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ABFM |\HEART |\DISEASE |\exam |\questions |\
with |\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 |\ANSWERS |\✔✔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 |\ANSWERS |\✔✔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 |\
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 |\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 |
ANSWERS |\✔✔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 |\
|\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 |\ANSWERS |\✔✔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 Enoxaparin |(Lovenox), |\ 1 |\mg/kg |\subcutaneously, |\and |
nitroglycerin, |\0.4 |\mg |\sublingually Ticagrelor |(Brilinta), |\ 60 |\mg |\orally, |\and |\enoxaparin, |\ 1 |\mg/kg |
subcutaneou |- |\CORRECT |\ANSWERS |\✔✔E
Non-Hispanic |\whites |\more |\than |\Asian-Americans |- |\CORRECT |
ANSWERS |\✔✔B There |\is |\no |\evidence |\that |\silent |\myocardial |\infarction |(MI), |\as |
detected |\by |\the |\Minnesota |\code, |\is |\more |\common |\in |\women |\than |\in |\men |\in |\the |\ACCORD |(Action |\to |\Control |\Cardiovascular |\Risk |\in |
Diabetes) |\trial |\cohort. |\Men |\were |\found |\to |\have |\a |\higher |
prevalence |\of |\silent |\MI |\on |\baseline |\EKGs |\than |\women |(6% |\versus |\4%, |\P |= |\0.001). |\Women |\had |\lower |\odds |\of |\silent |\MI |\than |\men |
after |\adjusting |\for |\other |\risk |\factors |(odds |\ratio |= |\0.80, |\P |= |\0.04). |\Race |\and |\ethnicity |\were |\significantly |\associated |\with |\silent |\MI |(P |
= |\0.02), |\with |\Asian-Americans |\having |\the |\highest |\incidence |\and |
African-Americans |\and |\Hispanics |\having |\a |\lower |\incidence |\than |
non-Hispanic |\whites. A |\78-year-old |\male |\with |\chronic |\hypertension |\presents |\with |\a |
sudden |\onset |\of |\severe |\chest |\pain |\radiating |\to |\the |\back, |
associated |\with |\dyspnea |\and |\near-syncope. |\Which |\one |\of |\the |
following |\would |\suggest |\a |\diagnosis |\other |\than |\acute |\myocardial |
infarction? A |\3/6 |\holosystolic |\apical |\murmur |\and |\diffuse |\ST-segment |
elevation A |\2/6 |\diastolic |\murmur |\and |\weak |\radial |\and |\femoral |\pulses Diffuse |\ST-segment |\elevation |\of |\1-2 |\mm A |\pulsus |\paradoxus |\of |\ 10 |\mm |\Hg Chest |\and |\back |\pain |\that |\was |\mild |\initially |\and |\increased |\over |
the |\next |\ 2 |\hours |- |\CORRECT |\ANSWERS |\✔✔B
The |\chest |\pain |\of |\aortic |\dissection |\is |\typically |\described |\as |
searing, |\ripping, |\or |\tearing, |\and |\frequently |\radiates |\to |\the |\back |
or |\lower |\extremities. |\The |\pain |\is |\worst |\at |\the |\time |\of |\onset |\and |
lasts |\for |\hours. |\Helpful |\findings |\on |\physical |\examination |\include |
asymmetry |\of |\pulses |\or |\blood |\pressure, |\as |\well |\as |\a |\new |\murmur |\of |\aortic |\regurgitation |(a |\decrescendo |\early |\diastolic |\murmur |
heard |\best |\in |\the |\aortic |\area, |\as |\opposed |\to |\holosystolic |
murmurs). |\This |\type |\of |\murmur |\indicates |\a |\dissection |\involving |
the |\ascending |\aorta. |\The |\dissection |\can |\extend |\to |\the |\pericardial |
sac |\and |\produce |\a |\pericardial |\friction |\rub |\on |\examination, |\as |\well |\as |\findings |\of |\cardiac |\tamponade. |\Pulsus |\paradoxus |\is |\a |\common |\finding |\of |\cardiac |\tamponade |\and |\is |\defined |\by |\a |\decrease |\in |
blood |\pressure |\of |\at |\least |\ 12 |\mm |\Hg |\with |\inspiration.Aortic |
