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C. Year 3: SBOM > Heart/Cardiac Failure > Flashcards

Heart/Cardiac Failure Flashcards

1
Q

Heart failure is a collection of symptoms (syndrome) where the heart is unable to deliver sufficient blood to the body. What is the most common cause of heart failure?

1 - hepatic fibrosis
2 - CKD
3 - IHD (cardiomyopathy)
4 - aortic stenosis

A

3 - IHD (cardiomyopathy)

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2
Q

Heart failure is due to a cardiomyopathy. Which 2 are the key causes?

1 - LV pumps too much blood
2 - atrium over fill
3 - atrium cannot fill with sufficient blood
4 - ventricles cannot pump sufficient blood

A

3 - atrium cannot fill with sufficient blood
- associated with diastolic function

4 - ventricles cannot pump sufficient blood
- associated with systolic function

  • BOTH cause blood to back up into lungs and fluid builds up
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3
Q

How may new patients are diagnosed with heart failure per year in the UK?

1 - 200
2 - 2000
3 - 20,000
4 - 200,000

A

4 - 200,000
- this is incidence

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4
Q

What is the mean age at presentation of heart failure?

1 - 50 y/o
2 - 65 y/o
3 - 77 y/o
4 - 85 y/o

A

3 - 77 y/o

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5
Q

What is the 5-year mortality in patients with heart failure in the UK?

1 - 1%
2 - 5%
3 - 20%
4 - 50%

A

4 - 50%
- almost like a cancer
- <1 year in advanced heart failure

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6
Q

Left systolic heart failure failure is as a result of which of the following?

1 - LV weakness
2 - LV dilation
3 - dilated cardiomyopathy
4 - all of the above

A

4 - all of the above

  • means any subsequent contractions are weaker
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7
Q

All of the following are causes of left ventricular heart failure. What is by far the most common cause?

1 - IHD (acute MI or chronic ischaemia)
2 - Hypertension
3 - Inherited (autosomal dominant)
4 - Alcohol excess
5 - Post viral
6 - Toxins (eg chemotherapy drugs)
7 - Metabolic (eg hypothyroid, iron overload, thiamine deficiency)
8 - Unknown cause (‘idiopathic’)

A

1 - IHD (acute MI or chronic ischaemia)

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8
Q

Afterload is the force the heart has to generate to eject blood out of the LV. What is the key determining factor that determines afterload?

1 - SV
2 - HR
3 - SVR
4 - preload

A

3 - SVR

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9
Q

How do we calculate stroke volume?

1 - SVR / end diastolic volume (EDV)
2 - SVR / end systolic volume (ESV)
3 - EDV - ESV
4 - EDV - ejection fraction

A

3 - EDV - ESV

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10
Q

To measure LV function we can look at the ejection fraction (EF). Which of the following is the correct formula for this?

1 - EF = HR x SV
2 - EF = (HR / SVR) x 100
3 - EF = (SV / EDV) x 100
4 - EF = (SV / ESV) x 100

SV = stroke volume
HR = heart rate
EDV = end diastolic volume
ESV = end systolic volume

A

3 - EF = (SV / EDV) x 100

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11
Q

What is a normal ejection fraction?

1 - 20%
2 - 30%
3 - 40%
4 - >50%

A

4 - >55%

  • 40-50% is borderline
  • <40% is systolic HF
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12
Q

The frank starling mechanism is useful to understand the relationship between systolic and diastolic function. What does the frank starling mechanism show?

1 - increased atrium filling means more ventricular contraction
2 - increased ventricular stretching results in greater stroke volume
3 - increased ventricular stretching results in reduced preload
4 - reduced ventricular filling increased afterload

A

2 - increased ventricular stretching results in greater stroke volume

  • like a rubber band, the more the stretch the ventricle in diastole = a greater contract force and a larger SV in systole
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13
Q

All of the following occur in systolic left sided heart failure, what is the first common sign of left sided heart failure?

1 - increased LV diastolic pressure
2 - increased end diastolic volume
3 - reduced ejection fraction
4 - increased SV

A

3 - reduced ejection fraction
- results in reduced SV
- SV = EDV - ESV
- EF = (SV / EDV) x 100

  • weak heart so decreased left ventricle contractility
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14
Q

What is the diagnostic cut off for systolic heart failure?

