D
- Which of the following diuretic combinations is used for the purpose of reducing congestion in the setting of diuretic resistance?
A. Hydrochlorothiazide and spironolactone
B. Spironolactone and torsemide
C. Furosemide and spironolactone
D. Furosemide and metolazone
E. Nesiritide and spironolactone
D
- A 68-year-old African American woman is admitted to the hospital for new onset acute decompensated heart failure. Her current medications include felodipine 2.5 mg Qday and atorvastatin 20 mg Qday. Hemodynamic readings include a PCWP of 16 (2.1 kPa) and a CI of 1.8 L/min/m2. Which of the following is the MOST appropriate treatment plan?
A. Fluids, inotropes
B. Diuretics, vasodilators
C. Fluids, inotropes, vasodilators
D. Diuretics, fluids, inotropes
E. Diuretics, inotropes, vasodilators
A
- Which of the following statements is most appropriate for patient counseling on
nonpharmacologic management of heart failure?
A. Supervised exercise is recommended including aerobic activity and weight lifting
B. Contact health care provider if weight increases by more than 3 lb (1.4 kg) in a
day or 5 lb (2.3 kg) in a week
C. Lower dietary sodium intake to no more than 2 grams per day
D. Maintain alcohol intake to no more than 2 drinks per day if diagnosed with
alcohol-induced cardiomyopathy
E. Weight should be kept at 15% above ideal body weight to maintain adequate
nutrition absorption
B
- A 68-year-old woman is admitted for decompensated heart failure, hemodynamic subset IV. Her current medication regimen includes enalapril 10 mg BID, digoxin 0.125 mg Qday, carvedilol 12.5 mg BID, furosemide 80 mg BID, and potassium chloride (K-Dur) 40 mEq (40 mmol) BID. Which of the following is TRUE regarding using milrinone therapy in this patient?
A. Milrinone can interact with her β-blocker therapy due to its β-agonist mechanism
B. Effects begin to wear off after 72 hours due to tolerance
C. Dose needs to be adjusted in renal dysfunction
D. Milrinone is not appropriate to use in subset IV
E. a and c
C
- A left ventricular ejection fraction of less than what value is the threshold for diagnosis of HF with reduced ejection fraction?
A. 20% (0.20)
B. 30% (0.30)
C. 40% (0.40)
D. 50% (0.50)
C
- What is the most common etiology of heart failure?
A. Ischemic
B. Idiopathic, unknown cause
C. Viral cardiomyopathy
D. Drug-induced
A
- What is the medical term for the symptom requiring a person to sleep more upright in order to feel comfortable breathing?
A. Orthopnea
B. Hepatojugular reflux
C. Paroxysmal nocturnal dyspnea
D. Pulmonary congestion
A
- Which of the following guideline-directed medical therapies is not associated with an
improvement in survival in HFrEF?
A. Spironolactone
B. Sacubitril and valsartan
C. Hydralazine and isosorbide dinitrate
D. Ivabradine
D
- A 64-year-old Hispanic man with HFrEF is currently receiving GDMT including
losartan, carvedilol, and torsemide. The patient is NYHA FC III. Vitals and laboratory
values are within normal limits. What additional therapy would be most appropriate to initiate in this patient to further reduce morbidity and mortality?
A. Eplerenone
B. Digoxin
C. Hydralazine and isosorbide dinitrate
D. Metoprolol succinate
A
- A 66-year-old woman presents to clinic for HF follow-up. She has no complaints other than noticing increasing lower extremity edema despite being compliant with her furosemide regimen of 20 mg twice daily. She also reports a reduction in urine output. Vitals and laboratory values are within normal limits. Which of the following interventions is most appropriate at this time?
A. Switch furosemide to torsemide 20 mg twice daily
B. Add metolazone 10 mg once daily
C. Increase furosemide to 30 mg twice daily
D. Switch furosemide to hydrochlorothiazide 25 mg once daily
A
- A 68-year-old woman returns to clinic after having a follow-up echocardiogram for evaluation of cardiac structure and function on optimal HF medications to assess next steps. Her echo reveals an LVEF of 30% to 35% (0.300.35), which is only marginally improved compared to her baseline echocardiogram of 25% to 30% (0.250.30). She is NYHA FC II by symptoms today. Her current cardiac medications include enalapril 10mg twice daily, carvedilol 25 mg twice daily, digoxin 0.125 mg once daily, and
spironolactone 25 mg once daily. She is euvolemic. Vitals: BP 122/74 mm Hg, HR 58
beats/min, weight 82 kg (180 lb; dry weight). What is the most appropriate treatment plan for the patient at this point?