dissection |\is |\not |\usually |\associated |\with |\acute |\ischemic |
electrocardiographic |\changes. |\Data |\from |\the |\International |
Registry |\of |\Aortic |\Dissection |\indicates |\that |\ischemic |\changes |
were |\present |\on |\an |\EKG |\in |\only |\15% |\of |\cases. |\The |\diagnosis |\can |
be |\established |\with |\transesophageal |\echocardiography, |\CT, |\or |
MRI. |\The |\importance |\of |\early |\diagnosis |\in |\a |\patient |\being |
evaluated |\for |\myocardial |\infarction |\is |\underscored |\by |\the |\fact |
that |\aortic |\dissection |\is |\exacerbated |\by |\fibrinolytic |\therapy |\and |
anticoagulation.Acute |\aortic |\dissection |\has |\a |\lethality |\rate |\of |\1%- 2% |\per |\hour |\after |\the |\onset |\of |\symptoms |\in |\untreated |\patients. |
Prompt |\diagnosis |\is |\therefore |\vital |\to |\increase |\the |\patient's |
chances |\of |\survival |\and |\prevent |\serious |\complications. |\Advanced |
age, |\male |\sex, |\a |\long-term |\history |\of |\arterial |\hypertension, |\and |
the |\presence |\of |\an |\aortic |\aneurysm |\confer |\the |\greatest |
population-attributable |\risk. |\However, |\patients |\with |\genetic |
connective |\tissue |\disorders |\such |\as |\Marfan, |\Loeys-Dietz, |\or |
Ehlers-Danlos |\syndrome, |\and |\patients |\wit A |\62-year-old |\male |\comes |\to |\your |\office |\for |\a |\routine |\health |
maintenance |\evaluation. |\He |\has |\a |\history |\of |\hypertension, |\type |\ 2
You |\see |\a |\63-year-old |\female |\for |\follow-up |\ 2 |\months |\after |
coronary |\artery |\bypass |\graft |(CABG) |\surgery. |\In |\addition |\to |
clopidogrel |\or |\a |\similar |\antiplatelet |\medication, |\which |\one |\of |\the |
following |\should |\you |\recommend |\to |\reduce |\the |\repeat |
revascularization |\rate |\following |\CABG |\surgery? Aspirin |\and |\β-blockers Aspirin |\and |\statin |\therapy β-Blockers |\and |\statin |\therapy Postmenopausal |\hormone |\therapy |\and |\statin |\therapy |- |\CORRECT |
ANSWERS |\✔✔B Aspirin |\has |\been |\shown |\to |\significantly |\reduce |\vein |\graft |\closures |\through |\the |\first |\postoperative |\year. |\According |\to |\current |
guidelines |\it |\should |\be |\continued |\indefinitely, |\given |\its |\benefit |\in |
preventing |\subsequent |\clinical |\events. |\After |\off-pump |\coronary |
artery |\bypass |\graft |(CABG) |\surgery, |\dual |\antiplatelet |\therapy |
should |\be |\administered |\for |\ 1 |\year |\using |\a |\combination |\of |\aspirin, |\81-162 |\mg |\daily, |\and |\clopidogrel, |\ 75 |\mg |\daily, |\to |\reduce |\graft |
occlusion. |\Aggressive |\statin |\therapy |\following |\CABG |\has |\been |
shown |\to |\result |\in |\less |\disease |\progression |\in |\saphenous |\vein |
grafts |\and |\to |\reduce |\the |\repeat |\revascularization |\rate. |\The |
American |\Heart |\Association |\recommends |\high-intensity |\statin |
therapy |(atorvastatin, |\40-80 |\mg |\daily, |\or |\rosuvastatin, |\20-40 |\mg |
daily) |\after |\surgery |\for |\all |\CABG |\patients |<75 |\years |\of |\age |\and |
moderate-intensity |\statin |\therapy |\for |\patients |\intolerant |\of |\high- intensity |\statin |\therapy |\and |\those |>75 |\years |\of |\age. |\Hormone |
therapy |\and |\β-blockers |\have |\not |\been |\shown |\to |\affect |\the |
revascularization |\rate. |\Postmenopausal |\hormone |\therapy |
(estrogen/progesterone) |\should |\not |\be |\given |\to |\women |
undergoing |\CABG |(SOR |\B).
