Cardiology Intensive Board Review, 3th Edition

Chapter 8 - 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

e.Enrolling her in an exercise training program

22.Prognosis in heart failure correlates best with which of the following?

a.Peak O2 during exercise

b.E/O2 slope during exercise

c.EF at rest

d.Blood gases during exercise

e.Myocardial contractility measurements

23.An 86-year-old woman is transferred from a nursing home in respiratory distress. She was found to be short of breath. On examination, she has labored breathing, and her BP is 62/34 mmHg with an HR of 60 bpm. She is intubated in the ER and admitted to the CCU. She is started on norepinephrine and dopamine at high doses without significant effect. Her ECG shows sinus bradycardia but is otherwise unremarkable. Her chest X-ray (CXR) shows pulmonary edema. The nursing home calls and says that she has mistakenly received 100 mg IV metoprolol tartrate. Which of the following should be your next step?

a.Glucagon and milrinone

b.Glucagon and dobutamine

c.IABP

d.Fluid resuscitation

e.Transvenous pacemaker

24.A 62-year-old man with an EF of 20% and chronic renal insufficiency presents to your office for follow-up. He has non-insulin-dependent diabetes mellitus and has developed worsening renal failure caused by diabetes. His medication regimen includes a β-blocker that is significantly affected by reduced renal function. Which of the following β-blockers is he taking?

a.Propranolol

b.Atenolol

c.Carvedilol

d.Metoprolol

e.Sotalol

25.A 38-year-old patient with CHF is transferred from another hospital. You are doing rounds in the CCU while the clinicians are performing a TTE. They ask you to assess his LV function. You notice that the E:A wave ratio is greater than 1.5, with an E-wave deceleration time of 120 milliseconds. Which of the following do you guess is his PCWP?

a.PCWP is 12 mmHg.

b.PCWP is 18 mmHg.

c.PCWP is 26 mmHg.

d.You cannot tell from the E:A wave ratio and deceleration time.

26.For the patient in the previous question, the E:A wave ratio and the E-wave deceleration time indicate which of the following?

a.Low filling pressure and reduced LV compliance

b.High filling pressure and increased LV compliance

c.Low filling pressure and increased LV compliance

d.High filling pressure and reduced LV compliance

27.A 67-year-old patient with HTN, hyperlipidemia, and an EF of 45% comes to your office for a second opinion. He had an exercise test and was told that his HR recovery was abnormal. His physician told him not to worry unlesshis heart function deteriorates. He is not convinced and wants your opinion and treatment. What should you recommend?

a.Abnormal HR recovery does not predict mortality in patients with an EF greater than 35%; therefore, no treatment is needed.

b.Abnormal HR recovery predicts mortality only in patients after MI; therefore, no treatment is needed.

c.Abnormal HR recovery predicts mortality in all patients; however, there is no treatment.

d.Abnormal HR recovery predicts mortality in all patients, and exercise training is the treatment of choice.

28.A 41-year-old man presents to the CCU with CHF symptoms. On examination, he has elevated neck veins, severe peripheral edema, and S3 gallop. He is started on medication and has improvement in all of his symptoms. He has a PET scan, which shows a large area of hibernating myocardium. His cardiac catheterization reveals mild disease in the right coronary artery, a focal 80% lesion in the circumflex, and a focal 70% lesion in the LAD. All of his lesions are type A American College of Cardiologists/American Heart Association score. His EF is 15%. According to randomized clinical trials, which of the following is the best treatment for this patient?

a.Percutaneous transluminal coronary angioplasty (PTCA)/stent with abciximab and clopidogrel bisulfate

b.PTCA/stent with cardiothoracic surgery backup

c.CABG

d.PTCA/stent with abciximab and IABP

29.A 28-year-old woman comes to your office for a second opinion. She had peripartum cardiomyopathy and wants to get pregnant again. You obtain a TTE, which shows a normal LV. What should you recommend?

a.She should not have another pregnancy because she is likely to have recurrent cardiomyopathy.

b.She may conceive again because her LV is normal. Her chance of having recurrent cardiomyopathy is less than 5%.

c.She may conceive again because her LV is normal. However, her chance of having recurrent cardiomyopathy is 30% to 50%.

d.She should undergo exercise testing for better assessment.

