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Cardiology USMLE Step 3 > Section 3: Congestive Heart Failure > Flashcards

Section 3: Congestive Heart Failure Flashcards

1
Q

Clinical features of congestive heart failure

A
  • Shortness of breath
  • Edema
  • Rales on lung examination
  • Ascites
  • Jugular venous distention
  • S3 gallop
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Fatigue

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1943-1945). . Kindle Edition.

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2
Q

A 63-year-old woman comes to the emergency department with acute, severe shortness of breath; rales on lung exam; S3 gallop; and orthopnea. Which of the following is the most important step?

a. Chest x-ray
b. Oxygen, furosemide, nitrates, and morphine
c. Echocardiogram
d. Digoxin
e. ACE inhibitors
f. Carvedilol

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1946-1952). . Kindle Edition.

A

B. Oxygen, furosemide, nitrates, and morphine are the mainstay of therapy for acute pulmonary edema. Although they are not associated with a concrete mortality benefit, they are the standard of care for pulmonary edema, which is the worst manifestation of CHF. Removing volume from the vascular system and, therefore, the lungs is more important than any form of diagnostic testing. Pulmonary edema is a clinical diagnosis. Shortness of breath, rales, S3, and orthopnea are more important in establishing the diagnosis than any single test.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1953-1959). . Kindle Edition.

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3
Q

List the main stay of therapy for acute pulmonary edema

A
  • Oxygen
  • Furosemide
  • Nitrates
  • Morphine
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4
Q

List the initial tests to be ordered in CHF

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1966-1967). . Kindle Edition.

A
  • Chest x-ray
  • EKG
  • Pulse oximeter
  • Echocardiogram

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1968-1983). . Kindle Edition.

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5
Q

What are the expected findings on CXRay in a patient with CHF

A
  • Pulmonary vascular congestion
  • Cephalization of flow
  • Effusion
  • Cardiomegaly
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6
Q

What are the expected findings on EKG in a patient with CHF

A
  • Sinus tachycardia
  • Atrial and ventricular arrhythmia
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7
Q

What are the expected findings on Pulse Oximeter (consider ordering arterial blood gases [ABG]) in a patient with CHF

A
  • Hypoxia
  • Respiratory alkalosis (on ABG)
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8
Q

What are the uses of echocardiogram in a patient with CHF

A

Distinguishes systolic from diastolic dysfunction

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9
Q

True or False:

Digoxin is used for the acute Rx of pulmonary edema

A

False

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10
Q

What is the use of digoxin in patients with CHF?

A

Digoxin can be used to slow the rate of atrial fibrillation.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1990-1991). . Kindle Edition.

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11
Q

True or False:

The vast majority of patients with pulmonary edema will respond to preload reduction alone to control the acute symptoms.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 1993-1994). . Kindle Edition.

A

True

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12
Q

List the positive inotropic agents used intravenously in ICU

A
  • Dobutamine (drug of choice)
  • Amrinone
  • Milrinone

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2001-2002). . Kindle Edition.

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13
Q

An 80-year-old woman is admitted to the intensive care unit for acute pulmonary edema. She has rales to the apices and jugulovenous distention. Her EKG shows ventricular tachycardia. Which of the following is the best therapy?

a. Synchronized cardioversion
b. Unsynchronized cardioversion
c. Lidocaine
d. Amiodarone
e. Procainamide

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2007-2012). . Kindle Edition.

A

A. Synchronized cardioversion is used when ventricular tachycardia is associated with acute pulmonary edema. The same answer would be used if the acute pulmonary edema was associated with the onset of atrial fibrillation, flutter, or supraventricular tachycardia. Unsynchronized cardioversion is used for ventricular fibrillation or ventricular tachycardia without a pulse. Medical therapy, such as lidocaine, amiodarone, or procainamide, can be used for sustained ventricular tachycardia that is hemodynamically stable.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2013-2017). . Kindle Edition.

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14
Q

When is nesiritide the answer?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2018-2020). . Kindle Edition.

A

Nesiritide is a synthetic version of atrial natriuretic peptide that is used for acute pulmonary edema as a part of preload reduction. It decreases symptoms of shortness of breath and is not clearly associated with a reduction in mortality.

There is no clear indication that the answer is nesiritide.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2020-2022). . Kindle Edition.

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15
Q

When is a BNP level the answer?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2023). . Kindle Edition.

A

BNP or “brain natriuretic peptide” level is a blood test that can be used to establish a diagnosis of CHF in a patient who is short of breath. If the presentation is not clear, a BNP level can be used to help distinguish between pulmonary embolus, pneumonia, asthma, and CHF. BNP level goes up in CHF but is rather nonspecific. A normal BNP level excludes CHF.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2024-2027). . Kindle Edition.

