ABFM Heart Disease Exam
/. A 65-year-old female who has heart failure with an ejection fraction of 35% is found to
have a TSH level of 13.8 µU/mL (N 0.3-4.82). Her T3 and T4 levels are normal, and her
thyroid gland is normal to palpation. You check her levels again in 2 months and they
are unchanged. You advise her that
hypothyroidism decreases her metabolic rate, which reduces the stress on her heart
hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms
subclinical hypothyroidism has negative effects on heart failure and treatment should be
considered
treatment of subclinical hypothyroidism would raise her LDL-cholesterol level - Answer-
C
Clinical hypothyroidism has long been associated with cardiac dysfunction. It has also
been shown that subclinical hypothyroidism (TSH >4 µU/mL with normal or borderline
low thyroid hormone levels) can cause left ventricular systolic and diastolic dysfunction,
which improves with thyroid replacement therapy. Patients with overt or subclinical
hypothyroidism should be treated with levothyroxine to improve their cardiovascular
function and decrease the potential risk of heart failure. Thyroxine in excess can
exacerbate coronary artery disease, and should be started at low doses and increased
slowly in patients with possible underlying coronary artery disease. Results of meta-
analyses indicate that therapy will lower, not raise, serum LDL-cholesterol levels.
/.A 58-year-old male is hospitalized with severe decompensated heart failure refractory
to intravenous inotropic therapy and guideline-directed medical therapy. You are
considering referral to a tertiary care hospital for mechanical circulatory support to
bridge to transplantation.Which one of the following is true regarding mechanical
circulatory support bridge therapy?
It should be limited to patients who meet the criteria for heart transplantation
It should only be used in patients with biventricular heart failure
It generally improves quality of life while waiting for transplantation
It greatly reduces quality of life while waiting for transplantation - Answer-c
Mechanical circulatory support (MCS) with a ventricular assist device has continued to
evolve and has emerged as a viable therapeutic option for patients with advanced stage
D heart failure with reduced ejection fraction refractory to guideline-directed medical
therapy and cardiac device intervention. A variety of ventricular assist devices are now
available. These devices may be either intracorporeal or extracorporeal, and may be
designed to assist the left ventricle, right ventricle, or both.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 can occur, including
stroke, infection, and death, but these devices can be lifesaving in patients with
refractory heart failure.The data from the Interagency Registry for Mechanically Assisted
Circulatory Support indicates that cardiogenic shock, advanced age, and severe right
heart failure (manifested as ascites or increased bilirubin) are major risk factors for
death after MCS. This led to a recommendation that referral for MCS be considered
before severe right ventricular failure develops. Possible indications for a bridge-to-
candidacy ventricular assist device include obesity, tobacco use, and severe pulmonary
hypertension in patients who might otherwise be candidates for transplantation.
/.An active 66-year-old female presents with intermittent chest pain and dyspnea. She is
currently pain free. A resting EKG is normal.If found on the history and examination,
which one of the following symptoms is most likely to be associated with myocardial
ischemia as the cause of chest pain?
An episode of diaphoresis associated with the chest pain
Pain reproduced by chest wall palpation on the left side of the chest
Pain that comes and goes with and without exertion
Intermittent pleuritic-type pain and dyspnea - Answer-A
Cardiac ischemia is classically defined as deep, poorly localized chest or arm
discomfort reproducibly associated with exertion or emotional stress. It is relieved with
rest and nitroglycerin. It can present in an atypical fashion, and the discomfort can
localize or radiate to the neck, lower jaw, throat, shoulder, epigastrium, hands, or upper
back. It may be entirely absent in some cases. In older patients without chest pain, new-
onset or unexplained exertional dyspnea is the most common anginal equivalent, even
with a normal resting EKG.Although they may be present, pleuritic-type pain, pain
reproduced with movement or palpation of the chest wall or arm, and sharp or stabbing
pain are not characteristic features of myocardial ischemia. Very brief episodes of pain,
lasting a few seconds or less, are also not characteristic of myocardial ischemia. In a
meta-analysis of symptoms useful in diagnosing acute coronary syndrome in a low-risk
setting, diaphoresis was found to be the strongest predictor of myocardial infarction (MI)
(likelihood ratio [LR] = 2.44), and the presence of chest wall tenderness significantly
reduced the possibility of MI (LR = 0.23). A completely normal EKG does not exclude
the possibility of acute coronary syndrome because 1%-6% of such patients eventually
are found to have an acute myocardial infarction (non-ST-segment elevation by
definition) and at least 4% have unstable angina.