1 - left ventricle ejection fraction <60%
2 - left ventricle ejection fraction <50%
3 - left ventricle ejection fraction <40%
4 - left ventricle ejection fraction <30%

A

3 - left ventricle ejection fraction <40%

  • when ejection fraction drops <40% is when patients present with symptoms
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15
Q

The volume of blood the left ventricle is able to eject is dependent on preload (stretching of the cardiomyocytes) as they fill. If the preload is low, what can this cause?

1 - LV hypertrophy
2 - reduced ejection fraction
3 - increases ejection fraction
4 - insufficient SV

A

4 - insufficient SV

  • essentially less blood being pumped around the body per beat
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16
Q

Heart failure can be subdivided into 3 clinical syndromes. What are these 3 syndromes?

A

1 - chronic heart failure = peripheral oedema

2 - acute heart failure = pulmonary oedema

3 - cardiogenic shock = low BP (<90mmHg)

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17
Q

In systolic left sided heart failure, stroke volume is decreased due to a weakened left ventricle. More blood is left in the left side of the heart at the end of systole. Which of the following can this then cause?

1 - increased left atrium (LA) pressure
2 - increased pulmonary venous pressure
3 - pulmonary oedema
4 - all of the above

A

4 - all of the above
- more blood left in LV
- LA requires more pressure to force blood into LV
- venous pressure builds up to overcome pressure in LA
- fluid backs up into the lungs causing pulmonary oedema

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18
Q

If the pressure in the left atrium increases as a response to having to work harder to pump blood into the left ventricle (if not emptying properly), what affect does this have on the left atrium?

1 - tricuspid regurgitation
2 - left atrium hypertrophy
3 - left atrium dilation
4 - atrial flutter

A

3 - left atrium dilation

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19
Q

In systolic left sided heart failure, stroke volume is decreased due to a weakened LV. LA pressure to force blood into LV, venous pressure increases up to overcome pressure in LA and fluid backs up into the lungs causing pulmonary oedema. Which of the following can this then lead to?

1 - increased pulmonary artery pressure (back to the RV)
2 - increased right atrium pressure
3 - increased right ventricle pressure
4 - peripheral oedema
5 - all of the above

A

5 - all of the above

  • pressure essentially works backwards from the lung to the heart, and eventually increases pressure for blood to return to the heart
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20
Q

If there is a decrease in the contractility of the left ventricle that causes a reduction in cardiac output, what does this activate?

1 - sympathetic activity
2 - RAAS system
3 - Na+ and H2O retention
4 - all of the above

A

4 - all of the above

  • low blood flow to kidneys activates RAAS
  • RAAS retains H2O and Na+ to increase BP
  • sympathetic activity aims to increase contractility and increase cardiac output
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21
Q

Which of the following are the common symptoms that patient present with in heart failure may present with?

1 - breathlessness on exertion
2 - Orthopnoea (breathlessness lieing down)
3 - Paroxysmal nocturnal dyspnea (PND) (breathlessness sleeping)
4 - Fatigue due to low cardiac output
5 - Leg swelling (oedema) due to change in pressures
6 - cyanosis
7 - cough/wheeze/crackles
8 - all of the above

A

6 - all of the above

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22
Q

A clinical sign of heart failure is a raised jugular venous pressure. What is this an indicator of?

1 - raised LV pressure
2 - raised LA pressure
3 - raised RV pressure
4 - raised RA pressure

A

4 - raised RA pressure
- but this can be caused by an increase in pressure in all the other options as well

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23
Q

Which are the most typical clinical signs of oedema that we may see in a patient with heart failure?

1 - ankle
2 - shins
3 - thighs
4 - genitals
5 - trunk
6 - all of the above

A

6 - all of the above

  • depends on the severity of the heart failure
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24
Q

A clinical sign of a patient with heart failure is a pleural effusion. What is this?

1 - fluid collecting in the pericardial sac
2 - fluid collect the diaphragm
3 - fluid collecting in the space between the lungs and chest cavity
4 - all of the above

A

3 - fluid collecting in the space between the lungs and chest cavity

  • pleural = space between lungs and chest cavity
  • effusion = collection of fluid
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25
Q

Which of the following are clinical signs that we may be able to identify in a patient with heart failure?

