Heart failure

Heart failure US Medical PG Question 1: An 18-year-old man presents to a rural emergency department after being stabbed multiple times. The patient's past medical history is notable for obesity, diabetes, chronic upper respiratory infections, a 10 pack-year smoking history, and heart failure. He is protecting his airway and he is oxygenating and ventilating well. His temperature is 97.6°F (36.4°C), blood pressure is 74/34 mmHg, pulse is 180/min, respirations are 24/min, and oxygen saturation is 98% on room air. The patient is started on whole blood and the surgeon on call is contacted to take the patient to the operating room. During the secondary survey, the patient complains of shortness of breath. His blood pressure is 54/14 mmHg, pulse is 200/min, respirations are 24/min, and oxygen saturation is 90% on room air. Physical exam is notable for bilateral wheezing on lung exam. The patient goes into cardiac arrest and after 30 minutes, attempts at resuscitation are terminated. Which of the following is associated with this patient's decompensation during resuscitation?

• A. COPD
• B. Congenital long QT syndrome
• C. Heart failure
• D. IgA deficiency
• E. Persistent intraabdominal bleeding (Correct Answer)

Heart failure Explanation: ***Persistent intraabdominal bleeding*** - The patient's initial presentation with **uncontrolled hemorrhage due to multiple stab wounds** is the most likely cause of his subsequent decompensation and cardiac arrest. Despite transfusion, persistent bleeding would lead to ongoing **hypovolemic shock**, explaining the worsening hypotension and tachycardia. - The patient's complaint of shortness of breath and wheezing could be a **reaction to hypovolemic shock** or a **transient pulmonary response** related to the ongoing volume loss and metabolic state, rather than a primary respiratory obstructive process. *COPD* - While the patient has a smoking history, his age (18 years old) makes significant **COPD** unlikely to be established enough to cause such a rapid and severe decompensation. - The **wheezing** could be a non-specific response to shock or hypoperfusion, not necessarily indicative of COPD exacerbation in this acute setting. *Congenital long QT syndrome* - This condition is a **cardiac electrical disorder** predisposing to arrhythmias, but it is not directly linked to the traumatic injury or the progressive hypovolemic shock in this clinical scenario. - There is no specific information in the vignette to suggest an **arrhythmia originating from a prolonged QT interval** as the primary cause of his cardiac arrest. *Heart failure* - Although the patient has a history of heart failure, his primary and overwhelming problem is **acute hemorrhagic shock** from the stab wounds. The dramatic drop in blood pressure and rise in heart rate point to volume loss, not primarily cardiogenic shock exacerbation. - While heart failure can complicate resuscitation, it is not the **direct cause of decompensation** in the face of active, life-threatening hemorrhage. *IgA deficiency* - **IgA deficiency** is an immunodeficiency associated with recurrent infections, but it has no direct pathophysiological link to acute traumatic hemorrhage or the rapid cardiovascular collapse experienced by this patient. - It would not explain the sudden severe signs of **hypovolemic shock** or cardiac arrest in this context.

Heart failure US Medical PG Question 2: A 49-year-old man presents to his physician complaining of weakness and fatigue. On exam, you note significant peripheral edema. Transthoracic echocardiogram is performed and reveals a preserved ejection fraction with impaired diastolic relaxation. A representative still image is shown in Image A. Which of the following is likely the cause of this patient's symptoms?

• A. Hemochromatosis (Correct Answer)
• B. Heavy, long-term alcohol consumption
• C. History of myocardial infarction
• D. History of a recent viral infection
• E. Previous treatment with doxorubicin

