Categories/Classification
60 YO male with HFpEF which is well controlled with medication management. He has no limitations to his physical activity and is able to engage in all daily activities without problem. Which NYHA classification does he fall within?
Class I
Which one of the following medication classes reduces heart failure–related hospitalizations in patients without diabetes mellitus?
A) Calcium channel blockers
B) DPP-4 inhibitors
C) Insulin
D) SGLT2 inhibitors
E) Statins
D) SGLT2 inhibitors
Name 3 ways to improve medication adherence in geriatric patients
Simplifying medication regimens
Pill organizers
Blister packs
Written instructions
Caregiver involvement
Home health
A 65-year-old male with symptomatic heart failure presents for follow-up. He currently has
no symptoms of dyspnea at rest, but has moderate to significant limitations with ordinary
activity. His most recent echocardiogram showed a left ventricular ejection fraction of 38%.
His last hemoglobin A1c was the highest it has ever been at 6.3%, and he does not take any
glucose-lowering medications. His current medications include losartan (Cozaar), carvedilol
(Coreg), furosemide (Lasix), and spironolactone (Aldactone). On examination he has a blood
pressure of 120/75 mm Hg and an oxygen saturation of 94% on room air, and there are no
pulmonary crackles or peripheral edema.
Adding which one of the following would be most likely to further reduce this patient’s
mortality risk?
A) A calcium channel blocker
B) A GLP-1 receptor agonist
C) An SGLT2 inhibitor
D) A thiazide diuretic
E) Metformin
C. SGLT2 inhibitor
45 YO male smokes 1 ppd and takes amlodipine for well-controlled hypertension. He presents asymptomatic, for an annual physical. Which ABCD stage does he fall within?
Stage A
A 63-year-old female with a history of obesity and hypertension sees you for evaluation of shortness of breath on exertion and lower extremity edema. Echocardiography shows grade 2 diastolic dysfunction and an ejection fraction of 50%. You diagnose heart failure with preserved ejection fraction. Which one of the following medications has the best evidence to reduce hospitalization due to heart failure or cardiovascular death in patients such as this?
A) Carvedilol (Coreg)
B) Empagliflozin (Jardiance)
C) Lisinopril (Zestril)
D) Sacubitril/valsartan (Entresto)
E) Spironolactone (Aldactone)
B. Empagliflozin
Concerning weight gain?
Over 2 days and Over 5 days
2-3lbs over 2 days
5 lbs or more over 5 days
Name the 4 pharmacologic pillars of HFrEF GDMT
ARNI
Beta blocker
Mineralcorticoid
SGLT2 inhibitor
60 YO male has long-standing heart failure. His EF last year was 35%. He received a cardiac stent, sacubitril/valsartan, carvedilol, empagliflozin, and spironolactone. His EF today is now 45%. Which is the correct classification of his heart failure?
HFpEF
HFmrEF
HFrEF
HFimpEF
HFimpEF
A 90-year-old female sees you regularly for follow-up of several chronic medical conditions including systolic hypertension, coronary artery disease, previous ischemic stroke, and heart failure with preserved ejection fraction. Her systolic blood pressure is usually >160 mm Hg while her diastolic blood pressure is usually <50 mm Hg, making management challenging. In managing this patient’s blood pressure, an important physiologic consideration is that coronary artery perfusion is determined by which one of the following?
A) Diastolic blood pressure
B) Systolic blood pressure
C) Mean arterial pressure
D) Pulse pressure
E) Ejection fraction
A) Diastolic blood pressure
Heart failure guideline range for iron deficiency
Ferritin <100 ng/mL
OR
Ferritin 100–299 ng/mL + TSAT <20%
An 80-year-old male presents to your office for follow-up of stable angina. He has a medical
history of coronary artery disease with placement of a single drug-eluting stent, and stage 4
chronic kidney disease secondary to hypertension. His most recent echocardiogram
demonstrated a normal ejection fraction. He does not want additional cardiovascular
intervention and prefers you to handle all of his care in the future. The patient’s current
medications include the following:
Aspirin, 81 mg daily
Carvedilol (Coreg), 12.5 mg twice daily
Empagliflozin (Jardiance), 10 mg daily
Losartan (Cozaar), 50 mg daily
On examination he has a blood pressure of 140/85 mm Hg, a heart rate of 52 beats/min, and
an oxygen saturation of 98% on room air. A cardiopulmonary examination is within normal
limits and an EKG is unchanged from past EKGs.
Which one of the following changes to this patient’s medication regimen would be most
appropriate to decrease his anginal symptoms?
