Trial Flashcards
1
Q
Heart failure (HF) is a progressive clinical syndrome associated with:
A
Impairment of the ability of the ventricle to fill with or eject blood
2
Q
HF may be caused by an abnormality in:
A
1) Systolic function
2) Diastolic function
3) Both
3
Q
What are the leading causes of HF?
A
1) Coronary artery disease
2) Hypertension
4
Q
In heart failure with reduced ejection fraction (HFrEF) there is a decrease in:
A
Cardiac output
5
Q
What compensatory responses happen due to heart failure with reduced ejection fraction (HFrEF)?
A
1) Activation of the sympathetic nervous system (SNS) and the renin–angiotensin–aldosterone system (RAAS)
2) Vasoconstriction
3) Sodium and water retention
4) Ventricular hypertrophy and remodeling
6
Q
Pharmacotherapy targeted at ____ has slowed the progression of HFrEF and improved survival.
A
Antagonizing the neurohormonal activation
7
Q
Heart failure with preserved ejection fraction (HFpEF) is primarily due to:
A
1) Diastolic dysfunction
2) Disturbances in relaxation
8
Q
What are the causes of systolic dysfunction (decreased contractility)?
A
1) Reduction in muscle mass (MI)
2) Dilated cardiomyopathies
3) Ventricular hypertrophy
4) Pressure overload (systemic or pulmonary hypertension, aortic or pulmonary valve stenosis)
5) Volume overload (valvular regurgitation, shunts, high-output states)
9
Q
What are the causes of diastolic dysfunction (restriction in ventricular filling)?
A
1) Increased ventricular stiffness
2) Ventricular hypertrophy (hypertrophic cardiomyopathy, others)
3) Infiltrative myocardial diseases (amyloidosis, sarcoidosis, endomyocardial fibrosis)
4) Myocardial ischemia and infarction
5) Mitral or tricuspid valve stenosis
6) Pericardial disease (pericarditis, pericardial
tamponade)
10
Q
What are the factors precipitating/exacerbating
heart failure?
A
1) Cardiac events
2) Noncardiac events
3) Nonadherence with prescribed HF medications or with dietary recommendations
4) Drugs
11
Q
How can drugs precipitate or exacerbate HF?
A
1) Negative inotropic effects
2) Direct cardiotoxicity
3) Increased sodium and/or water retention
12
Q
Which drugs have negative inotropic effects?
A
1) Antiarrhythmics
2) Beta-blockers
3) Calcium channel blockers
13
Q
Which Antiarrhythmics have negative inotropic effects?
A
1) Disopyramide
2) Flecainide
3) Propafenone
14
Q
Which Beta-blockers have negative inotropic effects?
A
1) Propranolol
2) Metoprolol
3) Carvedilol
15
Q
Which Calcium channel blockers have negative inotropic effects?
A
1) Verapamil
2) Diltiazem
16
Q
Which drugs can cause cardiotoxicity?
A
1) Doxorubicin
2) Epirubicin
3) Daunomycin
4) Ethanol
5) Cyclophosphamide
6) Trastuzumab
7) Bevacizumab
8) Ifosfamide
9) Lapatinib
10) Sunitinib
11) Imatinib
12) Amphetamines
13) Cocaine
17
Q
Which drug contains high sodium?
A
Ticarcillin disodium
18
Q
Which drugs can cause sodium and/or water retention?
A
1) NSAIDs
2) COX2-inhibitors
3) Rosiglitazone
4) Pioglitazone
5) Glucocorticoids
6) Androgens and Estrogens
7) High dose Salicylates
8) High sodium-containing drugs
19
Q
___ and _____ are part of
CHF therapy.
A
Medication history; Discontinuation of medications known to exacerbate HF
20
Q
What are key elements in the pathogenesis of progressive myocardial failure?
A
Left ventricular hypertrophy and remodeling
21
Q
Ventricular remodeling is a broad term describing:
A
Changes in both:
1) Myocardial cells
2) Extracellular matrix
= changes in the size, shape, structure, and function of the heart.
22
Q
What is the normal shape of the left ventricle?
A
Ellipse
23
Q
What is the shape of the left ventricle after remodeling?
A
Sphere
24
Q
The change in ventricular size and shape during remodeling further:
A
1) Depresses the mechanical performance of the heart
2) Increases regurgitant flow through the mitral valve
3) Sustains progression of remodeling
25
The onset of the ___ precedes
the development of HF symptoms.