A. Increase carvedilol to 50 mg twice daily
B. Switch enalapril to sacubitril/valsartan
C. Add candesartan
D. Increase digoxin to 0.25 mg daily
B
- A 73-year-old man is admitted to the hospital presenting with peripheral and sacral edema and hepatomegaly. Patient is having difficulty concentrating and peripheral pulses are diminished. Urinary output is diminished. Pertinent values: PCWP = 32 mm Hg (4.3 kPa), cardiac index (CI) = 1.7 L/min/m 2 (0.028 L/s/m 2 ). Based on his presentation, what hemodynamic subset is he in?
A. I
B. II
C. III
D. IV
D
- Which of the following diuretic combinations provides sequential blockade of sodium reabsorption in the nephron to overcome diuretic resistance in HF?
A. Hydrochlorothiazide and eplerenone
B. Torsemide and ethacrynic acid
C. Furosemide and spironolactone
D. Bumetanide and metolazone
D
- Which of the following statements is most appropriate for patient counseling on
nonpharmacologic management of HF?
A. Heavy weightlifting is recommended for physical activity.
B. Fluid intake should be restricted no more than 1 L/day.
C. Lower dietary sodium intake to no more than 3 g/day.
D. Daily weight should be checked each evening prior to sleeping.
C
A 70-year-old white man presents to the emergency department in severe respiratory distress. Past medical history includes coronary artery disease, HFrEF, hypertension, and COPD. The patient doesn’t manifest signs of volume overload and only endorses minimal pedal edema.
- Which test would be most appropriate to obtain to help determine a diagnosis?
A. Serum sodium
B. BNP level
C. Swan-Ganz catheter placement
D. ECG
B
A 70-year-old white man presents to the emergency department in severe respiratory distress. Past medical history includes coronary artery disease, HFrEF, hypertension, and COPD. The patient doesn’t manifest signs of volume overload and only endorses minimal pedal edema.
- The patient is treated for the acute respiratory event and is being prepared for discharge home. You are consulted as the pharmacy clinician on the cardiology team to optimize his HF regimen. His current HF medication regimen: aspirin 81 mg once daily, lisinopril 20 mg once daily, metoprolol succinate 200 mg once daily, and furosemide 40 mg twice
daily. His BP is 122/75 mm Hg and HR 79 beats/min (in normal sinus rhythm). Pertinent laboratory values include sodium 135 mEq/L (mmol/L), potassium 5.3 mEq/L (mmol/L), and SCr 2.1 mg/dL (186 μmol/L). Which therapy is most appropriate to add at this time to further improve prognosis?
A. Spironolactone
B. Sacubitril/valsartan
C. Hydralazine and isosorbide dinitrate
D. I M,vabradine
D
An 81-year-old woman presents to the clinic today with a chief complaint of increasing fatigue and swelling in her legs. She used to be able to walk without limitations, but for the last month now gets short of breath when walking her dog after five to six blocks. She also noticed that her legs get progressively swollen throughout the day. She denies trouble sleeping and uses one pillow. She denies any fever, cough, chills, or nausea. Past medical
history is significant for hypertension × 25 years, recurrent persistent nonvalvular atrial fibrillation × 15 years, and osteoporosis × 10 years. Physical examination reveals the following: BP 150/96 mm Hg, pulse 110 beats/min, Wt 130 lb (59 kg)
Lungs: decreased breath sounds at the bases, no wheezes or rhonchi
CV: + JVD, tachycardic, irregularly, irregular rhythm, +S3, PMI nondisplaced
GI: +BS, soft, NTND, no hepatomegaly
Extr: 1+ pitting edema to the knees, pulses intact, skin warm
ECG: HR 110 beats/min, irregularly, irregular rhythm, LVH, no acute ST–T wave changes
ECHO: EF 35% (0.35)
CXR: cephalization
Laboratory values:
Sodium: 140 mEq/L (mmol/L)
Potassium: 5.1 mEq/L (mmol/L)
Magnesium: 1.9 mEq/L (0.95 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 560 pg/mL (ng/L; 162 pmol/L)
Current medications:
Apixaban 2.5 mg twice daily
Amlodipine 5 mg daily
Metoprolol succinate 25 mg once daily
Calcium carbonate 500 mg three times daily
Vitamin D 800 IU once daily
- Which of the following is the correct classification of this patient by NYHA function class?