/.A 69-year-old female with a history of chronic hypertension and a previous myocardial
infarction sees you for follow-up 6 weeks after being hospitalized for chest pain. During
her hospitalization she underwent cardiac catheterization, which showed only a lesion in
the circumflex that was less than 50% occluded. An EKG revealed sinus bradycardia of
52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography
revealed a left ventricular ejection fraction of 32%.Although the patient feels comfortable
at rest she reports that she has difficulty walking up a single flight of stairs. Her current
medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg
,daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 40 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 - Answer-D
Aldosterone antagonists are important in the management of severe heart failure. The
addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in
the Randomized Aldactone Evaluation Study 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
EMPHASIS-HF trial (Eplerenone in Mild Patients Hospitalization and Survival Study in
Heart Failure trial) found that the addition of eplerenone in heart failure patients with
mild symptoms consistent with New York Heart Association (NYHA) class II heart failure
and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths.
Current American Heart Association guidelines recommend 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). According to
recent guidelines, patients are considered candidates for cardiac resynchronization
therapy if they have NYHA class II-IV heart failure, a left ventricular ejection fraction
≤35%, and a QRS duration >130 ms on an EKG. However, 30%-35% of patients who
meet these criteria are nonresponders with no symptomatic improvement or reverse left
ventricular remodeling. Left bundle branch block morphology, a QRS duration ≥150 ms,
and adequate coronary sinus anatomy have been most closely associated with a
favorable response. Mitral valve regurgitation, right ventricular dysfunction, and atrial
fibrillation have been shown to have a negative impact on patient r
/.You admit a patient with acute coronary syndrome to the hospital. Which one of the
following is true regarding the differences between low molecular weight heparin
(LMWH) and unfractionated heparin (UFH) in this situation?
The use of glycoprotein IIb/IIIa inhibitors does not require a change in the dosage of
UFH
The dosage of both should be titrated to achieve a partial thromboplastin time of 1.5-2.5
times control
Platelet activation is the same for both
The incidence of thrombocytopenia is lower with LMWH
UFH has higher bioavailability because it is given intravenously - Answer-D
Anticoagulation is recommended in addition to antiplatelet therapy for all patients with
acute coronary syndrome regardless of the initial treatment strategy. For patients
managed with an early invasive strategy, heparin exerts its anticoagulant effect by
accelerating the action of circulating antithrombin. It is available as either intravenous
unfractionated heparin (UFH) or subcutaneous low molecular weight heparin
(LMWH).LMWH offers greater bioavailability than UFH because of decreased binding to
plasma proteins and endothelial cells, and it results in less platelet activation. The
, incidence of thrombocytopenia in patients treated with LMWH is less than with UFH.
LMWH does not change the partial thromboplastin time (PTT) appreciably, so PTT
should not be used to monitor the dosage. LMWH is a viable option for treatment of
acute coronary artery syndrome and is preferred in many situations.If UFH is used it
should be given intravenously at a dosage of 85 U/kg unless a glycoprotein IIb/IIIa
inhibitor is also administered, in which case the dosage should be reduced to 60 U/kg.
Dosing adjustments should be based on the target activated clotting time. Patients
treated with UFH should be monitored by factor Xa assays.
/.An 82-year-old female presents with increasing dyspnea. Her husband is worried
because she occasionally stops breathing when she is asleep. You have been treating
the patient for heart failure for the past 2 years with ACE inhibitors, β-blockers, diuretics,
and low-dose spironolactone (Aldactone). The nurse who measures the patient's blood
pressure 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 the nurse hears Korotkoff sounds at a
regular rate of 80/min.Which one of the following is true regarding this patient?
The examination findings are normal for patients in this age group
The patient's breathing pattern is normal for patients in this age group
Both the breathing and blood pressure findings may improve with more intensive
treatment
Medications should be reduced in this patient because her blood pressure is unstable -
Answer-C
This 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 is also common in patients with
decompensated heart failure. If the heart failure is treated, the breathing abnormality
can disappear. The patient has symptomatic heart failure, which classifies her heart
failure as stage C at least, according to the American College of Cardiology/American
Heart Association heart failure guidelines.
/.A 69-year-old female presents to the emergency department with a 1-hour episode of
severe substernal chest pain that has now resolved. Her past medical history is notable
for current tobacco abuse, hypertension, and depression. Her current medications
include lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily; citalopram (Celexa),
20 mg daily; and aspirin, 81 mg daily. On examination she has a blood pressure of
150/92 mm Hg and a pulse rate of 92 beats/min. An EKG reveals a sinus rhythm with
deep and symmetrical T-wave inversions in the inferior leads.You decide to admit the
patient to the hospital. Which one of the following should be administered on
admission?