30.A 78-year-old retired federal judge comes to your office for follow-up. He has long-standing HTN and has undergone PTCA/stent for a mid-LAD lesion. He has normal LV function and is active and healthy. Currently he is on ramipril (Altace), atorvastatin, and aspirin. He heard on television that the combination of aspirin and ramipril increases mortality. He wants your opinion. What is your answer?

a.These are only observational studies, and they have not been proven. Continue the current regimen.

b.There are randomized studies to support this; however, the sample size was too small to make any conclusive recommendations. Continue the current regimen.

c.This has been shown in large trials; we should change aspirin to clopidogrel bisulfate or ramipril to metoprolol tartrate.

d.Although this has been seen in retrospective trials, it has not been validated in a randomized trial; therefore, continue the current regimen.

31.A 56-year-old man with dilated cardiomyopathy with an EF of 15% comes to your office for an opinion regarding medication. He is in NYHA class II and wants to know about biventricular pacing. He heard on television news that this may save lives. His ECG shows a sinus rate of 71, a PR interval of 210 milliseconds, a QRS duration of 188 milliseconds, and a QT/QTC of 364:427 milliseconds. What should you recommend?

a.Refer the patient for biventricular pacing based on PR interval.

b.Refer the patient for biventricular pacing based on QRS duration.

c.Refer the patient for biventricular pacing based on QT/QTC interval.

d.Refer the patient for exercise test to further assess.

32.A 31-year-old woman with hypertrophic cardiomyopathy presents to your office for follow-up. She has been doing well. She denies any palpitation or syncope. She has researched her disease on the Web and found out that most people die of arrhythmia. She would like to have an EP study. Which of the following is the predictive value of the EP study for ventricular arrhythmia?

a.20%

b.40%

c.50%

d.80%

e.100%

33.A 61-year-old woman with an EF of 50% is admitted with an AFib with rapid ventricular response. She is started on metoprolol tartrate with excellent rate control and heparin. Her daughter, who is a nurse, wants to know why you did not start her on dofetilide because this is the best new drug. What is your response?

a.Dofetilide showed increased mortality when compared with amiodarone and would be a bad choice for her mother.

b.Dofetilide had safety and efficacy comparable to those of β-blockers.

c.Dofetilide was used in patients with an EF less than 35%.

d.Dofetilide has safety and efficacy comparable to those of calcium channel blockers.

e.Dofetilide is reserved for patients with chronic renal insufficiency.

34.A 79-year-old woman with HTN and non-insulin-dependent diabetes mellitus comes to your office for a second opinion. She is doing well and is currently on enalapril, aspirin, simvastatin, glipizide, and metformin. She read in her monthly American Association of Retired Persons newsletter that losartan is better than enalapril. She wants you to change her prescription. Based on trial data, which of the following is your recommendation?

a.Losartan did not show mortality benefit but did show reduced hospitalization; because she has no history of CHF, there is no reason to change her medication.

b.Losartan showed neither mortality benefit nor reduced hospitalization.

c.Losartan did not show mortality benefit but decreased the risk of MI; therefore, she should have her prescription changed.

d.Losartan did show mortality benefit, but only in patients younger than 60 years.

35.A 61-year-old woman with CHF and an EF of 25% is admitted with CHF exacerbation to your partner’s service. On the day of discharge, your partner is sick, and you must explain her discharge medications. You explain to her the benefits of lisinopril, simvastatin, aspirin, digoxin, and furosemide. Finally, you want to explain the benefit of spironolactone (Aldactone) to her. What is your explanation?

a.Spironolactone in addition to standard therapy (ACE inhibitor, diuretic) does not decrease mortality or morbidity.

b.Spironolactone in addition to standard therapy only decreases rehospitalization—it does not improve NYHA functional class.

c.Spironolactone in addition to standard therapy decreases mortality and rehospitalization.

d.Spironolactone only benefits those not on standard therapy.