A) Increasing carvedilol
B) Increasing empagliflozin
C) Adding clopidogrel (Plavix)
D) Adding isosorbide mononitrate
E) Adding ivabradine (Corlanor)
D. Adding Isosorbide Mononitrate
60 YO female with diagnosed HFrEF and EF of 35% presents to ED with dyspnea, orthopnea, and respiratory failure. Her symptoms improved while admitted with lasix. Which ABCD stage does she fall within?
Stage C
A 58-year-old female with coronary artery disease and alcohol use disorder presents with progressive shortness of breath over the past 3 weeks. A chest radiograph demonstrates bilateral pleural effusions that are greater on the right side. Laboratory studies, including pleural fluid analysis, show the following:
Serum protein 5.5 g/dL (N 6.0–8.0) Serum LDH 305 IU/L (N 105–333) Plasma glucose 88 mg/dL (N 70–100) Pleural fluid protein 2.9 g/dL
Pleural fluid LDH 295 IU/L
Pleural fluid glucose 51 mg/dL
Which one of the following is the most likely cause of the effusion?
A) Cirrhosis of the liver
B) Congestive heart failure
C) COPD
D) Malignancy
E) Pulmonary embolism
D) Malignancy
Key criteria to refer for AICD evaluation
LVEF equal or less than 35% despite GDMT optimization
NYHA II-III
Expected survival > 1 year
A 72-year-old male with a medical history of dilated cardiomyopathy with an ejection fraction (EF)
of 30%, type 2 diabetes, and benign prostatic hyperplasia comes to your clinic for follow-up. His
most recent echocardiogram shows an improved EF of 55%–60%. His current medications include
the following:
Carvedilol (Coreg), 25 mg twice daily
Dapagliflozin (Farxiga), 10 mg daily
Furosemide (Lasix), 20 mg daily
Metformin, 500 mg twice daily
Sacubitril/valsartan (Entresto), 97/103 mg twice daily
Spironolactone (Aldactone), 25 mg daily
The patient walks 2 miles daily and does not have any dyspnea. On examination his blood pressure is
118/76 mm Hg, his pulse rate is 64 beats/min, and his respiratory rate is 12/min and regular. His
lungs are clear bilaterally, and his heart sounds are regular with no S3/S4 heart sounds or murmurs.
His lower extremities show no edema. He has a creatinine level of 0.8 mg/dL (N 0.7–1.3) and a
hemoglobin A1c of 7.0%. A urinalysis is negative for microalbuminuria.
Which one of the following is recommended at this time for management of this patient’s
cardiomyopathy?
A) No change to his current regimen
B) Changing spironolactone to as-needed for edema
C) Discontinuing carvedilol
D) Discontinuing dapagliflozin
E) Discontinuing sacubitril/valsartan
A. No change to current regimen
60 YO female with diagnosed HFpEF has been taking all of her prescribed medications and controlling her condition well. She does not require oxygen at home, however she gets winded when taking a short walk around the block. Which NYHA classification does she fall within?
Class III
A 63-year-old female with hypertension sees you for routine follow-up. She has been
bothered by swelling in her legs for the last several months. Her blood pressure is well
controlled and she does not have any shortness of breath, cough, difficulty breathing while
lying down, or pain in her legs when walking. She thinks the swelling is better earlier in the
day. Her current medications include hydrochlorothiazide, lisinopril (Zestril), estrogen,
levothyroxine (Synthroid), and as-needed acetaminophen. A physical examination
demonstrates mild pitting edema of both legs from the ankle to the distal third of each calf.
There are 2+ pedal pulses and no skin changes. Examinations of the heart and lungs are
normal.
Which one of the following would be the most appropriate next step?
A) Holding estrogen, and monitoring for improvement in peripheral edema
B) Holding lisinopril, and monitoring for improvement in peripheral edema
C) Bilateral ankle-brachial indices
D) Bilateral venous compression ultrasonography
E) Bilateral venous duplex ultrasonography with reflux
A. Holding estrogen, monitor for improvement in peripheral edema
Key criteria for LVAD consideration
Recurrent HF hospitalizations
Persistent NYHA IIIb-IV symptoms
Low cardiac output/hypoperfusion
Ionotrope depend or cardiogenic shock
An 80-year-old male who is taking furosemide (Lasix), 80 mg, for heart failure presents to the
emergency department (ED) with a gradual onset of somnolence. He is found to be hyponatremic
with a serum sodium level of 104 mEq/L (N 135–145).
You should order the administration of which one of the following?
A) 100 mL of 3% sodium chloride over 10 minutes
B) 150 mL of 5% sodium chloride over 30 minutes
C) 500 mL of 3% sodium chloride over 30 minutes
D) 1 L of 0.9% sodium chloride over 1 hour
E) 1 L of 3% sodium chloride over 1 hour
A. 100 mL of 3% sodium chloride over 10 minutes