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83 Cards in this Set
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Following a myocardial infarction, ventricular wall changes occur that can eventually lead to heart failure. True statements regarding ventricular remodeling after myocardial infarction include which of the following? (Mark all that are true.)
1 The early phase of remodeling (within 72 hours of infarction) involves mural hypertrophy 2 The early phase of remodeling involves activation of the renin-angiotensin system 3 Necrotic myocytes are replaced by fibrous tissue within 28 days of infarction 4 Myocardial reperfusion does not improve late-phase (>72 hours after infarction) regional or global ventricular function |
answer 2,3,
During the early phase of post-infarction remodeling, the infarcted ventricular wall thins and dilates; this increases wall stress that stimulates subsequent mural hypertrophy. Early-phase changes include activation of the renin-angiotensin system and production of atrial and brain natriuretic peptides (ANP and BNP). By 4 weeks post infarction, the affected myocytes are replaced by fibrous tissue. Myocardial reperfusion does improve late-phase regional and global ventricular function. |
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A 55-year-old asymptomatic female with an ejection fraction of 35% is found to have a TSH level of 13.8 µU/L (N 0.3–4.82). Her T3 and T4 levels are normal, and her thyroid gland is normal to palpation.
You advise her that 1 hypothyroidism increases her metabolic rate, requiring greater cardiac output 2 her subclinical hypothyroidism has negative effects on her heart and she should consider treatment 3 hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms 4 treatment of her subclinical hypothyroidism would raise her LDL-cholesterol levels |
answer 2
Clinical hypothyroidism has long been associated with cardiac dysfunction. It has also been shown that subclinical hypothyroidism (TSH >4 µU/L with normal or borderline low thyroid hormone levels) can cause left ventricular systolic and diastolic dysfunction, which improves with thyroid replacement therapy. Thyroxine can exacerbate coronary artery disease, and should be started at low doses and titrated slowly upward in patients with possible underlying CAD. Results of meta-analyses indicate that therapy will lower, not raise, serum LDL levels. |
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Conditions associated with heart failure in patients with a normal left ventricular ejection fraction include which of the following? (Mark all that are true.)
1 Hypothyroidism 2 Hemochromatosis 3 Pericardial constriction 4 Atrial myxoma 5 Primary valvular disease |
answer 2,3,4,5
Depending on the diagnostic criteria used, it has been estimated that 20%–60% of patients with heart failure have a relatively normal left ventricular ejection fraction, arising from reduced ventricular compliance and abnormal diastolic function. In a patient with heart failure found to have a normal left ventricular ejection fraction, other diagnostic possibilities should be excluded, such as primary valvular disease. Heart failure can arise from high metabolic demand (high output states), and anemia, hyperthyroidism, and arteriovenous fistulae should be considered as possible causes. Other considerations in the differential diagnosis include restrictive heart disease (e.g., amyloidosis, sarcoidosis, hemochromatosis), pericardial constriction, episodic left ventricular systolic dysfunction, severe hypertension, chronic pulmonary disease with right heart failure, atrial myxoma, and obesity. |
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In the patient treated for heart failure, use of an angiotensin converting enzyme (ACE) inhibitor is associated with reduced levels of which of the following? (Mark all that are true.)
1 BNP 2 Renin 3 Angiotensin II 4 Aldosterone 5 Bradykinin |
answer 1,3,4
The renin–angiotensin–aldosterone system is inappropriately activated in patients with heart failure, and its degree of activation correlates with the prognosis. In addition to causing pathologic increases in preload and afterload, angiotensin II has direct mitogenic effects on cardiac myocytes and endothelial cells that lead to adverse ventricular remodeling. ACE inhibitors work by blocking the conversion of angiotensin I to angiotensin II. Angiotensin II has several actions, including promotion of the constriction of arterioles within the renal and systemic circulations and the reabsorption of sodium in proximal segments of the nephron. It also stimulates the adrenal cortex to secrete aldosterone. By blocking the formation of angiotensin II, ACE inhibitors reduce both angiotensin II and aldosterone levels. By blocking angiotensin II negative feedback, they also raise plasma renin levels. ACE inhibitors can produce a bothersome dry cough by inhibiting kinase II, which degrades bradykinin. Long-term treatment of heart failure with ACE inhibitors has been shown to reduce BNP levels. |
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How do ace inhibitors work
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ACE inhibitors work by blocking the conversion of angiotensin I to angiotensin II.
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What does angiotensin II do
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including promotion of the constriction of arterioles within the renal and systemic circulations and the reabsorption of sodium in proximal segments of the nephron. It also stimulates the adrenal cortex to secrete aldosterone. By blocking the formation of angiotensin II, ACE inhibitors reduce both angiotensin II and aldosterone levels. By blocking angiotensin II negative feedback, they also raise plasma renin levels.
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Why do you get a cough with ace inhibitors
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ACE inhibitors can produce a bothersome dry cough by inhibiting kinase II, which degrades bradykinin.
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In patients with untreated systolic heart failure, elevated activity levels would be expected for which of the following hormones? (Mark all that are true.)
1 Norepinephrine 2 Renin 3 Angiotensin 4 Aldosterone |
answer 1,2,3,4
The failing cardiac output of heart failure produces a compensatory response in the autonomic nervous system. Elevated norepinephrine activity initially helps to maintain systemic vascular resistance (and blood pressure) and ventricular contractility. Eventually this results in downregulation of β-adrenergic receptors and causes impairment in contractility. Similarly, the renin-angiotensin-aldosterone system activates in an initial compensatory response, thereby increasing systemic vascular resistance and maintaining blood pressure. However, the resulting increase in afterload and retention of sodium and fluid ultimately exacerbate the problem. |
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True statements regarding left ventricular remodeling include which of the following? (Mark all that are true.)
1 It usually causes an immediate decline in cardiac output 2 It is a response to increased pressure or volume stress on the ventricle 3 It can occur after a myocardial infarction 4 It can result from chronic hypertension 5 It can be caused by valvular heart disease |
answer 2,3,4,5
Ventricular remodeling occurs as a compensatory response to increased pressure or volume in the ventricle. As the myocardium thickens (as in concentric left ventricular hypertrophy) or dilates (as in fluid overload states and after myocardial infarction), cardiac output is increased and adequate function is maintained. While helpful in the short term, this has adverse effects on contractility in the long term and ultimately contributes to declining function and symptomatic heart failure. |
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Which of the following mechanisms contribute to high heart failure rates in patients with diabetes mellitus? (Mark all that are true.)
1 Increased risk of left ventricular hypertrophy 2 Macrovascular coronary heart disease 3 Microvascular coronary heart disease 4 Endothelial dysfunction |
answer 1,2,3,4
Diabetes mellitus is a major independent risk factor for heart failure, in addition to its contribution to coronary heart disease. Multiple studies have shown an increased risk of heart failure in diabetic patients, even when other variables are accounted for. Demonstrated mechanisms include an increased risk of left ventricular hypertrophy, macrovascular coronary heart disease, microvascular coronary heart disease, and endothelial dysfunction, as well as autonomic dysfunction and other metabolic abnormalities. |
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In heart failure patients with a normal left ventricular ejection fraction, contributors to diastolic dysfunction include which of the following? (Mark all that are true.)
1 Abnormal renal sodium metabolism 2 Increased arterial wall compliance 3 Decreased myocardial wall compliance 4 Decreased diastolic ventricular filling |
answer 1,3,4
Diastolic heart failure accounts for most cases of heart failure in patients whose left ventricular ejection fraction is essentially normal. Abnormal renal sodium metabolism, decreased arterial wall compliance, decreased myocardial wall compliance, and diminished diastolic ventricular filling all contribute to the development of heart failure symptoms in these patients. |
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Which one of the following cancer therapy drugs is a significant cause of heart failure?
1 5-Fluorouracil (5-FU) 2 Doxorubicin (Adriamycin) 3 Tamoxifen (Nolvadex) 4 Methotrexate 5 Vinblastine (Velban) |
answer 2
Doxorubicin causes direct cardiotoxicity in a dose-related fashion, sometimes producing clinical heart failure. In one series, 5% of all patients taking doxorubicin developed clinical heart failure. While tamoxifen increases the risk of thromboembolic events, it is not cardiotoxic. The other drugs listed are not known contributors to heart failure. |
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70-year-old white male presents to your clinic with increased fatigue and cough. His family history is notable for several first degree relatives with atherosclerotic cardiac disease. On examination he has a normal S1 and S2, with a 2/6 holosystolic murmur at the apex. He has no edema and lung sounds are normal.
Which of the following would be appropriate to further assess the patient for heart failure? (Mark all that are true.) 1 A chemistry profile 2 Cardiac echocardiography 3 A serum norepinephrine level 4 A BNP level |
answer 1,2,4
In a patient with suspected heart failure, the usefulness of a chemistry profile, a chest film, a 12-lead EKG, and echocardiography is supported by evidence or general agreement. Pulmonary venous congestion is associated with a positive likelihood ratio (LR) of 12.0 for heart failure, and a negative LR of 0.48. Cardiomegaly has a positive LR of 3.3 and a negative LR of 0.33. If the left ventricular ejection fraction is <40% and angina is present, then cardiac catheterization is also recommended to determine the extent of ischemic burden. In patients with strong risk factors for coronary disease, such as family history, the evidence for cardiac catheterization is rated class II (conflicting evidence and/or divergence of opinion about the usefulness of the procedure). A B-natriuretic peptide (BNP) level may be drawn for further monitoring, but the evidence for doing this routinely is not rated class I at this time. A BNP level is most helpful if the diagnosis is unclear and to help determine if cardiac or respiratory disease is causing dyspnea. In this patient, a negative BNP would essentially eliminate heart failure as a possibility (negative LR 0.06–0.15 depending on the threshold selected for positivity.) A BNP level is not helpful in patients with significant renal disease, as they often have elevated BNP. Measurement of serum norepinephrine is not recommended in the routine initial evaluation of heart failure. |
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BNP level is not helpful in patients with
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significant renal disease, as they often have elevated BNP
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According to ACC/AHA heart failure guidelines, which of the following should be asked about when taking a patient history as part of the initial evaluation of heart failure? (Mark all that are true.)
