ABFM HEART DISEASE EXAM QUESTIONS
WITH CORRECT ANSWERS
A 65-year-old female who has heart failure with an ejection fraction of 35% is found to have a TSH level of 13.8 µU/mL (N 0.3-4.82). Her T3 and T4 levels are normal, and her thyroid gland is normal to palpation. You check her levels again in 2 months and they are unchanged. You advise her that hypothyroidism decreases her metabolic rate, which reduces the stress on her heart hypothyroidism is detrimental to her heart only if she develops hypothyroid symptoms subclinical hypothyroidism has negative effects on heart failure and treatment should be considered treatment of subclinical hypothyroidism would raise her LDL-cholesterol level - Correct Answer C Clinical hypothyroidism has long been associated with cardiac dysfunction. It has also been shown that subclinical hypothyroidism (TSH >4 µU/mL with normal or borderline low thyroid hormone levels) can cause left ventricular systolic and diastolic dysfunction, which improves with thyroid replacement therapy. Patients with overt or subclinical hypothyroidism should be treated with levothyroxine to improve their cardiovascular function and decrease the potential risk of heart failure. Thyroxine in excess can exacerbate coronary artery disease, and should be started at low doses and increased slowly in patients with possible underlying coronary artery disease. Results of meta-analyses indicate that therapy will lower, not raise, serum LDL-cholesterol levels.A 58-year-old male is hospitalized with severe decompensated heart failure refractory to intravenous inotropic therapy and guideline-directed medical therapy. You are considering referral to a tertiary care hospital for mechanical circulatory support to bridge to transplantation.Which one of the following is true regarding mechanical circulatory support bridge therapy?It should be limited to patients who meet the criteria for heart transplantation It should only be used in patients with biventricular heart failure It generally improves quality of life while waiting for transplantation It greatly reduces quality of life while waiting for transplantation - Correct Answer c Mechanical circulatory support (MCS) with a ventricular assist device has continued to evolve and has emerged as a viable therapeutic option for patients with advanced stage D heart failure with reduced ejection fraction refractory to guideline-directed medical therapy and cardiac device intervention. A variety of ventricular assist devices are now available. These devices may be either intracorporeal or extracorporeal, and may be designed to assist the left ventricle, right ventricle, or both.Bridge therapy refers to the use of left ventricular assist devices to help a patient survive until a donor heart becomes available for transplantation. Several devices are available, some of which are implantable and allow patients to be discharged to their homes. These devices can increase patient 1 / 4
activity levels and quality of life. Complications can occur, including stroke, infection, and death, but these devices can be lifesaving in patients with refractory heart failure.The data from the Interagency Registry for Mechanically Assisted Circulatory Support indicates that cardiogenic shock, advanced age, and severe right heart failure (manifested as ascites or increased bilirubin) are major risk factors for death after MCS. This led to a recommendation that referral for MCS be considered before severe right ventricular failure develops. Possible indications for a bridge-to-candidacy ventricular assist device include obesity, tobacco use, and severe pulmonary hypertension in patients who might otherwise be candidates for transplantation.An active 66-year-old female presents with intermittent chest pain and dyspnea. She is currently pain free. A resting EKG is normal.If found on the history and examination, which one of the following symptoms is most likely to be associated with myocardial ischemia as the cause of chest pain?An episode of diaphoresis associated with the chest pain Pain reproduced by chest wall palpation on the left side of the chest Pain that comes and goes with and without exertion Intermittent pleuritic-type pain and dyspnea - Correct Answer A Cardiac ischemia is classically defined as deep, poorly localized chest or arm discomfort reproducibly associated with exertion or emotional stress. It is relieved with rest and nitroglycerin. It can present in an atypical fashion, and the discomfort can localize or radiate to the neck, lower jaw, throat, shoulder, epigastrium, hands, or upper back. It may be entirely absent in some cases. In older patients without chest pain, new-onset or unexplained exertional dyspnea is the most common anginal equivalent, even with a normal resting EKG.Although they may be present, pleuritic-type pain, pain reproduced with movement or palpation of the chest wall or arm, and sharp or stabbing pain are not characteristic features of myocardial ischemia. Very brief episodes of pain, lasting a few seconds or less, are also not characteristic of myocardial ischemia. In a meta-analysis of symptoms useful in diagnosing acute coronary syndrome in a low-risk setting, diaphoresis was found to be the strongest predictor of myocardial infarction (MI) (likelihood ratio [LR] = 2.44), and the presence of chest wall tenderness significantly reduced the possibility of MI (LR = 0.23). A completely normal EKG does not exclude the possibility of acute coronary syndrome because 1%-6% of such patients eventually are found to have an acute myocardial infarction (non-ST-segment elevation by definition) and at least 4% have unstable angina.A 69-year-old female with a history of chronic hypertension and a previous myocardial infarction sees you for follow-up 6 weeks after being hospitalized for chest pain. During her hospitalization she underwent cardiac catheterization, which showed only a lesion in the circumflex that was less than 50% occluded. An EKG revealed sinus bradycardia of 52 beats/min, multifocal PVCs, and a QRS interval of 0.10 sec. Echocardiography revealed a left ventricular ejection fraction of 32%.Although the patient feels comfortable at rest she reports that she has difficulty walking up a single flight of stairs. Her current medications include atorvastatin (Lipitor), 40 mg daily; lisinopril (Prinivil, Zestril), 20 mg daily; metoprolol succinate (Toprol-XL), 100 mg daily; furosemide (Lasix), 40 mg daily; and 2 / 4
