Heart Failure

Question 1

Worsening dyspnea is a cardinal symptom of HF and is typically related to increases in cardiac filling pressures, but also may represent restricted cardiac output

Answer 1

related to increases in cardiac filling pressures,

Question 2

Another cardinal symptom of HF is fatigue, generally held to be reflective of

Answer 2

f reduction in cardiac output a

Question 3

Additional findings supporting amyloidosis include

Answer 3

deltoid muscle infiltration (leading to the “shoulder pad sign”), tongue hypertrophy, and bilateral thenar wasting from carpal tunnel syndrome.

Question 4

A characteristic holosystolic murmur of mitral regurgitation is heard in many HF patients. Tricuspid regurgitation, which s also common, can be differentiated from mitral regurgitation by the location of the murmur at the left sternal border, an increased intensity of the murmur during inspiration, and the presence of prominent “V” waves in the jugular venous waveform.

Answer 4

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increased intensity of the murmur during inspiration, and the presence of prominent “V” waves in the jugular venous waveform.

Question 5

The presence of a third heart sound is a crucially impo tant finding and suggests increased ventricula filling volume;

Answer 5

S3 increased ventricula filling volume;

s4 . A fourth heart sound usually indicates reduced ventricular compliance

Question 6

The most definitive method for assessing a patient’s volume status by physical examination is by the measurement of

Answer 6

jugular venous pressure (JVP).

Question 7

An elevated JVP has good sensitivity (70%) and specificity (79%) for

Answer 7

elevated left-sided filling pressure 13

Question 8

Conversely, the JVP may be elevated without an increase in left ventricular filling pressures in patients with severe tricuspid regurgitation is present

Answer 8

pulmonary arterial hypertension, in those with isolated right ventricular pressure, or when isolated

Question 9

(congested with normal perfusion, the most common combination found in decompensated heart failure),

Answer 9

“wet/warm”

Question 10

acute coronary ischemia is a leading cause of acutely decompensated HF,

Answer 10

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Question 11

Because of the differences in their clearance, BNP and NT-proBNP have considerably different half-lives (BNP: 20 minutes; NT-proBNP: 90 minutes),

Answer 11

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Question 12

romising biomarkers bear mention.

Soluble concentrations of ST2, a member of the interleukin receptor family, have been shown to be strongly linked to progressive HF and death in patients across the four ACC/AHA stages of HF.

Answer 12

ST2 fibrosis of the heart

Question 13

is a giant molecule, the largest protein yet described.

Answer 13

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Question 14

Both Otto Frank and Ernest Starling observed that the more the diastolic filling of the heart, the greater the strength of the heartbeat. The increased heart volume translates into increased sarcomere length, which acts by a length-sensing mechanism

Answer 14

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Question 15

The AT 2 receptor is localized more specifically in fibroblasts and the interstitium.

Answer 15

activation of the AT 2 receptor leads to vasodilation, inhibition of cell growth, natriuresis and bradykinin release

Question 16

T 1 receptor leads to v tion, cell growth, aldosterone secretion, and catecholamine release

Answer 16

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Question 17

In contrast, angiotensin III directly stimulates the zona glomerulosa of the adrenal glands to produce aldosterone, 2 which promotes sodium resorption in the distal collecting duct of the kidney

Answer 17

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Question 18

he V 1a receptors mediate vasoconstriction, platelet aggregation, and stimulation of myocardial growth factors, whereas V 1b modulates adrenocorticotropic hormone (ACTH) secretion from the anterior pituitary. The V 2 receptor mediates antidiuretic effects by stimulating adenyl cyclase to increase the rate of insertion of water channel − containing vesicles into the apical membrane.

Answer 18

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Question 19

Increased renal sympathetic activity leads to increased renin production by the kidneys, with a resultant sustained activation of RAS, despite an expanded extracellular volume.

Answer 19

Angiotensin II facilitates retention of sodium and water by multiple renal mechanisms, including a d rect proximal tubular effect, as well as through activation of aldosterone, which leads to increased sodium resorption in the distal tubule. Angiotensin II also stimulates the thirst center of the brain and provokes the release of AVP and aldosterone both of which can lead to further dysregulation of salt and water homeostasis.

Question 20

Whereas ANP is secreted in short bursts in response to acute changes in atrial pressure, the activation of BNP is regulated transcriptionally in response to chronic increases in atrial/ventricular pressure

Answer 20

and short burts HL 3 min

BP chronic HL 20 min

Question 21

The most powerful stimulus for peripheral vasoconstriction is sympathetic activation, which releases the potent vasoconstrictor

Answer 21

NE.

Question 22

“concentric” hypertrophy

Answer 22

In pressure overload hypertrophy (e.g., with aortic stenosis or hypertension), increased systolic wall stress leads to the addition of sarcomeres in parallel, an increase in myocyte cross-sectional area, and increased LV wall thickening

linked with alterations in Ca 2+ /calmodulindependent protein kinase II–dependent signaling

Question 23

eccentric” hypertrophy

Answer 23

volume overload hypertrophy (e.g., with aortic and mitral regurgitation),

increased diastolic wall stress leads to an increase in myocyte length with the addition of sarcomeres in series, thereby engendering increased LV ventricular dilation

protein kinase B (Akt) activation 2

Question 24

n HF there is decreased uptake of Ca 2+ by the SR secondary to decreased SERCA2a protein levels and SERCA2a function.