A. FC I
B. FC II
C. FC III
D. FC IV
B
An 81-year-old woman presents to the clinic today with a chief complaint of increasing fatigue and swelling in her legs. She used to be able to walk without limitations, but for the last month now gets short of breath when walking her dog after five to six blocks. She also noticed that her legs get progressively swollen throughout the day. She denies trouble sleeping and uses one pillow. She denies any fever, cough, chills, or nausea. Past medical
history is significant for hypertension × 25 years, recurrent persistent nonvalvular atrial fibrillation × 15 years, and osteoporosis × 10 years. Physical examination reveals the following: BP 150/96 mm Hg, pulse 110 beats/min, Wt 130 lb (59 kg)
Lungs: decreased breath sounds at the bases, no wheezes or rhonchi
CV: + JVD, tachycardic, irregularly, irregular rhythm, +S3, PMI nondisplaced
GI: +BS, soft, NTND, no hepatomegaly
Extr: 1+ pitting edema to the knees, pulses intact, skin warm
ECG: HR 110 beats/min, irregularly, irregular rhythm, LVH, no acute ST–T wave changes
ECHO: EF 35% (0.35)
CXR: cephalization
Laboratory values:
Sodium: 140 mEq/L (mmol/L)
Potassium: 5.1 mEq/L (mmol/L)
Magnesium: 1.9 mEq/L (0.95 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 560 pg/mL (ng/L; 162 pmol/L)
Current medications:
Apixaban 2.5 mg twice daily
Amlodipine 5 mg daily
Metoprolol succinate 25 mg once daily
Calcium carbonate 500 mg three times daily
Vitamin D 800 IU once daily
- Which of the following is the correct classification of this patient by HF stage?
A. Stage A
B. Stage B
C. Stage C
D. Stage D
C
An 81-year-old woman presents to the clinic today with a chief complaint of increasing fatigue and swelling in her legs. She used to be able to walk without limitations, but for the last month now gets short of breath when walking her dog after five to six blocks. She also noticed that her legs get progressively swollen throughout the day. She denies trouble sleeping and uses one pillow. She denies any fever, cough, chills, or nausea. Past medical
history is significant for hypertension × 25 years, recurrent persistent nonvalvular atrial fibrillation × 15 years, and osteoporosis × 10 years. Physical examination reveals the following: BP 150/96 mm Hg, pulse 110 beats/min, Wt 130 lb (59 kg)
Lungs: decreased breath sounds at the bases, no wheezes or rhonchi
CV: + JVD, tachycardic, irregularly, irregular rhythm, +S3, PMI nondisplaced
GI: +BS, soft, NTND, no hepatomegaly
Extr: 1+ pitting edema to the knees, pulses intact, skin warm
ECG: HR 110 beats/min, irregularly, irregular rhythm, LVH, no acute ST–T wave changes
ECHO: EF 35% (0.35)
CXR: cephalization
Laboratory values:
Sodium: 140 mEq/L (mmol/L)
Potassium: 5.1 mEq/L (mmol/L)
Magnesium: 1.9 mEq/L (0.95 mmol/L)
BUN: 22 mg/dL (7.9 mmol/L)
SCr: 1.3 mg/dL (115 µmol/L)
BNP: 560 pg/mL (ng/L; 162 pmol/L)
Current medications:
Apixaban 2.5 mg twice daily
Amlodipine 5 mg daily
Metoprolol succinate 25 mg once daily
Calcium carbonate 500 mg three times daily
Vitamin D 800 IU once daily
- Which of the following is the most appropriate acute intervention for this patient?
A. Add furosemide
B. Switch metoprolol succinate to tartrate
C. Add sacubitril/valsartan
D. Switch apixaban to warfarin
A
