Congestive Heart Failure
Miriam S. Jacob • Gary S. Francis • Leslie Cho
QUESTIONS
1.Your patient is a 50-year-old woman with nonischemic cardiomyopathy who just received an orthotopic heart transplant. Which of the following is NOT important to help prevent transplant vasculopathy?
a.Empirically starting statin therapy
b.Strict control of hypertension (HTN) and diabetes
c.Use of rapamycin as part of the immunosuppressive regimen
d.Abstinence from smoking
2.You are taking care of a 65-year-old man with history of coronary artery disease and prior bypass surgery. He is currently taking carvedilol and lisinopril at maximum doses. He was recently hospitalized for heart failure 3 months ago. Which of the following criteria would make it reasonable to add eplerenone to his regimen?
a.Ejection fraction (EF) of 15% with creatinine clearance of 20 mL/min/1.73 m2
b.EF of 20% and dyspnea while doing chores at home (New York Heart Association [NYHA] class II symptoms)
c.EF of 35% with QRS >130 milliseconds
d.EF of 45% and dyspnea with walking less than a block
3.For a patient with heart failure, coronary artery bypass grafting (CABG) is not reasonable for a patient with severe three-vessel coronary artery disease and
a.chest pain on exertion.
b.no viability found on dobutamine echo with EF of 15%.
c.recent ST-elevation myocardial infarction (MI).
d.heart failure with preserved EF.
e.systolic heart failure with EF of 30% and viable myocardium.
4.A 60-year-old African American man comes to your clinic with few months’ history of fatigue, dyspnea on exertion, and lower extremity edema. He has no history of prior coronary artery disease or heart failure. What features on an echo would not be consistent with amyloid heart disease?
a.Presence of a pericardial effusion
b.Biatrial enlargement
c.Normal tissue Doppler measurement of the left ventricular (LV) lateral and septal walls
d.LV hypertrophy
e.Grade 3 diastolic dysfunction
5.Which of the following characterizes heart failure?
a.Downregulation of β1– and β2-receptors
b.Downregulation primarily of β1-receptors with little change in β2-receptors
c.Downregulation of G proteins and β1– and β2-receptors
d.Increase in myocardial norepinephrine stores
e.Intact baroreceptor function
6.In the Veterans Administration Heart Failure Trial II (V-HeFT II), which combination of medications improved LV function and exercise tolerance?
a.Angiotensin-converting enzyme (ACE) inhibitors
b.Hydralazine plus nitrates
c.ACE inhibitor plus hydralazine plus nitrates
d.ACE inhibitor plus nitrates
7.A 56-year-old man presents to your clinic for follow-up after being discharged from the hospital 6 weeks ago. He underwent a successful primary angioplasty for acute anterior MI; however, his EF is now 40%. He is currently taking simvastatin (Zocor), acetylsalicylic aspirin, clopidogrel bisulfate (Plavix), metoprolol tartrate (Lopressor), and losartan (Cozaar). He states that he cannot afford all of these medications. He would like to know which medications are essential for a longer life. Which medications should you tell him are essential?
a.All of them
b.All of them except clopidogrel bisulfate
c.All of them except losartan
d.All except clopidogrel bisulfate and losartan
8.A 78-year-old woman with congestive heart failure (CHF) (EF, 25%), chronic atrial fibrillation (AFib), gastroesophageal reflux disease, HTN, hyperlipidemia, diabetes, and osteoporosis takes 12 different pills. At the recent senior citizen day at the local church, a nurse told her that she does not need to take digoxin because she is on amiodarone. She wants to eliminate digoxin from her medication regimen, and she wants to know why you put her on it in the first place. What is your answer?
a.Digoxin improves survival.
b.Digoxin reduces hospitalization.
c.Digoxin improves contractility.
d.Digoxin decreases the volume of distribution of amiodarone.
e.Digoxin reduces sympathetic nervous system activity.
