ABFM HEART DISEASE QUESTIONS AND ANSWERS
A 65-year-old female who has heart failure with an ejection fraction of 35% is found to have
a TSH level of 13rh8 µU/mL (N 0rh3-4rh82)rh Her T3 and T4 levels are normal, and her
thyroid gland is normal to palpationrh You check her levels again in 2 months and they are
unchangedrh 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 - answersC
Clinical hypothyroidism has long been associated with cardiac dysfunctionrh 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 therapyrh Patients with overt or subclinical hypothyroidism should
be treated with levothyroxine to improve their cardiovascular function and decrease the
potential risk of heart failurerh 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 diseaserh Results of meta-analyses indicate that therapy will lower, not
raise, serum LDL-cholesterol levelsrh
A 58-year-old male is hospitalized with severe decompensated heart failure refractory to
intravenous inotropic therapy and guideline-directed medical therapyrh You are considering
referral to a tertiary care hospital for mechanical circulatory support to bridge to
transplantationrhWhich 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 - answersc
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 interventionrh A variety of ventricular assist devices are now availablerh
These devices may be either intracorporeal or extracorporeal, and may be designed to assist
the left ventricle, right ventricle, or bothrhBridge therapy refers to the use of left ventricular
assist devices to help a patient survive until a donor heart becomes available for
transplantationrh Several devices are available, some of which are implantable and allow
patients to be discharged to their homesrh These devices can increase patient activity levels
and quality of liferh Complications can occur, including stroke, infection, and death, but
these devices can be lifesaving in patients with refractory heart failurerhThe 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 MCSrh This led to a recommendation that
referral for MCS be considered before severe right ventricular failure developsrh 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
transplantationrh
An active 66-year-old female presents with intermittent chest pain and dyspnearh She is
currently pain freerh A resting EKG is normalrhIf 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 - answersA
Cardiac ischemia is classically defined as deep, poorly localized chest or arm discomfort
reproducibly associated with exertion or emotional stressrh It is relieved with rest and
nitroglycerinrh 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 backrh It may
be entirely absent in some casesrh In older patients without chest pain, new-onset or
unexplained exertional dyspnea is the most common anginal equivalent, even with a normal
resting EKGrhAlthough 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 ischemiarh Very brief episodes of pain, lasting a few
seconds or less, are also not characteristic of myocardial ischemiarh 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] =
2rh44), and the presence of chest wall tenderness significantly reduced the possibility of MI
(LR = 0rh23)rh 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 anginarh
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 painrh During her
hospitalization she underwent cardiac catheterization, which showed only a lesion in the
circumflex that was less than 50% occludedrh An EKG revealed sinus bradycardia of 52
beats/min, multifocal PVCs, and a QRS interval of 0rh10 secrh Echocardiography revealed a
left ventricular ejection fraction of 32%rhAlthough the patient feels comfortable at rest she
reports that she has difficulty walking up a single flight of stairsrh 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
dailyrhOn examination the patient is not in acute distressrh Her blood pressure is 132/78
mm Hg and her pulse rate - answersD
Aldosterone antagonists are important in the management of severe heart failurerh 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)rh 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 deathsrh 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 LVEFrhAlthough 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)rh 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 EKGrh However, 30%-35% of
patients who meet these criteria are nonresponders with no symptomatic improvement or
reverse left ventricular remodelingrh Left bundle branch block morphology, a QRS duration
≥150 ms, and adequate coronary sinus anatomy have been most closely associated with a
favorable responserh 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 hospitalrh 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 1rh5-2rh5
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 - answersD
Anticoagulation is recommended in addition to antiplatelet therapy for all patients with
acute coronary syndrome regardless of the initial treatment strategyrh For patients managed
with an early invasive strategy, heparin exerts its anticoagulant effect by accelerating the
action of circulating antithrombinrh It is available as either intravenous unfractionated
heparin (UFH) or subcutaneous low molecular weight heparin (LMWH)rhLMWH offers
greater bioavailability than UFH because of decreased binding to plasma proteins and
endothelial cells, and it results in less platelet activationrh The incidence of
thrombocytopenia in patients treated with LMWH is less than with UFHrh LMWH does not
change the partial thromboplastin time (PTT) appreciably, so PTT should not be used to
monitor the dosagerh LMWH is a viable option for treatment of acute coronary artery
syndrome and is preferred in many situationsrhIf 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/kgrh Dosing adjustments
should be based on the target activated clotting timerh Patients treated with UFH should be