Remodeling process
26
Which mediators play an important role in initiating the signal transduction cascade responsible for ventricular remodeling?
1) Angiotensin II
2) NE
3) Endothelin
4) Aldosterone
5) Vasopressin
6) Numerous inflammatory cytokines
27
The goals of therapy in management of chronic
HF are to:
1) Improve the patient’s quality of life
2) Relieve or reduce symptoms
3) Prevent or minimize hospitalizations
4) Slow progression of the disease
5) Prolong survival
28
The general principles used to guide the treatment of HFrEF are based on:
Numerous large, randomized, double-blind, multicenter clinical trials.
29
The guidelines for the management of HFpEF are based primarily on:
Studies in relatively small groups of patients and on clinical experience.
30
The complexity of the HF syndrome necessitates a comprehensive approach to management, which includes:
1) Accurate diagnosis
2) Identification and treatment of risk factors
3) Elimination or minimization of precipitating factors
4) Appropriate pharmacologic and nonpharmacologic therapy
5) Close monitoring and follow up
31
What is the first step in management of chronic HF?
Determine the etiology and/or precipitating factors
32
___ in patients with CHD may reduce HF symptoms.
Revascularization or anti-ischemic therapy
33
___ reduces cardiac workload and is recommended for all patients with acute congestive symptoms, until patient’s symptoms have stabilized and excess fluid is removed.
Restriction of physical activity
34
What may improve functional status & quality of life, and may reduce hospitalizations and death from cardiovascular causes?
Exercise training
35
In patients with hyponatremia (Na ˂130 mEq/L) or those with persistent volume retention despite high diuretic doses and sodium restriction, daily fluid intake should be:
Limited to 2 L/day from all sources.
36
You should be careful with sodium and fluid restriction in patients with:
HFpEF
37
Why should you be careful with sodium and fluid restriction in patients with HFpEF?
Because excessive restriction can lead to:
1) Hypotension
2) Low-output state
3) Renal insufficiency
38
What are the four identified stages of HF?
1) Patients at Risk for HF
2) Patients With Pre-HF
3) Stage C HF
4) Stage D (Advanced) HF
39
What is the first stage of HF? (Patients at Risk for HF)
Patients with cardiac disease but without limitations of physical activity
40
What interventions can be taken to prevent the first stage of HF from progressing?
1) If Hypertensive: Reduce BP
2) If type 2 diabetes: SGLT2i
3) Healthy life style habits
4) Risk factor identification and prevention
41
Risk factors act ___(additively/synergistically) to develop both HFrEF and HFpEF.
Synergistically
42
___ and ___ are recommended for HF prevention in patients with multiple cardiovascular risk factors.
ACE inhibitors/ARBs; Statins
43
What is the second stage of HF? (Patients With Pre-HF)
Patients with cardiac disease that results in slight limitations of physical activity.
44
Patients with the second stage of HF (Patients With Pre-HF) have:
Structural heart disease but NOT
HF symptoms.
45
What does structural heart disease include in patients with the second stage of HF (Patients With Pre-HF)?
1) Left ventricular hypertrophy
2) Recent or old MI
3) Valvular heart disease
4) LVEF ˂ 0.4
46
How can you prevent clinical HF in patients with Pre-HF (2nd stage) with LVEF ≤ 40%?
ACEIs should be used to prevent symptomatic HF and reduce mortality
47
How can you prevent clinical HF in patients with Pre-HF (2nd stage) with a history of MI or ACS?
Statins should be used to prevent symptomatic HF and adverse cardiovascular events.
48
How can you prevent clinical HF in patients with Pre-HF (2nd stage) with a history of MI or ACS and LVEF ≤ 40%?
Evidence-based beta blocker should be used to reduce mortality
49
Which drugs should not be used in patients with LVEF ≤50%?
1) Thiazolidindiones
2) Non-hydropyridine calcium channel blockers
50
What is the third stage of HF? (Stage C HF)
Patients with cardiac disease that results in marked limitation of physical activity.
Although patients are comfortable at rest, less than ordinary activity will lead to symptoms
51
Patients with structural heart disease and previous or current symptoms are classified as ___ and can have HFrEF or HFpEF.