1 - Lung crackles (inspiration, bases)
2 - Low volume pulse, low BP
3 - Tachycardia, increased respiratory rate
4 - Displaced apex beat
5 - Murmur (functional MR)
6 - Liver enlargement (hepatomegaly)
7 - ascites
8 - all of the above

A

8 - all of the above

  • Lung crackles = pulmonary oedema
  • Low volume pulse, low BP = poor contractility
  • Tachycardia = aim to increase cardiac output
  • Displaced apex beat
  • Murmur = mitral regurgitation during systole
  • Liver enlargement (hepatomegaly) - congested liver due to fluid backed up
  • ascites = fluid backs up into portal system
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26
Q

What method is used to stratify the severity of heart failure?

1 - NICE severity score
2 - AHA classification
3 - Fredricks classification
4 - New York Heart Association (NYHA)

A

4 - New York Heart Association (NYHA)
- class 1 = asymptomatic
- class 2 = mild symptoms (ADLs)
- class 3 = moderate symptoms (exertion)
- class 4 = symptoms at rest

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27
Q

In patients with heart failure, which 3 of the following are simple non invasive assessments can clinicians perform?

1 - JVP assessment
2 - ECG
3 - brain natriuretic peptide (BNP)
4 - lung auscultation
5 - pitting oedema
6 - ascites test

A

1 - JVP assessment
4 - lung auscultation
5 - pitting oedema

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28
Q

When looking at an ECG in a patient with heart failure, which of the following traits are we likely to see?

1 - Tall complexes (‘LV hypertrophy’)
2 - Broad complexes (‘Left bundle branch block’)
3 - T wave inversion
4 - Tachycardia
5 - all of the above

A

4 - all of the above

  • Tall complexes = LV hypertrophy
  • Broad complexes (‘Left bundle branch block’)
  • T wave inversion
  • Tachycardia = aims to increased cardiac output
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29
Q

Which of the basic blood tests should be requested?

1 - FBC
2 - U&Es
3 - renal function
4 - liver function
5 - serum electrolytes
6 - serum ferritin
7 - all of the above

A

7 - all of the above

  • FBC = anaemia, MVC
  • renal function = CKD
  • liver function = hepatic congestion/alcohol
  • serum electrolytes = Na+, K+ etc..
  • serum ferritin = rare form of heart failure
30
Q

Brain Natriuretic Peptide (BNP) is a marker released from the heart. When is BNP released in heart failure?

1 - released by LA due to increased LA pressure
2 - released by RA due to increased LA pressure
3 - released by LA due to decreased LA pressure
4 - released by LV due to increase LA pressure

A

1 - released by LA due to increased LA pressure

  • released when stretched too much
  • signals kidneys to stop retaining Na+ and H2O
  • good sensitivity = confirms patient with HF
  • poor specificity = confirms patient doesn’t have HF
31
Q

Transthoracic echocardiogram (TEE), which means ultrasound through the chest useful for?

1 - LV dimensions/function
2 - LV ejection fraction
3 - Estimate intra-cardiac pressures
4 - Investigate for valvular heart disease
5 - RV dimensions/Function
6 - Estimation of pulmonary hypertension
7 - all of the above

A

7 - all of the above

this is the most common form of echocardiogram

32
Q

What can cardiac MRI be used to assess?

1 - assessment and follow-up of iron overload cardiomyopathy
2 - LV dimensions/function
3 - LV ejection fraction
4 - Characterise myocardial pathology
5 - Congenital heart disease/
pericardial disease
6 - all of the above

A

6 - all of the above

33
Q

Cardiac catheterisation is an invasive assessment of cardiac function. What is it able to assess?

1 - LV dimensions/function
2 - Direct measurement of intra-cardiac pressures
3 - Coronary angiography and invasive measurement of pressure across valves
4 - all of the above

A

4 - all of the above

  • used mainly to assess for IHD
  • go in through arm or groin
34
Q

If you suspect a patient has heart failure due to peripheral oedema, you must first rule out other causes. Which of the following is NOT a common differential?

