1、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 un
2、derlying 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、 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,
4、Carotid and LABaroreceptors,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-Angiotensi
5、n System,Renin,Angiotensin I,Angiotensin II,decreased renal perfusion,decreased Na delivery,sympatheticactivity,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 ca
6、techolamines 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-
7、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,S
8、ymptoms 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
9、 paroxyxmal nocturnal dyspnea severe respiratory distress respiratory failure,NYHA Functional Classification,Class I: patients with cardiac disease but no limitation of physical activityClass II: ordinary activity causes fatigue, palpitations, dyspnea or anginal painClass III: less than ordinary act
10、ivity 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 objectiv
11、e 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 periphe
12、ral 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 hea
13、rt 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 Pointsr
14、est dyspnea 4orthopnea 4PND 3dyspnea walking on level 2dyspnea on climbing 1CHEST X-Rayalveolar pulmonary edema 4interstitial pulm edema 3bilateral pleural effusion 3CT ratio 0.50 3flow redistribution 2,PHYSICAL PointsHR 91-110 1HR 110 2JVP 6 cm 2JVP 6 cm & hepatom 3lung crackles in base 1lung crack
15、les above base 2wheezing 3S3 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 He
16、art 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 (sudde
17、n 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,
18、 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
19、normal LV systolic function. The most likely underlying cause of this patients 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
20、increase in myocardial demands diastolic LV dysfunction,Question 13 The following mechanisms contribute to myocardial dysfunction in heart failure patients:,Increased circulating epinephrine Increased circulating norepinephrine Increased aldosterone production Increased angiotensin production all of
21、 the above,Rationale for Treatment of Heart Failure,LV dysfunction,sympatheticactivation,Renin- angiotensin,Adrenal stimulation,epinephrine norepinephrine,angiotensin I,aldosterone,angiotensin II,Question 14 All of the following have been shown to improve prognosis in patients with heart failure exc
22、ept:,digoxin carvedilol enalapril metoprolol ramipril,Medical Management of Heart Failure,Drugs that improve symptoms furosemide thiazide diuretics spironolactone digoxin ACE Inhibitors beta blockers aldosterone antagonists,Drugs that improve prognosis ACE inhibitors beta blockers spironolactone*,Ra
23、tionale for Treatment of Heart Failure,LV dysfunction,sympatheticactivation,Renin- angiotensin,Adrenal stimulation,epinephrine norepinephrine,angiotensin I,aldosterone,angiotensin II,BABs,ACEIs,ARBs,spironolactone,Beta Blocker Trials,Mortality per year,Enalapril vs Placebo in Symptomatic CHF CONSENS
24、US,Probability of Death,Months,Question 15 The following are all adverse effects of beta blockers except:,bronchospasm bradycardia hypotension depression anxiety,Beta Blockers Adverse Effects,excessive fatigue bradycardia, heart block hypotension reactive airways mood disturbances, depression interm
25、ittent claudication impotence,Beta Blockers in Heart Failure Practical Tips,start with low doses (3.125-6.25 mg carvedilol bid or 6.25-12.5 mg metoprolol bid) increase dose slowly at intervals of 2 weeks or more avoid in patients with bronchospasm or advanced heart block without pacemaker improvemen
26、t symptomatically and objectively may be slow avoid abrupt withdrawl,Question 16 The following are all adverse effects of ACE Inhibitors except:,Renal dysfunction bradycardia hypotension cough hyperkalemia,ACE Inhibitors Adverse Effects,hypotension renal dysfunction hyperkalemia cough skin rash tast
27、e disturbance angioneurotic edema,Question 17 Current evidence supports the following approach with respect to digoxin:,Should be used in all patients with LV dysfunction Should be used chronically in patients with controlled heart failure to improve symptom status Should be used chronically in pati
28、ents with controlled heart failure to improve prognosis Should be used acutely in patients with new onset heart failure Digoxin has no role in heart failure patients,Digitalis and other Inotropic Drugs Recommendations,to improve symptoms and reduce hospitalizations in patients in sinus rhythm who re
29、main symptomatic on ACEIs patients in atrial fibrillation and LV failure parenteral use of dopaminergic agents or phosphodiesterase inhibitors not recommended routinely, but may be used in select patients with intractable heart failure,Question 18 Current evidence supports the following approach wit
30、h respect to Angiotensin receptor antagonists:,Should be used in all patients with LV dysfunction Should be used chronically in patients with controlled heart failure to improve symptom status Should be used chronically in patients with controlled heart failure to improve prognosis Should be used in
