Cardiology - Family Medicine EOR || with 100% Valid Answers.
What is the definition of Heart Failure? correct answers Inability of the heart to pump sufficient
blood to meet the metabolic demands of the body at normal filling pressures
What is the MCC of heart failure? correct answers Coronary Artery Disease
What is the MCC of left-sided heart failure? correct answers Coronary Artery Disease
HTN
What is the MCC of right-sided heart failure correct answers Left sided heart failure - Pulmonary
disease (COPD, pulmonary HTN), mitral stenosis
What is the difference in systolic and diastolic heart failure? correct answers Systolic (S3 - 3
syllables): **impaired contractility** DECREASED EF, THIN ventricular walls, DILATED LV
chamber
Diastolic (S4 - 4 syllabus): **impaired filling/relaxation**Normal/increased EF, THICK
ventricular walls, SMALL LV chamber
Systolic Dysfunction Etiologies correct answers **Post MI infarction**
**Dilated Cardiomyopathy**'Ischemic Heart Disease
Chronic HTN
Myocarditis
Diastolic Dysfunction Etiologies correct answers **HTN with LV Hypertrophy**
**Elderly**
Restrictive Cardiomyopathy
Hypertrophic Cardiomyopathy
Constrictive Pericarditis
Fibrosis
Amyloidosis
Sarcoidosis
Hemochromatosis
Valvular Disease
What is the difference between high-output and low-output heart failure? correct answers High:
Metabolic demands of body EXCEEDS normal cardiac function (Thyrotoxicosis, wet beriberi,
severe anemia, AV shunting, Paget's disease of the bone)
Low: Inherent problem of myocardial contraction, ischemia, chronic HTN
What is the difference between acute and chronic heart failure? correct answers Acute: Largely
systolic (HTN crisis, acute MI, papillary muscle rupture)
Chronic: Typically seen in pt's with dilated cardiomyopathy or valvular disease
What are the four New York Heart Association Functional Class of Heart Failure? correct
answers I: No symptoms, no limitation of PE
,II: Mild symptoms (dyspnea/angina), slight limitation during activity
III: Symptoms cause limitation to activity; comfortable ONLY at rest
IV: Symptoms at rest, severe limitations & inability to carry out PE
Pathophysiology of Heart Failure correct answers Initial insult leads to INCREASED afterload,
INCREASED preload, DECREASED contractility. Injured heart tries to make short-term
compensations that, over time, promote cardiovascular deterioration.
Compensations:
1) Sympathetic nervous system activation
2) Myocyte hypertrophy/remodeling
3) RAAS activation: Fluid overload, **ventricular remodeling/hypertrophy**-->CHF
What are the 4 major clinical manifestations of Left-Sided Heart Failure? correct answers 1)
Dyspnea MC symptom*** that is initially exertional and turns into orthopnea (dyspnea when the
patient is supine - increased venous return, increased cardiac work); paroxysmal nocturnal
dyspnea; dyspnea at rest (advanced disease)
2) Pulmonary congestion/edema: **rales (fluid in alveoli), rhonchi, chronic NONproductive
cough with pink frothy sputum (surfactant)*** "cardiac asthma" d/t airway edema
3) PE showing HTN, Cheyne-Stokes breathing (deeper faster breathing with gradual decrease &
periods of apnea), rapid/shallow breathing (tachypnea), S3 or S4 on auscultation, laterally
displaced PMI
4) Increased adrenergic activation (dusky, pale skin; diaphoresis, sinus tachy, cool extremities d/t
poor perfusion & peripheral arteriole vasoconstriction)
What are the 3 major clinical manifestations of Right-Sided Heart Failure? correct answers 1)
Peripheral edema
-pitting edema in legs
2) JVD
-increased jugular venous pressure
3) GI/Hepatic Congestion
-Anorexia, N/V (edema in GI tract), hepatosplenomegaly, RUQ tenderness, hepatojugular reflex
(↑JVP with liver palpation)
what is the MCC of transudative pleural effusion? correct answers CHF
Diagnosis of Heart Failure correct answers 1) ECHO*** diagnostic: Measures ventricular
function & EF (most important determinant of prognosis)
2) CXR: Useful in CHF - Cephalization of flow→Kerley B Lines→Butterfly
Pattern→Cardiomegaly, infiltrates, pleural effusions→pulmonary edema
3) BNP: Help identify heart failure caused by dyspnea in the ER (severity and prognosis); BNP
>100 = CHF is likely
What is the most important diagnostic test to determine prognosis for heart failure? correct
answers Ejection Fraction on ECHO (<35% ↑mortality)