9.Recently, a 43-year-old lawyer received heart transplantation. His hospital course was unremarkable, and he was discharged. He found out from the heart failure nurses that allograft vasculopathy is the leading cause of long-term morbidity and mortality in transplant patients. He wants to know what proven treatments prevent allograft vasculopathy. Which of the following treatments should you recommend?
a.Annual cardiac catheterization, intravascular ultrasound, and percutaneous coronary intervention (PCI), as needed
b.Annual stress test
c.Biannual stress test
d.Statins
e.No known treatment
10.A 72-year-old woman is transferred from another hospital. She was initially admitted with palpitation, diagnosed with AFib, and treated with amiodarone. A transthoracic echocardiogram (TTE) showed an EF of 10% with a regional wall motion abnormality. She underwent cardiac catheterization and was found to have a heavily calcified 80% lesion in the mid–left anterior descending artery (LAD), a 40% lesion in a nondominant circumflex, and an 80% lesion in the posterior descending artery. Her children want to know what you plan to do for her. What should you recommend?
a.She has terrible EF and should be on medication only because CABG would be of too high risk.
b.She should undergo PCI because she is too high risk for CABG.
c.She should undergo CABG because this is the definitive treatment.
d.She should have a positron emission tomography (PET) scan to assess the area of viability before proceeding with CABG or PCI.
11.A 53-year-old woman with a history of CHF presents to the emergency room (ER). She is cool and clammy. She reports being short of breath. Her blood pressure (BP) is 71/40 mmHg, her heart rate (HR) is 110 bpm, and her respiratory rate is 30. She has elevated neck veins and a prominent S3. Her echocardiogram (ECG) shows sinus tachycardia. She is admitted to the CCU (coronary care unit) with heart failure. A pulmonary artery (PA) catheterization is performed, and her hemodynamics are as follows: right atrial (RA) pressure, 12 mmHg; PA pressure, 62/30 mmHg; cardiac output, 1.9 L/min/m2; pulmonary capillary wedge pressure (PCWP), 36 mmHg; and systemic vascular resistance (SVR), 2,000 dyne/s/cm5. Which of the following is your next step?
a.Start furosemide (Lasix).
b.Start dopamine.
c.Insert intra-aortic balloon pump (IABP).
d.Begin dobutamine.
e.Start nesiritide.
12.This patient continues to deteriorate after your initial treatment. Her BP is 64/32 mmHg, and her HR is 132 bpm. She is now intubated on maximal pressor support and has an IABP in place. Which of the following should be your next therapeutic option?
a.There is no option. She is on maximal therapy.
b.Consider emergent cardiac transplant.
c.Consider LV assist device.
d.Consider cardiopulmonary bypass.
13.A 35-year-old man with a history of HTN presents to the ER in respiratory distress. He is intubated in the ER for respiratory distress. His BP is 73/48 mmHg, his HR is 130 bpm, and his respiratory rate is 20. He is taken to the medical ICU (intensive care unit), and a PA catheterization is performed. His hemodynamics are as follows: RA pressure, 22 mmHg; PA pressure, 20/10 mmHg; cardiac output, 3.5 L/min/m2; PCWP, 12 mmHg; and SVR, 1,690 dyne/s/cm5. What is your diagnosis?
a.Pulmonary embolism
b.Cardiogenic shock
c.Acute right ventricular (RV) failure
d.Decompensated heart failure
e.Hypovolemic shock
14.You receive a call from a cardiologist in a small community hospital regarding a patient in heart failure. She states that the patient was admitted last night with heart failure and was started on intravenous (IV) nitroglycerin; IV furosemide infusion; captopril, 12.5 mg t.i.d.; and digoxin. There has been no improvement; therefore, the cardiologist placed a Swan-Ganz catheter this morning. The patient’s hemodynamics are as follows: BP, 120/89 mmHg; HR, 89 bpm; cardiac output, 2.0 L/min/m2; PCWP, 29 mmHg; and SVR, 1,766 dyne/s/cm5. The cardiologist also added dobutamine. Which of the following additional therapies should you recommend to the cardiologist for this patient?
a.Begin patient transfer arrangement.
b.Suggest nitroprusside.
c.Suggest nesiritide.
d.Suggest dopamine.
e.Suggest IABP.