1 Diabetes mellitus 2 Hypertension 3 Excessive alcohol use 4 Illicit drug use 5 Chemotherapy |
Answer 1,2,3,4,5
According to the ACC/AHA guidelines for heart failure, the initial evaluation of a heart failure patient should include queries regarding any history of diabetes mellitus, hypertension, excess alcohol and/or illicit drug use, and chemotherapy. For each of these items there is evidence and/or general agreement that including them in the history is useful. |
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A 69-year-old female presents to your office with symptoms of shortness of breath when walking to the bathroom, and a new onset of edema in her lower extremities. Three years ago she had a non–Q-wave myocardial infarction. Her LDL-cholesterol level is 115 mg/dL.
Which one of the following would provide the most useful information regarding the diagnosis and future management of heart failure in this patient? 1 A serum transferrin saturation level 2 A TSH level 3 A fluorescent antinuclear antibody level 4 Echocardiography |
answer 4
This patient has heart failure that can be classified as stage C (structural heart disease with symptoms of heart failure), New York Heart Association class III (symptoms with minimal exertion). Echocardiography will provide information regarding her ejection fraction, and there is general agreement that this can help to guide therapy. Treatment should include ACE inhibitors, lipid management if needed, and diuretics. There is less evidence of potential benefit from serum transferrin levels and tests for rheumatologic disorders in unselected populations. |
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A 50-year-old African-American male presents with dyspnea, pleural effusion, and lower extremity edema. He has no history of elevated blood pressure or anginal symptoms. A routine chemistry profile and a CBC are normal. An EKG shows reduced voltage but is otherwise unremarkable. An echocardiogram shows increased wall thickening, with an ejection fraction of 55%. The patient has been a lifelong abstainer from alcohol.
Which one of the following is the most likely cause of this patient’s heart failure? 1 Hypertensive heart disease 2 Ischemic heart disease 3 Alcoholic cardiomyopathy 4 Amyloid infiltration 5 Hemochromatosis |
answer 4
The absence of a history of high blood pressure or anginal symptoms, along with an EKG that reveals no signs of left ventricular hypertrophy or ischemia, makes hypertensive and ischemic heart disease unlikely causes for this patient's heart failure. The lack of a history of excess alcohol use also makes alcoholic cardiomyopathy unlikely. Hereditary hemochromatosis is seen primarily in patients of Northern European descent. In patients with heart failure symptoms and reduced voltage on an EKG, the possibility of cardiac amyloidosis must be considered. Genetic cardiac amyloidosis can be treated, and family members must be screened for the disease. |
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In the United States, the most common primary cause of heart failure with systolic dysfunction is
1 hypertension 2 valvular heart disease 3 myocarditis 4 coronary artery disease 5 alcohol abuse |
answer 4
Coronary artery disease (CAD) is the primary cause of left ventricular systolic dysfunction in two-thirds of cases. While hypertension, valvular heart disease, myocarditis, and alcohol abuse can cause heart failure, they are less common than CAD. Hypertension can contribute to CAD, but it is the primary cause of heart failure in a smaller number of patients, and some of these patients have diastolic, rather than systolic, dysfunction |
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Which of the following would place a patient in the category of ACC/AHA stage B heart failure? (Mark all that are true.)
1 A history of dyspnea on exertion 2 A history of myocardial infarction 3 A grade 3/6 apical holosystolic murmur radiating to the axilla 4 Hypertension 5 An EKG demonstrating left ventricular hypertrophy |
answer 2,3,5
Heart failure is a progressive disorder that is best thought of as a clinical continuum. The American College of Cardiology/American Heart Association classification of heart failure, first presented in 2005, reflects this continuum and is broken down into four stages. Stage A is defined as the absence of structural disease in a patient at high risk for the development of heart failure. This includes patients with hypertension, atherosclerotic disease, diabetes mellitus, obesity, metabolic syndrome, or a family history of cardiomyopathy as well as those using cardiotoxins. Patients with stage B heart failure have evidence of structural heart disease (e.g., a previous myocardial infarction, asymptomatic valvular disease, or evidence of left ventricular remodeling such as left ventricular hypertrophy or a low ejection fraction). Stage C is defined as structural heart disease with prior or current symptoms of heart failure. Stage D patients have refractory heart failure requiring specialized interventions. |
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stage A heart failure
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Stage A is defined as the absence of structural disease in a patient at high risk for the development of heart failure. This includes patients with hypertension, atherosclerotic disease, diabetes mellitus, obesity, metabolic syndrome, or a family history of cardiomyopathy as well as those using cardiotoxins.
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Stage B heart failure
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stage B heart failure have evidence of structural heart disease (e.g., a previous myocardial infarction, asymptomatic valvular disease, or evidence of left ventricular remodeling such as left ventricular hypertrophy or a low ejection fraction).
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Stage C heart failure
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Stage C is defined as structural heart disease with prior or current symptoms of heart failure. Stage
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Stage D heart failure
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Stage D patients have refractory heart failure requiring specialized interventions.
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Which of the following laboratory abnormalities appear commonly in patients with structural heart disease and signs and symptoms of heart failure? (Mark all that are true.)
1 Elevated serum transaminases 2 Hyponatremia 3 Low circulating complement levels 4 Low BNP |
answer 1,2
Elevation of serum transaminases and hyponatremia may occur with heart failure, due to chronic passive congestion of the liver and expansion of total body water under the influence of vasopressin. Heart failure is associated with increased circulating complement levels. The BNP level is typically elevated in patients with symptomatic heart failure. |
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An 82-year-old female presents with recent symmetric bilateral leg swelling and exertional dyspnea. Laboratory evaluation rules out thyroid disease, anemia, and renal insufficiency, but her BNP level is 350 pg/mL (N <100). Echocardiography reveals an ejection fraction of 55%, and a chest film shows pulmonary vascular congestion and small pleural effusions with a normal-sized heart and no other abnormal findings. Her peak flow is 85% of the predicted value for her age, height, and weight.
Based on this presentation, which one of the following is the most likely diagnosis? 1 Systolic heart failure 2 COPD 3 Venous insufficiency edema 4 Diastolic heart failure |
answer 4
This patient most likely has diastolic heart failure, which is characterized by a normal ejection fraction (>50%) and clinical findings of heart failure. Her ejection fraction of 55% rules out systolic dysfunction, and the physical findings and radiographic findings make COPD and venous insufficiency unlikely as the cause for her symptoms. |
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What do you see with diastolic heart failure
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has diastolic heart failure, which is characterized by a normal ejection fraction (>50%) and clinical findings of heart failure.
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Of the following clinical findings seen in patients with known systolic dysfunction, which one has the highest predictive value for identifying elevated ventricular pressure in patients with heart failure?
1 Radiographic redistribution (cephalization) on a chest film 2 Low systolic blood pressure 3 Orthopnea 4 Abnormal abdominojugular reflux |
answer 1
Among patients with a high prevalence of increased ventricular filling pressure (such as patients presenting for cardiac transplantation and with known systolic dysfunction), radiographic redistribution indicates an 80%–90% probability of increased pressure actually being present. The predictive values of low systolic blood pressure, orthopnea, and abnormal abdominojugular reflux are not as high in this context. |
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A 65-year-old female with treated hypertension and a fasting glucose level of 118 mg/dL presents with exertional dyspnea and lower extremity edema. She is found to be in heart failure, with mild bibasilar rales. An EKG is normal, but echocardiography reveals global hypokinesis with an ejection fraction of 40%. She responds well to initial diuretic therapy but at her follow-up visit 1 week later she reports chest heaviness with walking, which is relieved by rest.
The most appropriate next step in the management of this patient is urgent scheduling of 1 a treadmill stress EKG 2 treadmill stress echocardiography 3 a dipyridamole (Persantine), technetium-sestamibi (Cardiolite) stress test 4 cardiac catheterization |
answer 4
In patients with left ventricular dysfunction and angina, the pretest probability of coronary artery disease is high enough to make a stress test of minimal utility. Coronary angiography, and revascularization if indicated, is the appropriate next step. |
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Which of the following patients would be considered to have stage A heart failure according to the current American Heart Association classification system? (Mark all that are true.)
1 A 29-year-old male with Hodgkin’s lymphoma treated with doxorubicin (Adriamcyin), bleomycin (Blenoxane), vinblastine, and dacarbazine (DTIC-Dome) 2 A 36-year-old male with a BMI of 29.3 kg/m2, a blood pressure of 128/82 mm Hg, a fasting blood glucose level of 112 mg/dL, a serum triglyceride level of 190 mg/dL, and an HDL-cholesterol level of 37 mg/dL 3 A 45-year-old male with a congenital bicuspid aortic valve 4 A 50-year-old female with type 2 diabetes mellitus 5 A 61-year-old male with a history of hypertension and concentric left ventricular hypertrophy on echocardiography |
answer 1,2,4
In 2001, the American Heart Association developed a new approach to the classification of heart failure that emphasized both the development and progression of the disease. Heart failure was divided into four stages: A, B, C, and D. The first two stages, A and B, do not represent clinical heart failure. Instead, they represent an attempt to facilitate the early identification of patients who are at risk for developing heart failure. Stage A includes patients with hypertension, diabetes mellitus, obesity, metabolic syndrome, and atherosclerotic disease, as well as those taking cardiotoxins (such as adriamycin) or with a family history of cardiomyopathy. Stage B patients have evidence of structural heart disease without signs or symptoms of heart failure; this includes patients with a prior myocardial infarction, asymptomatic valvular heart disease, or evidence of left ventricular remodeling, including left ventricular hypertrophy or a low ejection fraction. Stage C patients have structural heart disease and a history of previous or current symptoms of heart failure. Stage D patients have refractory heart failure requiring specialized interventions. |
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A heart failure patient who experiences shortness of breath while walking to the bathroom would best be described as having what New York Heart Association (NYHA) class of symptoms?