A |\68-year-old |\male |\with |\New |\York |\Heart |\Association |\class |\III |\heart |\failure |\with |\reduced |\ejection |\fraction |\and |\a |\blood |\pressure |\of |
110/70 |\mm |\Hg |\is |\currently |\taking |\furosemide |(Lasix), |\ 40 |\mg |
twice |\daily, |\and |\carvedilol |(Coreg), |\12.5 |\mg |\twice |\daily. |\Which |
one |\of |\the |\following |\changes |\to |\this |\patient's |\current |\regimen |\will |\reduce |\his |\mortality |\risk |\and |\risk |\of |\future |\hospitalization |\for |
heart |\failure? Increasing |\the |\dosage |\of |\furosemide Adding |\digoxin Adding |\lisinopril |(Prinivil, |\Zestril) Adding |\metolazone |- |\CORRECT |\ANSWERS |\✔✔C ACE |\inhibitors |\such |\as |\lisinopril |\have |\been |\shown |\to |\decrease |
both |\mortality |\and |\rehospitalizations |\for |\heart |\failure, |\and |\are |\the |\mainstay |\of |\treatment |\for |\patients |\who |\can |\take |\them. |\Digoxin |
improves |\symptoms |\and |\exercise |\tolerance |\but |\does |\not |
decrease |\mortality. |\There |\have |\been |\no |\long-term |\studies |
conducted |\to |\determine |\the |\effects |\of |\diuretics |\such |\as |
furosemide |\and |\metolazone |\on |\morbidity |\and |\mortality. A |\29-year-old |\male |\is |\evaluated |\in |\the |\emergency |\department |\for |\chest |\pain |\that |\started |\after |\he |\used |\cocaine, |\and |\which |\has |\now |\resolved. |\An |\EKG |\shows |\a |\prolonged |\QTc |\interval, |\new |\T-wave |
inversions, |\and |\biphasic |\T |\waves |\in |\leads |\V2 |\and |\V3. |\The |
physical |\examination |\reveals |\an |\anxious |\male |\with |\a |\blood |
pressure |\of |\160/100 |\mm |\Hg |\and |\a |\heart |\rate |\of |\ 118 |\beats/min.Which |\one |\of |\the |\following |\is |\true |\in |\this |\situation?
were |\harmful |\in |\patients |\with |\chest |\pain |\associated |\with |\cocaine |
ingestion |\but |\that |\has |\been |\disproven |\in |\many |\recent |\studies. |
Labetalol |\and |\metoprolol |\are |\both |\safe |\and |\may |\have |\a |\beneficial |\effect |\in |\this |\situation.This |\patient's |\EKG |\is |\characteristic |\of |
Wellens |\syndrome, |\or |\left |\anterior |\descending |\coronary |\artery |
(LAD) |\T-wave |\syndrome. |\These |\EKG |\changes A |\61-year-old |\male |\sees |\you |\for |\a |\follow-up |\visit. |\His |\medical |
history |\includes |\end-stage |\heart |\failure, |\chronic |\atrial |\fibrillation, |
a |\left |\ventricular |\ejection |\fraction |\of |\30%, |\and |\stage |\ 4 |\chronic |
kidney |\disease. |\He |\is |\taking |\optimal |\dosages |\of |\lisinopril |(Prinivil, |
Zestril), |\metoprolol |\succinate |(Toprol-XL), |\furosemide |(Lasix), |
digoxin, |\and |\spironolactone |(Aldactone). |\He |\continues |\to |\have |
symptoms |\of |\heart |\failure |\with |\minimal |\exertion, |\but |\not |\at |\rest. |
An |\EKG |\shows |\a |\ventricular |\rate |\of |\ 85 |\beats/min, |\a |\QRS |\duration |
of |\0.14 |\sec, |\and |\old |\Q |\waves |\in |\the |\inferior |\leads.Appropriate |
management |\options |\for |\this |\patient |\include |\which |\one |\of |\the |
following? Adding |\a |\nondihydropyridine |\calcium |\channel |\blocker Adding |\a |\thiazide |\diuretic Switching |\from |\metoprolol |\succinate |\to |\metoprolol |\tartrate |
