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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(s) //✔✔ //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(s) //✔✔ //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 //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?
//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 //answer(s) //✔✔ //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(s) //✔✔ //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 //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 //management //of //unstable //angina //or //non-ST-elevation //myocardial //infarction //(NSTEMI) //is //similar //to //the //management //of //ST-elevation //myocardial //infarction //except //that //fibrinolytic //therapy //has //no //role //in //unstable //angina //or //NSTEMI //(SOR //A). //Studies //indicate //that //fibrinolytic //therapy //in //these //patients //has //no //benefit //in //terms //of //mortality //or //myocardial //infarction //(MI), //and //may //even //increase //the //risk //for //intracranial //hemorrhage //and //both //fatal //and //nonfatal //MI.Unless //there //is //a //contraindication, //all //patients //with //acute //coronary //syndrome //should //begin //dual //antiplatelet //therapy //with //aspirin, //starting //with //a //loading //dose //of // 325 //mg //followed //by //a //maintenance //dosage //of // 81 //mg //daily, //and //a //P2Y12 //inhibitor //(either //clopidogrel, //prasugrel, //or //ticagrelor), //as //well //as //anticoagulation //therapy //with //either //low //molecular //weight //heparin //(SOR //A), //fondaparinux //in //combination //with //a //factor //IIa //inhibitor //(SOR //B), //unfractionated //heparin //(SOR //B), //or //bivalirudin //in //patients //managed //with //an //early //invasive //strategy //(SOR //B). //β- Blockers //have //been //shown //to //reduce //myocardial //ischemia, //reinfarction, //and //the //frequency //of //complex //ventricular //dysrhythmias, //and //they //increase //long-term //survival. //Provided //there //are //no //contraindications, //American //Heart //Association //guidelines //recommend //that //oral //β-blocker //therapy //be //initiated //within //the //first // 24 //hours //in //patients //with //acute //coronary //syndrome //(SOR //A). In //the //United //States, //silent //myocardial //infarction //is //more //common //in //which //one //of //the //following //population //groups? Women //more //than //men Men //more //than //women Hispanics //more //than //non-Hispanic //whites Non-Hispanic //whites //more //than //Asian-Americans //- //correct //answer(s) //✔✔ //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 //answer(s) //✔✔ //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
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 //answer(s) //✔✔ //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 //answer(s) //✔✔ //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? The //initial //treatment //should //include //aspirin //and //clopidogrel β-Blockers //should //never //be //used //in //patients //with //cocaine-related //chest //pain The //treatment //of //choice //is //intravenous //benzodiazepines //and //oral //or //intravenous //nitrate //therapy Nifedipine //(Procardia) //should //be //used //as //first-line //therapy //if //the //patient's //blood //pressure //is //elevated //- //correct //answer(s) //✔✔ //C Myocardial //infarction //has //been //found //in //6% //of //patients //presenting //to //the //emergency //department //with //cocaine-associated //chest //pain. //Cocaine //precipitates //coronary //artery //spasm //by //stimulating //α-adrenergic //receptors //in //smooth //muscle //cells //in //coronary //arteries, //as //well //as //by //increasing //levels //of //endothelin- 1 //and //reducing //production //of //nitric //oxide. //Cocaine //has //also //been //found //to //increase //the //response //of //platelets //to //arachidonic //acid, //thus //increasing //thromboxane //A2 //production //and //platelet //aggregation, //and //to //lead //to //accelerated //atherosclerosis //in //chronic //users. //Increased //motor //activity,
//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 //answer(s) //✔✔ //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 //Association //classification //of //heart //failure //includes //four //stages. //Stage //A //is //defined //as //the //absence //of //structural //disease //in //a //patient //at //high //risk //for //the //development //of //heart //failure. //This //includes //patients //with //hypertension, //atherosclerotic //disease, //diabetes //mellitus, //obesity, //metabolic //syndrome, //or //a //family //history //of //cardiomyopathy, //as //well //as //those //using //cardiotoxins. //Patients //with //stage //B //heart //failure //have //evidence //of //structural //heart //disease, //such //as //a //previous //myocardial //infarction, //asymptomatic //valvular //disease, //or //evidence //of //left //ventricular //remodeling
