Question 1 Ten year survival after the onset of heart failure:
80-90%
60-79%
40-59%
20-39%
Under 20%
Prognosis in Heart Failure Men over 45 years of Age
Surviving (%)
Years from Diagnosis
Prognosis in Heart Failure Women over 45 years of Age
Surviving (%)
Years from Diagnosis
Question 2 Potential underlying causes of heart failure include:
Coronary artery disease
Hemochromatosis
Mitral regurgitation
Ventricular septal defect
all of the above
Heart Failure The Final Common Pathway
ischemic disease
valvular disease
cardiomyopathy
pericardial disease
hypertension
congenital
Heart
Failure
Question 3 The pathophysiology of heart failure can best be described as:
a failure of protective mechanisms
activation of harmful pathways
introduction of pathogenic influences
inappropriate activation of normal mechanisms
all of the above
Physiologic Response to Heart Failure
LV Dysfunction
Renal-Adrenal
Carotid and LA
Baroreceptors
Renin-
Angiotensin
Aldosterone
Sympathetic
Output
Sodium
and fluid
retention
tachycardia
vasoconstriction
Question 4 Physiologic effects of Angiotensin II include:
vasoconstriction
activation of thirst
sodium retention
aldosterone release
all of the above
Renin-Angiotensin System
Renin
Angiotensin I
Angiotensin II
decreased
renal perfusion
decreased
Na delivery
sympathetic
activity
AVP Release
vasoconstriction
aldosterone
Increased thirst
NE release
sodium retention
decreased GFR
Question 5 The following is a feature of the heart failure state:
reduced circulating catecholamines
increased left ventricular end diastolic pressure
reduced plasma volume
increased renal sodium excretion
reduced pulmonary capillary wedge pressure
Compensatory Mechanisms in Heart Failure
increased preload
increased sympathetic tone
increased circulating catecholamines
increased Renin-angiotensin-aldosterone
increased vasopressin
increased atrial natriuretic factor
Question 6 Patients with early heart failure typically present with:
No symptoms
Dyspnea on exertion only
Dyspnea with minimal activity
Dyspnea at rest
Acute respiratory distress
Heart Failure Clinical Manifestations
Symptoms
dyspnea
fatigue
exertional limitation
weight gain
poor appetite
cough
Signs
tachycardia, tachypnea
edema
jugular venous distension
pulmonary rales
pleural effusion
hepato/splenomegaly
ascites
cardiomegaly
S3 gallop
Dyspnea Clinical Presentations
exertional shortness of breath
cough
orthopnea
paroxyxmal nocturnal dyspnea
severe respiratory distress
respiratory failure
NYHA Functional Classification
Class I: patients with cardiac disease but no limitation of physical activity
Class II: ordinary activity causes fatigue, palpitations, dyspnea or anginal pain
Class III: less than ordinary activity causes fatigue, palpitations, dyspnea or angina
Class IV: symptoms even at rest
Question 7 Edema in heart failure takes the following form:
Peripheral edema
Sacral edema
Abdominal distention
anasarca
Any of the above
Edema Clinical Presentations
where - peripheral, sacral, generalized
objective weight gain
bloating
abdominal distension
Question 8 Signs of right heart failure include all the following except:
Peripheral edema
Pulmonary rales
Elevated jugular veins
hepatomegaly
Pleural effusions
Left vs Right Heart Failure
Left Heart Failure
pulmonary congestion
Right Heart Failure
peripheral edema
sacral edema
elevated JVP
ascites
hepatomegaly
splenomegaly
pleural effusion
Question 9 A diagnosis of heart failure is best extablished on the basis of the following:
Dyspnea at rest, increased heart size on chest X ray and elevated jugular veins
Dyspnea with stair climbing, increased heart size on chest X ray and heart rate of 105
Rest dyspnea, interstitial edema on chest X ray, and elevated jugular veins
Orthopnea, flow redistribution on chest X Ray, and crackles in lung bases
PND, bilateral pleural effusions and crackles in lung bases
Criteria for Diagnosis of CHF
HISTORY Points
rest dyspnea 4
orthopnea 4
PND 3
dyspnea walking on level 2
dyspnea on climbing 1
CHEST X-Ray
alveolar pulmonary edema 4
interstitial pulm edema 3
bilateral pleural effusion 3
CT ratio > 0.50 3
flow redistribution 2
PHYSICAL Points
HR 91-110 1
HR > 110 2
JVP > 6 cm 2
JVP > 6 cm & hepatom 3
lung crackles in base 1
lung crackles above base 2
wheezing 3
S3 3
8-12 points - definite CHF
5-7 points - possible CHF
< 5 points - unlikely CHF
Question 10 All the following medications can precipitate heart failure in susceptible patient except:
metoprolol
spironolactone
procainamide
diltiazem
rosiglitazone
Precipitating Causes of Heart Failure
1. ischemia
2. change in diet, drugs or both
3. increased emotional or physical stress
4. cardiac arrhythmias (eg. atrial fib)
5. infection
6. concurrent illness
7. uncontrolled hypertension
8. New high output state (anemia, thyroid)
9. pulmonary embolism
10. Mechanical disruption (sudden MR, VSD, AR)
Question 11 The following investigations should always be carried out in patient presenting with heart failure except:
Renal function tests
A ventilation-perfusion scan
Blood counts
Electrocardiogram
Echocardiogram
Investigations for Heart Failure
EKG
evidence of ischemia, infarction, LVH, RVH
rhythm analysis
Chest X-Ray
cardiac size
evidence of pulmonary vascularity
Blood work
CBC, renal function, electrolytes
Assessment of LV Function
Question 12 Patient A.B. presents with clear signs of left heart failure and responds quickly to standard therapy. Follow-up assessment reveals normal LV systolic function. The most likely underlying cause of this patient’s heart failure is:
Diastolic dysfunction
Mitral valve disruption
Pulmonary embolism
Dilated cardiomyopathy
Ischemic heart disease
Heart Failure with Normal LV systolic function between symptomatic episodes
ischemia
sudden increase in myocardial demands
diastolic LV dysfunction
Question 13 The following mechanisms contribute to myocardial dysfunction in heart failure patients:
Increased circulating epinephrine
Increased circulatin