Heart failure Explanation: ***Hemochromatosis*** - **Hemochromatosis** can lead to **restrictive cardiomyopathy** due to iron deposition in the myocardium, causing **diastolic dysfunction** with a **preserved ejection fraction**. - The symptoms of **weakness**, **fatigue**, and **peripheral edema** are consistent with **heart failure** secondary to this cardiac impairment. *Heavy, long-term alcohol consumption* - **Alcoholic cardiomyopathy** typically presents as **dilated cardiomyopathy**, characterized by **systolic dysfunction** and a **reduced ejection fraction**, which contradicts the preserved ejection fraction seen in this patient. - While chronic alcohol use can cause heart failure symptoms, the specific echocardiographic findings do not align with this etiology. *History of myocardial infarction* - A **myocardial infarction** commonly leads to **systolic dysfunction** or **ischemic cardiomyopathy**, resulting in a **reduced ejection fraction** due to scar tissue formation and impaired contractility. - The patient's preserved ejection fraction and primary diastolic relaxation abnormality make this diagnosis less likely. *History of a recent viral infection* - A recent viral infection can cause **viral myocarditis**, which typically leads to **dilated cardiomyopathy** and **systolic dysfunction** with a **reduced ejection fraction**. - The observed preserved ejection fraction and isolated diastolic relaxation impairment are not characteristic features of acute viral myocarditis. *Previous treatment with doxorubicin* - **Doxorubicin** (an anthracycline) is a well-known cardiotoxic agent that causes **dilated cardiomyopathy** with a **reduced ejection fraction**, primarily affecting **systolic function**. - The patient's preserved ejection fraction makes doxorubicin-induced cardiotoxicity an unlikely cause of his current presentation.

Heart failure US Medical PG Question 3: A 15-year-old female presents to her family physician for an annual school physical exam and check-up. She is accompanied by her mother to the visit and is present in the exam room. The patient has no complaints, and she does not have any past medical problems. She takes no medications. The patient reports that she remains active, exercising 5 times a week, and eats a healthy and varied diet. Which of the following would be the best way for the physician to obtain a more in-depth social history, including sexual history and use of alcohol, tobacco, or recreational drugs?

• A. Disallow the mother to be present in the examination room throughout the entirety of the visit
• B. Give the patient a social history questionnaire to fill out in the exam room
• C. Ask the mother to step outside into the hall for a portion of the visit (Correct Answer)
• D. Ask the patient the questions directly, with her mother still in the exam room
• E. Speak softly to the patient so that the mother does not hear and the patient is not embarrassed

Heart failure Explanation: ***Ask the mother to step outside into the hall for a portion of the visit*** - This approach allows the physician to speak with the adolescent **privately and confidentially**, which is crucial for obtaining sensitive information such as sexual history, drug use, and mental health concerns. - Adolescents are more likely to disclose personal information when their parents are not present, fostering trust and ensuring **comprehensive history-taking** vital for their well-being. *Disallow the mother to be present in the examination room throughout the entirety of the visit* - This is an **overly restrictive** approach that might create tension or distrust between the physician, patient, and parent, especially at the start of the visit. - While privacy is essential for sensitive topics, parental presence can be valuable for discussing general health, family history, and **treatment plans**, especially for younger adolescents. *Give the patient a social history questionnaire to fill out in the exam room* - While questionnaires can be useful for gathering basic information, they often **lack the nuance** of a direct conversation and may not prompt the patient to elaborate on sensitive issues. - Furthermore, having the mother present while the patient fills out a questionnaire on sensitive topics still **compromises confidentiality** and may lead to incomplete or dishonest answers. *Ask the patient the questions directly, with her mother still in the exam room* - Asking sensitive questions with a parent present is **unlikely to yield truthful and complete answers**, as adolescents may feel embarrassed, judged, or fear parental disapproval. - This approach compromises the **confidentiality** that is fundamental to building trust with adolescent patients. *Speak softly to the patient so that the mother does not hear and the patient is not embarrassed* - Speaking softly is **unprofessional** and still does not guarantee privacy, as the mother might still overhear parts of the conversation. - This method also **fails to establish true confidentiality**, which is central to building rapport and encouraging open communication with adolescent patients about sensitive topics.

Heart failure US Medical PG Question 4: The serum brain natriuretic peptide and N-terminal pro-BNP are elevated. A diagnosis of heart failure with preserved ejection fraction is made. In addition to supplemental oxygen therapy, which of the following is the most appropriate initial step in management?

