4.1 E) Congestive Cardiac Failure

Front 1

NYHA Classification has 4 categories T/F

Back 1

True

Front 2

NYHA III = angina /dyspnoea on

ordinary / mild activity T/F

Back 2

False {Marked limitation / angina on less than

ordinary activity }
NYHA II = angina / dyspnoea on mild activity

Front 3

Which of the following , in regards to

Echocardiography in Heart failure is False:

1. Segmental hypokinesia suggests that ischaemia is the cause of

cardiac failure
2. Mitral annular calcification is a common finding in elderly patients.
3. The presence of left atrial enlargement suggests that the mitral

regurgitation is not acute
4. TR is common in patients with heart failure
5. The normal LVEF is > 65%

Back 3

5. LVEF > 50-55%

(Tintinalli = > 60% )

Front 4

Which is the most common cause of dilated

cardiomyopathy?
1. Drugs
2. Alcohol
3. Idiopathic
4. Familial
5. Myocarditis

Back 4

3. Idiopathic

Front 5

In regards to Digoxin in Heart Failure, which is incorrect?

1. It's use is no longer controversial when used with ACEI and diuretic
2. Most likely to benefit those with EF < 20%
3. Most likely to benefit those with S3 Gallop.
4. It increases myocardial contractility
5. It improves mortality.

Back 5

5. Improves symptoms only

Does not benefit mortality

Front 6

In regards to Heart failure and implanted

defibrillators, which is incorrect?

1. 50% of patients with cardiac failure die suddenly of a ventricular

arrhythmia
2. Detecting a ventricular arrhythmia is an indication for an implantable defibrillator
3. Survival in heart failure is proven with defibrillators

4. Routine use of implanted defibrillators in CCF and low EF but no

documented arrhythmias, does not improve survival.
5. Cardiac failure has a poor prognosis

Back 6

4. Routine use of ACID in CCF patients with low EF has been shown to improve survival.

Front 7

Which is incorrect in regards to heart failure?

1. Most breathless patients with heart failure have an abnormal Left

ventricular systolic function.

2. Abnormal LVSF is characterised by DILATATION and HYPOKINESIS

3. Diastolic Dysfunction = stiff, hypertrophied myocardium that DOES NOT RELAX properly
4. Diastolic heart failure is caused by HTN
5. The Clinical and Echocardiographic diagnosis of diastolic heart failure is usually very clear.

Back 7

5. The diagnosis of diastolic dysfunction is

usually difficult

Front 8

Which is not a precipitant for Cardiac Failure:

1. High salt intake
2. Arrhythmia
3. Hypothyroidism
4. Drugs that cause salt and water retention {NSAIDS}
5. Pregnancy

Back 8

3. Thyrotoxicosis not hypothyroidism

Front 9

The ECG in Heart Failure - which is the least

likely?

1. It is rarely entirely normal
2. RBBB is a common finding
3. LBBB is a common finding
4. LVH can be seen
5. Arrhythmias are common

Back 9

2. LBBB is common - RBBB less so.

Front 10

Blood tests in heart failure - which is incorrect?

1. Hypokalaemia can cause arrhythmais
2. Hypernatraemia may indicate severe longstanding cardiac failure

3. Hyponatraemia can be a poor prognostic sign in severe heart failure
4. Renal impairment can be found on Biochemistry

5. Haematology is a useful test for excluding precipitating

causes {eg. anaemia}

Back 10

2. HYPOnatraemia may indicate severe

longstanding cardiac failure.

Front 11

CCF and CXR- which is incorrect:

1. Pulmonary venous hypertension is usually due to LVF, mitral stenosis or mitral regurgitation.
2. Peribronchial cuffing is a sign of increased interstitial thickening

from oedema.

3. Kerley B lines are peripherally placed thickened interlobar septa.
4. Kerley C lines are superimposed Kerley B lines
5. Kerley A lines radiate from the hilar region

Back 11

3. Kerley B lines are thickened INTERLOBULAR septa.

Front 12

CCF and CXR - which is incorrect:
1. Cephalisation is upper zone blood vessel distension
2. Only 2 diseases cause acutely increased interstitial lung markings-

interstitial pulmonary oedema and interstitial pneumonitis

3. The perihilar haze on CXR represents airspace pulmonary oedema
4. The 3 stages of CCF on CXR are "cephalisation", "interstitial pulmonary oedema" and "airspace pulmonary oedema."
5. Pulmonary venous hypertension = cephalisation

Back 12

3. NO : Pulmonary venous hypertension

causes enlargement of the superior

pulmonary veins in the upper portions of the hilum.
Cephalisation is upper zone pulmonary

vascular distension.

Front 13

Patient characteristics associated with

Noninvasive ventilation Failure : which is

incorrect?
1. pH <7.25
2. RR > 30
3. APACHE II <=29
4. Pneumonia / ARDS
5. GCS <=13

Back 13

3. APACHE II > 29

Front 14

Complications of BIPAP/CPAP include all

except:

1. Aerophagia and vomiting
2. Barotrauma
3. Pressure necrosis of skin
4. Increased nosocomial infections compared with intubated patients
5. Aspiration

Back 14

4. DECREASED nosocomial infections

compared with intubated patients

Front 15

In regards to BIPAP and CPAP, which is

incorrect:
1. CPAP delivers a variable gas flow to achieve a constant airway pressure {Paw}
2. Increases in IPAP generally increase FRC
3. Increases in EPAP generally increase O2
4. Increases in IPAP will increase Vt
5. Increases in IPAP generally will decrease PCO2.

Back 15

2. Increases in CPAP generally increase FRC

Front 16

Define the NYHA Classification Categories.