, What is brain natriuretic peptide (BNP)? correct answers Ventricles release BNP during volume
overload (CHF) in attempt to reverse the process of volume overload→decreased rening-
angiotensin-aldosterone activation→decreased total body fluid volume→increased sodium
excretion
What is the initial management for heart failure? correct answers ACE-I + diuretic for symptoms
(ACE-I & BB best 2 drugs to ↓mortality)
What are diet and exercise recommendations in heart failure patients? correct answers Sodium
restriction <2g/day
Fluid restriction <2L/day
Exercise
Smoking Cessation
What is the MOA, indications, S/E, CI of ACE-I correct answers MOA: ↓preload/afterload,
↓aldosterone production (↓synthesis of AG II). Increases activity of vasodilators (bradykinin, Pg,
nitric oxide). ↑exercise tolerance
Indications: FIRST LINE TREATMENT FOR HEART FAILURE; ↓mortality (post MI),
↓rehospitalization, reverses pathology by decreases renin/sympathetic activation, decreases
ventricular remodeling
S/E: 1st dose HYPOtension, renal insufficiency (esp if Cr >3, CrCl <30, dilation of efferent
arteriole), HYPERkalemia; Cough & angioedema (↑bardykinin)
CI: HYPOtension, pregnancy (teratogenic)
What is the indication for angiotensin II receptor blockers (ARB) in heart failure? correct
answers Unable to tolerate ACE-I. Blocks effects of angiotensin II (no cough/angioedema)
What is the the indication/side effects of BB in heart failure? correct answers 35% ↓ mortality
(↑EF & reduces ventricular size)
Add WITH ACE-I or ARB
****ACE-I/ARB + BB*****
S/E: Dizziness, HYPOtension (α1-receptor blockade); EF↓ transiently then increases so
STOP/reduce BB during DECOMPENSATION
What is the inidication, MOA, S/E of hydralazine + nitrates combined in heart failure? correct
answers Unable to tolerate ACE-I or BB. It ↓mortality and good for African Americans****.
Hydralazine **safe in pregnancy***
MOA: NTG ↓preload (venous relaxation) & afterload; Hydralazine ↓afterload
S/E: Dizziness, headache, tachyphylaxis (rapidly diminished response with recurrent use - 8 hour
nitrate-free period to prevent this)
What is the definition of Heart Failure? correct answers Inability of the heart to pump sufficient
blood to meet the metabolic demands of the body at normal filling pressures
What is the MCC of heart failure? correct answers Coronary Artery Disease
What is the MCC of left-sided heart failure? correct answers Coronary Artery Disease
HTN
What is the MCC of right-sided heart failure correct answers Left sided heart failure - Pulmonary
disease (COPD, pulmonary HTN), mitral stenosis
What is the difference in systolic and diastolic heart failure? correct answers Systolic (S3 - 3
syllables): **impaired contractility** DECREASED EF, THIN ventricular walls, DILATED LV
chamber
Diastolic (S4 - 4 syllabus): **impaired filling/relaxation**Normal/increased EF, THICK
ventricular walls, SMALL LV chamber
Systolic Dysfunction Etiologies correct answers **Post MI infarction**
**Dilated Cardiomyopathy**'Ischemic Heart Disease
Chronic HTN
Myocarditis
Diastolic Dysfunction Etiologies correct answers **HTN with LV Hypertrophy**
**Elderly**
Restrictive Cardiomyopathy
Hypertrophic Cardiomyopathy
Constrictive Pericarditis
Fibrosis
Amyloidosis
Sarcoidosis
Hemochromatosis
Valvular Disease
What is the difference between high-output and low-output heart failure? correct answers High:
Metabolic demands of body EXCEEDS normal cardiac function (Thyrotoxicosis, wet beriberi,
severe anemia, AV shunting, Paget's disease of the bone)
Low: Inherent problem of myocardial contraction, ischemia, chronic HTN
What is the difference between acute and chronic heart failure? correct answers Acute: Largely
systolic (HTN crisis, acute MI, papillary muscle rupture)
Chronic: Typically seen in pt's with dilated cardiomyopathy or valvular disease
What are the four New York Heart Association Functional Class of Heart Failure? correct
answers I: No symptoms, no limitation of PE
,II: Mild symptoms (dyspnea/angina), slight limitation during activity
III: Symptoms cause limitation to activity; comfortable ONLY at rest
IV: Symptoms at rest, severe limitations & inability to carry out PE
Pathophysiology of Heart Failure correct answers Initial insult leads to INCREASED afterload,
INCREASED preload, DECREASED contractility. Injured heart tries to make short-term
compensations that, over time, promote cardiovascular deterioration.
