NU 665D EXAMINATION SCRIPT 2025/2026 QUESTIONS
WITH ANSWERS GRADED A+
✔✔Ablation Procedure - ✔✔-Pulmonary vein Isolation (LA)
-Radiofreq. ablation
-Not curative, but sign. reduces the amount of A. Fib
-General anesthesia, groin access
-Generally reserved for pts who have failed at least one attempt at DC cardioversion, 1
or 2 antiarrhythmic agents
✔✔Rate Control - ✔✔General goal: 60-80 BPM at rest
Not all pts req drug therapy for this
Tx with: BB (metoprolol, atenolol, carvidolol (HF), Non-dihydropyridine CCB (diltiazem,
verapamil), Digoxin (not 1st line)
Consider co-morbidities: HF (non-dihydropyrodine CCB should not be used in HF with
low EF d/t negative ionotropic effect; LVEF
-Rate control strategy can be appropriate for older pts who are more prone to drug
interactions and are asymptomic in A.Fib
✔✔Heart failure - ✔✔Inability of the heart to provide forward output to meet the
perfusion and oxygenation requirements while maintaining normal filling pressures
✔✔Systolic Dysfunction - ✔✔Impaired cardiac contractile function
-Majority of heart failure cases
-Left or right sided
-Abnormalities in the systolic function
-Reduced LVEF often <50%
-Progressive chamber dilation
✔✔Diastolic Function - ✔✔Abnormal cardiac relaxation, stiffness or filling
-Normal LVEF
-Often dx'd when pts present w/HF sxs and preserved LVEF
-Often hypertrophic w/impaired relaxation
-Longstanding uncontrolled HTN
✔✔Left Sided Heart Failure - ✔✔-Often presents w/pulmonary edema, fluid backing up
in pulmonary circuit
-Decreased contracility and cardiac output
-Compensatory increase in catecholamines to drive up cardiac output
-Catecholamin increase causes increased BP
-Laterally displaced apical pulse
-S3 Gallop rhythm
✔✔Right Sided Heart Failure - ✔✔Presents w/systemic edema:
-JVD
,-Leg edema
-Hepatosplenomegaly
Left sided HF is most common cause
Chronic lung disease
Elevated JVD (hepatojugular reflux)
LE edema
Poor perfsuon
-poor capillary refill
-cool distal extremities
✔✔AHA Definition of Heart Failure - ✔✔-HF with reduced EF: EF</= 40% (HFrEF)
-HF with preserved EF: EF >/= 50% (HFpEF)
-Borderline HFpEF, EF 41-49%
✔✔AHA Guidelines for Heart Failure - ✔✔-Continuously address risk factors (HTN,
lipids, obesity, DM, tobacco)
-Mortality benefit from using guideline-directed medical therapy
-Anticoagulation should not be used in pts w/chronic HFrEF w/no risk factors
-Aim for control of systolic and diastolic BPs, as well as volume stats, to tx HFrEF
-HF education, dietary restrictions, exercise training
-HF multidisciplinary team including palliative care should be provided involved when tx-
ing pts w/advanced HF
✔✔Causes of Heart Failure - ✔✔-CAD
-MI- 15-fold increased risk, single most potent risk factor for developing HF
-HTN (major cause of diastolic dysfunction)
-Valvular heart disease: Ventricular remodeling
-Cardiomyopathy
-LVH
-DM
-Dyslipidemia
-Cocaine abuse
-Exposure to cardiotoxic agents- chemo
✔✔PMH for Heart Failure - ✔✔Acute Presentation:
-Dyspnea
-Orthopnea
-Paroxysmal nocturnal sleep dyspnea
Chronic Presentation:
-Abd distension (ascites)
-Peripheral edema
-Reduction in cardiac output (fatigue, weakness)
Prior MI
HTN
A. Fib
Valvular heart disease
,OSA
PE
Renal Failure
Nephrotic syndrome
ETOH abuse
Cocaine abuse
Chemo
Anemia
Dietary non-compliance
Thyroid, Hepatic disease
✔✔Clinical Presentation for Heart Failure - ✔✔-Dyspnea (most common sx in LHF, may
occur w/exertion or at rest)
-Rales
-Orthopnea (worsens immediately after laying down)
-Paroxysmal nocturnal dyspnea (several hours after pt lies down to sleep)
-Neck vein distention
-S3 Gallop
-Cardiomegaly (LV dilation or hypertrophy)
Hepatojugular reflux
✔✔PE for Heart Failure - ✔✔VS, general appearance
Exacerbation:
-Resting sinus tachycardia
-Narrow pulse pressure
-Diaphoresis
-Cool pale extremities (decline in cardiac output and decrease in tissue perfusion)
Volume Assessment:
-Pulmonary congestion: rales do not clear w/cough
-Peripheral edema: swelling of legs, ascites, scrotal edema, hepatosplenomegaly
-Hepatojugular reflux: manual compression of RUQ may elevate JVP
-Elevated JVP
-Abd distension- ascites, fluid wave
Wt gain
Fluid retention caused by fall in cardiac output
PMI laterally displaced
✔✔Testing for Heart Failure - ✔✔EKG:
-Arrhythmias