• A. Intravenous dobutamine
• B. Intravenous furosemide therapy (Correct Answer)
• C. Intravenous morphine therapy
• D. Thoracentesis
• E. Intermittent hemodialysis

Heart failure Explanation: ***Intravenous furosemide therapy*** - Heart failure with **preserved ejection fraction (HFpEF)** often presents with **pulmonary congestion** due to elevated filling pressures. - **Furosemide**, a loop diuretic, effectively reduces fluid overload and associated symptoms by increasing renal excretion of sodium and water. *Intravenous dobutamine* - **Dobutamine** is an inotropic agent that increases myocardial contractility and heart rate. - It is typically used for **acute decompensated heart failure with low cardiac output** and is generally avoided in HFpEF unless there is significant hypoperfusion, as it can worsen myocardial oxygen demand and diastolic dysfunction. *Intravenous morphine therapy* - **Morphine** can be used in acute heart failure to reduce preload and anxiety, but it is not a primary treatment for the underlying fluid overload. - It can cause respiratory depression and hypotension, and its use is typically reserved for patients with severe pain or dyspnea not adequately managed by other therapies. *Thoracentesis* - **Thoracentesis** is indicated for symptomatic **pleural effusions** causing respiratory distress. - While pleural effusions can occur in heart failure, initial management of generalized fluid overload typically involves diuretics, making thoracentesis a secondary intervention if diuretic therapy is insufficient. *Intermittent hemodialysis* - **Intermittent hemodialysis** is an invasive procedure primarily used for severe renal failure or refractory fluid overload that has not responded to maximal diuretic therapy. - It is not the initial step in managing heart failure with preserved ejection fraction and would only be considered in highly selected cases with **acute kidney injury** or diuretic resistance.

Heart failure US Medical PG Question 5: A 60-year-old male engineer who complains of shortness of breath when walking a few blocks undergoes a cardiac stress test because of concern for coronary artery disease. During the test he asks his cardiologist about what variables are usually used to quantify the functioning of the heart. He learns that one of these variables is stroke volume. Which of the following scenarios would be most likely to lead to a decrease in stroke volume?

• A. Anxiety
• B. Heart failure (Correct Answer)
• C. Exercise
• D. Pregnancy
• E. Digitalis

Heart failure Explanation: ***Heart failure*** - In **heart failure**, the heart's pumping ability is impaired, leading to a reduced **ejection fraction** and thus a decreased **stroke volume**. - The weakened myocardium cannot effectively contract to expel the normal volume of blood, resulting in lower blood output per beat. *Anxiety* - **Anxiety** typically causes an increase in **sympathetic nervous system** activity, leading to increased heart rate and myocardial contractility. - This often results in a temporary **increase in stroke volume** due to enhanced cardiac performance, not a decrease. *Exercise* - During **exercise**, there is a significant **increase in venous return** and sympathetic stimulation, leading to increased **end-diastolic volume** and contractility. - This physiological response causes a substantial **increase in stroke volume** to meet the body's higher oxygen demands. *Pregnancy* - **Pregnancy** leads to significant **physiological adaptations** to accommodate the growing fetus, including a substantial increase in **blood volume**. - This increased blood volume and cardiac output result in an **increase in stroke volume** to maintain adequate perfusion for both mother and fetus. *Digitalis* - **Digitalis** is a cardiac glycoside that **increases intracellular calcium** in myocardial cells, enhancing the **force of contraction**. - This positive inotropic effect leads to an **increased stroke volume** by improving the heart's pumping efficiency.

Heart failure Flashcard 1 of 5

Question: What is the treatment plan for acute decompensated heart failure? L_____ - most important intervention M_____ - limited evidence for use N_____ O_____ P_____

Answer: asix (furosemide)

Extra Information:  https://onlinemeded.org/spa/cardiology/heart-failure/acquire?ref=anki 

Heart failure Flashcard 2 of 5

Question: High-output heart failure = _____ LAP and _____ CO and _____ TPR

Answer: ↑

Extra Information:  https://onlinemeded.org/spa/surgery?ref=anki 

Heart failure Flashcard 3 of 5

Question: ACE inhibitors are first line agents in the treatment of heart _____

Answer: failure

Heart failure Flashcard 4 of 5

Question: Right-heart failure following implantable pacemaker / cardioverter-defibrillator placement = _____

Answer: tricuspid regurgitation

Extra Information:  https://onlinemeded.org/spa/surgery?ref=anki 

Heart failure Flashcard 5 of 5

Question: The NYHA classification of heart failure is based on _____

Answer: degree of functional limitation (i.e. activity tolerance)

Extra Information:  https://onlinemeded.org/spa/cardiology/heart-failure/acquire?ref=anki