Heart Failure And Cardiomyopathies - USMLE Step 2

1. A 63-year-old man with HFrEF (EF 20%) presents with acute dyspnea, pink frothy sputum, fatigue, and severe orthopnea. Exam: JVD, diffuse rales, S3, and 2+ edema. BP 182/104, HR 124, SpO2 82% on room air. Labs: BNP 2400 pg/mL; troponin negative. CXR shows bilateral alveolar edema. Echo shows EF 20% and no valvular stenosis. Which of the following is the most appropriate next step in management?
   Answer: Noninvasive positive-pressure ventilation and IV diuresis This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest flash pulmonary edema in HFrEF, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for treating acute pulmonary edema with ventilatory support and diuresis, ensuring best patient outcomes. Choice B is incorrect due to the risk of precipitating cardiogenic shock in decompensated HFrEF, often seen when students overlook contraindications to beta-blockers in acute settings. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
2. A 73-year-old woman with HFrEF (EF 26%) presents with dyspnea, orthopnea, fatigue, and edema. Exam: JVD, rales, S3. BP 118/72. Labs: BNP 2000 pg/mL; troponin negative. CXR shows pulmonary edema. She has no chest pain and no fever. Which of the following is the most appropriate next step in management to address volume overload?
   Answer: Administer intravenous loop diuretic and reassess urine output This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest volume-overloaded decompensated HFrEF, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for IV diuretics in acute congestion, ensuring best patient outcomes. Choice B is incorrect due to contraindication in HFrEF, often seen when students select therapies inappropriate for systolic dysfunction. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
3. A 70-year-old woman with HFrEF (EF 30%) presents with dyspnea, fatigue, and edema after dietary indiscretion. Exam: JVD, rales, S3. BP 138/82. Labs: BNP 1700 pg/mL; troponin negative; sodium 128 mEq/L. CXR shows pulmonary edema. Echo shows EF 30%. She is alert and not hypotensive. Which lifestyle modification should be recommended to this patient to reduce future decompensations?
   Answer: Restrict dietary sodium and monitor daily weights This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF from dietary indiscretion, which guides the management approach. The correct answer is B because it aligns with ACC/AHA guidelines for sodium restriction and weight monitoring in HFrEF, ensuring best patient outcomes. Choice A is incorrect due to worsening hyponatremia and fluid retention, often seen when students misapply electrolyte correction principles. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
4. A 61-year-old man with HFrEF (EF 22%) presents with acute dyspnea, orthopnea, and leg edema. Exam shows JVD, rales, S3. BP 158/90. Labs: BNP 1900 pg/mL; troponin negative. CXR shows pulmonary edema. He receives IV furosemide but has minimal urine output after 2 hours. Which of the following is the most appropriate next step in management?
   Answer: Add a thiazide-type diuretic for sequential nephron blockade This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest diuretic-resistant decompensated HFrEF, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for sequential nephron blockade in refractory edema, ensuring best patient outcomes. Choice B is incorrect due to the risk of worsening congestion, often seen when students overprioritize renal protection without addressing volume status. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
5. A 60-year-old man with HFrEF (EF 33%) presents with dyspnea and edema. Exam shows JVD, rales, S3. BP 136/80. Labs: BNP 1300 pg/mL; troponin negative. CXR shows pulmonary congestion. He reports taking an over-the-counter "cold medicine" for 5 days. Which medication is most likely contributing to his decompensation?
   Answer: Pseudoephedrine This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF from OTC medication, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines avoiding sympathomimetics in HF, ensuring best patient outcomes. Choice B is incorrect due to lack of association with decompensation, often seen when students fail to identify vasoconstrictor effects. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
6. A 67-year-old man with HFrEF (EF 29%) presents with dyspnea, fatigue, and edema. Exam: JVD, rales, S3. BP 124/76. Labs: BNP 1700 pg/mL; troponin negative. CXR shows pulmonary edema. He is treated with IV diuretics and improves. Before discharge, which of the following is the most appropriate counseling to reduce readmission risk?
   Answer: Low-sodium diet, medication adherence, and close follow-up This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF responsive to treatment, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for discharge education to prevent readmissions, ensuring best patient outcomes. Choice B is incorrect due to risk of recurrent congestion, often seen when students discontinue therapies prematurely. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
7. What is the most appropriate initial pharmacologic intervention?
   Answer: Intravenous furosemide This patient is presenting with acute decompensated heart failure (ADHF). His clinical profile is 'wet' (volume overloaded, as evidenced by JVD, crackles, edema, weight gain) and 'warm' (well-perfused, with adequate blood pressure). The cornerstone of initial management for 'wet and warm' ADHF is intravenous loop diuretics, such as furosemide, to relieve congestion and improve symptoms.