aspirin, 81 mg daily.On examination the patient is not in acute distress. Her blood pressure is 132/78 mm Hg and her pulse rate - Correct Answer D Aldosterone antagonists are important in the management of severe heart failure. The addition of an aldosterone antagonist to a β-blocker and an ACE inhibitor was shown in the Randomized Aldactone Evaluation Study to reduce rates of death and hospital readmissions in selected patients with moderate to severe symptoms of heart failure and a reduced left ventricular ejection fraction (LVEF) (SOR B). More recently, the EMPHASIS-HF trial (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure trial) found that the addition of eplerenone in heart failure patients with mild symptoms consistent with New York Heart Association (NYHA) class II heart failure and a mean LVEF of 26% resulted in a reduction in both hospitalizations and deaths. Current American Heart Association guidelines recommend the addition of an aldosterone antagonist to an ACE inhibitor and a β-blocker in selected patients with moderately severe to severe symptoms of heart failure and a reduced LVEF.Although the addition of digoxin can be of benefit in selected heart failure patients by reducing the risk for hospitalization, it has not been shown to reduce mortality (SOR B).According to recent guidelines, patients are considered candidates for cardiac resynchronization therapy if they have NYHA class II-IV heart failure, a left ventricular ejection fraction ≤35%, and a QRS duration >130 ms on an EKG. However, 30%-35% of patients who meet these criteria are nonresponders with no symptomatic improvement or reverse left ventricular remodeling. Left bundle branch block morphology, a QRS duration ≥150 ms, and adequate coronary sinus anatomy have been most closely associated with a favorable response. Mitral valve regurgitation, right ventricular dysfunction, and atrial fibrillation have been shown to have a negative impact on patient r You admit a patient with acute coronary syndrome to the hospital. Which one of the following is true regarding the differences between low molecular weight heparin (LMWH) and unfractionated heparin (UFH) in this situation?The use of glycoprotein IIb/IIIa inhibitors does not require a change in the dosage of UFH The dosage of both should be titrated to achieve a partial thromboplastin time of 1.5-2.5 times control Platelet activation is the same for both The incidence of thrombocytopenia is lower with LMWH UFH has higher bioavailability because it is given intravenously - Correct Answer D Anticoagulation is recommended in addition to antiplatelet therapy for all patients with acute coronary syndrome regardless of the initial treatment strategy. For patients managed with an early invasive strategy, heparin exerts its anticoagulant effect by accelerating the action of circulating antithrombin. It is available as either intravenous unfractionated heparin (UFH) or subcutaneous low molecular weight heparin (LMWH).LMWH offers greater bioavailability than UFH because of decreased binding to plasma proteins and endothelial cells, and it results in less platelet activation.The incidence of thrombocytopenia in patients treated with LMWH is less than with UFH. LMWH 3 / 4
does not change the partial thromboplastin time (PTT) appreciably, so PTT should not be used to monitor the dosage. LMWH is a viable option for treatment of acute coronary artery syndrome and is preferred in many situations.If UFH is used it should be given intravenously at a dosage of 85 U/kg unless a glycoprotein IIb/IIIa inhibitor is also administered, in which case the dosage should be reduced to 60 U/kg. Dosing adjustments should be based on the target activated clotting time.Patients treated with UFH should be monitored by factor Xa assays.An 82-year-old female presents with increasing dyspnea. Her husband is worried because she occasionally stops breathing when she is asleep. You have been treating the patient for heart failure for the past 2 years with ACE inhibitors, β-blockers, diuretics, and low-dose spironolactone (Aldactone). The nurse who measures the patient's blood pressure notes that the systolic sounds are heard first at a pressure of 135 mm Hg and a pulse rate of 40 beats/min. At 120 mm Hg the nurse hears Korotkoff sounds at a regular rate of 80/min.Which one of the following is true regarding this patient?The examination findings are normal for patients in this age group The patient's breathing pattern is normal for patients in this age group Both the breathing and blood pressure findings may improve with more intensive treatment Medications should be reduced in this patient because her blood pressure is unstable - Correct Answer C This patient has pulsus alternans, which is common in patients with decompensated heart failure and advanced myocardial disease. Effective treatment can make this finding disappear. Cheyne- Stokes breathing is also common in patients with decompensated heart failure. If the heart failure is treated, the breathing abnormality can disappear. The patient has symptomatic heart failure, which classifies her heart failure as stage C at least, according to the American College of Cardiology/American Heart Association heart failure guidelines.A 69-year-old female presents to the emergency department with a 1-hour episode of severe substernal chest pain that has now resolved. Her past medical history is notable for current tobacco abuse, hypertension, and depression. Her current medications include lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily; citalopram (Celexa), 20 mg daily; and aspirin, 81 mg daily. On examination she has a blood pressure of 150/92 mm Hg and a pulse rate of 92 beats/min. An EKG reveals a sinus rhythm with deep and symmetrical T-wave inversions in the inferior leads.You decide to admit the patient to the hospital. Which one of the following should be administered on admission?Alteplase (Activase) intravenously Aspirin, 81 mg, and nitroglycerin via intravenous drip
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