36.A 63-year-old man with non-insulin-dependent diabetes mellitus, HTN, hyperlipidemia, and chronic renal insufficiency is admitted with acute anterior wall MI 10 hours after symptom onset. He is taken emergently to the cardiac catheterization laboratory. He is noted to have proximal LAD occlusion, and he undergoes a successful PTCA/stent to the LAD with abciximab and heparin. His EF is noted to be 30% on a TTE performed 3 days later. On hospital day 4, he reports chest pain and is found to be in AFib with an HR of 121. His BP is 90/44 mmHg, and he is short of breath and anxious. Which of the following should you administer next?

a.Procainamide

b.Lidocaine

c.Amiodarone

d.Metoprolol tartrate

e.Cardioversion

37.An LV pressure–volume loop is shown in Figure 8.1. Label 1, 2, 3, and 4.

a.Mitral valve opening

b.End diastole

c.Aortic valve opening

d.End systole

38.A 57-year-old man with a history of CHF presents with acute pulmonary edema. His BP is 110/60 mmHg with an HR of 92 bpm. His examination is consistent with heart failure. His hemodynamics are as follows: PA pressure, 62/27 mmHg; PCWP, 12 mmHg; cardiac output, 1.8 L/min/m2; and SVR, 1,968 dyne/s/cm5. Which way should the LV pressure–volume loop be shifted?

a.To the right

b.To the left

c.Up

d.Down

Figure 8.1 ESPVR, end-systolic pressure–volume relation (From Little WC, Braunwald E. Assessment of cardiac function. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine, 5th ed. Philadelphia, PA: WB Saunders; 1997, with permission.)

Questions 39 to 43

Figures 8.2, 8.3, 8.4, 8.5, and 8.6 are schematic illustrations of the carotid pulse. Match the diagnosis with the pulse.

a.Normal

b.Aortic stenosis

c.Aortic regurgitation

d.Hypertrophic cardiomyopathy

e.Severe CHF decompensation

Figure 8.2 (From Chatterjee K. Physical examination. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002: Fig. 15.2, with permission.)

Figure 8.3 (From Chatterjee K. Physical examination. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002: Fig. 15.2, with permission.)

Figure 8.4 (From Chatterjee K. Physical examination. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002: Fig. 15.2, with permission.)

Figure 8.5 (From Chatterjee K. Physical examination. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002: Fig. 15.2, with permission.)

Figure 8.6 (From Chatterjee K. Physical examination. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002: Fig. 15.2, with permission.)

44.During physical examination, you notice an elevated systemic venous pressure with sharp y-descent Kussmaul sign and quiet pericardium. What might the patient have?

a.Constrictive pericarditis

b.Restrictive myocardial disorder

c.Tricuspid regurgitation

d.Pulmonary HTN

e.Tamponade

45.During another physical examination, you notice a prominent v wave with a sharp y descent. What condition does the patient have?

a.Constrictive cardiomyopathy

b.Restrictive cardiomyopathy

c.Tricuspid regurgitation

d.Pulmonary HTN

e.Tamponade

46.Again you notice an elevated systemic venous pressure without obvious x or y descent and quiet precordium and pulsus paradoxus. What does the patient have?

a.Constrictive cardiomyopathy

b.Restrictive cardiomyopathy

c.Tricuspid regurgitation

d.Pulmonary HTN

e.Tamponade

ANSWERS

1.c. Use of rapamycin as part of the immunosuppressive regimen. Transplant vasculopathy is a possible complication after transplant that is best to be avoided. The recommended intervention is to control cardiovascular risk factors and start every patient on a statin. Once there is vasculopathy, proliferation signal inhibitors (PSIs) such as sirolimus and everolimus can be used (substituted for mycophenolate mofetil or azathioprine).

