Acute decompensated heart failure

Question 1

A 70-year-old with known heart failure presents with increasing dyspnea, weight gain of 5 lbs in a week, and new bilateral rales. She is warm to the touch, no signs of poor perfusion. Which Forrester subset does she likely fall under?
A) Subset I (dry/warm)
B) Subset II (wet/warm)
C) Subset III (dry/cold)
D) Subset IV (wet/cold)

Answer 1

Answer: B
Rationale: “Wet/warm” means signs of volume overload (rales, weight gain) but normal perfusion (warm extremities, stable BP).

Question 2

A 65-year-old with chronic HFrEF arrives tachypneic and hypotensive. Exam: cool extremities, JVD, pulmonary crackles. This suggests low output and volume overload. Which Forrester subset?
A) Subset I (dry/warm)
B) Subset II (wet/warm)
C) Subset III (dry/cold)
D) Subset IV (wet/cold)

Answer 2

Answer: D
Rationale: “Wet/cold” → signs of congestion (wet) + hypoperfusion (cold).

Question 3

Which of the following most commonly triggers an acute decompensation in heart failure patients?
A) High altitude exposure
B) Medication nonadherence (excess salt/fluid)
C) Minor dehydration
D) Frequent nebulized bronchodilator use

Answer 3

Answer: B
Rationale: Dietary indiscretion (high salt) or med nonadherence is a very common cause of ADHF.

Question 4

An NT-proBNP level is measured in a patient with acute dyspnea. A very high value (>2000 pg/mL) is typically suggestive of:
A) Asthma exacerbation
B) COPD exacerbation
C) Pulmonary embolism
D) Acute decompensated heart failure

Answer 4

Answer: D
Rationale: NT-proBNP is released with ventricular volume expansion; high levels → probable ADHF.

Question 5

A 72-year-old with right-sided heart failure primarily presents with:
A) Pulmonary edema and orthopnea
B) Jugular venous distension, peripheral edema, hepatomegaly
C) Marked paroxysmal nocturnal dyspnea
D) Elevated troponin alone

Answer 5

Answer: B
Rationale: Right HF → systemic venous congestion (JVD, edema, hepatic congestion).

Question 6

A 68-year-old with HFpEF is admitted with acute pulmonary edema. Which mechanism best explains why they are susceptible to fluid overload?
A) Low ejection fraction decreases forward flow
B) Impaired ventricular filling due to stiffness
C) Overly compliant ventricle
D) High stroke volume with no back pressure

Answer 6

Answer: B
Rationale: HFpEF = diastolic dysfunction → stiff LV impairs filling, leads to higher filling pressures & fluid backup.

Question 7

7.
In acute decompensated HF with flash pulmonary edema, the priority is:
A) Increase oral beta-blocker dose
B) Diuresis + vasodilators to relieve pulmonary congestion
C) IV fluids to improve preload
D) Start a dopamine infusion at high dose

Answer 7

Answer: B
Rationale: Flash pulmonary edema = urgent need for diuretics, possibly vasodilators to reduce preload/afterload.

Question 8

Which sign in a patient with suspected right-sided HF indicates hepatic congestion?
A) Rales at lung bases
B) Hepatojugular reflux
C) S3 gallop at apex
D) Narrow pulse pressure

Answer 8

Answer: B
Rationale: Hepatojugular reflux suggests fluid overload and hepatic congestion from right HF.

Question 9

A patient with advanced HFrEF has acute dyspnea. Exam: JVD, S3, BP 88/50, cool extremities. The best initial management?
A) High-dose beta-blocker
B) Aggressive IV fluids
C) IV loop diuretic + consider inotropic support
D) Strict bed rest only

Answer 9

Answer: C
Rationale: “Wet/cold” → loop diuretic for congestion + possible inotrope for low output.

Question 10

Which lab test helps distinguish acute decompensated HF from noncardiac causes of pulmonary symptoms?
A) D-dimer
B) BNP or NT-proBNP
C) Serum sodium
D) AST/ALT.

