HF Flashcards
What defines heart failure with recovered ejection fraction (HFrecEF)?
a) Persistent heart failure despite improved ejection fraction
b) Gradual or rapid improvement of ejection fraction to normal levels in patients with heart failure with reduced ejection fraction (HFrEF)
c) Acute heart failure following a myocardial infarction
d) A condition where ejection fraction remains low despite guideline-directed therapy
Answer: b) Gradual or rapid improvement of ejection fraction to normal levels in patients with heart failure with reduced ejection fraction (HFrEF)
Rationale: HFrecEF is a condition in which patients diagnosed with HFrEF experience rapid or gradual improvement in their ejection fraction to normal levels, typically due to effective guideline-directed therapy.
Which of the following is a predictor of heart failure with recovered ejection fraction (HFrecEF)?
a) Older age
b) Larger ventricular volumes
c) Ischemic etiology
d) Shorter duration of heart failure
Answer: d) Shorter duration of heart failure
Rationale: Predictors of HFrecEF include younger age, shorter duration of heart failure, nonischemic etiology, smaller ventricular volumes, and the absence of myocardial fibrosis.
Which of the following clinical conditions can lead to heart failure with recovered ejection fraction (HFrecEF)?
a) Chronic ischemic heart disease
b) Stress cardiomyopathy
c) Idiopathic dilated cardiomyopathy
d) Heart failure with preserved ejection fraction (HFpEF)
Answer: b) Stress cardiomyopathy
Rationale: Clinical examples that can lead to HFrecEF include conditions such as stress cardiomyopathy, fulminant myocarditis, peripartum cardiomyopathy, tachycardia-induced cardiomyopathy, and reversible toxin exposures like chemotherapy, immunotherapy, or alcohol.
How does the prognosis of patients with heart failure with recovered ejection fraction (HFrecEF) compare to those with HFrEF or HFpEF?
a) Prognosis is similar to that of patients with HFrEF
b) Prognosis is similar to that of patients with HFpEF
c) Prognosis is superior to that of both HFrEF and HFpEF patients
d) Prognosis is worse than that of HFrEF and HFpEF patients
Answer: c) Prognosis is superior to that of both HFrEF and HFpEF patients
Rationale: Generally, the prognosis of patients with HFrecEF is superior to that of patients with either HFrEF or HFpEF, as recovery of ejection fraction indicates a better overall functional outcome.
Which of the following is NOT a condition commonly associated with heart failure with recovered ejection fraction (HFrecEF)?
a) Peripartum cardiomyopathy
b) Tachycardia-induced cardiomyopathy
c) Chronic ischemic heart disease
d) Fulminant myocarditis
Answer: c) Chronic ischemic heart disease
Rationale: Chronic ischemic heart disease is not typically associated with HFrecEF. In contrast, HFrecEF is more commonly seen in conditions such as peripartum cardiomyopathy, stress cardiomyopathy, tachycardia-induced cardiomyopathy, and fulminant myocarditis.
What was the outcome of the CHARM Preserved study regarding the use of candesartan in HFpEF patients?
a) Significant reduction in all-cause mortality
b) Significant reduction in heart failure hospitalizations
c) No effect on heart failure hospitalizations
d) Significant improvement in functional capacity
Answer: b) Significant reduction in heart failure hospitalizations
Rationale: The CHARM Preserved study showed that treatment with the ARB candesartan led to a statistically significant reduction in HF hospitalizations in patients with HFpEF but did not affect all-cause mortality.
What was the result of the I-PRESERVE trial regarding irbesartan treatment in HFpEF patients?
a) Significant reduction in both cardiovascular death and HF hospitalizations
b) No difference in cardiovascular death or HF hospitalization compared to placebo
c) Improvement in functional capacity and quality of life
d) Increased risk of adverse cardiovascular events
Answer: b) No difference in cardiovascular death or HF hospitalization compared to placebo
Rationale: The I-PRESERVE trial demonstrated no difference in the composite of cardiovascular death or HF hospitalization between patients treated with irbesartan and those given a placebo.
What did the DIG Ancillary Trial conclude regarding the use of digoxin in patients with chronic heart failure and EF >45%?
a) Digoxin significantly reduced all-cause mortality
b) Digoxin had a modest reduction in HF hospitalizations
c) Digoxin improved exercise capacity and quality of life
d) Digoxin led to a significant reduction in cardiovascular hospitalizations
Answer: b) Digoxin had a modest reduction in HF hospitalizations
Rationale: The DIG Ancillary Trial found that digoxin did not impact all-cause mortality or all-cause/cardiovascular hospitalization in patients with chronic HF and EF >45%, though it did show a modest reduction in HF hospitalizations.