1 Class I 2 Class II 3 Class III 4 Class IV |
answer 3
The New York Heart Association system classifies heart failure patients on the basis of functional capacity and symptoms. Class I patients are asymptomatic. Class II patients experience symptoms only with moderate exertion. Class III patients experience heart failure symptoms with minimal exertion, and Class IV patients experience symptoms at rest. |
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New York Heart Association system Class I
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Class I patients are asymptomatic
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New York Heart Association system Class II
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Class II patients experience symptoms only with moderate exertion.
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New York Heart Association system Class 3
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Class III patients experience heart failure symptoms with minimal exertion
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New York Heart Association system Calss 4
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Class IV patients experience symptoms at rest.
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A 55-year-old African-American male presents with increased dyspnea on exertion. He has a 50-pack-year history of cigarette smoking but quit 5 years ago. On examination his blood pressure is 140/80 mm Hg. His pulse rate is 80 beats/min and regular. A lung examination reveals slightly diminished lung sounds but no crackles. He has had 1+ edema of the left lower extremity since suffering a deep venous thrombosis 5 years ago, which is why he stopped smoking. His hemoglobin level is 13.1 mg/dL (N 13.0–18.0). You order a chest radiograph and an EKG.
Which one of the following would be most helpful in distinguishing heart failure from pulmonary disease as the source of his dyspnea? 1 An EKG 2 A BNP level 3 A serum ferritin level 4 A high-sensitivity C-reactive protein (hs-CRP) level |
answer 2
A serum BNP level is most helpful in confirming a diagnosis of heart failure in a patient with symptoms that could be arising from different sources. A BNP level over 300 pg/mL is usually associated with heart failure. An EKG could be done, but since the patient has a normal pulse and regular rhythm it is not as likely to be helpful. Hereditary hemochromatosis occurs in patients of Northern European descent, making a ferritin level unlikely to yield useful information in this patient. C-reactive protein is a marker for inflammation and therefore could be elevated due to either pulmonary or cardiac inflammatory disorders, making it less useful for distinguishing between the two. |
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How do you diagnose hematomachrosis
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elevated ferritin
low to normal TIBC |
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An 82-year-old white female presents with increasing dyspnea. Her husband tells you that he is worried about her because he has noticed that she occasionally stops breathing while asleep. You have been treating the patient for heart failure for the past 2 years with ACE inhibitors, β-blockers, diuretics, and digoxin. When the nurse takes the patient’s blood pressure she notes that the systolic sounds are heard first at a pressure of 135 mm Hg and a pulse rate of 40 beats/min. At 120 mm Hg she hears Korotkoff sounds at a rate of 80/min.
True statements regarding this patient include which of the following? 1 This is a common presentation in stage A heart failure 2 This is a common presentation in stage B heart failure 3 Both the breathing and blood pressure findings may improve in the future with treatment 4 The patient’s breathing is normal for her age |
answer 3
The patient has pulsus alternans, which is common in patients with decompensated heart failure and advanced myocardial disease. Effective treatment can make this finding disappear. Cheyne-Stokes breathing also commonly occurs in the setting of decompensated heart failure. If the heart failure is treated, the breathing abnormality can disappear. The patient has symptomatic heart failure, which by definition places her in at least stage C heart failure, according to the ACC/AHA heart failure guidelines |
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A 56-year-old male with hypertension, heart failure, and osteoarthritis is started on a new medication. Three weeks later he presents to the emergency department with dyspnea and wheezing. He has jugular venous distention and 1+ pitting peripheral edema, and a chest film reveals pulmonary vascular congestion.
Which one of the following medications he is taking is most likely to cause these findings? 1 Spironolactone (Aldactone) 2 Digoxin 3 Enalapril (Vasotec) 4 Naproxen |
answer 4
This patient's findings are consistent with an exacerbation of heart failure. NSAIDs can precipitate heart failure by causing vasoconstriction and sodium retention, and by attenuating the beneficial effects of diuretics and ACE inhibitors. Non-dihydropyridine calcium channel blockers (verapamil and diltiazem) have negative inotropic and chronotropic effects and can worsen systolic heart failure. This is not true of long-acting dihydropyridine calcium channel blockers (amlodipine and felodipine). ACE inhibitors, angiotensin receptor blockers, and diuretics would generally be expected to improve rather than worsen heart failure. |
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Calcium channels and heart failure
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Non-dihydropyridine calcium channel blockers (verapamil and diltiazem) have negative inotropic and chronotropic effects and can worsen systolic heart failure. This is not true of long-acting dihydropyridine calcium channel blockers (amlodipine and felodipine
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How do NSAIDS cause heart failure
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NSAIDs can precipitate heart failure by causing vasoconstriction and sodium retention, and by attenuating the beneficial effects of diuretics and ACE inhibitors.
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A 72-year-old male is admitted to the hospital with a 4-day history of increasing fatigue and dyspnea. His previous medical history includes hypertension, a myocardial infarction, and heart failure, with a left ventricular ejection fraction of 35%. His blood pressure on admission is 126/82 mm Hg. His jugular veins are distended and he has rales halfway up both lungs. The cardiac examination reveals a regular rhythm with S3 and S4 gallops, and 3+ pitting pretibial edema is noted. A chest radiograph reveals cephalization of flow with bilateral pleural effusions. His BNP level is 600 pg/mL.
The patient is treated with intravenous morphine and furosemide and started on an intravenous nitroglycerin infusion. The addition of nesiritide (Natrecor) in this situation has been shown to result in which of the following? (Mark all that are true.) 1 A significant reduction in dyspnea 2 An increased risk for hypotension 3 Worsening of renal function 4 A reduced risk for rehospitalization at 30 days 5 A reduction in mortality at 30 days |
answer 2
Nesiritide is a B-type natriuretic peptide with vasodilatory properties. It was approved in 2001 for use in acute heart failure. However, subsequent pooled analyses of small randomized trials raised questions about possible renal toxicity and higher mortality associated with this agent. To clarify these issues, the Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND-HF) trial was conducted from 2007 to 2010 at 398 centers around the world. This trial was a randomized, double-blind, placebo-controlled study of 7141 patients hospitalized with acute heart failure who received either nesiritide or placebo in addition to routine care. Nesiritide was found to neither increase nor decrease the rate of rehospitalization or death within 30 days of treatment. Although it did not result in a worsening of renal function, it was associated with a higher rate of hypotension. It also resulted in a small, but not significant, improvement in dyspnea when used in combination with other therapies (SOR A). |
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Nesiritide
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Nesiritide is a B-type natriuretic peptide with vasodilatory properties. It was approved in 2001 for use in acute heart failure. However, subsequent pooled analyses of small randomized trials raised questions about possible renal toxicity and higher mortality associated with this agent.
Nesiritide was found to neither increase nor decrease the rate of rehospitalization or death within 30 days of treatment. Although it did not result in a worsening of renal function, it was associated with a higher rate of hypotension. It also resulted in a small, but not significant, improvement in dyspnea when used in combination with other therapies |
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Which one of the following is true regarding the use of digoxin in heart failure?
1 Digoxin should be used only in New York Heart Association Class IV heart failure 2 Digoxin decreases the risk for hospitalization for worsening heart failure in patients with stage C or D symptoms 3 Digoxin improves both morbidity and mortality rates in heart failure patients 4 Digoxin therapy increases the risk for hospitalization for supraventricular arrhythmias |
answer 2
Digoxin improves symptoms of pump failure and decreases hospitalizations, but it does not decrease overall mortality. The likely explanation for this is that decreased deaths from congestive pump dysfunction are offset by increased rhythm-related deaths. Digoxin therapy decreases, rather than increases, the risk for hospitalization for supraventricular arrhythmias. |
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In patients with heart failure, contraindications to initiation of β-blocker therapy include which of the following? (Mark all that are true.)
1 Hospitalization in an intensive-care unit with acute cardiac decompensation and pulmonary edema 2 Severe volume depletion in a patient with ventricular dysfunction 3 A requirement for continuous use of a β-agonist for circulatory support 4 Reactive airways disease requiring continuous nebulized β-adrenergic agonist therapy 5 Complete heart block without a pacemaker in place |
answer 1,2,3,4,5
Contraindications to the initiation of β-blocker therapy include high degrees of heart block without pacemaker support, as well as ventricular decompensation that is acute, with signs of either fluid overload or volume depletion. Reactive airways disease requiring inhaled or other β-agonist therapy is also a relative contraindication. If the disease is severe and requires continuous β-agonist therapy, then it would be unwise to give the patient a β-blocker. |
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In patients with severe decompensated heart failure refractory to intravenous inotropic therapy who are awaiting heart transplantation, left ventricular assist devices
1 have been used but largely fail to improve survival 2 can improve survival to transplantation but require the patient to be attached to a machine, with a reduction in quality of life in the interim 3 improve survival to transplantation and generally improve quality of life in the interim 4 should be used even if the patient is determined to be an unsuitable candidate for heart transplantation |
answer 3
Bridge therapy refers to the use of left ventricular assist devices to help a patient survive until a donor heart becomes available for transplantation. Several devices are available, some of which are implantable and allow patients to be discharged to their homes. These devices can increase patient activity levels and quality of life. Complications, including stroke, infection, and death, can occur, but these devices can be life-saving in patients with refractory heart failure. While some devices are under investigation for long-term or destination therapy, benefits in non-transplant candidates with chronic severe heart failure must be weighed against the risk of eventual device-related complications. |
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A 68-year-old male with New York Heart Association Class III heart failure and a blood pressure of 110/70 mm Hg is currently on furosemide (Lasix), 40 mg twice daily, and carvedilol (Coreg).