Answer 10

Answer: B
Rationale: BNP/NT-proBNP significantly elevated in HF vs noncardiac etiologies

Question 11

A patient with chronic HF on loop diuretics presents with increased edema. No improvement with IV furosemide at their usual dose. Which approach helps overcome diuretic resistance?
A) Add a thiazide (metolazone) before loop
B) Discontinue all diuretics
C) Switch to sublingual nitrates
D) Give IV fluids to “challenge” the kidney

Answer 11

Answer: A
Rationale: Diuretic resistance is often addressed by combination therapy (loop + thiazide).

Question 12

A 55-year-old in acute HF shows severe hypertension (BP 210/120) and pulmonary edema. Which medication combination is preferred?
A) IV vasodilator (e.g., nitroprusside) + loop diuretic
B) IV beta-blocker + fluid bolus
C) Low-dose dopamine + oral nitrates
D) High-flow oxygen only

Answer 12

Answer: A
Rationale: Severe HTN + ADHF → reduce afterload with a vasodilator + diuretic for volume overload.

Question 13

A “cold and dry” Forrester subset III patient typically has:
A) Normal perfusion, no congestion
B) Low perfusion (cool extremities), no volume overload signs
C) Low perfusion, high volume overload
D) Normal perfusion, high volume overload

Answer 13

Answer: B
Rationale: “Cold” = poor perfusion, “dry” = not volume overloaded (no significant edema/rales).

Question 14

A patient with severe right-sided HF might demonstrate:
A) Orthopnea as the primary complaint
B) Pulmonary edema with pink frothy sputum
C) Marked jugular venous distension and ascites
D) Widened pulse pressure

Answer 14

Answer: C
Rationale: Right HF → systemic venous congestion: JVD, ascites, edema.

Question 15

Cardiac index <2.0 L/min/m² with elevated wedge pressure typically indicates:
A) Normal hemodynamics
B) Wet/warm profile
C) Wet/cold profile
D) Dry/warm profile

Answer 15

Answer: C
Rationale: Low CI = “cold,” high PCWP = “wet” → “wet/cold” Forrester IV.

Question 15

A 70-year-old with EF of 25% arrives with acute HF. He’s in sinus tachycardia, BP 95/60, warm extremities, bilateral rales. The best initial therapy?
A) IV diuretic (loop)
B) IV vasopressor
C) Oral beta-blocker load
D) IV fluid challenge

Answer 15

Answer: A
Rationale: He’s “wet/warm” → loop diuretics for volume overload relief.

Question 16

Which of the following is least likely to cause an acute decompensation of chronic HF?
A) High-salt diet noncompliance
B) New atrial fibrillation
C) Uncontrolled hypertension
D) Strict medication compliance, stable vitals

Answer 16

Answer: D
Rationale: Adherence typically prevents exacerbations. Nonadherence, arrhythmias, or hypertension can worsen HF.

Question 17

A 75-year-old with HFpEF presents with severe hypertension and pulmonary edema. He’s Forrester subset II (wet/warm). After IV loop diuretic, BP remains 210/110. Next step?
A) IV inotrope (dobutamine)
B) IV vasodilator (e.g., nitroglycerin)
C) Increase sedation
D) IV fluid bolus

Answer 17

Answer: B
Rationale: HFpEF + severe HTN → vasodilator (reduce afterload/preload) to help relieve pulmonary edema.

Question 18

Patients with right-sided HF due to pulmonary hypertension often benefit from:
A) High afterload to improve output
B) Diuretics + addressing underlying pulmonary vasoconstriction
C) Heavy fluid loading to increase RV stroke volume
D) Oral nitrates alone

Answer 18

Answer: B
Rationale: Right HF from pHTN is managed by diuretics (carefully) + pulmonary vasodilators or therapies addressing pHTN.

Question 19

An ADHF patient is unresponsive to high-dose loop diuretics. They still have severe pulmonary edema. A typical next intervention?
A) Stop diuretics and give fluids
B) Add a thiazide or spironolactone to augment diuresis
C) Oral nitrates
D) Beta-blockers IV bolus

Answer 19

Answer: B
Rationale: If loop diuretic alone is insufficient, add a second diuretic or aldosterone antagonist (or consider IV vasodilators/inotropes if indicated).