What was the outcome of the TOPCAT trial regarding spironolactone in HFpEF patients?
a) Spironolactone improved the primary composite endpoint of cardiovascular death, HF hospitalization, and aborted cardiac arrest
b) Spironolactone reduced the incidence of arrhythmias in HFpEF patients
c) Spironolactone reduced HF hospitalizations but did not affect cardiovascular death or HF hospitalization in the overall population
d) Spironolactone improved exercise capacity and quality of life in all HFpEF patients
Answer: c) Spironolactone reduced HF hospitalizations but did not affect cardiovascular death or HF hospitalization in the overall population
Rationale: The TOPCAT trial demonstrated no improvement in the primary composite endpoint but showed a reduction in HF hospitalizations among patients treated with spironolactone.
When should a pulmonary artery catheter be used in the management of ADHF?
a) As a first-line diagnostic tool for all patients with ADHF
b) Only in patients with low-output HF or cardiogenic shock who may need vasopressors or mechanical circulatory support
c) In all patients with high blood pressure
d) For routine assessment of fluid overload in all patients
Answer: b) Only in patients with low-output HF or cardiogenic shock who may need vasopressors or mechanical circulatory support
Rationale: The pulmonary artery catheter should be reserved for patients with features of low-output HF or cardiogenic shock who may require vasopressors or mechanical circulatory support, or those who are resistant to diuretic therapy.
Which of the following clinical findings is associated with worse outcomes in patients with ADHF?
a) Serum creatinine level >2.75 mg/dL
b) Systolic blood pressure >150 mmHg
c) Blood urea nitrogen level <20 mg/dL
d) Normal natriuretic peptide levels
Answer: a) Serum creatinine level >2.75 mg/dL
Rationale: A serum creatinine level greater than 2.75 mg/dL, along with other factors such as elevated blood urea nitrogen levels, low systolic blood pressure, and elevated cardiac biomarkers, has been associated with worse outcomes in ADHF.
Which of the following is a recommended therapy for hypertensive acute decompensated heart failure (ADHF) that is not volume overloaded?
A) Diuretics
B) Inotropic therapy
C) Vasodilators
D) Mechanical circulatory support
Answer: C) Vasodilators
Rationale: The image categorizes hypertensive ADHF as typically not volume overloaded, and vasodilators are the preferred treatment in such cases to reduce afterload and improve cardiac output.
In acute decompensated heart failure (ADHF) with severe pulmonary congestion and hypoxia, which of the following therapies is specifically indicated?
A) Inotropic therapy
B) Mechanical circulatory support
C) O₂ and noninvasive ventilation
D) Hemodynamic monitoring
Answer: C) O₂ and noninvasive ventilation
Rationale: Pulmonary congestion and hypoxia require oxygen therapy and noninvasive ventilation to improve oxygenation and reduce respiratory distress.
Which of the following is a key feature of “Low Output” acute decompensated heart failure?
A) High blood pressure
B) Low pulse pressure and cool extremities
C) Severe pulmonary congestion
D) Isolated right heart failure
Answer: B) Low pulse pressure and cool extremities
Rationale: “Low Output” ADHF is characterized by hypoperfusion and end-organ dysfunction, leading to signs like low pulse pressure and cool extremities due to reduced cardiac output.
What is a key management strategy for cardiogenic shock in acute decompensated heart failure?
A) Opioids
B) Vasodilators
C) Mechanical circulatory support (e.g., intraaortic balloon pump)
D) Diuretics
Answer: C) Mechanical circulatory support (e.g., intraaortic balloon pump)
Rationale: Cardiogenic shock is a severe form of ADHF with hypotension, low cardiac output, and end-organ failure, requiring mechanical circulatory support for stabilization.
Which of the following beta blockers is NOT proven to improve survival in heart failure with reduced ejection fraction (HFrEF)?
A) Carvedilol
B) Bisoprolol
C) Metoprolol succinate
D) Xamoterol
Answer: D) Xamoterol
Rationale:
The beta blockers proven to improve survival in HFrEF are carvedilol, bisoprolol, and metoprolol succinate, as supported by clinical trial data.