-LV abnormality; precordial leads and QRS duration--> LBBB
-Ischemia
Labs:
-CBC- r/o anemia, infection
-Lytes- renal impairment, electrolyte disturbances r/t diuretics
-LFTs- hepatic congestion
, -BNP (limitations)- hormone released from heart, generally >400mg/mL, Elevated levels
do not exclude presence of other contributing conditions
CXR- Cardiomegaly, pleural effusions, Kerley B lines
ECHO- Cavity sizes, left and right ventricular function, wall motion abnormalities,
valvular heart disease
✔✔Framingham Heart Failure Diagnostic Criteria - ✔✔Requires 2 major OR 1 major
and two minor criteria
Major:
-Acute pulmonary edema
-Cardiomegaly
-Hepatojugular Reflux
-Neck vein distension
-Paroxysmal nocturnal dyspnea or orthopnea
-Rales
-S3 gallop rhythm
Minor:
-Bilateral leg edema
-Exertional dyspnea
-Hepatomegaly
-Nocturnal cough
-Pleural effusion
-Tachycardia
✔✔2013 American College of Cardiology/AHA Classification of HF - ✔✔-Stage A: At
risk for HF w/o structural heart disease or sxs of HF
-Stage B: Structural heart disease but w/o sxs of HF
-Stage C: Structural heart disease w/prior or current HF sxs
-Stage D: Refractory HF exacerbations requiring specialized interventions
✔✔NYHA Classification of Heart Failure - ✔✔-I)Pts w/cardiac disease w/o limitations of
physical activity. Ordinary physical activity does not cause sxs
-II)Pts w/cardiac disease resulting in slight limitation; Comfortable at rest; Ordinary
physical activities result in sxs (eg fatigue, palpitations, dyspnea, anginal pain)
-III)Pts w/cardiac disease resulting in inability to perform physical activity w/o discomfort.
Sxs of cardiac insufficiency may be present at rest. If any physical activity is
undertaken, discomfort is increased
✔✔Treatment Approach to Heart Failure by Stage - ✔✔Stage A: Treat HTN and other
comorbidities, encourage healthy lifestyle
Stage B: Continue Stage A tx plan; ACEI, BB
Stage C: Continue Stage A tx plan; Diuretics, ACEI,, BB, Digoxin, Aldosterone
Inhibitors, Lifestyle modifications (Na+/Fluid restriction)
Stage D: All previous measures, mechanical assist, Heart transplant, Hospice
✔✔Lifestyle Management of Heart Failure - ✔✔-2gm Na restriction
WITH ANSWERS GRADED A+
✔✔Ablation Procedure - ✔✔-Pulmonary vein Isolation (LA)
-Radiofreq. ablation
-Not curative, but sign. reduces the amount of A. Fib
-General anesthesia, groin access
-Generally reserved for pts who have failed at least one attempt at DC cardioversion, 1
or 2 antiarrhythmic agents
✔✔Rate Control - ✔✔General goal: 60-80 BPM at rest
Not all pts req drug therapy for this
Tx with: BB (metoprolol, atenolol, carvidolol (HF), Non-dihydropyridine CCB (diltiazem,
verapamil), Digoxin (not 1st line)
Consider co-morbidities: HF (non-dihydropyrodine CCB should not be used in HF with
low EF d/t negative ionotropic effect; LVEF
-Rate control strategy can be appropriate for older pts who are more prone to drug
interactions and are asymptomic in A.Fib
✔✔Heart failure - ✔✔Inability of the heart to provide forward output to meet the
perfusion and oxygenation requirements while maintaining normal filling pressures
✔✔Systolic Dysfunction - ✔✔Impaired cardiac contractile function
-Majority of heart failure cases
-Left or right sided
-Abnormalities in the systolic function
-Reduced LVEF often <50%
-Progressive chamber dilation
✔✔Diastolic Function - ✔✔Abnormal cardiac relaxation, stiffness or filling
-Normal LVEF
-Often dx'd when pts present w/HF sxs and preserved LVEF
-Often hypertrophic w/impaired relaxation
-Longstanding uncontrolled HTN
✔✔Left Sided Heart Failure - ✔✔-Often presents w/pulmonary edema, fluid backing up
in pulmonary circuit
-Decreased contracility and cardiac output
-Compensatory increase in catecholamines to drive up cardiac output
-Catecholamin increase causes increased BP
-Laterally displaced apical pulse
-S3 Gallop rhythm
✔✔Right Sided Heart Failure - ✔✔Presents w/systemic edema:
-JVD
,-Leg edema
-Hepatosplenomegaly
Left sided HF is most common cause
Chronic lung disease
Elevated JVD (hepatojugular reflux)
LE edema
Poor perfsuon
-poor capillary refill
-cool distal extremities
✔✔AHA Definition of Heart Failure - ✔✔-HF with reduced EF: EF</= 40% (HFrEF)
-HF with preserved EF: EF >/= 50% (HFpEF)
-Borderline HFpEF, EF 41-49%