Which one of the following changes in treatment will reduce this patient’s mortality risk and risk of future hospitalization for heart failure? 1 Increasing the dosage of furosemide 2 Adding lisinopril (Prinivil, Zestril) to his regimen 3 Adding digoxin to his regimen 4 Adding metolazone (Zaroxolyn) to his regimen |
answer 2
ACE inhibitors such as lisinopril have been shown to decrease both mortality and rehospitalizations for heart failure. Digoxin improves symptoms and exercise tolerance, but does not decrease mortality. There have been no long-term studies conducted to determine the effects of diuretics such as furosemide and metolazone on morbidity and mortality. |
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Which of the following may interfere with the efficacy of thiazide diuretics in the treatment of heart failure? (Mark all that are true.)
1 Chondroitin 2 Glucosamine 3 Nabumetone 4 Naproxen (Naprosyn) 5 Tramadol (Ultram) |
answer 3,4
Thiazide diuretics are not subject to substantial medication interaction related to the hepatic cytochrome pathway, from either inducers or inhibitors of cytochrome systems. However, prostaglandin inhibitors such as NSAIDs, including both traditional and COX-2 types, do interfere with the mechanism of action of thiazide diuretics and their concomitant use is a risk factor for precipitation of heart failure and hospitalization due to sodium and water retention. Both nabumetone and naproxen are NSAIDs, and can interfere with thiazides. Tramadol is a narcotic-like analgesic, and is not known to interact with thiazide diuretics. Glucosamine and chondroitin may have anti-inflammatory activity, but they have not been shown to interact with thiazides. |
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Which one of the following is true regarding head-to-head trials of ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) for the treatment of heart failure?
1 ACEIs have been shown to be clearly superior to ARBs 2 ARBs have been shown to be clearly superior to ACEIs 3 ACEIs and ARBs have been shown to be equivalent 4 All studies have shown that combination therapy with an ACEI and an ARB is superior to therapy with either type of agent alone 5 Various trials involving either a single drug class or combination therapy have produced conflicting results |
answer 5
When angiotensin receptor blockers (ARBs) first became available, head-to-head studies comparing them to ACE inhibitors (ACEIs) showed that ACEIs were superior. These studies compared lisinopril to losartan, for example. Studies of combined therapy, sometimes using newer ARBs, have produced conflicting results. Some trials have shown worse outcomes when an ARB is added to an ACEI, especially in patients receiving concurrent β-blocker therapy. Other studies have shown additional benefit from combination therapy with an ACEI, an ARB, and a β-blocker. Hence, the answer to this question may depend upon which ARB is being considered or the methodology of the trials in question. The most important point is that patients who cannot tolerate an ACEI should be switched to an ARB. It is also important to know that it is more useful to add β-blockers to therapy with either an ACEI or an ARB, rather than combine all three types of agents. If a patient cannot take β-blockers, then combining an ACEI with an ARB may be a logical strategy. |
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Question 1 of 11 to be reviewed in this competency
Instructions: Choose the single best answer. Click once on a response letter (A, B, C, etc.) to select an answer, and the letter will change color. Change your answer by clicking once on another response letter. To record your answer and continue, click "Next Question." To stop the assessment now without recording your answer, click "Suspend Assessment." SELF-ASSESSMENT MODULE - KNOWLEDGE ASSESSMENT Current Module - Heart FailureCME DISCLOSURECOCHRANE LIBRARY | REFERENCES | DOWNLOAD QUESTIONS -------------------------------------------------------------------------------- Critique: By inhibiting uptake of solute at different sites in the renal tubule, the combination of metolazone plus a loop diuretic has proven to be especially potent. However, it can also be dangerous when used on an ongoing basis, as severe hypokalemia is quite common. Hence, intermittent therapy is preferable, and ongoing monitoring of serum electrolytes on a frequent basis is highly advisable. Combining a thiazide with a loop diuretic is also a proven combination, but is not as potent. Combining an aldosterone inhibitor with a loop diuretic for symptomatic relief has proven to decrease mortality in selected classes of heart failure, but is not as likely to relieve this patient's persistent pulmonary edema. Bumetanide and furosemide are both loop diuretics, and combining them would be unlikely to have the additive potency of using two agents that act at different sites on the renal tubule. References: 1.Gomberg-Maitland M, Baran DA, Fuster V: Treatment of congestive heart failure: Guidelines for the primary care physician and the heart failure specialist. Arch Intern Med 2001;161(3):342-352. http://archinte.ama-assn.org/cgi/content/full/161/3/342 2.Guidelines for the evaluation and management of heart failure: Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Evaluation and Management of Heart Failure). Circulation 1995;92(9):2764-2784. http://circ.ahajournals.org/cgi/content/full/92/9/2764 3.Nohria A, Lewis E, Stevenson LW: Medical management of advanced heart failure. JAMA 2002;287(5):628-640. http://jama.ama-assn.org/cgi/content/full/287/5/628 A 62-year-old African-American male has poorly controlled heart failure with persistent dyspnea, bibasilar rales, and pleural effusions. His edema is refractory to treatment with furosemide (Lasix) alone. Which one of the following additions to his drug therapy would be most likely to mobilize fluid quickly and relieve his edema? 1 Bumetanide 2 Hydrochlorothiazide 3 Chlorthalidone (Thalitone) 4 Metolazone (Zaroxolyn) 5 Spironolactone (Aldactone) |
answer 4
By inhibiting uptake of solute at different sites in the renal tubule, the combination of metolazone plus a loop diuretic has proven to be especially potent. However, it can also be dangerous when used on an ongoing basis, as severe hypokalemia is quite common. Hence, intermittent therapy is preferable, and ongoing monitoring of serum electrolytes on a frequent basis is highly advisable. Combining a thiazide with a loop diuretic is also a proven combination, but is not as potent. Combining an aldosterone inhibitor with a loop diuretic for symptomatic relief has proven to decrease mortality in selected classes of heart failure, but is not as likely to relieve this patient's persistent pulmonary edema. Bumetanide and furosemide are both loop diuretics, and combining them would be unlikely to have the additive potency of using two agents that act at different sites on the renal tubule. |
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A 58-year-old male sees you for a routine annual evaluation. A complete review of systems is performed and is negative except for episodic left knee pain relieved by rest. His past medical history is notable only for a history of an inferior wall myocardial infarction 2 years ago. His current medications are atorvastatin (Lipitor), 20 mg daily, and aspirin, 162 mg daily. He is a nonsmoker. His blood pressure is 126/82 mm Hg. His jugular veins are not distended and his lungs are clear. The cardiac examination reveals a regular rhythm with an S4 and no murmur. There is no edema.
An EKG shows a normal sinus rhythm with Q waves in leads II, III, and AVF. Echocardiography demonstrates hypokinesis of the basal to mid-inferomedial wall with an estimated left ventricular ejection fraction of 55%–60%. Which of the following medications would be indicated at this time? (Mark all that are true.) 1 Enalapril (Vasotec) 2 Furosemide (Lasix) 3 Extended-release metoprolol (Toprol-XL) 4 Diltiazem (Cardizem) 5 Spironolactone (Aldactone) |
answer 1,3
Despite the absence of symptoms and a left ventricular ejection fraction within the normal range, the patient’s previous myocardial infarction (MI) is evidence of structural heart disease, making his ACC/AHA heart failure classification stage B. Patients without heart failure symptoms who have had an MI or who have evidence of left ventricular remodeling are felt to be at considerable risk of developing heart failure and warrant intervention. In addition to optimal management of hyperlipidemia and hypertension, the AHA recommends that ACE inhibitors (ACEIs) and β-blockers be used in all patients with a recent or remote history of MI, regardless of ejection fraction or the presence of heart failure (SOR A). Two large-scale studies have demonstrated that prolonged therapy with an ACEI reduces the risk of a major cardiovascular event even when treatment is initiated months or years after the MI. Furosemide is not recommended for use in stage B patients, and calcium channel blockers such as diltiazem can lead to worsening heart failure and are best avoided. The AHA recommends that angiotensin receptor blockers be administered to post-MI patients without heart failure who are intolerant of ACE inhibitors and have a low left ventricular ejection fraction (SOR B). Aldosterone antagonists have not been studied in stage B heart failure and their use is generally recommended for selected patients with moderately severe to severe symptoms and a reduced left ventricular ejection fraction (stages C and D). |
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There is evidence or general agreement to support the usefulness of treating diastolic heart failure with which of the following? (Mark all that are true.)
1 Diuretics 2 Hypertension control 3 Negative chronotropic agents 4 Digoxin |
answer 1,2,3
Methods of treating diastolic heart failure that are supported by evidence or general agreement include controlling hypertension, controlling heart rate and preventing tachycardia, managing vascular volume with diuretics, and treating and preventing myocardial ischemia. In addition, promoting regression of hypertrophy and preventing myocardial fibrosis would be of theoretical benefit. Digoxin is recommended for systolic heart failure but not for diastolic heart failure. |
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A 69-year-old female with a history of chronic hypertension and a previous myocardial infarction is seen for follow-up 6 weeks after being hospitalized for heart failure. Although she feels comfortable at rest, she reports she is unable to walk up even a single flight of stairs and becomes breathless carrying groceries in from the car. Her current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 20 mg daily; and aspirin, 81 mg daily.