Back 16

I – no symptoms and no limitation in ordinary physical activity

II – mild symptoms and slight limitation during ordinary physical

activity

III – marked limitation in activity due to symptoms, even

during less than ordinary activity

IV – severe limitations, experiences symptoms even while at rest

Front 17

List the 8 CXR findings of Acute Left heart

failure (APO) In decreasing order.

Back 17

1. Cephalisation (dilated upper lobe vessels)

2. Cardiomegaly

3. Intersitial oedema

4. Enlarged pulmonary artery

5. Pleural effusion

6. Alveolar oedema

7. Prominent SVC

8. Kerley B lines

Front 18

[ Tintinalli ]

List 4 co-morbid conditions likely to be present in acute heart failure.

Back 18

1. Arterial Hypertension ( HTN)

2. Ischaemic Heart Disease (IHD)

- Acute coronary syndrome 25-33% of new acute heart failure presentations

3. Diabetes (DM)

4. Atrial fibrillation (AF)

Front 19

[Tintinalli]

In regards to Systolic and Diastolic

heart Failure, which of the following is correct ?

A. The normal Ejection Fraction is 70%

B. Systolic Dysfunction is defined as an EF < 55%

C. Diastolic dysfunction usually has a normal or high EF

D. Diastolic dysfunction is more common in Men.

Back 19

C.

A = Normal EF 60%

B = Systolic Dysfunction = EF < 40%

D = Diastolic Dysfunction more common in

Females ( and increasing age )

Front 20

[ Tintinalli ]

Which of the following is incorrect regarding

Systolic and Diastolic Heart Failure ?

A. Systolic dysfunction is commonly from IHD

B. Diastolic dysfunction is impaired ventricular relaxation.

C. Patents with Diastolic dysfunction are after load dependent.

D. Determining the type of heart failure is difficult from History and

Clinical examination.

Back 20

C. Diastolic Dysfunction = preload dependent

Front 21

[Tintinalli]

List 5 symptoms associated with Isolated

Left heart failure.

Back 21

1. Dyspnoea

2. Fatigue and weakness

3. Cough

4. PND

5. Orthopnea

Front 22

[Tintinalli]

List 5 signs associated with isolated right

heart failure.

Back 22

1. Peripheral oedema

2. Jugular venous distension (JVD)

3. RUQ pain

4. Hepatojugular reflex

5. Absence of pulmonary signs

Front 23

[Tintinalli]

List the 3 types of acute decompensated heart failure syndromes.

Back 23

1. Hypotensive Acute heart Failure Syndrome

2. Hypertensive Acute heart failure

Syndrome* (Most common)

3. Normotensive Acute heart failure syndrome

Front 24

[Tintinalli]

Which of the following is the most specific for the diagnosis of heart failure?

A. Presence of an S3

B. Orthopnea

C. Dyspnoea

D. Oedema

Back 24

A. S3 99% specific for an elevated pulmonary capillary wedge pressure

Orthopnea = 88% specific

Rales = 70% specific

Dyspnoea = 50% specific

Oedema least specific

Front 25

[Tintinalli]

Which of the following is incorrect regarding the CXR in Acute heart Failure ?

A. Cardiomegaly suggests heart failure

B. Acute abnormalities can lag the clinical appearance by 1-2 hours

C. Up to 18% of patients with have no findings of congestion on CXR.

D. Cephalisation is the most frequent finding.

Back 25

B. Lag can be up to 6 hours

Front 26

[ Tintinalli ]

** List 5 precipitants of an acute heart failure syndrome.

Back 26

1. Non compliance

{ excess salt ; medication omission }

2. Acute coronary syndrome ( AMI)

3. Atrial fibrillation ( with RVR )

4. Renal Failure ( missed dialysis )

5. Infections

Front 27

[ Tintinalli ]

** List the conditions that are

contraindications to Vasodilator use in acute heart failure .

Back 27

1. HOCM

2. Pre-load dependent states:

- Aortic stenosis ( AS )

- RV infarction

- volume depletion

Front 28

[ Tintinalli ]

List the evidence based drugs providing

neurohormonal antagonism, and therefore,

morbidity / mortality benefits ,in stable

Systolic heart failure .

Back 28

1. ACEI or ARB

2. B Blockers

3. Diuretics

4. Digoxin

5. Aldosterone antagonists (spironolactone)

6. Hydralazine / isosorbide dinitrate.

Front 29

[ Tintinalli ]

which drugs should be avoided in Heart

Failure?

Back 29

1. NSAIDS

- inhibit diuretic / ACEI effects

- worsen renal / cardiac function

2. Calcium Channel Blockers (CCB)

3. Antiarrhythmics ( esp. Class I )

Front 30

[ Tintinalli]

List the strongest predictors of inpatient

mortality in acute heart failure presentations to hospital.

Back 30

1. Elevated Urea

2. Elevated Creatinine

3. SBP < 115 mmHg

4. Troponin ( T or I ) elevation

Front 31

[Tintinalli]

Which of the following is incorrect regarding the management of Acute Heart failure?

A. Poor diuresis in APO has a 4-fold increase in mortality

B. Before the use of vasodilators (GTN) , the diagnosis of

HOCM (Hx) and Aortic stenosis (Auscultation ) must be sought.

C. GTN dilates coronary arteries and reduces preload only.

D. IV nitrates are initially dosed at 0.5 ug/kg/min

Back 31

C. Nitrates reduce preload and afterload.

Front 32

[Tintinalli]

List the benefits of B Blockers in Heart Failure management .

Back 32

1. Decreases 1 year mortality in NYHA Class II and III by 34%

2. Decreases sudden death by 41%

- Reduces SNS activity

- Elevated NA levels in HF contribute to :

1. Myocardial hypertrophy

2. Increased after load

3. Coronary vasconstriction.