According to the Cardiac Insufficiency Bisoprolol Study (CIBIS) III, what is the impact of the sequence of drug initiation (ACEIs vs beta blockers) on outcomes in HFrEF?
A) Initiating ACEIs first leads to better outcomes
B) Initiating beta blockers first leads to better outcomes
C) The sequence of initiation does not affect outcomes
D) Beta blockers should always be initiated before ACEIs
Answer: C) The sequence of initiation does not affect outcomes
Rationale:
The CIBIS III trial showed that the order in which ACEIs and beta blockers are initiated does not affect patient outcomes in HFrEF. What matters is the timely initiation and optimal titration of both classes of medications.
How frequently can pharmacotherapy be uptitrated in stable ambulatory patients with HFrEF, assuming no symptoms of hypotension?
A) Every 1 week
B) Every 2 weeks
C) Every 4 weeks
D) Every 6 weeks
Answer: B) Every 2 weeks
Rationale:
In stable ambulatory patients with HFrEF, pharmacotherapy can be uptitrated every 2 weeks as tolerated, provided that there are no symptoms suggestive of hypotension, such as fatigue or dizziness. This approach ensures that patients reach target doses in a timely manner.
Which mineralocorticoid receptor antagonist (MRA) is most commonly utilized in the treatment of HFrEF based on efficacy shown in clinical trials?
A) Eplerenone
B) Spironolactone
C) Amiloride
D) Fludrocortisone
Answer: B) Spironolactone
Rationale:
Spironolactone is the most commonly used mineralocorticoid receptor antagonist in the treatment of HFrEF. It has demonstrated proven efficacy in the Randomized Aldactone Evaluation Study (RALES), particularly in patients with HFrEF and NYHA class III–IV symptoms.
What is a major advantage of eplerenone over spironolactone in certain patients with HFrEF?
A) Eplerenone is more effective in treating fluid retention
B) Eplerenone has a lower risk of hyperkalemia
C) Eplerenone lacks antiandrogen effects and may be suitable for patients with sexual side effects
D) Eplerenone is preferred in patients with acute kidney injury
Answer: C) Eplerenone lacks antiandrogen effects and may be suitable for patients with sexual side effects
Rationale:
Eplerenone, unlike spironolactone, lacks the antiandrogenic effects, such as gynecomastia, erectile dysfunction, and diminished libido. As a result, it may be a suitable alternative for patients who experience these side effects while taking spironolactone.
What was the primary benefit of sacubitril-valsartan compared to enalapril in patients with symptomatic HFrEF?
A) No difference in outcomes
B) 20% reduction in the composite primary endpoint of cardiovascular death or HF hospitalization
C) Increased rate of symptomatic hypotension
D) Greater rates of hyperkalemia and worsening renal function
Answer: B) 20% reduction in the composite primary endpoint of cardiovascular death or HF hospitalization
Rationale:
Sacubitril-valsartan demonstrated a dramatic 20% reduction in the composite primary endpoint of cardiovascular death or heart failure hospitalization compared to enalapril. This indicates better clinical outcomes in patients treated with sacubitril-valsartan.
When transitioning from ACEIs to sacubitril-valsartan, how long should the gap be to reduce the risk of overlap and angioedema?
A) 12 hours
B) 24 hours
C) 36 hours
D) 48 hours
Answer: C) 36 hours
Rationale:
To minimize the risk of angioedema, patients transitioning from an ACEI to sacubitril-valsartan should have a 36-hour gap between discontinuing the ACEI and starting the ARNI. This helps avoid overlap of the two medications’ effects.
What is the primary mechanism of action of ivabradine in patients with heart failure with reduced ejection fraction (HFrEF)?
A) Inhibition of the sodium-potassium pump
B) Inhibition of the If current in the sinoatrial node
C) Blockade of beta-adrenergic receptors
D) Inhibition of the angiotensin-converting enzyme
Answer: B) Inhibition of the If current in the sinoatrial node
Rationale:
Ivabradine selectively reduces heart rate by inhibiting the If current in the sinoatrial node. Unlike beta blockers, it does not affect cardiac contractility or vascular tone, making it a distinct therapeutic option.
What was the primary outcome of the Systolic Heart Failure Treatment with Ivabradine Compared with Placebo Trial (SHIFT)?