Question 20

A “wet/cold” patient (subset IV) typically requires which immediate approach?
A) IV fluids to improve perfusion
B) Vasodilators alone
C) Combine diuretics (to reduce volume) and possibly inotropes (to improve perfusion)
D) Early beta-blocker load

Answer 20

Answer: C
Rationale: “Wet/cold” means volume overload + low output → diuretics + possible inotropes to improve perfusion.

Question 21

A 65-year-old with HFrEF is admitted with ADHF. He has an S3 gallop, crackles, mild hypotension (BP 90/60), and evidence of end-organ hypoperfusion. Which drug might improve cardiac output but risk arrhythmias?
A) Dobutamine (inotrope)
B) Furosemide only
C) Beta-blocker infusion
D) High-dose nitrates

Answer 21

Answer: A
Rationale: Dobutamine boosts contractility (↑CO) but can provoke tachyarrhythmias.

Question 22

A 72-year-old’s EF is 25%. He’s stable, receiving guideline-directed therapy. Which best explains why he needs an ACE inhibitor?
A) ACEIs are only used in stable HFpEF
B) They reduce preload but increase mortality
C) They reduce afterload and limit maladaptive remodeling
D) They are given solely for arrhythmia prophylaxis

Answer 22

Answer: C
Rationale: ACE inhibitors reduce afterload & block RAAS, preventing remodeling → improved mortality in HFrEF.

Question 23

A known HF patient with chronic atrial fibrillation stops taking diuretics and has rapid weight gain. He develops acute dyspnea. Why do arrhythmias often worsen HF?
A) They always reduce afterload
B) They can reduce cardiac filling time/coordinate contraction, ↓CO
C) They have no significant impact on HF
D) They permanently lower EF

Answer 23

Answer: B
Rationale: Arrhythmias (e.g., AF) → poor synchronization & shorter filling → decreased CO → worsen HF.

Question 24

A 68-year-old in acute HF. He has confusion, cold limbs, oliguria. His BP is 85/45, pulmonary edema. An SVO₂ is low. This suggests: A) Adequate peripheral perfusion B) Excessive sedation C) Cardiogenic shock with end-organ hypoperfusion D) Normal Forrester subset II status

Answer 24

Answer: C Rationale: Low BP, cold extremities, confusion → shock; low SVO₂ = poor perfusion/oxygen extraction.

Question 25

Which is a common reason for hospital readmissions in HF? A) Lack of telephone access B) Rigorous adherence to fluid/salt restrictions C) Inadequate follow-up + diet noncompliance D) Overtreatment with inotropes

Answer 25

Answer: C Rationale: Inadequate outpatient follow-up + nonadherence to diet/meds are prime factors for HF readmissions.

Question 26

A patient on chronic carvedilol for HFrEF arrives with acute decompensation. Generally, the recommended approach: A) Discontinue beta-blocker immediately B) Continue or slightly reduce beta-blocker if stable, do not abruptly stop C) Convert to IV beta-blocker bolus D) Overdrive sedation

Answer 26

Answer: B Rationale: Abrupt stopping can worsen HF. If stable, continue or slightly adjust but do not fully stop.

Question 27

In “dry/cold” subset (Forrester III), if PCWP is very low (<15 mmHg), which step might improve cardiac output? A) Gentle fluid bolus to optimize preload B) High-dose loop diuretic C) Beta-blocker infusion D) Nitroglycerin infusion

Answer 27

Answer: A Rationale: “Dry/cold” = low output, low filling → fluid bolus can restore adequate preload & ↑CO.

Question 28

For long-term mortality benefit in HFrEF, which class is key? A) Loop diuretics alone B) Inotropes (dobutamine) C) Beta-blockers, ACE inhibitors, mineralocorticoid receptor antagonists D) Vasopressors

Answer 28

Answer: C Rationale: Beta-blockers, ACEIs/ARBs, MRAs (spironolactone) → improved survival in HFrEF.

Question 29

A 72-year-old with HFpEF presents with severe hypertension, pulmonary edema, normal EF on echo. The best initial therapy? A) IV fluids to augment preload B) IV vasodilator ± diuretic to reduce afterload/preload C) Dopamine at high dose D) Beta-blocker infusion for immediate effect

Answer 29

Answer: B Rationale: HFpEF + HTN + edema → use vasodilators + diuretic to reduce pressure & fluid overload.