1 - inactivity oedema
2 - Nephrotic syndrome
3 - Drugs (e.g. calcium channels blockers)
4 - COPD
5 - Hypoalbuminaemia
6 - Venous insufficiency

A

4 - COPD

35
Q

In a patient with an acute presentation of acute left sided heart failure due to an MI for example, the LV is dysfunction. This increases LA and pulmonary vein pressure, increasing pulmonary capillaries and causing pulmonary oedema. What must the pressure in the capillaires be at in order to cause pulmonary oedema?

1 - >25mmHg
2 - <100mmHg
3 - <5mmHg
4 - <10mmHg

A

1 - >25mmHg

  • serum albumin is 25 g/L, so it must be higher than this
  • causes increased hydrostatic pressure
36
Q

In a patient with acute myocardial infarction there is an increase in pressure in LV which is transmitted backward into pulmonary capillaries causing oedema in the lungs. What happens to patients pulse, BP and temperature?

A
  • pulse = thready and weak (heart not contracting properly)
  • BP = <90mmHg
  • cold and clammy (blood doesn’t reach skin properly)
  • together these are signs of cardiogenic shock
37
Q

In a patient with acute myocardial infarction there is an increase in pressure in LV which is transmitted backward into pulmonary capillaries causing oedema in the lungs. Which of the following are a sign of cardiogenic shock?

1 - thready and weak pulse
2 - BP = <90mmHg
3 - cold and clammy
4 - all of the above

A

4 - all of the above

  • most common cause of cardiogenic shock is an MI
38
Q

If the RV fails, the pressure in the RA increases as it has to work harder to pump blood in the RV. Increased RA pressure can cause a raised JVP. Although this can cause a lot of things to happen, the 1st and most obvious sign this is occurring is what?

1 - cor pulmonale
2 - hepatomegaly
3 - splenomegaly
4 - peripheral oedema

A

4 - peripheral oedema

  • can be sign of right sided heart failure
39
Q

What is the most common cause of right sided heart failure?

1 - left sided heart failure
2 - IHD
3 - liver failure
4 - CKD

A

1 - left sided heart failure

  • right sided heart failure is typically a chronic presentation
40
Q

In right sided heart failure in addition to oedema in the peripheries, fluid typically collects in all of the following EXCEPT?

1 - abdomen (ascites)
2 - pleural effusion
3 - elevated JVP
4 - cranial cavity

A

4 - cranial cavity

41
Q

Cor pulmonael is a specific type of right sided heart failure. What is Cor pulmonael a direct effect of?

1 - left sided heart failure
2 - IHD
3 - chronic lung disease
4 - hepatic fibrosis

A

3 - chronic lung disease

  • COPD, pulmonary hypertension, lung fibrosis
42
Q

Which of the following are causes of cor pulmonael?

1 - COPD
2 - pulmonary hypertension
3 - pulmonary fibrosis
4 - all of the above

A

4 - all of the above

43
Q

Which of the following is NOT a key feature we may see on an X-ray in a patient with cor pulmonael?

1 - hyper inflated lungs
2 - pneumoperitoneum
3 - flattening of diaphragm
4 - enlargement of the central pulmonary arteries

A

2 - pneumoperitoneum

  • common in GIT perforation or following surgery
44
Q

Catecholamine cardiotoxicity is caused by over activity of the sympathetic system. Which of the following can this cause in the heart?

1 - LV dilation
2 - LV remodelling
3 - LV dysfunction
4 - all of the above

A

4 - all of the above

45
Q

The whole cardiac cycle is split into 3 parts. How many of these parts are systolic?

1 - 3
2 - 2
3 - 1

A

3 - 1

  • systolic = 1 part of cardiac cycle
  • diastolic = 2 parts of cardiac cycle
  • MORE TIME SPENT IN DYSTOLE
46
Q

In diastolic heart failure what is the main issue?

1 - heart unable to contract enough
2 - heart unable to fill enough

A

2 - heart unable to fill enough

  • heart contracts fine, but not enough blood in heart, so SV is reduced
47
Q

In diastolic heart failure is ejection fraction increased or decreased?