Alteplase (Activase) intravenously
Aspirin, 81 mg, and nitroglycerin via intravenous drip
Enoxaparin (Lovenox), 1 mg/kg subcutaneously, and nitroglycerin, 0.4 mg sublingually
Ticagrelor (Brilinta), 60 mg orally, and enoxaparin, 1 mg/kg subcutaneou - Answer-E
/. A 65-year-old female who has heart failure with an ejection fraction of 35% is found to
have a TSH level of 13.8 µU/mL (N 0.3-4.82). Her T3 and T4 levels are normal, and her
thyroid gland is normal to palpation. You check her levels again in 2 months and they
are unchanged. You advise her that
hypothyroidism decreases her metabolic rate, which reduces the stress on her heart
hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms
subclinical hypothyroidism has negative effects on heart failure and treatment should be
considered
treatment of subclinical hypothyroidism would raise her LDL-cholesterol level - Answer-
C
Clinical hypothyroidism has long been associated with cardiac dysfunction. It has also
been shown that subclinical hypothyroidism (TSH >4 µU/mL with normal or borderline
low thyroid hormone levels) can cause left ventricular systolic and diastolic dysfunction,
which improves with thyroid replacement therapy. Patients with overt or subclinical
hypothyroidism should be treated with levothyroxine to improve their cardiovascular
function and decrease the potential risk of heart failure. Thyroxine in excess can
exacerbate coronary artery disease, and should be started at low doses and increased
slowly in patients with possible underlying coronary artery disease. Results of meta-
analyses indicate that therapy will lower, not raise, serum LDL-cholesterol levels.
/.A 58-year-old male is hospitalized with severe decompensated heart failure refractory
to intravenous inotropic therapy and guideline-directed medical therapy. You are
considering referral to a tertiary care hospital for mechanical circulatory support to
bridge to transplantation.Which one of the following is true regarding mechanical
circulatory support bridge therapy?
It should be limited to patients who meet the criteria for heart transplantation
It should only be used in patients with biventricular heart failure
It generally improves quality of life while waiting for transplantation
It greatly reduces quality of life while waiting for transplantation - Answer-c
Mechanical circulatory support (MCS) with a ventricular assist device has continued to
evolve and has emerged as a viable therapeutic option for patients with advanced stage
D heart failure with reduced ejection fraction refractory to guideline-directed medical
therapy and cardiac device intervention. A variety of ventricular assist devices are now
available. These devices may be either intracorporeal or extracorporeal, and may be
designed to assist the left ventricle, right ventricle, or both.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 can occur, including
stroke, infection, and death, but these devices can be lifesaving in patients with
refractory heart failure.The data from the Interagency Registry for Mechanically Assisted
Circulatory Support indicates that cardiogenic shock, advanced age, and severe right
heart failure (manifested as ascites or increased bilirubin) are major risk factors for
death after MCS. This led to a recommendation that referral for MCS be considered
before severe right ventricular failure develops. Possible indications for a bridge-to-
candidacy ventricular assist device include obesity, tobacco use, and severe pulmonary
hypertension in patients who might otherwise be candidates for transplantation.
/.An active 66-year-old female presents with intermittent chest pain and dyspnea. She is
currently pain free. A resting EKG is normal.If found on the history and examination,
which one of the following symptoms is most likely to be associated with myocardial
ischemia as the cause of chest pain?
An episode of diaphoresis associated with the chest pain
Pain reproduced by chest wall palpation on the left side of the chest
Pain that comes and goes with and without exertion
Intermittent pleuritic-type pain and dyspnea - Answer-A
Cardiac ischemia is classically defined as deep, poorly localized chest or arm
discomfort reproducibly associated with exertion or emotional stress. It is relieved with
rest and nitroglycerin. It can present in an atypical fashion, and the discomfort can
localize or radiate to the neck, lower jaw, throat, shoulder, epigastrium, hands, or upper
back. It may be entirely absent in some cases. In older patients without chest pain, new-
onset or unexplained exertional dyspnea is the most common anginal equivalent, even
with a normal resting EKG.Although they may be present, pleuritic-type pain, pain
reproduced with movement or palpation of the chest wall or arm, and sharp or stabbing
pain are not characteristic features of myocardial ischemia. Very brief episodes of pain,
lasting a few seconds or less, are also not characteristic of myocardial ischemia. In a
meta-analysis of symptoms useful in diagnosing acute coronary syndrome in a low-risk
setting, diaphoresis was found to be the strongest predictor of myocardial infarction (MI)
(likelihood ratio [LR] = 2.44), and the presence of chest wall tenderness significantly
reduced the possibility of MI (LR = 0.23). A completely normal EKG does not exclude
the possibility of acute coronary syndrome because 1%-6% of such patients eventually
are found to have an acute myocardial infarction (non-ST-segment elevation by
definition) and at least 4% have unstable angina.