On examination the patient is not in acute distress. Her blood pressure is 132/78 mm Hg and her pulse rate is 55 beats/min. A lung examination reveals bibasilar rales. Auscultation of the heart reveals a regular rhythm with a soft S3 and S4 and no murmur. She has trace pretibial edema. An EKG reveals sinus bradycardia of 52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography shows a left ventricular ejection fraction of 32%. Which of the following interventions has been shown to improve survival in patients such as this? (Mark all that are true.) 1 Amiodarone (Cordarone) 2 Digoxin 3 Eplerenone (Inspra) 4 Amlodipine (Norvasc) 5 Cardiac resynchronization therapy |
The addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in the Randomized Aldactone Evaluation Study (RALES) to reduce rates of death and hospital readmissions in selected patients with moderate to severe symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF) (SOR B). More recently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) trial found that the addition of eplerenone in heart failure patients with mild symptoms (NYHA class II) and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths. Current AHA guidelines call for the addition of an aldosterone antagonist to an ACE inhibitor and a β-blocker in selected patients with moderately severe to severe symptoms of heart failure and a reduced LVEF.
Although the addition of digoxin can be of benefit in selected heart failure patients by reducing the risk for hospitalization, it has not been shown to reduce mortality (SOR B). Amiodarone, which is the preferred antiarrhythmic agent for preventing recurrent atrial fibrillation or symptomatic ventricular arrhythmias in heart failure patients, has been found to have a neutral impact on survival (SOR A). Cardiac resynchronization therapy (CRT) has been shown to improve survival in patients with advanced heart failure (NYHA class III or IV) with a QRS interval >0.12 sec (SOR A), but evidence of benefit in patients with a QRS interval <0.12 sec is lacking. It has been reported that unlike in heart failure patients with a QRS interval exceeding 0.12 sec, CRT does not improve peak oxygen consumption or survival in patients with narrow QRS intervals. Calcium channel blockers can lead to worsening heart failure and an increased risk of cardiovascular events and should be avoided. |
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69-year-old female with a history of chronic hypertension and a previous myocardial infarction is seen for follow-up 6 weeks after being hospitalized for heart failure. Although she feels comfortable at rest, she reports she is unable to walk up even a single flight of stairs and becomes breathless carrying groceries in from the car. Her current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 20 mg daily; and aspirin, 81 mg daily.
On examination the patient is not in acute distress. Her blood pressure is 132/78 mm Hg and her pulse rate is 55 beats/min. A lung examination reveals bibasilar rales. Auscultation of the heart reveals a regular rhythm with a soft S3 and S4 and no murmur. She has trace pretibial edema. An EKG reveals sinus bradycardia of 52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography shows a left ventricular ejection fraction of 32%. Which of the following interventions has been shown to improve survival in patients such as this? (Mark all that are true.) 1 Amiodarone (Cordarone) 2 Digoxin 3 Eplerenone (Inspra) 4 Amlodipine (Norvasc) 5 Cardiac resynchronization therapy |
answer 3
The addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in the Randomized Aldactone Evaluation Study (RALES) to reduce rates of death and hospital readmissions in selected patients with moderate to severe symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF) (SOR B). More recently, the Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure (EMPHASIS-HF) trial found that the addition of eplerenone in heart failure patients with mild symptoms (NYHA class II) and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths. Current AHA guidelines call for the addition of an aldosterone antagonist to an ACE inhibitor and a β-blocker in selected patients with moderately severe to severe symptoms of heart failure and a reduced LVEF. Although the addition of digoxin can be of benefit in selected heart failure patients by reducing the risk for hospitalization, it has not been shown to reduce mortality (SOR B). Amiodarone, which is the preferred antiarrhythmic agent for preventing recurrent atrial fibrillation or symptomatic ventricular arrhythmias in heart failure patients, has been found to have a neutral impact on survival (SOR A). Cardiac resynchronization therapy (CRT) has been shown to improve survival in patients with advanced heart failure (NYHA class III or IV) with a QRS interval >0.12 sec (SOR A), but evidence of benefit in patients with a QRS interval <0.12 sec is lacking. It has been reported that unlike in heart failure patients with a QRS interval exceeding 0.12 sec, CRT does not improve peak oxygen consumption or survival in patients with narrow QRS intervals. Calcium channel blockers can lead to worsening heart failure and an increased risk of cardiovascular events and should be avoided. |
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62-year-old Asian male comes to your office for his annual checkup. His past medical history is notable for a history of hypertension, type 2 diabetes mellitus, and heart failure. His current medications include metformin (Glucophage), 500 mg twice daily; benazepril (Lotensin), 20 mg daily; chlorthalidone, 15 mg daily; atorvastatin (Lipitor), 10 mg daily; and aspirin, 81 mg daily. The physical examination is notable only for a BMI of 29.1 kg/m2 and a blood pressure of 126/80 mm Hg. His hemoglobin A1c is 6.9%.
Which of the following β-blockers would be appropriate to help manage his heart failure? (Mark all that are true.) 1 Atenolol (Tenormin) 2 Sustained-release metoprolol (Toprol-XL) 3 Carvedilol (Coreg) 4 Labetalol (Trandate) 5 Propranolol |
answer 2,3
Current American Heart Association guidelines recommend that a β-blocker, specifically either carvedilol, misoprolol, or sustained-release metoprolol succinate, be prescribed to all patients with stable heart failure due to a reduced left ventricular ejection fraction. These three β-blockers have all been shown to prolong survival in patients with current or prior symptoms of heart failure. A class effect cannot be assumed, however. For example, in the β-Blocker Evaluation of Survival Trial (BEST), the use of bucindolol failed to produce a significant overall survival benefit in patients with advanced heart failure. Similarly, a survival benefit has not been demonstrated for atenolol or nebivolol. Studies have shown short-acting metoprolol to be less effective than sustained-release metoprolol succinate in reducing the risk of death in patients with chronic heart failure. |
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What 3 Beta Blockers should a pt with CHF be on
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coreg
misoprolol, or sustained-release metoprolol succinate Current American Heart Association guidelines recommend that a β-blocker, specifically either carvedilol, misoprolol, or sustained-release metoprolol succinate, be prescribed to all patients with stable heart failure due to a reduced left ventricular ejection fraction. These three β-blockers have all been shown to prolong survival in patients with current or prior symptoms of heart failure. A class effect cannot be assumed |
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A 73-year-old male is admitted to the hospital with a 1-week history of increasing dyspnea on exertion, 3-pillow orthopnea, and swollen legs. His past medical history includes type 2 diabetes mellitus, atrial fibrillation, and stage C heart failure with a left ventricular ejection fraction of 42%. His current medications include enalapril (Vasotec), 40 mg daily; carvedilol (Coreg), 12.5 mg twice daily; and liraglutide (Victoza), 1.2 mg subcutaneously daily.
On examination his blood pressure is 128/80 mm Hg and his heart rate is 80 beats/min and irregularly irregular. His neck veins are distended and he has inspiratory rales halfway up his lungs. He has 3+ pretibial edema. His BNP level is 6500 pg/mL. True statements regarding intravenous loop diuretic therapy in this situation include which of the following? (Mark all that are true.) 1 Continuous infusion is more effective than bolus therapy every 12 hr 2 Continuous infusion is associated with a lower risk of worsening renal function compared to bolus therapy 3 The median length of hospital stay is shorter with continuous therapy than with bolus therapy 4 High-dose therapy results in greater net fluid loss compared to low-dose therapy 5 High-dose therapy is more likely to cause transient worsening of renal function compared to low-dose therapy |
answer 4,5
The administration of intravenous loop diuretic therapy has been a mainstay in the management of acute decompensated heart failure. When prescribing loop diuretics in this setting, a number of strategies have been employed. The National Heart, Lung, and Blood Institute conducted the Diuretic Optimization Strategies Evaluation (DOSE) trial to study the effectiveness and safety of continuous administration as compared to a bolus administered every 12 hr. The study also compared low-dose therapy (equivalent to the patient’s previous oral dose) and high-dose therapy (2.5 times the previous oral dose). This prospective, randomized, controlled study of 308 patients with acute decompensated heart failure found no significant differences between the continuous and bolus strategies in terms of benefit, worsening renal function, or median length of hospital stay. Although the study found no difference using a global symptom assessment scale between low-dose and high-dose therapy, it did find high doses to be associated with greater net fluid loss, weight loss, and relief from dyspnea. In addition, a greater risk for a transient worsening of renal function was seen in the high-dose group (SOR A). |
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True statements regarding anticoagulation and antiplatelet therapy in patients with heart failure who are not known to have underlying coronary artery disease include which of the following? (Mark all that are true.)
1 Patients with atrial fibrillation and a depressed ejection fraction are most likely to benefit from anticoagulation or antiplatelet therapy 2 For patients in sinus rhythm, there is insufficient evidence to support the routine use of clopidogrel (Plavix) 3 For patients in sinus rhythm, there is insufficient evidence to support the routine use of dipyridamole (Persantine) 4 For patients in sinus rhythm, there is insufficient evidence to support the routine use of warfarin anticoagulation |
answer 1,2,3,4
Critique: While a clear role and benefit has been demonstrated for anticoagulation or antiplatelet therapy in patients with atrial fibrillation , there is no convincing evidence that it would play a consistently positive role in heart failure for patients in sinus rhythm. In addition, non-randomized studies have suggested a possible interaction between ACE inhibitors and antiplatelet agents, leading to less benefit than ACE inhibitors alone. Expert opinion suggests that patients with severely depressed ejection fractions may benefit from warfarin anticoagulation, although no randomized, controlled trials have been done to prove or disprove this. However, in patients who have heart failure due to myocardial infarction (MI), aspirin therapy may be of benefit in preventing a second MI. |
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A 70-year-old Asian female has a potassium level of 3.1 mmol/L (N 3.5–5.0) related to therapy with loop diuretics for stage IV heart failure. Which of the following additions to her therapy would help reduce her hypokalemia? (Mark all that are true.)