✔✔AHA Guidelines for Heart Failure - ✔✔-Continuously address risk factors (HTN,
lipids, obesity, DM, tobacco)
-Mortality benefit from using guideline-directed medical therapy
-Anticoagulation should not be used in pts w/chronic HFrEF w/no risk factors
-Aim for control of systolic and diastolic BPs, as well as volume stats, to tx HFrEF
-HF education, dietary restrictions, exercise training
-HF multidisciplinary team including palliative care should be provided involved when tx-
ing pts w/advanced HF
✔✔Causes of Heart Failure - ✔✔-CAD
-MI- 15-fold increased risk, single most potent risk factor for developing HF
-HTN (major cause of diastolic dysfunction)
-Valvular heart disease: Ventricular remodeling
-Cardiomyopathy
-LVH
-DM
-Dyslipidemia
-Cocaine abuse
-Exposure to cardiotoxic agents- chemo
✔✔PMH for Heart Failure - ✔✔Acute Presentation:
-Dyspnea
-Orthopnea
-Paroxysmal nocturnal sleep dyspnea
Chronic Presentation:
-Abd distension (ascites)
-Peripheral edema
-Reduction in cardiac output (fatigue, weakness)
Prior MI
HTN
A. Fib
Valvular heart disease
,OSA
PE
Renal Failure
Nephrotic syndrome
ETOH abuse
Cocaine abuse
Chemo
Anemia
Dietary non-compliance
Thyroid, Hepatic disease
✔✔Clinical Presentation for Heart Failure - ✔✔-Dyspnea (most common sx in LHF, may
occur w/exertion or at rest)
-Rales
-Orthopnea (worsens immediately after laying down)
-Paroxysmal nocturnal dyspnea (several hours after pt lies down to sleep)
-Neck vein distention
-S3 Gallop
-Cardiomegaly (LV dilation or hypertrophy)
Hepatojugular reflux
✔✔PE for Heart Failure - ✔✔VS, general appearance
Exacerbation:
-Resting sinus tachycardia
-Narrow pulse pressure
-Diaphoresis
-Cool pale extremities (decline in cardiac output and decrease in tissue perfusion)
Volume Assessment:
-Pulmonary congestion: rales do not clear w/cough
-Peripheral edema: swelling of legs, ascites, scrotal edema, hepatosplenomegaly
-Hepatojugular reflux: manual compression of RUQ may elevate JVP
-Elevated JVP
-Abd distension- ascites, fluid wave
Wt gain
Fluid retention caused by fall in cardiac output
PMI laterally displaced
✔✔Testing for Heart Failure - ✔✔EKG:
-Arrhythmias
-LV abnormality; precordial leads and QRS duration--> LBBB
-Ischemia
Labs:
-CBC- r/o anemia, infection
-Lytes- renal impairment, electrolyte disturbances r/t diuretics
-LFTs- hepatic congestion
, -BNP (limitations)- hormone released from heart, generally >400mg/mL, Elevated levels
do not exclude presence of other contributing conditions
CXR- Cardiomegaly, pleural effusions, Kerley B lines
ECHO- Cavity sizes, left and right ventricular function, wall motion abnormalities,
valvular heart disease
✔✔Framingham Heart Failure Diagnostic Criteria - ✔✔Requires 2 major OR 1 major
and two minor criteria
Major:
-Acute pulmonary edema
-Cardiomegaly
-Hepatojugular Reflux
-Neck vein distension
-Paroxysmal nocturnal dyspnea or orthopnea
-Rales
-S3 gallop rhythm
Minor:
-Bilateral leg edema
-Exertional dyspnea
-Hepatomegaly
-Nocturnal cough
-Pleural effusion
-Tachycardia
✔✔2013 American College of Cardiology/AHA Classification of HF - ✔✔-Stage A: At
risk for HF w/o structural heart disease or sxs of HF
-Stage B: Structural heart disease but w/o sxs of HF
-Stage C: Structural heart disease w/prior or current HF sxs
-Stage D: Refractory HF exacerbations requiring specialized interventions
✔✔NYHA Classification of Heart Failure - ✔✔-I)Pts w/cardiac disease w/o limitations of
physical activity. Ordinary physical activity does not cause sxs
-II)Pts w/cardiac disease resulting in slight limitation; Comfortable at rest; Ordinary
physical activities result in sxs (eg fatigue, palpitations, dyspnea, anginal pain)
-III)Pts w/cardiac disease resulting in inability to perform physical activity w/o discomfort.
Sxs of cardiac insufficiency may be present at rest. If any physical activity is
undertaken, discomfort is increased
✔✔Treatment Approach to Heart Failure by Stage - ✔✔Stage A: Treat HTN and other
comorbidities, encourage healthy lifestyle
Stage B: Continue Stage A tx plan; ACEI, BB
Stage C: Continue Stage A tx plan; Diuretics, ACEI,, BB, Digoxin, Aldosterone
Inhibitors, Lifestyle modifications (Na+/Fluid restriction)
Stage D: All previous measures, mechanical assist, Heart transplant, Hospice
✔✔Lifestyle Management of Heart Failure - ✔✔-2gm Na restriction