/.A 69-year-old female with a history of chronic hypertension and a previous myocardial
infarction sees you for follow-up 6 weeks after being hospitalized for chest pain. During
her hospitalization she underwent cardiac catheterization, which showed only a lesion in
the circumflex that was less than 50% occluded. An EKG revealed sinus bradycardia of
52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography
revealed a left ventricular ejection fraction of 32%.Although the patient feels comfortable
at rest she reports that she has difficulty walking up a single flight of stairs. Her current
medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg
,daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 40 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 - Answer-D
Aldosterone antagonists are important in the management of severe heart failure. The
addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in
the Randomized Aldactone Evaluation Study 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
EMPHASIS-HF trial (Eplerenone in Mild Patients Hospitalization and Survival Study in
Heart Failure trial) found that the addition of eplerenone in heart failure patients with
mild symptoms consistent with New York Heart Association (NYHA) class II heart failure
and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths.
Current American Heart Association guidelines recommend 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). According to
recent guidelines, patients are considered candidates for cardiac resynchronization
therapy if they have NYHA class II-IV heart failure, a left ventricular ejection fraction
≤35%, and a QRS duration >130 ms on an EKG. However, 30%-35% of patients who
meet these criteria are nonresponders with no symptomatic improvement or reverse left
ventricular remodeling. Left bundle branch block morphology, a QRS duration ≥150 ms,
and adequate coronary sinus anatomy have been most closely associated with a
favorable response. Mitral valve regurgitation, right ventricular dysfunction, and atrial
fibrillation have been shown to have a negative impact on patient r
/.You admit a patient with acute coronary syndrome to the hospital. Which one of the
following is true regarding the differences between low molecular weight heparin
(LMWH) and unfractionated heparin (UFH) in this situation?
The use of glycoprotein IIb/IIIa inhibitors does not require a change in the dosage of
UFH
The dosage of both should be titrated to achieve a partial thromboplastin time of 1.5-2.5
times control
Platelet activation is the same for both
The incidence of thrombocytopenia is lower with LMWH
UFH has higher bioavailability because it is given intravenously - Answer-D
Anticoagulation is recommended in addition to antiplatelet therapy for all patients with
acute coronary syndrome regardless of the initial treatment strategy. For patients
managed with an early invasive strategy, heparin exerts its anticoagulant effect by
accelerating the action of circulating antithrombin. It is available as either intravenous
unfractionated heparin (UFH) or subcutaneous low molecular weight heparin
(LMWH).LMWH offers greater bioavailability than UFH because of decreased binding to
plasma proteins and endothelial cells, and it results in less platelet activation. The
, incidence of thrombocytopenia in patients treated with LMWH is less than with UFH.
LMWH does not change the partial thromboplastin time (PTT) appreciably, so PTT
should not be used to monitor the dosage. LMWH is a viable option for treatment of
acute coronary artery syndrome and is preferred in many situations.If UFH is used it
should be given intravenously at a dosage of 85 U/kg unless a glycoprotein IIb/IIIa
inhibitor is also administered, in which case the dosage should be reduced to 60 U/kg.
Dosing adjustments should be based on the target activated clotting time. Patients
treated with UFH should be monitored by factor Xa assays.
/.An 82-year-old female presents with increasing dyspnea. Her husband is worried
because she occasionally stops breathing when she is asleep. You have been treating
the patient for heart failure for the past 2 years with ACE inhibitors, β-blockers, diuretics,
and low-dose spironolactone (Aldactone). The nurse who measures the patient's blood
pressure 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 the nurse hears Korotkoff sounds at a
regular rate of 80/min.Which one of the following is true regarding this patient?
The examination findings are normal for patients in this age group
The patient's breathing pattern is normal for patients in this age group
Both the breathing and blood pressure findings may improve with more intensive
treatment
Medications should be reduced in this patient because her blood pressure is unstable -
Answer-C
This 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 is also common in patients with
decompensated heart failure. If the heart failure is treated, the breathing abnormality
can disappear. The patient has symptomatic heart failure, which classifies her heart
failure as stage C at least, according to the American College of Cardiology/American
Heart Association heart failure guidelines.
/.A 69-year-old female presents to the emergency department with a 1-hour episode of
severe substernal chest pain that has now resolved. Her past medical history is notable
for current tobacco abuse, hypertension, and depression. Her current medications
include lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily; citalopram (Celexa),
20 mg daily; and aspirin, 81 mg daily. On examination she has a blood pressure of
150/92 mm Hg and a pulse rate of 92 beats/min. An EKG reveals a sinus rhythm with
deep and symmetrical T-wave inversions in the inferior leads.You decide to admit the
patient to the hospital. Which one of the following should be administered on
admission?
Alteplase (Activase) intravenously
Aspirin, 81 mg, and nitroglycerin via intravenous drip
Enoxaparin (Lovenox), 1 mg/kg subcutaneously, and nitroglycerin, 0.4 mg sublingually
Ticagrelor (Brilinta), 60 mg orally, and enoxaparin, 1 mg/kg subcutaneou - Answer-E