monitored by factor Xa assaysrh
A 65-year-old female who has heart failure with an ejection fraction of 35% is found to have
a TSH level of 13rh8 µU/mL (N 0rh3-4rh82)rh Her T3 and T4 levels are normal, and her
thyroid gland is normal to palpationrh You check her levels again in 2 months and they are
unchangedrh 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 - answersC
Clinical hypothyroidism has long been associated with cardiac dysfunctionrh 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 therapyrh Patients with overt or subclinical hypothyroidism should
be treated with levothyroxine to improve their cardiovascular function and decrease the
potential risk of heart failurerh 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 diseaserh Results of meta-analyses indicate that therapy will lower, not
raise, serum LDL-cholesterol levelsrh
A 58-year-old male is hospitalized with severe decompensated heart failure refractory to
intravenous inotropic therapy and guideline-directed medical therapyrh You are considering
referral to a tertiary care hospital for mechanical circulatory support to bridge to
transplantationrhWhich 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 - answersc
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 interventionrh A variety of ventricular assist devices are now availablerh
These devices may be either intracorporeal or extracorporeal, and may be designed to assist
the left ventricle, right ventricle, or bothrhBridge therapy refers to the use of left ventricular
assist devices to help a patient survive until a donor heart becomes available for
transplantationrh Several devices are available, some of which are implantable and allow
patients to be discharged to their homesrh These devices can increase patient activity levels
and quality of liferh Complications can occur, including stroke, infection, and death, but
these devices can be lifesaving in patients with refractory heart failurerhThe 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 MCSrh This led to a recommendation that
referral for MCS be considered before severe right ventricular failure developsrh 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
transplantationrh
An active 66-year-old female presents with intermittent chest pain and dyspnearh She is
currently pain freerh A resting EKG is normalrhIf 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 - answersA
Cardiac ischemia is classically defined as deep, poorly localized chest or arm discomfort
reproducibly associated with exertion or emotional stressrh It is relieved with rest and
nitroglycerinrh 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 backrh It may
be entirely absent in some casesrh In older patients without chest pain, new-onset or
unexplained exertional dyspnea is the most common anginal equivalent, even with a normal
resting EKGrhAlthough 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 ischemiarh Very brief episodes of pain, lasting a few
seconds or less, are also not characteristic of myocardial ischemiarh 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] =
2rh44), and the presence of chest wall tenderness significantly reduced the possibility of MI
(LR = 0rh23)rh 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 anginarh
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 painrh During her
hospitalization she underwent cardiac catheterization, which showed only a lesion in the
circumflex that was less than 50% occludedrh An EKG revealed sinus bradycardia of 52
beats/min, multifocal PVCs, and a QRS interval of 0rh10 secrh Echocardiography revealed a
left ventricular ejection fraction of 32%rhAlthough the patient feels comfortable at rest she
reports that she has difficulty walking up a single flight of stairsrh 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
dailyrhOn examination the patient is not in acute distressrh Her blood pressure is 132/78
mm Hg and her pulse rate - answersD
Aldosterone antagonists are important in the management of severe heart failurerh 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)rh 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 deathsrh 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 LVEFrhAlthough 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)rh 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 EKGrh However, 30%-35% of
patients who meet these criteria are nonresponders with no symptomatic improvement or
reverse left ventricular remodelingrh Left bundle branch block morphology, a QRS duration
≥150 ms, and adequate coronary sinus anatomy have been most closely associated with a
favorable responserh 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 hospitalrh 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 1rh5-2rh5
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 - answersD
Anticoagulation is recommended in addition to antiplatelet therapy for all patients with
acute coronary syndrome regardless of the initial treatment strategyrh For patients managed
with an early invasive strategy, heparin exerts its anticoagulant effect by accelerating the
action of circulating antithrombinrh It is available as either intravenous unfractionated
heparin (UFH) or subcutaneous low molecular weight heparin (LMWH)rhLMWH offers
greater bioavailability than UFH because of decreased binding to plasma proteins and
endothelial cells, and it results in less platelet activationrh The incidence of
thrombocytopenia in patients treated with LMWH is less than with UFHrh LMWH does not
change the partial thromboplastin time (PTT) appreciably, so PTT should not be used to
monitor the dosagerh LMWH is a viable option for treatment of acute coronary artery
syndrome and is preferred in many situationsrhIf 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/kgrh Dosing adjustments
should be based on the target activated clotting timerh Patients treated with UFH should be
monitored by factor Xa assaysrh