A
  • normal based on the cut offs
  • less blood to be pumped out as less filled, so appears normal
  • reduced preload
  • HF with preserved EJ
48
Q

What is the most common reason for diastolic heart failure?

1 - RV stiffness
2 - LV stiffness
3 - LA stiffness
4 - RA stiffness

A

2 - LV stiffness

49
Q

What is the diagnosis of heart failure with preserved ejection fraction?

1 - >40% without symptoms
2 - >50% with symptoms
3 - >60% with symptoms
4 - >40% with symptoms

A

4 - >40% with symptoms

50
Q

Right sided heart failure us common in the elderly. However, patients with specific conditions have an increased risk. Which of following increases the risk of right sided heart failure in the elderly?

1 - hypertension
2 - diabetes
3 - AF
4 - all of the above

A

4 - all of the above

51
Q

Which of the following are causes of right sided heart failure?

1 - Amyloid heart disease
2 - Sarcoidosis
3 - Severe LV hypertrophy (Hypertension and Hypertrophic cardiomyopathy)
4 - all of the above

A

4 - all of the above

52
Q

Is LV diastolic heart failure calssified as a restrictive or obstructive cardiac disease?

A
  • restrictive
  • heart is stiff so blood cannot fill
53
Q

What drug must we not give to patients in acute HF?

1 - morphine
2 - aspirin
3 - beta blockers
4 - anti-emetic

A

3 - beta blockers

  • can make condition worse
  • but can continue, if already on
  • BUT chronic and treated HF patients do use Beta blockers
54
Q

When managing a patient with heart failure and dilated cardiomyopathy we used the mnemonic PODMAN. What does the P relate to?

1 - paracetamol
2 - patient position
3 - pain management
4 - post operative care

A

2 - patient position

  • patient should be sat up
  • gravity will help remove fluid from lungs
55
Q

When managing a patient with heart failure dilated cardiomyopathy we used the mnemonic PODMAN. What does the O relate to?

1 - oxygen
2 - outcomes
3 - opiods

A

1 - oxygen

56
Q

When managing a patient with heart failure and dilated cardiomyopathy we used the mnemonic PODMAN. What does the D relate to?

1 - drugs
2 - DOACs
3 - diuretics
4 - dopamine

A

3 - diuretics
- removes fluid and lowers BP

57
Q

When managing a patient with heart failure and dilated cardiomyopathy we used the mnemonic PODMAN. What does the M relate to?

1 - morphine
2 - misoprostol
3 - medication

A

1 - morphine

58
Q

When managing a patient with heart failure and dilated cardiomyopathy we used the mnemonic PODMAN. What does the A relate to?

1 - anti-emetics
2 - anti-acids
2 - atorvastain
3 - amiodarone

A

1 - anti-emetics

59
Q

When managing a patient with heart failure and dilated cardiomyopathy we used the mnemonic PODMAN. What does the N relate to?

1 - NADH
2 - naproxen
2 - never give opioids
3 - nitrate

A

3 - nitrate (GTN spray)

60
Q

What medication is indicated in a patient with chronic HF and dilated cardiomyopathy with obvious fluid retention?

1 - Furosemide
2 - Ramipril
3 - Losartan or Candesartan
4 - Spironolactone

A

1 - Furosemide

  • loop diuretic
61
Q

Patients with chronic HF and dilated cardiomyopathy can be prescribed an angiotensin II inhibitor. Which of the following drugs is an angiotensin II inhibitor?

1 - Furosemide
2 - Ramipril
3 - Losartan or Candesartan
4 - Spironolactone

A

2 - Ramipril

  • reduces effects of RAAS system
62
Q

Patients with chronic HF and dilated cardiomyopathy can be prescribed an angiotensin II receptor inhibitor. Which of the following drugs is an angiotensin II receptor inhibitor?

1 - Furosemide
2 - Ramipril
3 - Losartan or Candesartan
4 - Spironolactone

A

3 - Losartan or Candesartan

  • if unable to have ACE-II
63
Q

Patients with chronic HF and dilated cardiomyopathy can be prescribed an aldosterone antagonist. Which of the following drugs is an aldosterone antagonist?