Stage C
52
Patients with HF should receive vaccination for ___ to reduce mortality.
Respiratory illnesses
53
Patients with HF should be screened for ___ and other risk factors for poor self care.
Depression
54
Which drugs are recommended in patients with heart failure with fluid retention?
1) Loop diuretics
2) Metolazone (If no response)
55
In patients with HFrEF and NYHA class II-III symptoms, the use of ___ is recommended to reduce morbidity and mortality.
ARNi (angiotensin receptor/neprilysin inhibitor)
56
In patients with previous or current symptoms of chronic HFrEF, the use of ___ is beneficial to reduce morbidity and mortality when the use of ARNi is not feasible.
ACEIs/ARBs
57
ARNi should not be coadministered with __ or within ____.
ACEIs; the last 36 hours of the last dose of ACEIs.
58
ARNi should not be administered in any patient with a history of ___.
Angioedema
59
___ should not be administered in any patient with a history of angioedema.
ACEIs
60
In patients with previous or current symptoms of chronic HFrEF, use of one of the three ____ is recommended to reduce mortality and hospitalization
Beta blockers
61
In patients with HFrEF and NYHA class II-IV symptoms, which drug is recommended to
reduce morbidity and mortality if eGFR is > than 30 mL/min and serum potassium < 5 mEq/L?
Aldosterone receptor antagonist (Spironolactone or Eplerenone)
62
For African-American patients with NYHA class III-IV HFrEF who receive optimal therapy, the combination _____ is recommended to improve symptoms and reduce morbidity and mortality,
Hydralazine and Isosorbide dinitrate
63
In patients who can not receive ACEIs, ARNi or ARB, ___ is recommended to reduce morbidity and mortality.
Hydralazine and isosorbide dinitrate
64
For patient with symptomatic (NYHA class II-III) stable chronic HFrEF (≤ 35%) who are receiving GDMT, including beta blocker at maximum tolerated dose, and who are in sinus rhythm with a heart rate of ≥ 70 bpm at rest, ___ can be beneficial to reduce heart failure hospitalization and cardiovascular death.
Ivabradine
65
In patients with symptomatic HFrEF despite GDMT (or who are unable to tolerate GDMT), ___ may be considered to decrease hospitalization for HF.
Digoxin
66
In selected high risk patients with HFrEF and recent worsening of HF already on GDMT an ____ may be considered to decrease HF hospitalization and cardiovascular death.
Oral soluble guanylate cyclase stimulator
67
Nonpharmacologic therapy with devices such as _____is also indicated in certain patients with HFrEF in Stage C.
1) Implantable cardioverter-defibrillator (ICD)
2) Cardiac resynchronization therapy (CRT) with a biventricular pacemaker
68
What is Stage D (Advanced) HF?
Patients with cardiac disease that results in an inability to carry on physical activity without discomfort.
Symptoms of congestive heart failure are present even at rest
69
In patients with advanced heart failure, when consistent with patient’s goal of care, timely
referral for HF specialty care is recommended to:
1) Review HF management
2) Assess suitability for advanced HF therapies (left ventricular assist device [LVAD], cardiac
transplantation, palliative care and palliative inotropes).
70
Guidelines for Stage D HFpEF recommend treating co-morbid
conditions by:
1) Controlling HR and BP
2) Alleviating causes of myocardial ischemia
3) Reducing volume
4) Restoring and maintaining sinus rhythm in patients with atrial fibrillation
71
What are the 3 treatment approaches for HFpEF?
1) Symptom-targeted treatment
2) Disease-targeted treatment
3) Mechanism-targeted treatment
72
What is the symptom-targeted treatment for HFpEF?
1) Decrease pulmonary venous pressure
2) Reduce myocardial oxygen demand
3) Maintain atrial contraction
4) Improve exercise tolerance
73
What is the rationale for decreasing pulmonary venous pressure in HFpEF?
Reduce left ventricular volume
74
What is the rationale for reducing myocardial oxygen demand in HFpEF?
1) Reduce HR
2) Control BP
75
What is the rationale for maintaining atrial contraction in HFpEF?
Restore sinus rhythm
76
Which agents can decrease pulmonary venous pressure?
1) Diuretics
2) Nitrates
3) Salt restriction
77
Which agents can reduce myocardial oxygen demand?