Question 30

An 80-year-old with ADHF, on IV furosemide with minimal urine output. Next step? A) Assume he is euvolemic B) Add a thiazide (metolazone) or increase loop dose C) Convert to sublingual nitrates D) Discharge with oral loop diuretic only

Answer 30

Answer: B Rationale: Diuretic resistance → escalate loop diuretic dose or add a thiazide for synergy.

Question 31

In acute decompensated right HF with normal LV function, the greatest concern is: A) High oxygen saturation B) Excessive afterload on the right ventricle (↑pulmonary pressures) C) Flash pulmonary edema D) Orthopnea

Answer 31

Answer: B Rationale: Right HF is very sensitive to increased pulmonary vascular resistance.

Question 32

A Forrester IV (wet/cold) patient remains hypotensive (SBP ~85) with pulmonary edema despite diuretics. The next adjunct for improving cardiac output? A) High-dose vasopressor only B) Inotrope (dobutamine or milrinone) ± vasodilator carefully C) Immediate oral beta-blocker load D) Strict fluid restriction only

Answer 32

Answer: B Rationale: “Wet/cold” + persistent hypoperfusion → inotrope helps CO; cautious vasodilators if BP tolerates.

Question 33

In ADHF management, ultrafiltration might be considered if: A) Patient is hypovolemic B) Patient is normovolemic with normal diuretic response C) Patient has diuretic resistance and volume overload D) The patient’s EF is >60%

Answer 33

Answer: C Rationale: Ultrafiltration is an option for refractory fluid overload not responding to diuretics.

Question 34

Which of the following arrhythmias commonly worsens heart failure and can precipitate decompensation? A) Atrial fibrillation with rapid ventricular response B) Sinus bradycardia at 55 bpm C) 1st-degree AV block D) Rare unifocal PVCs

Answer 34

Answer: A Rationale: AF with RVR shortens filling time, reduces CO, frequently triggers ADHF.

Question 35

A patient with severe HFrEF is on dobutamine infusion to support CO. This can result in: A) Lower risk of any arrhythmia B) Negative inotropy C) Potential tachyarrhythmias or increased myocardial O₂ demand D) Profound bradycardia

Answer 35

Answer: C Rationale: Dobutamine ↑contractility but can cause tachyarrhythmias, higher O₂ consumption.

Question 36

Which IV vasodilator might be used in ADHF with severe hypertension, but caution is required due to risk of cyanide toxicity with prolonged use? A) Nitroglycerin B) Nitroprusside C) Nesiritide D) Dobutamine

Answer 36

Answer: B Rationale: Nitroprusside can cause cyanide/thiocyanate toxicity if used high-dose/long-term.

Question 37

A 70-year-old with HFpEF and pulmonary edema has a BP 240/130. He’s “wet/warm.” The greatest immediate concern: A) Overdiuresis leading to hypotension B) Malignant hypertension leading to acute pulmonary edema C) Hypokalemia D) Slow heart rate

Answer 37

Answer: B Rationale: Extremely high BP in HFpEF → malignant HTN & acute edema. Rapid afterload reduction is critical.

Question 37

Invasive hemodynamic monitoring (e.g., pulmonary artery catheter) is recommended in ADHF when: A) Diagnosis is obvious and response to therapy is clear B) There’s uncertainty about volume status or therapy response C) The patient is stable and discharge-ready D) Routine HF admissions

Answer 37

Answer: B Rationale: Swan-Ganz used if volume status or hemodynamic uncertain, or refractory to standard therapy.

Question 38

A cardiorenal syndrome in ADHF typically manifests as: A) Marked improvement in GFR from high perfusion B) Worsening renal function due to poor cardiac output or congestion C) No effect on renal perfusion D) Hypoaldosteronism

Answer 38

Answer: B Rationale: ADHF can reduce renal perfusion, causing cardiorenal syndrome (↑ creatinine, ↓ GFR).