(Lopressor) Synchronized |\biventricular |\pacing |- |\CORRECT |\ANSWERS |\✔✔D Biventricular |\pacing |\with |\an |\implantable |\defibrillator |\can |\improve |\symptoms |\and |\increase |\survival |\in |\heart |\failure |\patients |\with |\a |
prolonged |\QRS |\duration, |\and |\is |\recommended |\for |\those |\with |\a |
low |\ejection |\fraction, |\given |\their |\increased |\risk |\for |\ventricular |
fibrillation.Patients |\with |\refractory |\heart |\failure |\on |\optimal |\
medical |\therapy |\should |\be |\considered |\for |\a |\heart |\transplant. |
Patients |\with |\an |\anticipated |\1-year |\survival |\probability |<50% |\can |\benefit |\from |\left |\ventricular |(LV) |\assist |\devices. |\Patients |\who |
have |\a |\narrow |\QRS |\and |\stage |\D |\heart |\failure |\despite |\optimal |
medical |\therapy, |\and |\who |\are |\not |\candidates |\for |\transplant |\or |\LV |
assist |\devices, |\should |\not |\receive |\a |\defibrillator |\if |\their |\expected |
survival |\related |\to |\heart |\failure |\or |\other |\comorbidities |\is |\less |\than |\1-2 |\years, |\since |\a |\defibrillator |\will |\not |\improve |\their |
survival.Changing |\from |\metoprolol |\succinate |\to |\metoprolol |
tartrate |\will |\not |\be |\beneficial |\since |\the |\succinate |\form |\is |\the |
preferred |\formulation |\for |\heart |\failure. |\Nondihydropyridine |
calcium |\channel |\blockers |\reduce |\the |\ejection |\fraction |\and |\would |
therefore |\not |\be |\beneficial |\in |\this |\patient. |\Patients |\with |\severe |
heart |\failure |\and |\severe |\chronic |\kidney |\disease |\generally |\do |\not |
respond |\favorably |\to |\thiazide |\diuretics. You |\see |\a |\58-year-old |\male |\for |\a |\routine |\examination. |\According |
to |\the |\American |\College |\of |\Cardiology/American |\Heart |
Association |\classification |\system, |\which |\one |\of |\the |\following |
would |\meet |\the |\criteria |\for |\stage |\B |\heart |\failure, |\assuming |\he |
has |\no |\additional |\complications? A |\history |\of |\dyspnea |\on |\exertion Well |\compensated |\heart |\failure A |\grade |\2/6 |\apical |\holosystolic |\murmur |\radiating |\to |\the |\axilla Uncontrolled |\type |\ 2 |\diabetes |- |\CORRECT |\ANSWERS |\✔✔C A |\significant |\heart |\murmur, |\such |\as |\a |\grade |\2/6 |\apical |
holosystolic |\murmur |\that |\radiates |\to |\the |\axilla, |\is |\generally |
meaningful. |\The |\American |\College |\of |\Cardiology/American |\Heart |\
Losartan |(Cozaar) Spironolactone |(Aldactone) |- |\CORRECT |\ANSWERS |\✔✔B Despite |\the |\absence |\of |\symptoms |\and |\a |\left |\ventricular |\ejection |
fraction |\within |\the |\normal |\range, |\this |\patient's |\previous |
myocardial |\infarction |(MI) |\is |\evidence |\of |\structural |\heart |\disease, |
making |\his |\American |\College |\of |\Cardiology/American |\Heart |
Association |(ACC/AHA) |\heart |\failure |\classification |\stage |\B. |
Patients |\without |\heart |\failure |\symptoms |\who |\have |\had |\an |\MI |\or |
who |\have |\evidence |\of |\left |\ventricular |\remodeling |\are |\thought |\to |
be |\at |\considerable |\risk |\of |\developing |\heart |\failure |\and |
intervention |\is |\warranted. |\Patients |\who |\are |\at |\risk |\of |\future |\heart |
failure |\should |\take |\an |\ACE |\inhibitor |\if |\they |\can |\tolerate |\it.In |
addition |\to |\optimal |\management |\of |\hyperlipidemia |\and |