2.b. EF of 20% and dyspnea while doing chores at home (New York Heart Association [NYHA] class II symptoms). Based on the results of Emphasis-HF trial, patients with NYHA class II symptoms and EF <30% are eligible for adding eplerenone to their regimen if they were hospitalized in the last 6 months or had an elevated brain natriuretic peptide. This extended the patients who could be placed on an aldosterone blocker. Previous studies studied the benefit of spironolactone in patients with NYHA class IV symptoms in the last 6 months and EF ≤35% and eplerenone in patients 2 weeks post-MI with EF ≤40% and signs of heart failure. Aldosterone antagonists should not be used in patients with creatinine clearance <30 mL/min/1.73 m2. EF or QRS alone are not enough to determine patients who would benefit. Functional class assessment is important.

3.b. No viability found on dobutamine echo with EF of 15%. The use of surgical revascularization of coronary disease and systolic heart failure is reasonable in patients with acute coronary syndrome and symptomatic angina. Although in the STITCH (Surgical Treatment for Ischemic Heart Failure) trial, a study of medical therapy versus CABG in patients with EF ≤35%, there was no difference in all-cause mortality, there was a suggestion of a trend toward patients with CABG having fewer hospitalizations for heart failure or death from cardiovascular causes. The choice of CABG in a patient with no viability and very low EF is unlikely to be successful in improving morbidity or mortality from heart failure.

4.c. Normal tissue Doppler measurement of the left ventricular (LV) lateral and septal walls. Patients with amyloid heart disease usually show restrictive pattern of diastology with low tissue Doppler of the LV myocardium.

5.b. Downregulation primarily of β1-receptors with little change in β2-receptors. In the cardiac myocyte, there are 3 adrenergic receptors (α1, β1, and β2). In a normal heart the predominant β receptor is β1. In a failing heart there is selective down-regulation of β1 receptors not β2 receptors.

6.b. Hydralazine plus nitrates. In the V-HeFT II trial, although ACE inhibitors improved survival, it was hydralazine in combination with nitrates that had greater improvement in LV function and exercise tolerance.

7.c. All of them except losartan. There is no trial evidence that angiotensin II receptor blocker improved mortality in post-MI patients. The Studies of Left Ventricular Dysfunction (SOLVD) prevention used ACE inhibitors in patients with an EF less than 35%.

8.b. Digoxin reduces hospitalization. In the large Digitalis Investigation Group study, digitalis only improved hospitalization. It had no effect on survival.

9.e. No known treatment. Allograft vasculopathy is the leading cause of long-term morbidity and mortality for cardiac transplant patients. Routine cardiac catheterization has been advocated for these patients but has not shown survival benefit with revascularization. Statin therapy appears to improve long-term survival in these patients and should be used for all heart transplant patients. However, its effect on allograft vasculopathy is unknown.

10.d. She should have a positron emission tomography (PET) scan to assess the area of viability before proceeding with CABG or PCI. This patient is at high risk for any type of intervention because of her low EF. However, if there are areas of viability on the PET scan, her EF might improve with complete revascularization. Studies have consistently shown that patients with low EF do better with CABG than with PCI.

11.b. Start dopamine. This patient is in cardiogenic shock. She needs BP support before all else. In these patients, dopamine is the first line of choice, followed by norepinephrine. If there is no change with dopamine and norepinephrine, then dobutamine may be added while the patient is being prepared for IABP placement.

12.c. Consider LV assist device. This is a relatively young patient with no contraindication to cardiac transplant. However, in the current state, she is not eligible for transplantation. LV assist device as a bridge to transplant has been performed with success.

13.c. Acute right ventricular (RV) failure. His hemodynamic pressures are characteristic of acute RV failure. He needs aggressive fluid resuscitation.

14.b. Suggest nitroprusside. This patient is in heart failure and needs to have her BP and SVR lowered. BP is adequate and does not need vasopressor or IABP support. Although nesiritide has been approved for use in acute heart failure, it only mildly lowers the BP.

15.a. Place an implantable defibrillator. She fits the criteria of the initial Multicenter Automatic Defibrillator Trial (MADIT). Therefore, based on randomized clinical trial data, she would benefit from an implantable defibrillator. Also, secondary prevention trials such as the Antiarrhythmics Versus Implantable Defibrillators Trial, the Canadian Implantable Defibrillator Study, and the Cardiac Arrest Study Hamburg trial also support an implantable defibrillator in this patient.