Answer 24

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Question 25

midrange ejection fraction” (generally considered as EF of)

Answer 25

40% to 49%

Question 26

the difference between systolic and diastolic blood pressure) is a useful measure that is an indirect marker of cardiac output.

Answer 26

Pulse Pressure

Question 27

High pulse pressure indicates

Answer 27

high-output state, including the possibility of unrecognized thyrotoxicosis, aortic regurgitation, or anemia

Question 28

jugular venous pressure (JVP)

Answer 28

barometer of systemic venous hypertension

Right atrial pressure

indirect measure of LV filling pressures.

Question 29

rales are often not heard in patients with a b ground of chronic HF and pulmonary venous hypertension, because of increased lymphatic drainage, reinforcing the important clinical pearl that the absence of rales does not necessarily imply normal LV filling pressures.

Answer 29

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Question 30

estimated that a m nimum of ——-of extracellular fluid is accumulated to produce clinically detectable edema.

Answer 30

4 liters

Question 31

peak early diastolic transmitral blood flow velocity (E) to the peak early-diastolic mitral annular tissue velocity (Ea) (E:Ea ratio)

Answer 31

An E:Ea ratio greater than 15 predicts a pulmonary capillary wedge pressure (PCWP) greater than 15 mm Hg

Question 32

f the identified triggers,——— was associated with the highest in-hospital mortality (8%)

Answer 32

worsening renal function

Question 33

inhaled oxygen (FiO 2 ≥0.4) may cause adverse hemodynamic effects (e.g., hyperoxia-induced vasoconstriction) in patients with systolic dysfunction

Answer 33

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Question 34

AF with rapid ventricular response is the most common t rhythmia requiring treatment in patients with AHF.

Answer 34

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Question 35

The most common cause of RV HF in AHF is left-sided failure.

Answer 35

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Question 36

Cardiogenic Shock definitions

Answer 36

Cardiogenic shock is c ized by marked hypotension (SBP <80 mm Hg) lasting more than 30 minute
associated with severe reduction of cardiac index (usually <1.8 L/min/m 2 )
despite adequate LV filling pressure (PCWP >18 mm Hg)
resulting in organ hypoperfusion.

Cardiogenic shock is an unusual presentation of AHF, occurring in less than 4% of the patients in EHFS II,

Question 37

commonly used practical definition is an increase in serum creatinine of more than 0.3 mg/dL (or 25% decreases in GFR) despite evidence of persistent clinical or hemodynamic congestion.

Answer 37

Cardiorenal Syndrome

Question 38

Although a “transfusion threshold” for maintaining the Hct above 30% in patients with CV disease has been generally been accepted,

Answer 38

HFREFZ

Question 39

IV iron replacement might be reasonable in patients with NYHA Class II and III HF and iron deficiency (ferritin <100 ng/mL or 100 to 300 ng/ mL if transferrin saturation < 20%) to improve functional status and quality of life. 10

Answer 39

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Question 40

Patients should be advised to weigh themselves regularly to monitor weight gain and to alert a health care provider or adjust their diuretic dose in the event of a sudden unexpected weight gain of more than 3 to 4 pounds over a 3 day period

Answer 40

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Question 41

ARTS-HF (Mineralocorticoid-Receptor Antagonist Tolerability Study). 17 ARTS-HF was a randomized, double-blind, comparator-controlled multicenter trial in 1066 patients with heart failure (LVEF ≤40%). The primary endpoint was the percentage of individuals with a decrease of more than 30% in plasma NT-p oBNP from baseline to day 90. When compared to eplerenone, finerenone was well tolerated and resulted in a 30% or greater decrease in NT-proBNP levels

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Question 42

Triamterene and amiloride are referred to as potassium-sparing diuretics

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Question 43

Triamterene is a pyrazinoylguanidine derivative, whereas amiloride is a pteridine

Answer 43

proximal tubule, where they block Na + reabsorption in the late distal tubule and collecting duc

Question 44

EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients) showed that empagliflozin reduced death from CV causes by 38%, hospitalization for HF by 35%, and progression to end-stage kidney disease in patients with type 2 diabetes and established CV disease 18

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Question 45

Angiotensin Receptor Neprilysin Inhibitors

Answer 45

combines valsartan (an AT1 receptor antagonist) with sacubitril (a neprilysin inhibitor) in a 1 : 1 mixture

slows the degradation of natriuretic peptides, bradykinin, and adre nomedullin

inhibits renin and aldosterone secretion, while selectively blocking the angiotensin type 1 (AT1) receptor reduces vasoconstriction, sodium, and water retention and myocardial hypertrophy

Question 46

Three beta blockers have been shown to be effective in reducing the risk of death in patients with chronic HF: bisoprolol and sustained-release metoprolol succinate both competitively block the β 1 receptor, and carvedilol competitively blocks the α 1 , β 1 , and β 2 receptors.

Answer 46

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Question 47

Patients with HFpEF have normal LV end-diastolic volume and normal (or near-normal) EF and stroke volume (at rest) and usually exhibit concentric remodeling of LV chamber and/or cardiomyocyte

Answer 47

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