hypertension, |\the |\AHA |\recommends |\that |\ACE |\inhibitors |\and |\β- blockers |\such |\as |\carvedilol, |\metoprolol |\succinate, |\or |\bisoprolol |\be |\used |\in |\all |\patients |\with |\a |\recent |\or |\remote |\history |\of |\MI, |
regardless |\of |\ejection |\fraction |\or |\the |\presence |\of |\heart |\failure |
(SOR |\A). |\Two |\large-scale |\studies |\have |\demonstrated |\that |
prolonged |\therapy |\with |\an |\ACE |\inhibitor |\reduces |\the |\risk |\of |\a |
major |\cardiovascular |\event |\even |\when |\treatment |\is |\initiated |
months |\or |\years |\after |\the |\MI.Furosemide |\is |\not |\recommended |\for |
use |\in |\stage |\B |\patients, |\and |\calcium |\channel |\blockers |\such |\as |
diltiazem |\can |\lead |\to |\worsening |\heart |\failure |\and |\should |\be |
avoided. |\The |\AHA |\recommends |\that |\angiotensin |\receptor |
blockers |\be |\administered |\to |\post-MI |\patients |\without |\heart |\failure |\who |\are |\intolerant |\of |\ACE |\inhibitors |\and |\have |\a |\low |\left |
ventricular |\ejection |\fraction |(SOR |\B). |\Aldosterone |\antagonists |
would |\not |\be |\the |\first-line |\therapy |\for |\stage |\B |\heart |\failure. A |\74-year-old |\female |\is |\discharged |\from |\the |\hospital |\after |\being |
treated |\for |\an |\exacerbation |\of |\heart |\failure |\with |\volume |\overload.
|\She |\has |\a |\previous |\history |\of |\coronary |\heart |\disease |\and |
hypertension. |\Her |\discharge |\medications |\include |\furosemide |
(Lasix), |\ 20 |\mg |\twice |\daily; |\lovastatin, |\ 40 |\mg |\daily; |\ramipril |
(Altace), |\ 5 |\mg |\daily; |\spironolactone |(Aldactone), |\12.5 |\mg |\twice |
daily; |\metoprolol |\succinate |(Toprol-XL), |\ 75 |\mg |\daily; |\and |\aspirin, |
81 |\mg |\daily. |\In |\addition, |\she |\is |\instructed |\to |\avoid |\the |\use |\of |
ibuprofen |\and |\other |\NSAIDs |\and |\to |\add |\metolazone, |\2.5 |\mg |\daily, |\with |\ 30 |\mL |\of |\10% |\potassium |\chloride |\elixir |\on |\mornings |\when |
her |\weight |\is |\more |\than |\ 3 |\lb |\over |\her |\target |\weight |\of |\ 130 |
lb.Which |\one |\of |\the |\following |\is |\the |\most |\common |\reason |\for |
medication |\nonadherence |\in |\patients |\such |\as |\this? Cost Concerns |\regarding |\potential |\side |\effects Conflicting |\instructions |\from |\different |\health |\care |\providers Failure |\to |\understand |- |\CORRECT |\ANSWERS |\✔✔D Medication |\compliance |\and |\understanding |\of |\how |\and |\why |\to |
take |\medications |\is |\a |\crucial |\aspect |\of |\medical |\care |\in |\heart |
failure. |\A |\study |\of |\patients |\recently |\discharged |\from |\the |\hospital |
following |\an |\exacerbation |\of |\heart |\failure |\found |\a |\high |\rate |\of |
medication |\nonadherence, |\with |\only |\one-third |\of |\patients |\taking |
all |\their |\medications |\as |\prescribed |\and |\not |\taking |\unprescribed |
medications. |\Of |\those |\not |\taking |\medications |\as |\prescribed, |\the |
most |\common |\reason |\given |\was |\not |\understanding |\discharge |
instructions |(57%). |\Less |\common |\reasons |\include |\confusion |\due |
to |\conflicting |\instructions |\from |\the |\discharging |\physician |\and |\the |
primary |\care |\physician, |\medication |\cost, |\being |\unconvinced |\of |
the |\utility |\of |\the |\medication, |\and |\concerns |\regarding |\potential |
side |\effects |(SOR |\B).