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16
Q

A patient comes with pulmonary edema. A right heart catheter is placed. Which of the following readings is most likely to be found?

a. CO: Decreased; SVR: Increased; WP: Increased; RAP: Increased
b. CO: Decreased; SVR: Increased; WP: Decreased; RAP: Decreased
c. CO: Increased; SVR: Decreased; WP: Decreased; RAP: Decreased
d. CO: Decreased; SVR: Increased; WP: Decreased; RAP: Increased

CO=Cardiac Output; SVR=Systemic Vascular Resistance; WP=Wedge Pressure; RAP=Right Atrial Pressure

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2036-2054). . Kindle Edition.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2028-2035). . Kindle Edition.

A

a. CO: Decreased; SVR: Increased; WP: Increased; RAP: Increased

Pulmonary edema is associated with a decrease in cardiac output because of pump failure, which results in the backup of blood into the left atrium and an increased wedge pressure. There is also an increase in right atrial pressure, which is the same as saying jugular venous distention. Increases in sympathetic outflow will increase systemic vascular resistance in an attempt to maintain intravascular filling pressure. Choice B represents hypovolemic shock, such as dehydration. Choice C represents septic shock, which is driven by massive systemic vasodilation, such as from gram-negative sepsis. Choice D represents pulmonary hypertension.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2071-2074). . Kindle Edition.

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17
Q

What is the place of echocardiogram in patients with CHF that have been stabilized from acute pulmonary edema?

A

All patients, having been stabilized from acute pulmonary edema, should have an echocardiogram to establish whether there is systolic dysfunction with a low ejection fraction or diastolic dysfunction with a normal ejection fraction.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2076-2078). . Kindle Edition.

18
Q

What medications are used in the long-term management of dilated cardiomyopathy or systolic dysfunction?

A
  • ACE inhibitors
  • Beta blockers
  • Spirinolactone
  • Diuretics (not shown to decrease mortality)
  • Digoxin (not shown to decrease mortality)
19
Q

What is the place of digoxin the the long-term management of CHF?

A

Digoxin is used to decrease symptoms and decrease the frequency of hospitalization but has not been shown to decrease mortality in congestive failure.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2080-2081). . Kindle Edition.

20
Q

List the beta blockers with evidence of lowering mortality in CHF

A
  • Metoprolol
  • Carvedilol
21
Q

—– (1) —– and —– (2) —– are indicated for CHF patients with systolic dysfunction at any stage of disease.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2084). . Kindle Edition.

A

ACE inhibitors and beta blockers are indicated for CHF patients with systolic dysfunction at any stage of disease.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2084). . Kindle Edition.

22
Q

—— (1) —— lowers mortality but has only been proven to do so for more advanced, symptomatic disease; any patient originally presenting with pulmonary edema should get ——- (2) —–

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2085-2086). . Kindle Edition.

A
  1. Spirinolactone
  2. Spirinolactone
23
Q

The single most important fact about the “further management” of CHF is that mortality is decreased by —– (1) —–, —– (2) —–, and —– (3) —–. —– (4) —– decreases symptoms but does not lower mortality.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2087-2089). . Kindle Edition.

A
  1. ACE Inhibitors/ARBs
  2. Beta blockers
  3. Spirinolactone
  4. Digoxin
24
Q

Long-term Rx of diastolic dysfunction in CHF

A
  • Beta blockers
  • (Loop) Diuretics - Furosemide
25
Q

A 69-year-old man is seen in the office for further management of congestive heart failure. He currently has no symptoms and good exercise tolerance. He has been on lisinopril, metoprolol, spironolactone, and furosemide for the last 6 months. His ejection fraction is 23 percent. Which of the following is most likely to benefit this patient?

a. Intermittent dobutamine therapy
b. Digoxin
c. Cardiac transplantation
d. Implantable cardioverter/ defibrillator
e. Chlorthaladine

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2106-2113). . Kindle Edition.

A

D. Implantable cardioverter/ defibrillators are indicated in dilated cardiomyopathy. The most common cause of death in CHF is sudden death from arrhythmia. Those with an ejection fraction below 35 percent that persists are candidates for implantable defibrillator placement.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2116-2117). . Kindle Edition.

26
Q

When is a biventricular pacemaker the answer for CHF?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Location 2118). . Kindle Edition.