16.d. β-Blockers should be started in stable CHF patients. They should not be started when the patient is congested. Although nonselective agents with vasodilating effects may be preferred, this is not clear at this time.

17.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. In the Prospective Randomized Amlodipine Survival Evaluation Trial, in which NYHA class III or IV patients with an EF less than 30% were enrolled, there was a statistically insignificant reduction in the combined mortality and morbidity in the amlodipine group. However, the benefit appeared to be greater in patients with nonischemic cardiomyopathy.

18.b. Begin ACE inhibitor and β-blockers. She has well-compensated cardiomyopathy. Only medication that prolongs her life needs to be started. She does not need medication for symptom relief; therefore, ACE inhibitor and β-blockers should be started.

19.b. Stop diuretics. This patient has prerenal azotemia caused by aggressive diuresis. His renal function should recover.

20.c. Bears little relation to the severity of LV dysfunction. Short-term administration of positive inotropic agents and vasodilators does not improve maximal exercise capacity in patients with CHF. Moreover, ACE inhibitors have failed to show consistent improvement in exercise tolerance. Numerous studies have not shown a correlation between LV function and exercise tolerance.

21.e. Enrolling her in an exercise training program. As stated, there is no medication that has consistently shown improvement in exercise tolerance; exercise training is the only method that has shown consistent improvement in these patients.

22.b. E/O2 slope during exercise. This is the best correlate of prognosis. There is a higher ventilation for any given CO2 production (E/O2 slope), which reflects the severity of heart failure and prognosis.

23.a. Glucagon and milrinone. Milrinone is a second-generation phosphodiesterase inhibitor. It has no β-effect; therefore, it is an ideal vasopressor in the setting of β-blocker overdose. Although a pacer is a good idea and should be placed, giving medication is faster and should be instituted first.

24.b. Atenolol. Atenolol is most affected by reduced renal function. Depending on how severe his creatinine clearance is, he should have his medication dose or frequency adjusted.

25.c. PCWP is 26 mmHg. Restrictive mitral inflow pattern in the presence of a short E-wave deceleration time has been shown to correlate with high pulmonary capillary pressure, impaired functional class, and bad prognosis in postinfarction patients.

26.d. High filling pressure and reduced LV compliance. These conditions are indicated by a restrictive mitral inflow pattern with short E-wave deceleration time.

27.c. Abnormal HR recovery predicts mortality in all patients; however, there is no treatment. A delayed decrease in HR after exercise or an abnormal HR recovery predicts all-cause mortality in healthy adults and in patients referred for exercise testing—independent of ischemia. However, at this time, there is no treatment to improve abnormal HR recovery.

28.c. CABG. This patient has left main trunk equivalent with low EF. He is a candidate for CABG with left internal mammary artery to the LAD. CABG will prolong his long-term survival compared with PTCA/stent.

29.d. She should undergo exercise testing for better assessment. Recurrent peripartum cardiomyopathy occurs in 20% of patients with normal resting LV function but abnormal stress ventricular response. Recurrent peripartum cardiomyopathy with decompensation occurred in 41% of patients with abnormal resting LV function.

30.d. Although this has been seen in retrospective trials, it has not been validated in a randomized trial; therefore, continue the current regimen. In a substudy done by the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico, aspirin did not decrease the mortality benefit of lisinopril after MI or increase the risk of adverse clinical events. There have been some retrospective studies to assess this question that have had conflicting results; therefore, it is best to stay with the current regimen.

31.b. Refer the patient for biventricular pacing based on QRS duration. Patients with QRS duration greater than 150 to 160 milliseconds derived the greatest benefit from biventricular pacing.

32.a. 20%. There is no role for routine EP study in the asymptomatic hypertrophic cardiomyopathy patient.

33.c. Dofetilide was used in patients with an EF less than 35%. The study compared dofetilide with amiodarone. Dofetilide did not increase mortality. It has not been studied against β-blockers or calcium channel blockers in patients with normal EF.