Compensations:
1) Sympathetic nervous system activation
2) Myocyte hypertrophy/remodeling
3) RAAS activation: Fluid overload, **ventricular remodeling/hypertrophy**-->CHF
What are the 4 major clinical manifestations of Left-Sided Heart Failure? correct answers 1)
Dyspnea MC symptom*** that is initially exertional and turns into orthopnea (dyspnea when the
patient is supine - increased venous return, increased cardiac work); paroxysmal nocturnal
dyspnea; dyspnea at rest (advanced disease)
2) Pulmonary congestion/edema: **rales (fluid in alveoli), rhonchi, chronic NONproductive
cough with pink frothy sputum (surfactant)*** "cardiac asthma" d/t airway edema
3) PE showing HTN, Cheyne-Stokes breathing (deeper faster breathing with gradual decrease &
periods of apnea), rapid/shallow breathing (tachypnea), S3 or S4 on auscultation, laterally
displaced PMI
4) Increased adrenergic activation (dusky, pale skin; diaphoresis, sinus tachy, cool extremities d/t
poor perfusion & peripheral arteriole vasoconstriction)
What are the 3 major clinical manifestations of Right-Sided Heart Failure? correct answers 1)
Peripheral edema
-pitting edema in legs
2) JVD
-increased jugular venous pressure
3) GI/Hepatic Congestion
-Anorexia, N/V (edema in GI tract), hepatosplenomegaly, RUQ tenderness, hepatojugular reflex
(↑JVP with liver palpation)
what is the MCC of transudative pleural effusion? correct answers CHF
Diagnosis of Heart Failure correct answers 1) ECHO*** diagnostic: Measures ventricular
function & EF (most important determinant of prognosis)
2) CXR: Useful in CHF - Cephalization of flow→Kerley B Lines→Butterfly
Pattern→Cardiomegaly, infiltrates, pleural effusions→pulmonary edema
3) BNP: Help identify heart failure caused by dyspnea in the ER (severity and prognosis); BNP
>100 = CHF is likely
What is the most important diagnostic test to determine prognosis for heart failure? correct
answers Ejection Fraction on ECHO (<35% ↑mortality)
, What is brain natriuretic peptide (BNP)? correct answers Ventricles release BNP during volume
overload (CHF) in attempt to reverse the process of volume overload→decreased rening-
angiotensin-aldosterone activation→decreased total body fluid volume→increased sodium
excretion
What is the initial management for heart failure? correct answers ACE-I + diuretic for symptoms
(ACE-I & BB best 2 drugs to ↓mortality)
What are diet and exercise recommendations in heart failure patients? correct answers Sodium
restriction <2g/day
Fluid restriction <2L/day
Exercise
Smoking Cessation
What is the MOA, indications, S/E, CI of ACE-I correct answers MOA: ↓preload/afterload,
↓aldosterone production (↓synthesis of AG II). Increases activity of vasodilators (bradykinin, Pg,
nitric oxide). ↑exercise tolerance
Indications: FIRST LINE TREATMENT FOR HEART FAILURE; ↓mortality (post MI),
↓rehospitalization, reverses pathology by decreases renin/sympathetic activation, decreases
ventricular remodeling
S/E: 1st dose HYPOtension, renal insufficiency (esp if Cr >3, CrCl <30, dilation of efferent
arteriole), HYPERkalemia; Cough & angioedema (↑bardykinin)
CI: HYPOtension, pregnancy (teratogenic)
What is the indication for angiotensin II receptor blockers (ARB) in heart failure? correct
answers Unable to tolerate ACE-I. Blocks effects of angiotensin II (no cough/angioedema)
What is the the indication/side effects of BB in heart failure? correct answers 35% ↓ mortality
(↑EF & reduces ventricular size)
Add WITH ACE-I or ARB
****ACE-I/ARB + BB*****
S/E: Dizziness, HYPOtension (α1-receptor blockade); EF↓ transiently then increases so
STOP/reduce BB during DECOMPENSATION
What is the inidication, MOA, S/E of hydralazine + nitrates combined in heart failure? correct
answers Unable to tolerate ACE-I or BB. It ↓mortality and good for African Americans****.
Hydralazine **safe in pregnancy***
MOA: NTG ↓preload (venous relaxation) & afterload; Hydralazine ↓afterload
S/E: Dizziness, headache, tachyphylaxis (rapidly diminished response with recurrent use - 8 hour
nitrate-free period to prevent this)