//such //as //left //ventricular //hypertrophy //or //a //low //ejection //fraction. //Any //patient //with //structural //heart //disease //is //at //risk //of //heart //failure //and //should //be //managed //aggressively //to //prevent //complications //in //the //future.Stage //C //is //defined //as //structural //heart //disease //with //prior //or //current //symptoms //of //heart //failure. //Patients //with //stage //D //heart //failure //have //refractory //heart //failure //requiring //specialized //interventions. A // 61 - year-old //male //sees //you //for //a //routine //annual //evaluation. //A //review //of //systems //is //notable //only //for //nocturia // 1 - 2 //times //per //night. //He //has //a //history //of //a //non-ST-elevation //myocardial //infarction // 2 //years //ago //treated //with //a //drug-eluting //stent. //His //current //medications //are //metoprolol //tartrate //(Lopressor), // 50 //mg //twice //daily; //hydrochlorothiazide, // 25 //mg //daily; //atorvastatin //(Lipitor), // 40 //mg //daily; //aspirin, // 81 //mg //daily; //and //docusate //as //needed. //He //is //a //nonsmoker. //His //blood //pressure //is //132/82 //mm //Hg. //A //physical //examination //is //normal.Which //one //of //the //following //medications //is //indicated //at //this //time? Diltiazem //(Cardizem) Enalapril //(Vasotec) Furosemide //(Lasix) Losartan //(Cozaar) Spironolactone //(Aldactone) //- //correct //answer(s) //✔✔ //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
//cost, //being //unconvinced //of //the //utility //of //the //medication, //and //concerns //regarding //potential //side //effects //(SOR //B). Which //one //of //the //following //is //true //regarding //the //use //of //clopidogrel //(Plavix) //with //aspirin //in //patients //with //coronary //artery //disease? A //loading //dose //of // 150 //mg //of //clopidogrel //is //recommended //at //the //time //acute //coronary //syndrome //is //diagnosed Clopidogrel //should //be //given //first //because //it //has //a //faster //onset //of //antiplatelet //activity Clopidogrel //should //be //discontinued //at //least // 5 //days //before //coronary //artery //bypass //graft //surgery //and //aspirin //should //be //continued //up //to //the //day //of //surgery When //used //with //clopidogrel, //aspirin //can //be //given //at //a //dosage //of // 325 //mg //daily //after //cardiac //stent //placement //- //correct //answer(s) //✔✔ //C Clopidogrel //should //be //discontinued //at //least // 5 //days //before //coronary //bypass //surgery //but //aspirin //should //be //continued. //Clopidogrel //is //a //thienopyridine //derivative //that //is //used //primarily //as //an //adjunctive //agent //in //patients //with //acute //coronary //syndrome //(ACS). //It //is //used //most //commonly //in //conjunction //with //aspirin //but //is //an //adequate //alternative //in //patients //who //are //aspirin //intolerant. //If //clopidogrel //is //used //alone, //initial //treatment //with //heparin //or //possibly //with //a //glycoprotein //IIb/IIIa //inhibitor //is //especially //important //because //of //clopidogrel's //delayed //onset //of //antiplatelet //activity //compared //to //that //of //aspirin. //The //CAPRIE //trial //(Clopidogrel //versus //Aspirin //in //Patients //at //Risk //of //Ischaemic //Events) //found //clopidogrel //to //be //comparable //to //aspirin //in //reducing //ischemic //events //in //patients //with //a //history //of //recent //myocardial //infarction, //recent //stroke, //or //symptomatic //peripheral //artery //disease. //The //CURE //trial //(Clopidogrel //in //Unstable //angina //to //prevent //Recurrent //Events) //found //the //combination //of //aspirin //and //clopidogrel //to //be //more //effective //in //reducing //ischemic //events //than //aspirin //alone //in //patients //with //ACS.Clopidogrel //should //be //started //with //a //loading //dose //of // 300 - 600 //mg, //followed //by // 75 //mg //daily. //When //clopidogrel //is //used //with //aspirin, //the //aspirin //dosage //should //be // 75 - 162
