Heart Failure CMC Exam (A+)

Heart Failure CMC Exam (A+) You are caring for a patient admitted with acute decompensated heart failure. Physical assessment reveals orthopnea, elevated neck veins, crackles throughout both lungs, skin is warm and diaphoretic. BP is 140/80, HR 96, RR 28. Which of the following drugs do you anticipate administering: A. Dobutamine infusion and a nitroprusside infusion. B. IV furosemide and a dobutamine infusion. C. Hydrochlorothiazide and a dopamine infusion. D. IV furosemide and a nitroglycerine infusion. - ANSWER-D. This patient has pulmonary and systemic congestion (crackles, orthopnea, elevated neck veins) but no signs of hypoperfusion (BP is good, skin warm). Preload reduction with diuretics (IV furosemide) and a venous dilator (nitroglycerine drip) is the therapy of choice for acute decompensated heart failure presenting with pulmonary and/or systemic congestion. Dobutamine and dopamine are not indicated because both are positive inotropic agents which are not needed in this patient since his BP is good and there are no signs of hypoperfusion. Nitroprusside is both an arterial and a venous dilator and might be used in a hypertensive patient for preload and afterload reduction. Hydrochlorothiazide is an appropriate diuretic for treating hypertension and can be added to furosemide in treating heart failure, but furosemide is the preferred first-line diuretic for acute decompensated heart failure. Which of these devices is a percutaneously inserted cardiac assist device that is placed across the aortic valve and used to support hemodynamics during high risk PCI procedures: A. Impella. B. Angiojet. C. IABP. D. HeartMateII. - ANSWER-A.The Impella is a percutaneously inserted catheter-based cardiac assist device that is inserted via the femoral artery and is positioned across the aortic valve with the tip in the LV and the outlet area in the aorta. A small motor on the catheter pulls blood from the left ventricle through an inlet area near the tip of the catheter and ejects it into the aorta. The device unloads the left ventricle, reduces myocardial workload and oxygen consumption, and increases cardiac output, coronary and peripheral perfusion. This image shows the Impella device placed across the aortic valve (image used with permission of Abiomed). The IABP (intra-aortic balloon pump) utilizes a percutaneously inserted balloon that is placed in the descending aorta and attached to an external pump that inflates the balloon during ventricular diastole and deflates it during ventricular systole. The IABP is a mechanical way to reduce ventricular afterload and improve coronary and peripheral perfusion. Angiojet is a thrombectomy device used to extract thrombus from a coronary artery or peripheral artery or vein. This catheter-based device is inserted into the thrombus in a blood vessel. High-speed water jets create a vacuum that pulls the thrombus into the catheter where the jets break it into tiny fragments. The fragments of thrombus are propelled back through the catheter and extracted from the vessel. Heart Mate is a left ventricular assist device (LVAD) that is used as a bridge to transplant as well as for destination therapy in patients with advanced heart failure. This device pumps blood from the LV into the aorta through cannulas placed in the LV and the ascending aorta. The pump can be run on battery power for up to 3 hours and the patient wears the portable battery pack externally. The pump can also run on AC power, requiring the patient to be connected via a power cord to an AC outlet. When administering the medications spironolactone or eplerenone to a patient, the nurse knows the following is true: A. The patient is at risk for increased bleeding. B. The patient is at risk for hypervolemia. C. The patient is at risk for thrombocytopenia. D. The patient is at risk for hyperkalemia. - ANSWER-D. Spironolactone (Aldactone) and eplerenone (Inspra) are aldosterone blockers. Aldosterone promotes Na+ retention which results in the loss of K+, so blocking aldosterone promotes loss of Na+ and K+ retention and can lead to hyperkalemia, especially when the patient is also taking ACE inhibitors or angiotensin receptor blockers (ARB). Aldosterone causes Na+ and H2O retention which can lead to hypervolemia. Aldosterone blockers cause loss of Na+ and H2O and result in intravascular volume reduction. Aldosterone blockers do not have a direct effect on platelet function and do not increase the risk of bleeding. Drugs used to decrease preload in patients with heart failure include which of the following: A. Dopamine, dobutamine, milrinone. B. Furosemide, nitrates, ACE inhibitors. C. Epinephrine, digoxin, dobutamine. D. Digoxin, diltiazem, amiodarone. - ANSWER-B. The two main ways to reduce preload are diuretics to remove volume from the circulation and venous dilators to hold blood in the dilated venous space and prevent it from returning to the heart. Furosemide (Lasix) is a diuretic; nitrates and ACE inhibitors dilate veins. Dopamine, dobutamine, milrinone, and digoxin are positive inotropes used to increase contractility. They are useful in heart failure to support contractility but not as direct preload reducers. Epinephrine has inotropic and vasopressor effects and is contraindicated in heart failure because it increases afterload and makes the heart work harder. Drugs with a positive mortality benefit in heart failure include: A. Digoxin, diuretics, beta blockers, calcium channel blockers. B. Calcium channel blockers, digoxin, beta