1 Spironolactone (Aldactone) 2 Lisinopril (Prinivil, Zestril) 3 Hydrochlorothiazide 4 Eplerenone (Inspra) 5 Candesartan (Atacand) |
answer 1,2,4,5
Aldosterone antagonists such as spironolactone and eplerenone have potassium-sparing properties. ACE inhibitors, and to a lesser degree angiotensin receptor blockers, also spare potassium. Thiazide diuretics such as hydrochlorothiazide exacerbate renal potassium loss |
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True statements regarding the use of second-generation dihydropyridine calcium channel blockers such as amlodipine (Norvasc) and felodipine (Plendil) in patients with heart failure include which of the following? (Mark all that are true.)
1 Unlike the nondihydropyridines such as verapamil (Calan, Isoptin) and diltiazem (Cardizem), they do not increase morbidity and mortality in patients with heart failure (HF) 2 Second-generation dihydropyridine calcium channel blockers can be used for symptomatic control of angina in HF patients 3 Second-generation dihydropyridine calcium channel blockers can be used safely for the treatment of hypertension in HF patients 4 Second-generation dihydropyridine calcium channel blockers often exacerbate heart block in susceptible patients, especially those on concurrent β-blocker therapy |
answer 1,2,3
Second-generation dihydropyridine calcium channel blockers (e.g., amlodipine) may be helpful in the management of hypertension and angina in patients with concurrent heart failure (HF). Unlike older non-dihydropyridine calcium channel blockers, they do not depress ventricular function. However, they have not been shown to improve mortality outcomes in heart failure patients. Unlike the non-dihydropyridine calcium channel blockers, which depress both conduction system function and contractility, these drugs can be safely given with β-blockers in HF patients. From the standpoint of management of HF and decreasing HF-related morbidity and mortality, it makes sense to maximize dosages of drugs that have been shown to yield mortality benefit (ACE inhibitors, angiotensin receptor blockers, β-blockers, aldosterone antagonists) before adding calcium channel blockers. Second-generation dihydropyridine calcium channel blockers (such as amlodipine) may have a greater role in patients with concurrent angina after the use of β-blocker therapy has been optimized, or for those in whom β-blockade is contraindicated. |
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can you give calcium channel blockers with CHF
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Second-generation dihydropyridine calcium channel blockers (e.g., amlodipine) may be helpful in the management of hypertension and angina in patients with concurrent heart failure (HF). Unlike older non-dihydropyridine calcium channel blockers, they do not depress ventricular function. However, they have not been shown to improve mortality outcomes in heart failure patients. Unlike the non-dihydropyridine calcium channel blockers, which depress both conduction system function and contractility, these drugs can be safely given with β-blockers in HF patients.
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A 55-year-old female with a previous history of hypertension, myocardial infarction, and degenerative knee arthritis complains of dyspnea and fatigue, even when just walking around the house. Her current medications include aspirin, 81 mg daily; lovastatin (Mevacor), 20 mg daily; enalapril (Vasotec), 10 mg daily; furosemide (Lasix), 40 mg daily; metoprolol succinate (Toprol-XL), 25 mg twice daily; and extended-release potassium chloride, 10 mEq twice daily. Echocardiography reveals a left ventricular ejection fraction of 32%.
True statements regarding the addition of an aldosterone antagonist to this patient’s treatment regimen include which of the following? (Mark all that are true.) 1 It can be safely prescribed provided her serum creatinine level is <2.5 mg/dL 2 It cannot be safely prescribed if her serum potassium level is >4.5 mg/dL 3 Potassium supplements should be discontinued 4 NSAIDs and COX-2 inhibitors should be avoided 5 Potassium levels and renal function should be checked 2 weeks and 4 weeks after initiation of an aldosterone antagonist and at least monthly thereafter |
answer 3,4
The aldosterone antagonists used for heart failure are spironolactone and eplerenone. Although studies have demonstrated reduced hospitalization rates and improved survival in select heart failure patients with use of these drugs, their use in heart failure carries a risk for life-threatening hyperkalemia. As a result, these drugs should be withheld, even from patients meeting recommended criteria, if there is significant renal dysfunction or hyperkalemia. Guidelines from the American Heart Association recommend avoiding aldosterone antagonists in patients with a serum potassium level >5.0 mEq/L and a serum creatinine level >2.5 mg/dL for men or >2.0 mg/dL for women. Moreover, serum creatinine may not be an accurate measure of renal function in elderly patients or others with low muscle mass, so confirmation that creatinine clearance exceeds 30 mL/minute is recommended. The recommended starting dosage for spironolactone is 12.5 mg daily and for eplerenone is 25 mg daily, with subsequent titration up to 25 mg daily and 50 mg daily, respectively, as appropriate. It is important to be aware that the risk for hyperkalemia is increased in patients on higher dosages of ACE inhibitors. NSAIDs and COX-2 inhibitors should be avoided in patients taking aldosterone antagonists, and potassium supplements should be discontinued or reduced. Close monitoring of serum potassium is recommended; serum potassium levels should be checked 3 days and 7 days after starting an aldosterone antagonist, followed by monthly measurement for the first 3 months (SOR C). |
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Name 2 aldosterone antagonists used in heart faiilure
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1. spironolactone
2. eplerenone The aldosterone antagonists used for heart failure are spironolactone and eplerenone. Although studies have demonstrated reduced hospitalization rates and improved survival in select heart failure patients with use of these drugs, their use in heart failure carries a risk for life-threatening hyperkalemia |
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What is the cuf ott for creatinine if on an aldosterone antagonist
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recommend avoiding aldosterone antagonists in patients with a serum potassium level >5.0 mEq/L and a serum creatinine level >2.5 mg/dL for men or >2.0 mg/dL for women.
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A 68-year-old African-American male with a history of hypertension, diabetes mellitus, and heart failure presents with a 6-week history of progressive fatigue, ankle swelling, and dyspnea on exertion. His current medications include lisinopril (Prinivil, Zestril), 20 mg daily; lovastatin (Mevacor), 20 mg daily; insulin glargine (Lantus), 10 units subcutaneously at bedtime; and sitagliptin (Januvia), 100 mg daily.
On examination, his pulse rate is 76 beats/min and regular and his blood pressure is 130/80 mm Hg. There is jugular venous distention, a laterally displaced apex beat, and 1+ pitting ankle edema. The lung examination reveals bibasilar rales. Cardiac auscultation reveals a regular rhythm with a soft S4. Echocardiography shows a left ventricular ejection fraction of 40%. Which of the following medications should be added at this time? (Mark all that are true.) 1 Furosemide (Lasix) 2 Carvedilol (Coreg) 3 Hydralazine/isosorbide dinitrate (BiDil) 4 Spironolactone (Aldactone) |
answer 1
This patient has signs of heart failure with fluid retention. Diuretics produce symptomatic benefits more rapidly than any other drug for heart failure and are the only agents that can adequately control fluid retention. Loop diuretics, such as furosemide, are more effective than thiazide diuretics for controlling sodium and free water clearance (SOR C). Although β-blockers should be prescribed for all patients with heart failure, they should not be started until the patient is sufficiently stable; specifically, it is recommended that β-blockers not be started while patients are hospitalized in intensive care or when they have even minimal evidence of fluid overload or volume depletion (SOR C). Aldosterone antagonists are relatively weak diuretics that are prescribed to improve survival in selected patients with severe symptoms and a reduced left ventricular ejection fraction (SOR B). The combination of hydralazine and nitrates is generally recommended for African-American patients with moderate to severe symptoms only if they are already on optimal therapy with ACE inhibitors, β-blockers, and diuretics (SOR B). |
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When should you start b blockers in a pt with CHF
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Although β-blockers should be prescribed for all patients with heart failure, they should not be started until the patient is sufficiently stable; specifically, it is recommended that β-blockers not be started while patients are hospitalized in intensive care or when they have even minimal evidence of fluid overload or volume depletion
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74-year-old female is discharged from the hospital after being treated for an exacerbation of heart failure with volume overload. Her past medical history is notable for a history of coronary heart disease and hypertension. Her discharge medications include furosemide (Lasix), 20 mg twice daily; lovastatin (Mevacor), 40 mg daily; ramipril (Altace), 5 mg daily; spironolactone (Aldactone), 12.5 mg twice daily; metoprolol succinate (Toprol-XL), 75 mg daily; and aspirin, 162 mg daily. In addition, she is instructed to avoid the use of ibuprofen and other NSAIDs and to add metolazone (Zaroxolyn), 2.5 mg daily, with 2 tablespoons of 10% KCl elixir, on mornings when her weight is more than 3 lb (1.4 kg) over her target weight of 130 lb (59 kg).
Which one of the following is the most common reason for medication nonadherence in patients such as this? 1 Cost 2 Concerns regarding potential side effects 3 Confusion regarding conflicting instructions given by different health care providers 4 Lack of understanding about the discharge instructions 5 Uncertainty regarding the need for the medication |
answer 4
A study of patients recently discharged from the hospital following an exacerbation of heart failure found a high rate of medication nonadherence, with only one-third of patients taking all their medications as prescribed and not taking unprescribed medications. Of those not taking medications as prescribed, the most common reason given was not understanding discharge instructions (57%). Less common reasons include confusion due to conflicting instructions from the discharging physician and the primary care physician, medication cost, being unconvinced of the utility of the medication, and concerns regarding potential side effects (SOR B). |
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A 74-year-old male with New York Heart Association class II heart failure and a left ventricular ejection fraction of 38% is on optimal dosages of an ACE inhibitor, a β-blocker, and pravastatin (Pravachol). His past medical history is notable only for a long history of hypertension. He is a nonsmoker and reports that he has a small glass of red wine with dinner each evening.