Question 39

A 68-year-old with HFrEF is admitted repeatedly for volume overload. He is on max diuretics, ACE inhibitor, beta-blocker. Which add-on therapy reduces mortality? A) Milrinone infusion at home B) Mineralocorticoid receptor antagonist (e.g., spironolactone) C) High-dose amiodarone prophylaxis D) IV morphine prn

Answer 39

Answer: B Rationale: Spironolactone (MRA) improves survival in advanced HFrEF.

Question 40

Nesiritide (synthetic BNP) can help by: A) Potent vasoconstriction B) Diuretic effect, vasodilation, lowering PCWP C) Negative inotropy D) Providing indefinite mortality benefit

Answer 40

Answer: B Rationale: Nesiritide lowers wedge pressure and has vasodilatory & mild natriuretic effects.

Question 41

Which is most correct about beta-blocker therapy in HFrEF? A) It immediately improves symptoms in ADHF B) It can be harmful if started at high dose in acute decompensation C) It is absolutely contraindicated once EF <35% D) It’s only used if heart rate is above 120

Answer 41

Answer: B Rationale: Beta-blockers improve mortality but must be started low & slow, avoided in acute decomp. Large initial doses in ADHF can worsen output.

Question 42

For an HF patient discharged after ADHF, which factor is most critical to reduce readmission? A) Strict nonadherence to medication B) Detailed discharge instructions on diet, meds, follow-up C) Eliminating all physical activity D) Passive approach to weight changes

Answer 42

Answer: B Rationale: Patient education on diet, meds, daily weights, and close follow-up greatly lowers readmissions.

Question 42

A patient with right HF from COPD/pulmonary hypertension complains of ascites and leg edema. He’s borderline low BP but warm. Which med might help reduce congestion without dropping BP too much? A) Loop diuretic carefully B) High-dose vasodilator C) Inotrope infusion D) Excess fluid intake.

Answer 42

Answer: A Rationale: For RV failure with volume overload, a loop diuretic helps reduce edema. Must do carefully to avoid dropping preload too severely

Question 43

After ADHF resolution, a patient’s ejection fraction is 30%. Which device might reduce sudden death risk? A) Pacemaker alone B) Implantable cardioverter-defibrillator (ICD) C) Transvenous temporary pacer D) IABP

Answer 43

Answer: B Rationale: EF <35% → ICD recommended to prevent lethal arrhythmias (sudden cardiac death).

Question 44

In advanced HFrEF with repeated hospitalizations, LV assist devices (LVADs) are considered when: A) EF is >40% B) The patient has multiple stable comorbidities preventing transplant C) They have stage D HF, unresponsive to meds, as a bridge or destination therapy D) They only have mild symptoms

Answer 44

Answer: C Rationale: LVAD is for end-stage or “stage D” HF not responding to medical therapy, as bridge to transplant or destination therapy.

Question 45

Pulmonary edema with pink frothy sputum is a hallmark of: A) Pure right-sided HF B) Acute left-sided HF exacerbation C) Lower extremity DVT D) Low wedge pressure

Answer 45

Answer: B Rationale: Pink frothy sputum → alveolar fluid from acute left-sided HF/pulmonary edema.

Question 46

A “wet/warm” Forrester II patient has not improved with diuretics alone. Next step to alleviate pulmonary congestion? A) Add gentle IV vasodilator if BP tolerates B) Increase fluids for better perfusion C) Stop diuretics abruptly D) Start dobutamine infusion

Answer 46

Answer: A Rationale: If still congested (wet) but perfusion is adequate (warm), an IV vasodilator helps reduce preload/afterload.

Question 47

In acute decompensated HF with preserved EF and severe HTN, which approach quickly improves alveolar fluid clearance? A) IV inotrope only B) Aggressive diuresis + afterload reduction C) Beta-blocker IV push D) No intervention is necessary

Answer 47

Answer: B Rationale: HFpEF + severe HTN → diuretics + vasodilators for prompt edema relief.

Question 48

identifying volume status (“wet” vs “dry”) and perfusion status (“warm” vs “cold”)—Forrester classification helps guide therapy

Answer 48

ADHF involves

Question 49

Mainstays is Loop diuretics

Answer 49

for volume overload,

Question 50

vasodilators ,

Answer 50

if BP is high

Question 51

inotropes

Answer 51

if perfusion is poor

Question 52

ACE inhibitors/ARBs, beta-blockers, and MRAs improve survival in HFrEF and treat arrhythmias and risk factors.