1) Beta-Blockers
2) Verapamil
3) Diltiazem
4) ACEi/ARBs
5) CCBs
78
Which agents can maintain atrial contraction?
Cardioversion of A-fib
79
Which agents can improve exercise tolerance?
Use positive inotropic agents with caution
80
What is the disease-targeted treatment for HFpEF?
1) Prevent or treat myocardial ischemia
2) Prevent or regress ventricular hypertrophy
81
Which agents can prevent or treat myocardial ischemia?
1) Beta-Blockers
2) Nitrates
3) Verapamil
4) Diltiazem
82
Which agents can prevent or regress ventricular hypertrophy?
Antihypertensives
83
What is the mechanism-targeted treatment for HFpEF?
1) Modify myocardial and extramyocardial mechanisms
2) Modify intracellular and extracellular mechanisms
84
Which agents can modify myocardial and extramyocardial mechanisms?
1) ACEis/ARBs
2) Diuretics
3) Spironolactone
85
Which agents can modify intracellular and extracellular mechanisms?
1) ACEis/ARBs
2) Diuretics
86
In patients with atrial fibrillation who are intolerant to or have NOT responded to a βblocker; ____ may be considered.
1) Diltiazem
2) Verapamil
87
A nondihydropyridine or dihydropyridine calcium channel blocker can be considered for ___.
Angina and hypertension
88
___ and __ are recommended for the treatment of both HFrEF and HFpEF.
β-blockers and diuretics
89
In HFpEF, β-blockers are used to:
1) Decrease HR
2) Prolong diastole
3) Modify hemodynamic response to exercise
90
In HFrEF, β-blockers are used in the long term to:
1) Improve the inotropic state
2) Modify LV remodeling
91
The doses of diuretics used to treat ___ are much smaller than those used to treat ___.
HFpEF; HFrEF
92
____ are useful in lowering BP and reducing LVH.
Antagonists of the RAAS
93
___ may be useful in the treatment of HFpEF.
Calcium channel blockers
94
Which calcium channel blockers are usefulin HFpEF?
1) Diltiazem
2) Amlodipine
3) Verapamil
95
The natriuretic peptides ANP and BNP cause:
1) Vasodilation
2) Natriuresis
3) Diuresis
96
What do the natriuretic peptides ANP and BNP do?
1) Inhibit renin secretion
2) Inhibit aldosterone production
3) Attenuate ventricular hypertrophy and fibrosis
97
What is Neprilysin?
A zinc-dependent metalloprotease
98
Function of Neprilysin?
1) Breaks down the natriuretic peptides ANP & BNP, bradykinin and other peptides
2) Clearance of amyloid-β from the brain and CSF
99
ARB/Neprilysin Inhibitor such as ___ can be used for the treatment of patients with HFrEF.
Valsartan/Sacubitril
100
___ is a prodrug, which inhibits the action of neprilysin.
Sacubitril
101
What are the adverse effects of Valsartan/Sacubitril?
1) Hypotension
2) Dizziness
3) Hyperkalemia
4) Worsening renal function
5) Cough
6) Angioedema
102
Valsartan/Sacubitril should not be used with:
1) ACEis or ARBs
2) Aliskiren
103
Valsartan/Sacubitril contraindications?
1) History of angioedema
2) Pregnancy
3) Hyperkalemia
4) Renal artery stenosis
5) Severe hepatic impairment
6) Renal dysfunction
7) Diabetic patients taking Aliskiren
104
Where does Ivabradine act?
Blocks the If current in the SA node that is responsible for controlling the heart rate.
105
What does Ivabradine do?
Slows the spontaneous depolarization of the sinus node = dose-dependent slowing of HR
106
Ivabradine’s effects are specific to the If current and does not affect:
1) Myocardial contractility
2) AV conduction
107
Ivabradine is extensively metabolized by intestinal and hepatic ___.
CYP3A4
108
Ivabradine is contraindicated in which patients?
1) Patients taking CYP3A4 inhibitors = bradycardia
2) Patients taking CYP3A4 inducers = prolongs QT
109
Adverse effects of Ivabradine?
1) Bradycardia
2) Effects on vision primarily manifesting as phosphenes (transient brightness in portions of the visual field)
3) Atrial fibrillation
110
In the heart, natriuretic peptides lead to the activation of the ___ pathway.