blockers, ACE inhibitors. C. Beta blockers, ACE inhibitors, ARBs, aldosterone blockers. D. Dobutamine, milrinone. Diuretics, calcium channel blockers. - ANSWER-C. Only 4 groups of drugs have been shown to have a positive mortality benefit in heart failure: beta blockers, ACEI, ARBs, and aldosterone blockers. Diuretics and digoxin have symptom benefit but no mortality benefit. Inotropes (dobutamine, milrinone, etc.) are associated with increased mortality in heart failure. Calcium channel blockers are generally contraindicated in heart failure but can be used with caution if needed for angina or hypertension control. Which type of diuretic is the first line choice for managing heart failure: A. Loop diuretics. B. Thiazides. C. Combination of loop and thiazide. D. Potassium sparing diuretics. - ANSWER-A. Loop diuretics are the preferred diuretic in heart failure because they have a rapid onset of action, have increasing effects at increasing doses (high ceiling diuretics), are more potent than thiazides, and may be effective even in the presence of renal failure, which often accompanies heart failure. Other types of diuretics can be added to a loop diuretic if necessary in treating heart failure. When caring for a patient with chronic heart failure the nurse recognizes that the following may predispose the patient to the development of hyperkalemia: A. Salt substitutes. B. Aldosterone antagonists. C. ACE inhibitors. D. Angiotensin receptor blockers (ARBs). E. All of the above. - ANSWER-E. ACE inhibitors block the formation of angiotensin II, and ARBs block the effects of angiotensin II at its receptor sites. Angiotensin II results in a release of aldosterone, which causes the renal tubules to retain sodium and water and excrete potassium. Aldosterone antagonists, such as spironolactone and eplerenone, directly block aldosterone and result in an increased retention of potassium. Salt substitutes can contain potassium chloride and predispose to hyperkalemia. Which of the following describes systolic dysfunction or HFrEF: A. Thick ventricular walls, normal LV cavity size, ejection fraction 50%. B. Thin walled, dilated left ventricle, ejection fraction 35%. C. impaired relaxation of the LV with reduced LV filling. D. Ejection fraction of 60% with clear lungs. - ANSWER-B. Systolic dysfunction, or HFrEF (heart failure with reduced ejection fraction), is defined as impaired LV contractility resulting in a reduced ejection fraction (less than 40%), with increased end diastolic volume and pressure that eventually causes thinning and dilation of the LV. An EF of > 50% is considered normal LV function. A thick walled ventricle with impaired relaxation, reduced LV filling and normal EF is diastolic dysfunction, or HFpEF (heart failure with preserved ejection fraction). The most common cause of right ventricular failure is: A. Left ventricular failure. B. Pulmonary embolism. C. Right ventricular MI. D. Pulmonary hypertension. - ANSWER-A. Most right ventricular failure results from left ventricular failure that causes high LV pressures to be transmitted backward into the pulmonary system, eventually affecting the right ventricle. RV MI, pulmonary hypertension, and pulmonary embolism can all cause RV failure but the most common cause is LV failure. Compensatory mechanisms in heart failure that contribute to the symptoms and to the progression of heart failure include: A. Natriuretic peptides. B. Nitric oxide and bradykinin. C. Sympathetic nervous system and renin-angiotensin-aldosterone system stimulation. D. Prostaglandins and brain natriuretic peptide (BNP). - ANSWER-C. Sympathetic nervous system and renin-angiotensin-aldosterone system are two compensatory mechanisms that are counterproductive in heart failure because they result in vasoconstriction and fluid retention. Both are stimulated by the decrease in cardiac output that occurs in heart failure. Natriuretic peptides, BNP and atrial natriuretic peptide (ANP), are vasodilators and diuretics and are released in an effort to counteract the vasoconstriction and fluid retention caused by other compensatory mechanisms. Prostaglandins, nitric oxide, and bradykinin are vasodilators that help counteract vasoconstriction caused by the sympathetic system and the renin-angiotensinaldosterone system. Drug therapy for heart failure includes which of the following types of drugs: A. Diuretics, beta blockers, ACE inhibitors, aldosterone blockers. B. Platelet inhibitors, nitrates, calcium channel blockers. C. Beta blockers, calcium channel blockers, inotropes. D. Diuretics, calcium channel blockers, vasopressin. - ANSWER-A. Treatment of heart failure includes preload reduction with diuretics and venous dilators, afterload reduction with arterial vasodilators, blocking chronic sympathetic nervous system activity with beta blockers, and blocking the renin-angiotensin-aldosterone system with ACE inhibitors, angiotensin receptor blockers, and aldosterone blockers. Inotropes can be used in decompensated heart failure to increase contractility, but they have a negative effect on mortality and are only indicated for short-term use in decompensated failure or for palliation of symptoms in end-stage patients. Drugs used to increase contractility in systolic heart failure include: A. Digoxin, dobutamine, milrinone. B. Amlodipine, diltiazem. C. Furosemide, spironolactone. D. Enalapril, captopril. - ANSWER-A. Digoxin, dobutamine, and milrinone are positive inotropic agents that increase cardiac contractility. Digoxin is the only oral inotrope Continues...