A) Reduction in all-cause mortality
B) Reduction in cardiovascular-related death and heart failure hospitalization
C) Improvement in left ventricular ejection fraction
D) Improvement in exercise tolerance
Answer: B) Reduction in cardiovascular-related death and heart failure hospitalization
Rationale:
In the SHIFT trial, ivabradine was shown to reduce the combined endpoint of cardiovascular-related death and heart failure hospitalization. This supports the idea that heart rate reduction may be a therapeutic target in HFrEF patients in sinus rhythm.
According to clinical guidelines, in which group of patients is ivabradine considered for use in HFrEF?
A) Patients who are not in sinus rhythm
B) Patients with a heart rate <60 beats/min
C) Patients who remain symptomatic despite treatment with guideline-directed therapy and have a heart rate >70 beats/min
D) Patients with acute decompensated heart failure
Answer: C) Patients who remain symptomatic despite treatment with guideline-directed therapy and have a heart rate >70 beats/min
Rationale:
Clinical guidelines suggest considering ivabradine in patients with HFrEF who remain symptomatic despite receiving guideline-based therapy (ACEI/ARB/ARNI, beta blockers, and MRAs), are in sinus rhythm, and have a residual heart rate >70 beats/min. It serves as an adjunct or alternative to beta blockers, especially for those who cannot tolerate them.
What is the primary effect of digitalis glycosides (e.g., digoxin) on the heart?
A) Negative inotropic effect
B) Mild inotropic effect
C) Vasodilation
D) Beta-adrenergic stimulation
Answer: B) Mild inotropic effect
Rationale:
Digitalis glycosides, such as digoxin, exert a mild inotropic effect, which increases the force of cardiac contraction. This is one of the key mechanisms by which they are used in heart failure management.
What was the primary outcome of the Digitalis Investigation Group (DIG) trial?
A) Reduction in mortality and improvement in quality of life
B) Reduction in heart failure hospitalizations but no reduction in mortality
C) Improvement in exercise tolerance and reduction in hospitalizations
D) Increase in mortality and hospitalizations in men
Answer: B) Reduction in heart failure hospitalizations but no reduction in mortality
Rationale:
The DIG trial demonstrated that digoxin resulted in a reduction in heart failure hospitalizations, but it did not lead to a reduction in mortality or improvement in quality of life. This suggests that while digoxin may help control symptoms, it does not improve overall survival.
In current clinical practice, when is digoxin typically used in heart failure management?
A) As a first-line therapy
B) As an adjunct to other therapies in patients with profound symptoms despite optimal treatment
C) As a replacement for ACE inhibitors
D) As a sole therapy in asymptomatic patients
Answer: B) As an adjunct to other therapies in patients with profound symptoms despite optimal treatment
Rationale:
Digoxin is generally reserved as a late-line therapy for patients with heart failure who remain profoundly symptomatic despite optimal neurohormonal blockade (e.g., ACE inhibitors, ARBs, beta blockers) and adequate volume control. It is not used as a first-line treatment.
Which class of diuretics is preferred for managing symptomatic heart failure (HF) to remedy congestive symptoms?
A) Thiazide diuretics
B) Loop diuretics
C) Potassium-sparing diuretics
D) Carbonic anhydrase inhibitors
Answer: B) Loop diuretics
Rationale:
Loop diuretics are the preferred agents for managing symptomatic heart failure because of their potent effect on renal sodium excretion. Thiazide diuretics are used in combination with loop diuretics for refractory volume overload.
Why should the use of first-generation calcium channel blockers (e.g., verapamil and diltiazem) be discouraged in patients with heart failure with reduced ejection fraction (HFrEF)?
A) They improve survival in HFrEF patients
B) They exert negative inotropic effects, which may destabilize patients
C) They cause excessive fluid retention
D) They reduce blood pressure too much, leading to hypotension
Answer: B) They exert negative inotropic effects, which may destabilize patients
Rationale:
First-generation calcium channel blockers such as verapamil and diltiazem have negative inotropic effects, which can destabilize patients with HFrEF by reducing contractility, potentially worsening heart failure symptoms.
What was the outcome of the CORONA and GISSI-HF trials regarding the use of rosuvastatin in patients with HFrEF?
A) Significant improvement in mortality and quality of life
B) Reduction in hospitalizations for heart failure
C) No improvement in aggregate clinical outcomes
D) Increase in survival and heart failure symptoms
Answer: C) No improvement in aggregate clinical outcomes
Rationale:
Both the CORONA and GISSI-HF trials tested low-dose rosuvastatin in HFrEF patients and found no improvement in overall clinical outcomes. Statins may be beneficial for treating atherosclerotic disease but do not appear to improve outcomes in established heart failure.