On examination he has a blood pressure of 128/70 mm Hg and a BMI of 29.1 kg/m2. His chest is clear and his cardiac examination is notable only for an S4. Self-help measures recommended for patients such as this include which of the following? (Mark all that are true.) 1 A sodium intake ≤2300 mg/day 2 Strict avoidance of alcohol consumption 3 Avoiding exercise 4 Avoiding NSAID use 5 A weight-loss program with a goal BMI of 25 kg/m2 or less |
answer 1,4
Self-care is advocated as a method of improving outcomes in patients with heart failure. The American Heart Association (AHA) currently recommends a sodium intake of no more than 2300 mg daily for heart failure patients, the same amount recommended for healthy adults. Although fluid restriction to <2 L/day may be appropriate for patients with hyponatremia or persistent or recurrent fluid retention, a more liberal intake would be appropriate for stable heart failure patients. Patients with heart failure should be advised to avoid NSAID use, which has been shown to increase the risk for renal insufficiency and hospitalization. Available studies indicate that survival is highest in patients with a BMI of 30–32 kg/m2, and no studies have demonstrated a survival benefit from weight loss in patients with heart failure. Consequently, AHA guidelines currently recommend that weight loss be encouraged only in patients with a BMI >40 kg/m2. Several epidemiologic studies have failed to demonstrate a correlation between alcohol consumption and the development of heart failure. With the exception of patients with alcoholic cardiomyopathy, who should abstain from alcohol use, heart failure patients who choose to drink should be advised to limit their alcohol intake to no more than 1–2 drinks a day. Although avoidance of physical exertion has been advised in the past, it is now thought that a reduction in physical activity leads to physical deconditioning and an unnecessary worsening of symptoms. Exercise training 3–5 days a week should be considered in all stable outpatients with chronic heart failure. |
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How much Na does the AHA recommend for pts in heart failure
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The American Heart Association (AHA) currently recommends a sodium intake of no more than 2300 mg daily for heart failure patients
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60-year-old female is discharged following a 3-day hospitalization for pulmonary edema, which readily resolved with intravenous diuretics. Her discharge medications are lisinopril (Prinivil, Zestril), 20 mg daily; furosemide (Lasix), 20 mg daily; carvedilol (Coreg), 25 mg twice daily; and aspirin, 81 mg daily. Her past medical history is notable for a 15-year history of hypertension. Despite several recent attempts to stop, she continues to smoke 1½ packs of cigarettes per day.
You suggest that the patient see you to develop a strategy to stop smoking. True statements regarding smoking cessation include which of the following? (Mark all that are true.) 1 It has been shown to reduce mortality in patients with heart failure 2 Tobacco quit rates increase as the number of interventions provided increases 3 Nicotine replacement therapy should be avoided in smokers with known heart disease 4 The benefit of self-help quit lines is enhanced by multiple call-back counseling 5 The provision of written self-help materials offers greater benefit than tailored interventions |
answer 1,2,4
The importance of smoking cessation in the patient with heart failure cannot be overstated. Nicotine possesses both vasoconstrictor and proinflammatory properties which make it particularly harmful to patients with heart failure. Accordingly, smoking cessation has been shown to reduce adverse outcomes and mortality in patients with heart failure. In general, tobacco quit rates have been shown to increase as the number of interventions provided. Tailored interventions have been shown to be of value, whereas an added value of written self-help materials to the provision of face-to-face advice or nicotine replacement therapy has not been shown. Self-help call lines have been also shown to increase quit rates in a range comparable with drug trials, and their effectiveness appears to be enhanced by a strategy of multiple call-back counseling. Nicotine replacement therapy is another effective measure, and is no longer contraindicated in patients with heart disease. Other interventions that warrant consideration include bupropion and varenicline |
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Alcohol consumption has been linked to several conditions related to heart failure. True statements regarding alcohol use and cardiovascular disease include which of the following? (Mark all that are true.)
1 Alcohol in modest amounts (1–2 drinks/day) decreases the risk of coronary heart disease 2 Alcohol intake raises HDL-cholesterol levels 3 Alcohol in larger quantities (>2 drinks/day) can cause cardiomyopathy 4 Alcohol in larger quantities (>2 drinks/day) increases the likelihood of hypertension 5 High-quality randomized, controlled trials have demonstrated the cardioprotective effects of moderate alcohol consumption All patients should be advised to drink one or two alcoholic beverages daily |
answer 1,2,3,4
Many observational and epidemiologic studies indicate a reduced risk of coronary heart disease with moderate alcohol consumption. However, no high-quality prospective randomized trials have examined this relationship, and confounding variables are impossible to eliminate in observational studies. Higher quantities of alcohol (>2 drinks/day) can cause cardiomyopathy and increase the risk of hypertension and hemorrhagic stroke. The decision to support alcohol consumption must be individualized and should take into account factors such as other disease states and a personal or family history of alcoholism. |
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A 63-year-old male was recently diagnosed with moderate obstructive sleep apnea. He complains of daytime drowsiness and has become progressively more fatigued. He has known heart failure that has resulted in three prior hospital admissions, but he has remained stable over the last 6 months. He asks you about continuous positive airway pressure (CPAP) therapy.
Which one of the following would be the most appropriate advice for this patient? 1 There is a significant risk from CPAP therapy in patients with heart failure, due to the risk of arrhythmia 2 There is a significant risk from CPAP therapy in patients with heart failure, due to intravascular fluid shifts that occur from the positive airway pressure 3 CPAP therapy will have a neutral effect on his heart failure and is indicated to help his symptoms 4 CPAP therapy will likely improve his heart function in addition to improving symptoms related to his sleep apnea |
answer 4
Continuous positive airway pressure (CPAP) therapy has been shown to improve a number of cardiovascular parameters. In a placebo-controlled trial, CPAP therapy in patients with heart failure resulted in improvements in blood pressure, heart rate, and ejection fraction after only one month of therapy. Long-term patient outcome studies have not been published. |
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what affect does alcohol have on cholesterol
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raises HDL
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68-year-old Native American male is being treated for symptomatic biventricular failure. He develops Stevens-Johnson syndrome, believed to be caused by the sulfa component of trimethoprim/sulfamethoxazole (Bactrim, Septra), which he is taking for a urinary tract infection.
Which of the following diuretics could be used to treat this patient’s heart failure without raising concerns of cross-reactivity with sulfa drugs? (Mark all that are true.) 1 Furosemide (Lasix) 2 Ethacrynic acid (Edecrin) 3 Metolazone (Zaroxolyn) 4 Hydrochlorothiazide 5 Chlorthalidone (Thalitone) |
answer 2
Most diuretics are related to sulfonamide antibiotics and have the potential to cross-react in a certain percentage of sulfa-allergic patients. Ethacrynic acid belongs to a different pharmacologic class and hence does not have the same cross-reactive potential. |
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A 78-year-old male with heart failure is being treated with furosemide (Lasix), digoxin, quinapril (Accupril), and atorvastatin (Lipitor). He presents to your office dizzy and nauseated. His heart rate is 46 beats/min.
This patient’s symptoms are most likely due to 1 atorvastatin toxicity 2 furosemide toxicity 3 quinapril toxicity 4 digoxin toxicity |
answer 4
Digoxin has a very narrow therapeutic range. Elevated levels of digoxin can cause bradycardia or other serious arrhythmias and commonly cause nausea, vomiting, diarrhea, and dizziness. Furosemide may contribute to digoxin toxicity by causing hypokalemia, and atorvastatin may cause elevated levels of digoxin, but they would not cause the symptoms seen in this patient through direct toxicity. Atorvastatin toxicity is manifested by elevated creatine kinase and transaminases, and rarely, rhabdomyolysis. Hypotension, cough, and hyperkalemia can occur with quinapril and other ACE inhibitors. |
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You see a 74-year-old patient at a routine follow-up visit for heart failure. He is currently taking lisinopril (Prinivil, Zestril), 20 mg daily, and extended-release metoprolol (Toprol XL), 100 mg daily. Based on the results of your evaluation, you increase his dosage of lisinopril to 40 mg daily.
Which one of the following sets of serum levels should be obtained in the next 1–2 weeks to assess the safety of this dosage change? 1 Sodium and potassium 2 Sodium and creatinine 3 Sodium and magnesium 4 Potassium and creatinine 5 Magnesium and creatinine |
answer 4
ACE inhibitors diminish renal reabsorption of sodium by decreasing levels of aldosterone. Because sodium is reabsorbed in exchange for potassium, renal potassium loss declines. Additionally, glomerular filtration is affected by angiotensin-mediated efferent renal arteriolar vasoconstriction. ACE inhibitor–mediated declines in angiotensin can therefore worsen renal function. When the dosage of an ACE inhibitor is changed, it is therefore important to assess serum potassium and creatinine. |
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65-year-old African-American male presents with a 2-month history of exertional dyspnea and ankle swelling. His past medical history is noteworthy for a history of hypertension and a history of angioedema related to peanut allergy.
On examination his blood pressure is 155/98 mm Hg. His jugular veins are mildly distended and bibasilar rales are noted. The cardiac examination reveals a regular rhythm with a soft S3 and no murmur. Examination of the lower extremities reveals 1+ pitting ankle edema. Echocardiography shows an estimated left ventricular ejection fraction of 40%. Which of the following medications should be avoided in this patient? (Mark all that are true.) 1 Enalapril (Vasotec) 2 Furosemide (Lasix) 3 Carvedilol (Coreg) 4 Diltiazem (Cardizem) 5 Valsartan (Diovan) |
answer 1,4
Angioedema occurs in less than 1% of patients taking an ACE inhibitor (ACEI) and is more common in African-Americans. The American Heart Association thus recommends that ACEIs not be initiated in any patient with a history of angioedema (SOR C). Calcium channel blockers, particularly those with negative inotropic effects (e.g., verapamil, diltiazem) can cause a worsening of heart failure and should also be avoided (SOR C). Although angiotensin receptor blockers (ARBs) would be regarded as safe in this patient and may be considered as alternative therapy for patients who develop angioedema while taking an ACEI, it should be recognized that angioedema can also occur in patients taking ARBs and that extreme caution is therefore advisable when substituting an ARB in a patient with a history of ACEI-associated angioedema (SOR C). There are no contraindications to the use of a diuretic or a β-blocker in this patient. |
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76-year-old female sees you for follow-up 2 weeks after her hospitalization for heart failure. Her past medical history is notable for heart failure, hypertension, and coronary heart disease. She is a nonsmoker. Her current medications are lisinopril (Prinivil, Zestril), 20 mg daily; hydrochlorothiazide, 25 mg daily; furosemide (Lasix), 40 mg daily; extended-release metoprolol (Toprol-XL), 50 mg daily; metformin (Glucophage), 850 mg twice daily; simvastatin (Zocor), 40 mg daily; and aspirin, 81 mg daily.