Answer 52

Chronic management of acute decompensated heart failure

Question 53

Nonadherence to meds or diet

Answer 53

often leads to acute decompensation; post-discharge care is vital.

Question 54

A patient with acute decompensated HF and flash pulmonary edema is hypotensive with altered mentation. Which complication requires emergent attention? A. Worsening stable angina B. Cardiogenic shock C. Gradual improvement in ejection fraction D. Mild ankle edema

Answer 54

**Correct Answer: B. Cardiogenic shock** *Rationale:* In a patient with acute decompensated heart failure and flash pulmonary edema who is hypotensive and exhibits altered mentation, the presentation is highly suggestive of cardiogenic shock. This condition represents a state of critical end-organ hypoperfusion due to severe pump failure and requires emergent management. The other options, such as worsening stable angina, gradual improvement in ejection fraction, or mild ankle edema, do not align with the life-threatening scenario presented by cardiogenic shock.

Question 55

In ADHF management, overdiuresis can lead to which harmful outcome? A. Elevated blood pressure B. Hypotension and renal hypoperfusion C. Reduced respiratory distress D. Stable electrolytes

Answer 55

**Correct Answer: B. Hypotension and renal hypoperfusion** *Rationale:* In the management of acute decompensated heart failure (ADHF), overdiuresis can lead to excessive fluid loss, which may result in hypotension. This decrease in blood pressure can reduce renal perfusion, potentially leading to renal hypoperfusion and acute kidney injury. Elevated blood pressure, reduced respiratory distress, or stable electrolytes are not expected outcomes of overdiuresis in this scenario.

Question 56

Which intravenous therapy is commonly given in ADHF to achieve rapid symptom relief? A. IV loop diuretics (e.g., furosemide) B. Oral statins C. Calcium channel blockers D. Long-term oral nitrates

Answer 56

**Correct Answer: A. IV loop diuretics (e.g., furosemide)** *Rationale:* In acute decompensated heart failure (ADHF), intravenous loop diuretics such as furosemide are used to rapidly reduce volume overload, which helps alleviate symptoms like dyspnea and pulmonary edema. This intervention provides prompt symptomatic relief by reducing fluid accumulation. Other options like oral statins, calcium channel blockers, or long-term oral nitrates are not effective for immediate symptom relief in this setting.

Question 57

46. Acute decompensated heart failure is characterized by: A. Gradual weight loss and improved exercise tolerance B. Sudden worsening of heart failure symptoms, including pulmonary congestion and edema C. Asymptomatic stable heart function D. Enhanced myocardial contractility

Answer 57

o Answer: B o Rationale: ADHF is defined by a sudden

Question 58

47. Which intervention “will kill your patient” in ADHF if mismanaged? A. Excessive diuresis leading to hypotension and renal dysfunction B. Slow titration of beta blockers C. Administration of ACE inhibitors at low doses D. Mild fluid restriction

Answer 58

o Answer: A o Rationale: Overdiuresis can precipitate hypotension, renal injury, and shock, worsening heart failure outcomes.

Question 59

48. What is “common” on physical exam in ADHF? A. Clear lung fields B. Bibasilar crackles and peripheral edema C. Bradycardia with strong pulses D. Warm, dry skin

Answer 59

o Answer: B o Rationale: Bibasilar crackles and edema are frequently observed due to pulmonary congestion and volume overload.

Question 60

49. Which pharmacologic agent is typically used for rapid symptomatic relief in ADHF? A. Intravenous loop diuretics (e.g., furosemide) B. Oral beta blockers C. Long-acting nitrates D. High-dose statins

Answer 60

o Answer: A o Rationale: IV loop diuretics provide quick relief from volume overload in decompensated heart failure.

Question 61

50. Which complication “will harm your patient” if ADHF is left untreated? A. Improved exercise tolerance B. Multi-organ failure due to low cardiac output C. Weight gain without symptoms D. Elevated LDL cholesterol only

Answer 61

o Answer: B o Rationale: Untreated ADHF can lead to end-organ hypoperfusion and multi-organ failure, which are life-threatening.