Nitric Oxide-soluble Guanylate Cyclase-cGMP
111
Soluble Guanylate Cyclase (sGC) stimulators activate:
sGC independent of NO by binding to a non-heme site in sGC
112
Which sGC stimulator has been in use for pulmonary hypertension?
Riociguat
113
What is Vericigaut?
sGC stimulator
114
Vericigaut has significant benefits in reducing hospitalizations in patients with ___ that are at high risk of cardiovascular events.
HFrEF
115
Does Vericiguat have a mortality benefit?
NO
116
Vericigaut is contraindicated in which patients?
1) Those with concomitant use of other soluble guanylate cyclase (sGC) stimulators
2) Pregnancy
117
Unless contraindicated, ___ should be initiated early as part of the foundational therapy in all patients with HF.
SGLT2 inhibitors
118
SGLT2 inhibitors have been shown to reduce risks of clinical events in patients with heart failure (HF), with early and sustained benefits regardless of:
1) Ejection fraction
2) Diabetic status
3) Care setting
119
Contraindications for SGLT2 inhibitors?
1) Type 1 DM or history of ketoacidosis
2) Hypotension (systolic BP<100mmHg)
3) Severe kidney disease (eGFR <20-25mL/min/1.73m2)
4) Pregnancy, risk of pregnancy, breast feeding
5) Caution in patients with a history of recurrent UGS infections
120
Association of ____ was the best combination for reducing all-cause death and the composite outcome of cardiovascular death or hospitalization for HF, and serious adverse renal outcomes in patients with a broad spectrum of severity of HFrEF.
1) ARNi
2) β-blockers
3) Aldosterone receptor antagonists
4) SGLT2 inhibitors
121
What should you monitor when giving SGLT2 inhibitors?
1) Check renal function when starting therapy and after 1-2 weeks
2) Blood glucose
3) Observe for acute illness or major surgery
122
Patient/caregiver counselling for SGLT2 inhibitors?
1) Ensure adequate daily genital hygiene
2) Watch for symptoms of volume depletion, urogenital infection, and diabetic ketoacidosis
3) Avoid dehydration, low carbohydrate (ketogenic) diet, and excessive alcohol consumption
123
What are the benefits of diuretics?
1) Reduction of symptoms associated with fluid retention
2) Improvement of exercise tolerance and quality of life
3) Reduction of hospitalizations from HF
4) Reduction of pulmonary and peripheral edema through reduction of preload
124
True or False:
Diuretics prolong survival and alter disease progression.
False
125
Over-diuresis may produce __ with ACE inhibitor or β-blocker therapy.
Hypotension
126
Hypotension can be a significant problem in the treatment of HFpEF because:
A small change in volume causes a large change in filling pressure and cardiac output.
127
___(Loop/Thiazide) diuretics may be preferred in patients with mild fluid retention and elevated BP because of their
more persistent antihypertensive effects.
Thiazide
128
____ or ____ can inhibit delivery of loop diuretics to their site of action and decrease effectiveness.
1) Probenecid
2) Organic by-products of uremia
129
Loop diuretics should not be given with:
NSAIDs
130
Unlike thiazides, loop diuretics maintain their effectiveness in the presence of:
Impaired renal function
131
The most common cause of HFrEF is:
Ischemic heart disease
132
Which ACEi's benefit post-MI patients whether therapy is initiated early or late after the infarct?
1) Captopril
2) Ramipril
3) Trandolapril
133
CKD patients should be monitored carefully for the development of:
1) Worsening renal function
2) Hyperkalemia
134
True or False: ACEi's improve survival rate.
True
135
Do ARBs cause cough or angioedema?
No
136
Do ACEi's cause cough or angioedema?
Yes
137
Which drugs are ARBs?
1) Candesartan
2) Losartan
3) Valsartan
138
ARBs are indicated in which patients?
Those who are unable to tolerate cough produced by ACE inhibitors.
139
____ should be used in all stable patients with HF and a reduced left ventricular EF in the absence of contraindications.
β-blockers
140
___ are recommended for asymptomatic patients with a reduced left ventricular EF to decrease the risk of progression to HF.
β-blockers
141
Three β-blockers have been shown to significantly reduce mortality compared with placebo:
1) Carvedilol
2) Metoprolol succinate (CR/XL)
3) Bisoprolol