On physical examination, she is afebrile. Her blood pressure is 130/82 mm Hg, pulse rate 90 beats/min, and respiratory rate 20/min. Her jugular veins are mildly distended. Examination of the lungs reveals bibasilar crackles. The cardiac examination reveals a regular rhythm, an S4, and no murmurs. She has 1+ bilateral edema to the shins. A laboratory evaluation is notable only for a serum sodium level of 122 mg/dL (N 135–145). Appropriate options for managing her hyponatremia include which of the following? (Mark all that are true.) 1 Discontinuing hydrochlorothiazide 2 Reducing water intake 3 Cautiously administering normal saline 4 Increasing salt intake 5 Prescribing desmopressin |
answer 1,2
Hyponatremia is a common problem in patients with heart failure, and its severity correlates directly with the degree of myocardial dysfunction. Hypervolemic hyponatremia is the type most commonly associated with heart failure, with the presence of edema indicative of increased total body sodium and water. Heart failure is associated with inappropriately elevated plasma arginine vasopressin levels, which causes impaired water excretion and a dilutional hyponatremia and increased ventricular preload. Management generally calls for a reduction in water intake and improving cardiac function. Thiazide diuretics are associated with impaired renal water excretion, and reducing the dosage of thiazide diuretics or discontinuing their use is recommended. Although increasing sodium and water intake is the primary treatment for hypovolemic hyponatremia, patients with heart failure do not benefit from this strategy. Desmopressin is a vasopressin analog and is contraindicated in patients with hyponatremia. Arginine vasopressin antagonists, including tolvaptan and conivaptan, can be considered for patients with severe or recalcitrant hyponatremia. |
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Hypervolemic hyponatremia is the type most commonly associated with heart failure, with the presence of edema indicative of increased total body sodium and water. what medication should be stopped
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Thiazide diuretics are associated with impaired renal water excretion, and reducing the dosage of thiazide diuretics or discontinuing their use is recommended.
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61-year-old male with end-stage heart failure, atrial fibrillation, and a left ventricular ejection fraction of 30% is on optimal doses of an ACE inhibitor, a β-blocker, furosemide (Lasix), digoxin, and spironolactone (Aldactone), and continues to have symptoms of heart failure. His EKG shows a QRS duration of 0.14 sec.
Appropriate management options for this patient include which of the following? (Mark all that are true.) 1 Synchronized biventricular pacing 2 An implantable defibrillator 3Intermittent administration of dobutamine (Dobutrex) 4 A left ventricular assist device 5 Consideration for heart transplantation |
answer 1,2,4,5
Biventricular pacing with an implantable defibrillator is recommended for this patient. Biventricular pacing can improve symptoms and survival of heart failure patients with a prolonged QRS duration, and defibrillators are recommended for those with a low ejection fraction because of the increased risk for ventricular fibrillation in this situation. Intermittent positive inotropic therapy is no longer recommended, as studies have shown that there is an increased risk of death associated with this therapy. Patients with refractory heart failure on optimal medical therapy should be considered for heart transplantation. Patients with an anticipated 1-year survival probability of less than 50% can benefit from left ventricular (LV) assist devices. Patients who have a narrow QRS and stage D heart failure despite optimal medical therapy, and who are not candidates for transplant or LV assist devices, should not receive a defibrillator if their expected survival related to heart failure or other comorbidities is less than 1–2 years, since a defibrillator will not affect survival in such patients. |
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Cardiac resynchronization therapy would be expected to lengthen survival in which of the following heart failure patients receiving optimal pharmacologic treatment? (Mark all that are true.)
1 A 55-year-old male with New York Heart Association (NYHA) class II heart failure, ischemic cardiomyopathy, a left ventricular ejection fraction (LVEF) of 25%, sinus rhythm, and a QRS interval of 0.13 sec 2 A 65-year-old male with NYHA class III heart failure who has an LVEF of 30%, sinus rhythm, and a QRS interval of 0.14 sec 3 A 70-year-old female with NYHA class III heart failure, alcoholic cardiomyopathy, an LVEF of 30%, atrial fibrillation, and a QRS interval of 0.13 sec 4 A 74-year-old female with NYHA class II heart failure, ischemic cardiomyopathy, an LVEF of 40%, sinus rhythm, and a QRS interval of 0.14 sec 5 A 78-year-old female with NYHA class III heart failure, a history of hypertension and diabetes mellitus, an LVEF of 45%, sinus rhythm, and a QRS interval of 0.10 sec |
answer 1,2,3
The 2009 American Heart Association heart failure guidelines recommend both cardiac resynchronization therapy (CRT) and placement of an implantable cardioverter defibrillator (ICD) for heart failure patients with either sinus rhythm (SOR A) or atrial fibrillation (SOR B) who meet the following criteria: a left ventricular ejection fraction (LVEF) ≤35%; New York Heart Association (NYHA) class III or ambulatory class IV heart failure symptoms despite optimal medical therapy; and a QRS interval of 0.12 seconds or longer. In the Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT), the addition of CRT to ICD resulted in reduced rates of hospitalization and death among patients with NYHA class II or III heart failure, a wide QRS complex, and an LVEF ≤30% (SOR A). In addition, a meta-analysis has confirmed that CRT improves LVEF and reduces all-cause mortality and heart failure hospitalization in all patients with a reduced LVEF, symptoms of heart failure, and a prolonged QRS interval, regardless of NYHA class. |
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A 70-year-old Hispanic female with a history of a previous myocardial infarction, long-standing hypertension, multiple hospitalizations for heart failure, and a left ventricular ejection fraction of 30% sees you for persistent dyspnea on exertion and 3-pillow orthopnea. Her current medications are ramipril (Altace), 10 mg daily; carvedilol (Coreg), 25 mg twice daily; spironolactone (Aldactone), 25 mg daily; digoxin, 0.25 mg daily; and furosemide (Lasix), 40 mg twice daily.
A physical examination reveals an elevated jugular venous pressure, an S3 gallop, bibasilar rales and wheezing, and bilateral lower extremity edema. Her EKG is shown below. Which one of the following would you advise? 1 Hydralazine and nitrates 2 Valsartan (Diovan) 3Intermittent intravenous infusions of milrinone 4 Cardiac resynchronization therapy 5 A left ventricular assist device |
answer 4
The EKG shows left bundle branch block with a prolonged QRS duration exceeding 0.12 seconds. There is strong evidence supporting the use of cardiac resynchronization therapy (CRT) to improve symptoms, exercise capacity, left ventricular ejection fraction, and survival. CRT can also reduce hospitalizations in patients who have persistently symptomatic heart failure despite optimal medical therapy, and have cardiac dyssynchrony (currently defined as a QRS duration ≥0.12 sec) (level of evidence 1). Although angiotensin receptor blockers (ARBs) are recommended for heart failure in patients intolerant of ACE inhibitors, there is little information regarding the benefit of adding an ARB to therapy with both an ACE inhibitor and an aldosterone antagonist; this would, however, further increase the risk of renal dysfunction and hyperkalemia (level of evidence 3). Intermittent infusions of positive inotropic agents (e.g., milrinone, dobutamine) are not recommended because of a lack of evidence to support their efficacy, as well as concerns about potential toxicity (SOR C). |
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Which one of the following is true regarding heart transplantation?
1 Patients over age 70 are not generally considered for transplantation 2 Heart transplant patients require limited immunosupression therapy, usually for approximately 6 months following the transplant 3 The primary limiting factor in the number of transplants performed in the United States is lack of suitable recipients 4 Heart transplantation has a 1-year mortality rate of over 50% 5 Patients with severe viral cardiomyopathy or severe valvular disease, but not those with severe ischemic failure, are good candidates for transplantation |
answer 1
Heart transplantation is generally not performed in patients over the age of 65–70. The procedure typically results in 1-year mortality rates of 10%–15%. Indications for heart transplantation include severe heart failure resulting from myocarditis, ischemic heart disease, or severe valvular disease, as well as high-risk malignant dysrhythmias. There is no shortage of recipients in this country, and the primary limiting factor is lack of donors. Heart transplant recipients need lifelong immunosuppressant therapy. |
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An 83-year-old female has a harsh III/VI systolic murmur heard across most of the precordium and radiating to both carotids. You suspect aortic stenosis, and an echocardiogram confirms moderate aortic stenosis with a valve area of 1.2 cm2; the echocardiogram also reveals normal systolic function, with an ejection fraction of 60%. The patient is asymptomatic, and specifically denies exertional dyspnea, exercise limitation, angina, and syncope.
Due to the patient’s risk of sudden death and progressive heart failure, aortic valve replacement surgery is clearly indicated 1 very soon, before the stenosis becomes severe 2 once her stenosis becomes severe (valve area < 1.0 cm2) 3 once her ejection fraction drops below 40% 4 when she becomes symptomatic |
answer 4
Aortic valve replacement remains the best therapy for correction of aortic stenosis. However, the natural history of aortic stenosis is generally one of slow, steady progression, and sometimes little change occurs for many years. Even in severe stenosis, the rates of surgical and delayed complications outweigh the benefits in the majority of asymptomatic patients. Patients with more severe aortic narrowing should be followed very closely for the onset of symptoms, with prompt intervention once symptoms occur. Some selected patients may benefit from surgery prior to the onset of symptoms, but there is not yet general consensus or clear evidence to support this recommendation. |