34.b. Losartan showed neither mortality benefit nor reduced hospitalization. In the large Evaluation of Losartan in the Elderly II study, losartan did not show mortality benefit or reduced hospitalization. Losartan was better tolerated than captopril. Because the patient has no side effects with enalapril, her prescription should not be changed.

35.c. Spironolactone in addition to standard therapy decreases mortality and rehospitalization. In the Randomized Aldactone Evaluation Study, patients with NYHA class III or IV with an EF less than 35% had improvement in mortality, reduction in hospitalization, and improvement in functional class when spironolactone was taken in addition to standard therapy (ACE inhibitor and diuretic).

36.e. Cardioversion. This patient has post-MI AFib. He has LV dysfunction and renal insufficiency. Procainamide should be used in patients with normal LV and renal clearance. Amiodarone would take too long to work, and he is already in distress. Lidocaine is not used in AFib. Metoprolol tartrate would exacerbate his heart failure; therefore, cardioversion is the only choice.

37.An LV pressure–volume loop.

a.= 1. Mitral valve opening

b.= 2. End diastole

c.= 3. Aortic valve opening

d.= 4. End systole

38.c. Up. The response of the LV to increased afterload is to shift the loop up. Increased preload would shift the loop to the right.

39.a. Normal. The initial peak of the carotid puse waveform reflects the ejection of the blood from the LV into the aorta before it goes into the periphery. After the pressure peaks, it begins a decline as ejection slows and blood continues to flow to the periphery. There is a reversal of blood flow from the compliant central arteries back toward the ventricle. With this reversal of flow, the aortic valves close. A notch on the descending limb of the aortic pressure curve is associated with this transient reversal of blood flow. The smaller secondary positive wave is attributed to the elastic recoil of the aorta and aortic valve.

40.b. Aortic stenosis. Pulsus parvus et tardus which is characteristic of aortic stenosis. Small and delayed carotid pulse.

41.c. Aortic regurgitation. Pulsus bisferiens or bifid arterial pulse.

42.d. Hypertrophic cardiomyopathy. This can also be characterized by a bisferiens carotid pulse with rapid fall in first wave with rapid rise of the second.

43.e. Severe CHF decompensation. Demonstrates the dicrotic pulse which can occur in diastole in patients with low stroke volume being ejected. This can occur in severe heart failure, cardiac tamponade, and hypovolemic shock.

44.a. Constrictive pericarditis. The high initial venous wave (a wave) is characteristic of atrial contraction. The rapid y descent is suggestive of rapid ventricular filling.

45.c. Tricuspid regurgitation. The v wave is a reflection of ventricular contraction and the pressure that is transmitted back to the atrium from a tricuspid valve that pushes back into the atrium. In the tricuspid regurgitation, there is increased pressure during ventricular systole.

46.e. Tamponade. There is constant pressure from the pericardium that does not allow for atrial relaxation so the y descent is blunted.

SUGGESTED READINGS

Greenberg B, Kahn AM. Chapter 26: Clinical assessment of heart failure. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed. Elsevier Saunders.

Chatterjee, K. Chapter 16: Physcial examniation. In: Topol EJ, Califf RM, eds. Textbook of Cardiovascular Medicine, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

Costanzo MR, Dipchand A, Starlin R, et al. The International Society of Heart and Lung Transplantation guidelines for the care of heart transplant recipients. J Heart Lung Transplant. 2010;29(8):914–956.

Francis G. Pathophysiology of the heart failure clinical syndrome. In: Topol EJ, ed. Textbook of Cardiovascular Medicine, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002.

Iyengar S, Haas GJ, Young JB. Chapter 86: Acute heart failure management. In: Topol EJ, Califf RM, eds. Textbook of Cardiovascular Medicine, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

Mann D. Chapter 28: Management of heart failure with reduced ejection fraction. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine, 9th ed. Elsevier Saunders.

Tang WHW, Young JB. Chapter 87: Chronic heart failure management. In: Topol EJ, Califf RM, eds. Textbook of Cardiovascular Medicine, 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.