What is the current guideline recommendation regarding the use of aspirin in patients with HFrEF?
A) Routine use in all patients with HFrEF
B) Use only in patients with ischemic cardiomyopathy who do not have contraindications
C) Contraindicated in all HFrEF patients
D) Only for those with severe left ventricular dysfunction
Answer: B) Use only in patients with ischemic cardiomyopathy who do not have contraindications
Rationale:
Current guidelines recommend aspirin for patients with ischemic cardiomyopathy who do not have contraindications, as it has proven benefits in this group. It is not routinely recommended for non-ischemic heart failure.
What effect did omega-3 polyunsaturated fatty acids (w-3 PUFAs) have in the GISSI-HF trial?
A) Significant improvement in mortality rates
B) No effect on clinical outcomes
C) Modestly improved clinical outcomes in patients with HFrEF
D) Increased hospitalizations for heart failure
Answer: C) Modestly improved clinical outcomes in patients with HFrEF
Rationale:
The GISSI-HF trial showed that treatment with omega-3 PUFAs was associated with modestly improved clinical outcomes in patients with HFrEF. Low eicosapentaenoic acid (EPA) levels were linked to higher mortality, suggesting a potential benefit from supplementation.
According to the HF-ACTION study, what was the impact of supervised exercise training on patients with moderate HFrEF?
A) No effect on quality of life or mortality
B) Improvement in quality of life, exercise capacity, and a trend toward mortality reduction
C) Significant reduction in hospitalizations for heart failure
D) Decreased oxygen consumption and exercise tolerance
Answer: B) Improvement in quality of life, exercise capacity, and a trend toward mortality reduction
Rationale:
The HF-ACTION study demonstrated that supervised exercise training in patients with moderate HFrEF improved quality of life, exercise capacity, and showed a trend toward reduced mortality. Exercise training is thus recommended as an adjunctive therapy in heart failure.
What were the findings of the HF-ACTION study regarding the effects of supervised exercise training in patients with moderate HFrEF?
A) Exercise training significantly reduced hospitalizations for heart failure
B) Exercise training improved patients’ sense of well-being and correlated with a trend toward mortality reduction
C) Exercise training led to a significant increase in peak oxygen consumption at 3 months
D) Exercise training was unsafe for patients with moderate HFrEF
Answer: B) Exercise training improved patients’ sense of well-being and correlated with a trend toward mortality reduction
Rationale:
The HF-ACTION study demonstrated that supervised exercise training was safe and improved patients’ sense of well-being. Additionally, it correlated with a trend toward mortality reduction. Maximal improvements in 6-minute walk distance were seen at 3 months, and significant improvements in cardiopulmonary exercise time and peak oxygen consumption persisted at 12 months. Exercise training is therefore recommended as an adjunctive treatment in patients with heart failure.
Which of the following patients with heart failure would be an appropriate candidate for prophylactic implantable cardioverter-defibrillator (ICD) therapy?
A) A patient with NYHA class IV symptoms who is refractory to medications and not a transplant candidate
B) A patient with NYHA class II symptoms and an LVEF of 40%
C) A patient with NYHA class II symptoms and an LVEF of 30%
D) A patient with a myocardial infarction and an LVEF of 40% despite optimal medical therapy
Answer: C) A patient with NYHA class II symptoms and an LVEF of 30%
Rationale:
Prophylactic ICD therapy is recommended for patients with NYHA class II or III symptoms of heart failure and an LVEF <35%, irrespective of the etiology of HF. Additionally, patients with a history of myocardial infarction and an LVEF ≤30% despite optimal medical therapy are also appropriate candidates. However, ICD placement is generally not recommended for patients with class IV symptoms who are refractory to treatment and not transplant candidates due to the potential burden of recurrent ICD shocks and limited survival benefit.
Parameters associated with worse outcomes among inpatients with ADHF are the following:
1. blood urea nitrogen level >43 mg/dL (to convert to mmol/L, multiply by 0.357)
2. systolic blood pressure <115 mmHg
3. serum creatinine level >2.75 mg/dL (to convert to umol/L, multiply by 88.4)
4. elevated cardiac biomarkers including natriuretic peptides and cardiac troponins.