1 - Furosemide
2 - Ramipril
3 - Losartan or Candesartan
4 - Spironolactone

A

4 - Spironolactone

64
Q

Patients with chronic HF and dilated cardiomyopathy can be prescribed a beta blocker. Which of the following drugs is a beta blocker?

1 - Furosemide
2 - Ramipril
3 - Losartan or Candesartan
4 - Spironolactone
5 - Bisoprolol

A

5 - Bisoprolol

  • reduces effects of sympathetic nervous system and arrhythmias
65
Q

Which diabetes medication has recently been shown to be affective in reducing fluid retention and reducing mortality in chronic HF and dilated cardiomyopathy patients?

1 - Metformin
2 - Dapagliflozin
3 - Dulaglutide
4 - Linagliptin

A

2 - Dapagliflozin

  • SGLT2 inhibitor
  • blocks the Na+/glucose transporter
  • reduces glucose absorption, producing an osmotic diuresis
66
Q

In heart failure, would you avoid giving a patient with acute or chronic heart failure a beta blocker?

A
  • acute heart failure
  • can be used in well managed chronic HF
67
Q

If there are signs of left and right sided heart failure, what is this called?

1 - coronary artery syndrome
2 - congestive heart failure
3 - idiopathic hypertension
4 - IHD

A

2 - congestive heart failure

68
Q

In patients with a QRS >120ms, LBBB and and are between I-IV according to the New York Heart Association Functional Classification should be referred to see who?

1 - electrophysiologist
2 - respiratory doctor
3 - cardiac surgeon
4 - all of the above

A

1 - electrophysiologist

  • need to be reviewed for a implantable cardioverter defibrillators and/or undergo cardioversion
69
Q

A 76-year-old man with a history of heart failure visits your clinic for a routine scheduled examination. He has underlying coronary heart disease. Echocardiogram 12 months ago showed left ventricular regional wall motion abnormality in the anterior wall. His ejection fraction at that time was 40%.

He takes lisinopril 20 mg/d, carvedilol 6.25 mg bid, atorvastatin 40 mg/d, and aspirin 75 mg/d, all of which he is tolerating well.

O/E: Blood pressure 132/82 mmHg, HR 83 bpm and regular, respiratory rate of 18 breaths/min, and a room air oxygen saturation of 96%. JVP is normal. Clear lung fields, and his heart examination reveals an S3 at the cardiac apex, which has been noted on previous examinations. He has no oedema in his extremities. Which of the options below should be performed?

1 - Document his current level of activity?
2 - Start furosemide 20 mg/d?
3 - Start valsartan 50 mg/d?
4 - Stop his aspirin?

A

1 - Document his current level of activity?

  • we need to see how impaired his ADL are

ACC/AHA activity classifications are:

  • Class I: cardiac disease but no limitation of physical activity
    Class II: cardiac disease causing slight limitation of physical activity. Ok at rest.
    Class III: cardiac disease with marked limitation of physical activity, but ok at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.
    Class IV: cardiac disease resulting in an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.
70
Q

An 82-year-old woman with a known history of heart failure from coronary heart disease visits you office because she is having increasing symptoms. Her last visit was 4 months ago, when you classified her as having NYHA class II functional status. Her ejection fraction is 35%.

She states that over the past 3 weeks she has gained 5 pounds with new onset of dyspnoea while walking from her kitchen to her living room, which she used to do without difficulty. She has recently begun sleeping in a chair propped up because of difficulty breathing while lying flat.

She takes valsartan 50 mg/d, sustained-release metoprolol 50 mg/d, simvastatin 40 mg/d, and aspirin 75 mg/d, all of which she is tolerating well.
O/E: 4kg weight gain BP 118/74 mmHg HR 63 bpm and regular, a respiratory rate of 18 breaths/min, room air oxygen saturation of 96% at rest that decreases to 91% with hallway ambulation. She has raised JVP. You hear basilar crackles in her lungs and her heart examination reveals a normal rhythm without murmurs or extra sounds. She has 1+ pitting edema in her extremities. What would the next step of treatment be?

1 - Direct admission to hospital?
2 - Order a stat echocardiogram?
3 - Start furosemide
4 - Increase her valsartan to 100 mg/d.

A

3 - Start furosemide
- for symptom relief

C. Year 3: SBOM (50 decks)

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