31、 patients unable to tolerate ACE Inhibitors Have no role in heart failure patients,Angiotensin Receptor Blockers Indications,may be considered for patients unable to tolerate ACEIs,Angiotensin Receptor Blockers Adverse Effects,hypotension renal dysfunction hyperkalemia,Question 19 Current evidence s
32、upports the following approach with respect to Aldosterone antagonists:,Should be used in all patients with LV dysfunction Should be used chronically in patients with controlled heart failure to improve symptom status Should be used chronically in patients with controlled heart failure to improve pr
33、ognosis Should be used in patients with severe heart failure to improve symptoms Should be used in patients with severe heart failure to improve symptoms and prognosis,Aldosterone Antagonists in Heart Failure Evidence,RALES trial 1663 patients with class III-IV heart failure already on ACEI randomiz
34、ed to spironolactone (25 mg od) vs placebo after 2 years, 30% reduction in mortality in treatment group,Aldosterone Antagonists in Heart Failure Indications,Patients with severe symptomatic heart failure who are already on standard medications,Question 20 Current evidence supports the following appr
35、oach with respect to diuretics:,Should be used in all patients with LV dysfunction Should be used only in patients with active heart failure Should be used all patients who have had symptomatic heart failure to prevent recurrences Should be used in all patients with severe LV dysfunction Have no rol
36、e in heart failure patients,Diuretics in Heart Failure,very useful for management of acute congestive state produce rapid symptom relief have no prognostic advantage in stable patients,Diuretics in Heart Failure Agents Used,furosemide hydrochlorthiazide metolazone,Question 21 The following are all a
37、dverse effects of furosemide except:,renal dysfunction skin rash hypotension hyponatremia hyperkalemia,Diuretics in Heart Failure Adverse Effects,electrolyte disturbances (K, Na) hypotension renal dysfunction rash ototoxicity (ethacrynic acid, furosemide),Question 22 The following are all options to
38、 consider in patients with highly symptomatic and refractory heart failure except:,revascularization resynchronization therapy cardiac transplantation plasmapheresis dialysis,Patients with:hypertensionCADDMrisk for CMP,Patients with:prior MILV systolicdysfunctionasymptomaticvalve disease,Patients wi
39、th:known structuralheart diseaseSOBfatigue exercisetolerance,Patients with: marked symptoms despite full therapy,Therapy treat RFs encourage exercise discouragealcohol,Therapy all for Stage A ACEIs BABs,Therapy all for StagesA and B diruetics digoxin dietary restrictions,Therapy all for ABC assist d
40、evices transplantation,Structural heart disease,Symptoms of Heart Failure,Refractory Symptoms,STAGE A,STAGE B,STAGE C,STAGE D,At risk,Question 23 The following all support the diagnosis of acute pericarditis except:,typical chest discomfort ST elevation on EKG history of a preceding viral illness S4
41、 gallop pericardial friction rub,Acute Pericarditis Diagnostic Criteria,chest painpericardial friction rubEKG changes,Question 24 The earliest EKG changes seen in acute pericarditis:,ST segment depression ST segment elevation hyperacute T waves T wave depression PR depression,EKG in Acute Pericardit
42、is,1. Diffuse ST segment elevation (except aVR and V1) + PR segment depression2. ST normalizes, T waves flatten3. T waves invert where STs were elevated4. Return to normal pattern,Question 25 Pericardial tamponade should be suspected in the following situations:,enlarged heart shadow on chest X ray
43、unexplained hypotension unexplained severe dyspnea exaggerated inspiratory decline in BP all of the above,Pericardial Tamponade Physical Examination Findings,hypotension tachycardia tachypnea distant heart sounds elevated JVP pulsus paradoxus,Question 26 Causes of pericardial effusions include all o
44、f the following except:,hypertensive crisis breast cancer myocarditis lymphoma renal failure,Pericarditis - causes,idiopathic infectious (viral, bacterial, TB) post MI (acute, Dresslers syndrome) neoplastic disease uremia radiation autoimmune disease drugs trauma dissecting aortic aneurysm myxedema
45、chylopericardium,Question 27 Constrictive pericarditis should be included in the differential diagnosis of:,acute ischemic syndrome right sided heart failure severe unexplained chest pain acute respiratory failure acute renal failure,Constrictive Pericarditis Differential Diagnosis,right heart failu
46、re hepatic failure renal failure restrictive cardiomyopathy,Question 28 The most common site of infection in patients with Infectious Endocaridits:,Aortic valve Mitral valve Tricuspid valve Pulmonic valve Endocardial surface of left ventricle,Sites of Infection,Question 29 The most common infecting
47、organism in patients with right sided endocarditis:,Staph epidermidis Staph aureus Strep viridans Strep faecalis Enterococci,Infective Endocarditis Microorganisms Responsible,Question 30 Underlying predispositions to the development of Infectious Endocarditis include:,Diabetes mellitus Old age Intravenous drug abuse History of rheumatic fever All of the above,Predisposing Conditions,rheumatic heart disease congenital heart disease mitral valve prolapse degenerative heart disease parenteral drug abuse Diabetes mellitus old age,