A

Biventricular pacemaker is associated with a decrease in mortality in those with severe congestive failure and a QRS duration > 120 msec. This is also referred to as “cardiac resynchronization therapy.”

If the patient is still short of breath and QRS is wide (> 120), then resynchronize with a biventricular pacer.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2119-2123). . Kindle Edition.

27
Q

When is warfarin the answer for CHF?

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2124-2125). . Kindle Edition.

A

There is no place for routine anticoagulation with warfarin, no matter how low the ejection fraction may be in CHF in the absence of a clot or chronic atrial fibrillation. Warfarin is generally a wrong answer for CHF.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2126-2127). . Kindle Edition.

28
Q

Which of the following is an absolute contraindication to the use of beta blockers?

a. Symptomatic bradycardia
b. Peripheral artery disease
c. Asthma
d. Emphysema
e. Diabetes

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2128-2133). . Kindle Edition.

A

Symptomatic bradycardia is an absolute contraindication for the use of beta blockers. The overwhelming majority of patients with peripheral artery disease can still use beta blockers. In a patient with a myocardial infarction, the mortality benefit of metoprolol far exceeds the risk of its use when asthma, emphysema, or peripheral artery disease is present. Two thirds of asthma patients can tolerate beta blockers.

Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 2135-2138). . Kindle Edition.

29
Q

Describe the pathophysiology of CHF with the aid of a diagram

A

Pathophysiology of Heart Failure

30
Q

Clinical features of pulmonary edema

A
  • SOB
  • Rales (on lung examination)
  • JVD
  • S3 gallop
  • Edema
  • Orthopnea
31
Q

List the common and less common causes of systolic dysfunction

A

Common causes:

  • Infarction
  • Cardiomyopathy
  • Valvular heart disease

Less common causes:

  • Alcohol
  • Postviral (idiopathic) mtocarditis
  • Radiation
  • Adriamycin (doxorubicin) use
  • Chagas disaese and other infections
  • Hemochromatosis (also causes restrictive cardiomyopathy)
  • Thyroid disease
  • Peripartum cardiomyopathy
  • Thiamine deficiency

(MTB STEP2)

32
Q

What is the most likely diagnosis for dyspnea based on the following key features:

  1. Sudden onset, clear lungs
  2. Sudden onset, wheezing, increased expiratory phase
  3. Slower, fever, sputum, unilateral rales/rhonchi
  4. Decreased breath sounds unilaterally, tracheal deviation
  5. Circumoral numbness, caffeine use, history of anxiety
  6. Palor, gradual over days or weeks
  7. Pulsus paradoxus, decreased heart sounds, JVD
  8. Palpitations, syncope
  9. Dullness to percussion ay bases
  10. Long smoking history, barrel chest
  11. Recent anesthetic use, brown blood not improved with oxygen, clear lungs on auscultation, cyanosis
  12. Burning building or car, wood-burning stove in winter, suicide attempt

(MTB STEP 2)

A
  1. Pulmonary embolus
  2. Asthma
  3. Pneumonia
  4. Pneumothorax
  5. Panic attack
  6. Anemia
  7. Tamponade
  8. Arrhythmia of almost any kind
  9. Pleural effusion
  10. COPD
  11. Methhemoglobinemia
  12. Carbon monoxide poisoning
33
Q

Ejection Fraction:

  1. Best initial test
  2. Most accurate test
A
  1. Transthoracic echo
  2. Multi-gated acquisition scan (MUGA) or nuclear ventriculography

(MTB STEP 2)

34
Q

How does beta blockers effects its benefits in patients with CHF

A
  • Antiischemic effect
  • Decrease in HR leading to decreased oxygen consumption
  • Antiarrhythmic effect
35
Q

What is the management of a patient with severe CHF who develops gynecomastia?

A

Switch spirinolactone to eplerenone

36
Q

list the devices used in CHF that helps lower mortality

A
  • Implantable defribillator
  • Biventricular pacemaker
37
Q

Indications for implantable defibrillator

A
  • Ischemic cardiomyopathy and
  • Ejection fraction below 35%
38
Q

Indications for biventricular pace maker

A
  • Dilated cardiomyopathy and
  • Ejection fraction below 35% and
  • A wide QRS above 120 milliseconds

who have persistent symptoms

39
Q

Mortality benefits in systolic dysfunction

A
  • ACEi/ARBs
  • Beta blockers
  • Spirinolactone or eplerenone
  • Hydralazine/nitrates
  • Implantable defibrillator
40
Q

The best initial therapy (single medication) for acute pulmonary edema

A

Loop diuretic (furosemide)

Cardiology USMLE Step 3 (12 decks)

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