ACNP Diagnosis & Management Exam 1
with Complete Solutions
Diastolic Heart Failure Correct Ans-characterized by s/s of HF, preserved EF
ventricular chamber is unable to accept adequate volumes of blood sufficient to maintain and
appropriate SV
Cause: increase in ventricular stiffness and/or decrease in ventricular relaxation
"compliance/relaxation problem"
Predisposing Factors for Diastolic HF Correct Ans--HTN
-AS
-hypertrophic cardiomyopathy
-CAD
-restrictive cardiomyopathy
-aging
-female
-glycogen storage disorders
-hemochromatosis
Diastolic HF Presentation Correct Ans--Often asymptomatic
,-tachycardia
-dyspnea on exertion
-systolic failure symptoms
Diagnostics for Diastolic HF Correct Ans--Hypertension
-EF > 50%
-LV --> *concentric hypertrophy* without wall motion abnormalities
-LVEDP increased
-FVE
-Tachycardia/afib
Management of Diastolic HF Correct Ans--Tx of HTN + prevention/regression of
hypertrophy --> diuretics, ACEI, ARBs, beta-blockers
-Meticulous volume management --> diuretics, sodium restriction (2-2.5g/d)
-Increase diastolic filling time --> beta-blockers, Ca-channel blockers
-Improve relaxation --> ACEI, ARBs, Ca-channel blockers
-Decrease/prevent ischemia --> beta-blockers, ACEI, nitrates, anti-platelet agents, CCBs
,Acute Pulmonary Edema Correct Ans--Sudden increase in wedge pressure as a result of
fulminant LV failure (very acute LHF - most common cause)
-Backup of blood returning from lungs to heart causes increase in blood pressure in lung
vasculature
-Fluid leaks from vessels to lung interstitial and alveoli, causing impaired gas exchange
Acute Pulmonary Edema Presentation Correct Ans--Severe respiratory distress, hypoxemia
-HTN, often profound
-rales over most/all lung field --> FLUID IN LUNGS!
-cool, most skin
-JVD
-frothy/blood tinged sputum
-+/- peripheral edema
Acute Pulmonary Edema Work-Up Correct Ans--Clinical exam --> severe resp distress,
hypoxemia, increased BP, used of accessory muscles
-CXR
-EKG
, -BNP (esp. if no hx of HF)
-PCWP via right heart cath (measure wedge pressure)
Treatment of Acute Pulmonary Edema Correct Ans--IV, O2, monitor, advanced airway
equipment and defibrillator by bedside!
-*NITRATES* --> best and quickest for reducing preload! (SL 400 mcg q5min or IV 60-100
mcg/min)
-*Bipap or CPAP* --> reduces work of breathing, decreases venous return, opens alveoli,
reduces need for intubation
-ACE Inhibitors --> decreased peripheral vascular resistance, help to reduce after load
-Lasix? --> not necessarily b/c pt is FVE, won't work immediately and is not most effective tx
-Ultrafiltration if available --> if renal contribution is suspected/known
Ischemic Heart Disease Correct Ans-Myocardial O2 demand > Myocardial O2 supply -->
spectrum of clinical syndromes
Results in myocardial hypoxia and accumulation of waste metabolites
with Complete Solutions
Diastolic Heart Failure Correct Ans-characterized by s/s of HF, preserved EF
ventricular chamber is unable to accept adequate volumes of blood sufficient to maintain and
appropriate SV
Cause: increase in ventricular stiffness and/or decrease in ventricular relaxation
"compliance/relaxation problem"
Predisposing Factors for Diastolic HF Correct Ans--HTN
-AS
-hypertrophic cardiomyopathy
-CAD
-restrictive cardiomyopathy
-aging
-female
-glycogen storage disorders
-hemochromatosis
Diastolic HF Presentation Correct Ans--Often asymptomatic
,-tachycardia
-dyspnea on exertion
-systolic failure symptoms
Diagnostics for Diastolic HF Correct Ans--Hypertension
-EF > 50%
-LV --> *concentric hypertrophy* without wall motion abnormalities
-LVEDP increased
-FVE
-Tachycardia/afib
Management of Diastolic HF Correct Ans--Tx of HTN + prevention/regression of
hypertrophy --> diuretics, ACEI, ARBs, beta-blockers
-Meticulous volume management --> diuretics, sodium restriction (2-2.5g/d)
-Increase diastolic filling time --> beta-blockers, Ca-channel blockers
-Improve relaxation --> ACEI, ARBs, Ca-channel blockers
-Decrease/prevent ischemia --> beta-blockers, ACEI, nitrates, anti-platelet agents, CCBs
,Acute Pulmonary Edema Correct Ans--Sudden increase in wedge pressure as a result of
fulminant LV failure (very acute LHF - most common cause)
-Backup of blood returning from lungs to heart causes increase in blood pressure in lung
vasculature
-Fluid leaks from vessels to lung interstitial and alveoli, causing impaired gas exchange
Acute Pulmonary Edema Presentation Correct Ans--Severe respiratory distress, hypoxemia
-HTN, often profound
-rales over most/all lung field --> FLUID IN LUNGS!
-cool, most skin
-JVD
-frothy/blood tinged sputum
-+/- peripheral edema
Acute Pulmonary Edema Work-Up Correct Ans--Clinical exam --> severe resp distress,
hypoxemia, increased BP, used of accessory muscles
-CXR
-EKG
, -BNP (esp. if no hx of HF)
-PCWP via right heart cath (measure wedge pressure)
Treatment of Acute Pulmonary Edema Correct Ans--IV, O2, monitor, advanced airway
equipment and defibrillator by bedside!
-*NITRATES* --> best and quickest for reducing preload! (SL 400 mcg q5min or IV 60-100
mcg/min)
-*Bipap or CPAP* --> reduces work of breathing, decreases venous return, opens alveoli,
reduces need for intubation
-ACE Inhibitors --> decreased peripheral vascular resistance, help to reduce after load
-Lasix? --> not necessarily b/c pt is FVE, won't work immediately and is not most effective tx
-Ultrafiltration if available --> if renal contribution is suspected/known
Ischemic Heart Disease Correct Ans-Myocardial O2 demand > Myocardial O2 supply -->
spectrum of clinical syndromes
Results in myocardial hypoxia and accumulation of waste metabolites