15.A 57-year-old woman, who experienced inferior wall MI in 1992, has an EF of 30% and was diagnosed with nonsustained ventricular tachycardia (VT) (four beats of VT) at another hospital on a routine ECG that she needed before cataract surgery. She has been in excellent health and has never been hospitalized for CHF. She has never had palpitation or syncopal episodes. Her doctors advised her that she would need an implantable defibrillator. She does not agree and wants a second opinion. She wants to know whether there is any evidence to support the implantable defibrillators. What is your advice?
a.Place an implantable defibrillator.
b.Do not place an implantable defibrillator: A single episode is probably insignificant.
c.Perform an electrophysiologic (EP) study.
d.Begin β-blockers with amiodarone.
16.A 49-year-old man is admitted with new-onset heart failure. He is diagnosed with dilated cardiomyopathy with an EF of 20%. On hospital day 1, he is diuresed and started on a regimen of furosemide, digoxin, acetylsalicylic aspirin, captopril, and simvastatin. A medical student wants to know why you did not start him on a β-blocker. What is your explanation?
a.β-Blockers have not been shown to decrease mortality in dilated cardiomyopathy patients. Only ischemic cardiomyopathy patients have derived benefit.
b.There have been several conflicting results from randomized trials; therefore, β-blockers are not recommended as the first line of therapy.
c.β-Blockers have been shown to improve survival but should only be used in patients with an EF greater than 25%.
d.β-Blockers should be started in stable CHF patients.
17.The same medical student wants to know whether the patient should also be started on calcium channel blockers. What is your answer?
a.There has never been a study to demonstrate the benefit of calcium channel blockers.
b.Diltiazem has proved to be of small but significant benefit in nonischemic cardiomyopathy patients and should be started.
c.Calcium channel blockers should be started after discharge once the patient has been stabilized.
d.Felodipine has proved to be of small benefit only in ischemic cardiomyopathy patients. This patient does not fit this criterion.
e.Amlodipine proved to be of small benefit in a NYHA class III or IV patient with an EF <30%. This benefit was seen more in dilated cardiomyopathy patients.
18.A 24-year-old female medical student presents to urgent care with 5 days of fever and shortness of breath. She is diagnosed with a viral infection and sent home. Five months later during her physical examination class, she is found to have an S3 by her fellow students. She presents to your office for a second opinion. On examination, she appears healthy and in no distress. Her BP is 96/50 mmHg, with an HR of 71 bpm and a respiratory rate of 12. Her neck veins are not distended, and her examination is unremarkable except for an enlarged heart. You do not appreciate an S3. You order a TTE, which shows an EF of 20% with a dilated heart. There is no valvular abnormality. Which of the following is your recommendation?
a.Begin ACE inhibitor, β-blockers, and steroid.
b.Begin ACE inhibitor and β-blockers.
c.Begin ACE inhibitor, β-blockers, diuretics, and digoxin.
d.Begin ACE inhibitor, β-blockers, diuretics, and spironolactone.
e.She is well compensated; nothing needs to be done.
19.A 79-year-old man with diabetes, HTN, chronic renal insufficiency, and ischemic cardiomyopathy was recently admitted with CHF exacerbation. At home, he takes captopril, 75 mg t.i.d.; digoxin, 0.125 mg per day; furosemide, 60 mg b.i.d.; aspirin; and atorvastatin calcium (Lipitor). When admitted, he was in heart failure with elevated neck veins and S3. During his admission, he was diuresed with IV furosemide and metolazone. His baseline creatinine was 1.7 and now is 2.5, with blood urea nitrogen of 100. What is your next step?
a.Stop captopril.
b.Stop diuretics.
c.Rule out renal artery stenosis.
d.Stop aspirin and ACE inhibitor.
20.The severity of symptomatic exercise limitation in heart failure
a.is caused by elevated PCWP.
b.is caused by reduced blood flow to skeletal muscles.
c.bears little relation to the severity of LV dysfunction.
d.can be reversed by inotropic therapy.
e.is related to markers of central hemodynamic disturbance.
21.A 59-year-old woman with CHF and an EF of 30% comes to your office for follow-up. She is on carvedilol (Coreg), enalapril, aspirin, atorvastatin calcium, digoxin, and furosemide. She has been doing well without any rehospitalization. However, she wants to improve her exercise tolerance. What should you recommend?
a.Cardiac transplantation
b.IV dobutamine
c.Higher doses of ACE inhibitor
d.Adding spironolactone
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