//mg //daily. //Because //of //an //increased //risk //of //bleeding, //current //guidelines //recommend //that //clopidogrel //be //discontinued //at //least // 5 //days, //and //preferably // 7 //days, //before //bypass //graft //surgery. //In //patients //undergoing //urgent //cardiac //catheterization //and //percutaneous //coronary //intervention //(PCI), //a //loading //dose //of // 600 //mg //of //clopidogrel //should //be //administered //either //before //or //at //the //time //of //the //PCI. //Clopidogrel //should //be //continued //at //a //dosage //of // 75 //mg //daily, //along //with //aspirin. A // 68 - year-old //male //with //a //history //of //hypertension, //diabetes //mellitus, //and //heart //failure //presents //with //a // 6 - week //history //of //progressive //fatigue, //ankle //swelling, //and //dyspnea //on //exertion. //His //current //medications //include //lisinopril //(Prinivil, //Zestril), // 20 //mg //daily; //atorvastatin //(Lipitor), // 40 //mg //daily; //insulin //glargine //(Lantus), // 10 //U //subcutaneously //at //bedtime; //and //sitagliptin //(Januvia), // 100 //mg //daily.On //examination //his //pulse //rate //is // 76 //beats/min //and //regular, //and //his //blood //pressure //is //130/80 //mm //Hg. //He //has //jugular //venous //distention, //a //laterally //displaced //apex //beat, //and //1+ //pitting //ankle //edema. //Lung //auscultation //reveals //bibasilar //crackles. //Cardiac //auscultation //reveals //a //regular //rhythm //with //a //soft //S4. //Echocardiography //shows //a //left //ventricular //ejection //fraction //of //40%. //A //basic //metabolic //panel //is //normal, //including //a //creatinine //level //of //1.1. //mg/dL //(N //0.7- 1.3).Which //one //of //the //following //should //be //started //at //this //time? Carvedilol //(C //- //correct //answer(s) //✔✔ //B This //patient //has //signs //of //heart //failure //with //fluid //retention. //Euvolemic //status //should //be //attained //first //in //patients //with //fluid //overload. //Diuretics //produce //symptomatic //benefits //more //rapidly //than //any //other //drug //for //heart //failure //and //are //the //only //agents //that //can //adequately //control //fluid //retention. //Loop //diuretics, //such //as //furosemide, //are //more //effective //than //thiazide //diuretics //for //controlling //sodium //and //free //water //clearance //(SOR //C).Although //β-blockers //should //generally //be //prescribed //for //all //patients //with //heart //failure, //they //should //not //be //started //in //patients //with //a //current //or //recent //history //of //fluid //retention //unless //the //patient //is //also //on //a //diuretic. //Furthermore, //treatment //with //a //β- blocker //should //be //initiated //at //very //low //doses //(e.g., //carvedilol, //3.125 //mg //twice //daily; //metoprolol //succinate //extended //release, //12.5-25.0 //mg //once //daily) //and //gradually //and //cautiously //increased //as //tolerated.Aldosterone //antagonists //are //relatively //weak //diuretics //that //are //prescribed //to //improve //survival //in //selected //patients //with //severe //symptoms //and //a //reduced //left //ventricular //ejection //fraction //(SOR //B).
//Association //class, //related //comorbidities //such //as //renal //dysfunction, //or //other //characteristics //such //as //age //or //ethnicity. //Because //sodium //intake //is //typically //high //(> //g/d) //in //the //general //population, //clinicians //should //consider //some //degree //of //sodium //restriction, //su A // 76 - year-old //female //sees //you //for //follow-up // 2 //weeks //after //she //was //hospitalized //for //heart //failure. //Her //past //medical //history //is //notable //for //heart //failure, //hypertension, //coronary //heart //disease, //and //well //controlled //depression. //She //does //not //smoke. //Her //current //medications //include //the //following:Lisinopril //(Prinivil, //Zestril), // 20 //mg //dailyHydrochlorothiazide, // 25 //mg //dailyFurosemide //(Lasix), // 40 //mg //dailyMetoprolol //succinate //(Toprol-XL), // 50 //mg //dailyMetformin //(Glucophage), // 850 //mg //twice //dailySimvastatin //(Zocor), // 40 //mg //dailyCitalopram //(Celexa), // 20 //mg //dailyAspirin, // 81 //mg //dailyOn //examination, //the //patient //is //afebrile, //her //blood //pressure //is //130/82 //mm //Hg, //her //pulse //rate //is // 90 //beats/min, //and //her //respiratory //rate //is //20/min. //Her //jugular //veins //are //mildly //distended. //Examination //of //the //lungs //reveals //bibasilar //crackles. //The //cardiac //examination //reveals //a //regular //rhythm, //an //S4 //gallop, //and //no //murmurs. //She //has //1+ //bilateral //edema //to //the //shins. //A //lab //- //correct //answer(s) //✔✔ //D Hyponatremia //is //a //common //problem //in //patients //with //heart //failure, //and //its //severity //correlates //directly //with //the //degree //of //myocardial //dysfunction. //Hypervolemic //hyponatremia //is //the //type //most //commonly //associated //with //heart //failure, //with //edema //indicating //increased //total //body //sodium //and //water. //Heart //failure //is //associated //with //inappropriately //elevated //plasma //arginine //vasopressin //levels, //which //causes //impaired //water //excretion, //a //dilutional //hyponatremia, //and //increased //ventricular //preload. //Management //generally //calls //for //a //reduction //in //water //intake //and //improving //cardiac //function.All //SSRIs //such //as //citalopram //are //associated //with //a //high //incidence //of //hyponatremia, //and //elderly //patients //may //be //at //increased //risk //for //this //side //effect. //Physicians //caring //for //elderly //patients //should //be //aware //of //this //potentially //serious //but //reversible //adverse //effect.Thiazide //diuretics //are //associated //with //impaired //renal //water //excretion, //and //reducing //the //dosage //of //thiazide //diuretics //or //discontinuing //their //use //is //recommended. //Although //increasing //sodium //and //water //intake //is //the //primary //treatment //for //hypovolemic //hyponatremia, //patients //with //heart //failure //do //not //benefit //from //this //strategy. //Desmopressin //is //a //vasopressin //analog //and //is //contraindicated //in //patients //with //hyponatremia. //Arginine //vasopressin //antagonists, //including //tolvaptan //and //conivaptan, //can //be //considered //for //patients //with //severe //or //recalcitrant //hyponatremia.
A // 57 - year-old //male //with //a //history //of //chronic //stable //angina //and //type // 2 //diabetes //presents //with //a //recent //increase //in //symptoms. //An //EKG //is //notable //for //the //presence //of //first //degree //AV //block //and //left //anterior //hemiblock. //Coronary //angiography //reveals //three- vessel //disease //with //a //left //ventricular //ejection //fraction //of //45%.Which //one //of //the //following //interventions //would //offer //the //greatest //survival //benefit? Intensive //medical //management A //permanent //pacemaker An //implantable //cardiac //defibrillator Percutaneous //coronary //intervention Coronary //artery //bypass //graft //surgery //- //correct //answer(s) //✔✔ //E Angiographic //characteristics //of //high-risk //groups //with //improved //survival //after //surgical //management //include //left //main //coronary //artery //stenosis, //three-vessel //disease //with //a //left //ventricular //ejection //fraction //<50%, //and //two- //or //three-vessel //disease //with //>75% //stenosis //of //the //proximal //left //anterior //descending //artery //(LAD).A //meta-analysis //of //three //major //trials //confirmed //the // 10 - year //survival //benefit //from //surgery //for //patients //with //three-vessel //disease, //two-vessel //disease, //and //single-vessel //disease //that //included //stenosis //of //the //proximal //LAD, //regardless //of //whether //the //patient //had //a //normal //or //abnormal //left //ventricular //ejection //fraction. //Large //randomized //trials //that //have //reached // 7 - 8 //years //of //follow-up //have //generally //shown //that //survival //for //patients //with //diabetes //mellitus //is //better //with //coronary //artery //bypass //(CABG) //surgery //than //with //percutaneous //coronary //intervention //(PCI). //The //patient //described //does //not //have //an //indication //for //the //placement //of //either //an //implantable //cardiac //defibrillator //or //a //pacemaker, //given //that //his //ejection //fraction //is //>35% //and //he //does //not //have //complete //heart //block.Patients //who //have //diabetes //with //significant //two- //or //three-vessel //disease //or //those //with //single-vessel //proximal //LAD //or //left //main //disease //generally //do //better //with //coronary //artery //bypass //than //with //percutaneous //intervention. //A //study //of // 3131 //patients //showed //that //at // 5 //years //or //the //longest //follow-up, //patients //with //diabetes //randomized //to //CABG //had //a //lower //all- cause //mortality //rate //than //those //randomized //to //PCI //with //either //a //drug-eluting //stent //or //a //bare //metal //stent //(relative //risk //= //0.67; //P //= //0.002). //There //is //a //higher //risk //of //stroke //with //CABG //than //with //PCI.