8. Which of the following interventions is indicated for primary prevention of sudden cardiac death in this patient?
   Answer: Implantable cardioverter-defibrillator (ICD) An implantable cardioverter-defibrillator (ICD) is indicated for primary prevention of sudden cardiac death in patients with HFrEF. The criteria are: LVEF ≤35% due to a prior MI (at least 40 days post-MI) or non-ischemic cardiomyopathy, who are on optimal medical therapy for at least 3-6 months, are NYHA class II or III, and have a reasonable expectation of survival for more than one year. This patient meets all these criteria.
9. This patient's condition is most likely caused by which of the following?
   Answer: Cardiac amyloidosis This patient's presentation of right-sided heart failure symptoms (JVD, hepatomegaly, ascites, edema) with a preserved ejection fraction points towards a restrictive cardiomyopathy. The history of multiple myeloma is a major risk factor for AL (light chain) amyloidosis. The classic ECG finding of low voltage despite ventricular hypertrophy on echo, along with the 'sparkling' myocardial appearance, is highly specific for cardiac amyloidosis, which is a common cause of restrictive cardiomyopathy.
10. A 64-year-old woman with HFrEF (EF 30%) presents with dyspnea, fatigue, and edema. Exam shows JVD, rales, and S3. BP 126/74. Labs: BNP 1550 pg/mL; troponin negative; potassium 5.8 mEq/L; creatinine 2.3 mg/dL (baseline 1.8). CXR shows pulmonary congestion. Current meds include lisinopril, carvedilol, spironolactone, and furosemide. Which medication should be discontinued in light of her symptoms and labs?
    Answer: Spironolactone This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF with hyperkalemia, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for holding MRAs in hyperkalemia, ensuring best patient outcomes. Choice E is incorrect due to overgeneralization, often seen when students discontinue all therapies without identifying the culprit. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
11. A 58-year-old man with HFrEF (EF 25%) presents with dyspnea and fatigue 1 week after running out of medications. Exam shows JVD, rales, S3, and 2+ edema. BP 110/70. Labs: BNP 1500 pg/mL; troponin negative; creatinine 1.4. CXR shows pulmonary congestion. After IV diuresis, symptoms improve and he is euvolemic. Which of the following is the most appropriate next step in management to reduce mortality long-term?
    Answer: Initiate guideline-directed therapy with ARNI/ACEi, beta-blocker, and MRA This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF from medication nonadherence, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for initiating GDMT to reduce mortality in HFrEF, ensuring best patient outcomes. Choice B is incorrect due to insufficient long-term benefits, often seen when students focus solely on symptomatic relief without mortality reduction. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
12. What is the most likely etiology of this patient's condition?
    Answer: Viral myocarditis This young, previously healthy patient's presentation of acute-onset heart failure following a recent viral illness is classic for viral myocarditis. Viruses, such as coxsackievirus B and adenovirus, can cause direct myocardial injury and trigger an inflammatory response that leads to myocardial dysfunction and dilated cardiomyopathy. The presentation can be fulminant, leading to cardiogenic shock, or more subacute as seen here. The slight troponin elevation reflects myocardial injury.
13. The patient's symptoms are most likely caused by which of the following mechanisms?
    Answer: Diastolic dysfunction This patient presents with symptoms of heart failure (dyspnea on exertion) but has a preserved ejection fraction (LVEF >50%). This is characteristic of heart failure with preserved ejection fraction (HFpEF), also known as diastolic heart failure. The underlying pathophysiology is diastolic dysfunction, where the stiff, hypertrophied ventricle (secondary to chronic hypertension) cannot relax and fill properly during diastole. This leads to increased left ventricular end-diastolic pressure, which is transmitted to the pulmonary circulation, causing dyspnea. The S4 gallop is a classic finding of a stiff ventricle.
14. Which of the following medication classes should be added to his regimen to provide additional cardiovascular benefit?
    Answer: SGLT2 inhibitor Sodium-glucose cotransporter-2 (SGLT2) inhibitors (e.g., dapagliflozin, empagliflozin) are now considered a fourth pillar of foundational therapy for HFrEF. They have been shown to reduce cardiovascular death and hospitalizations for heart failure in patients with HFrEF, regardless of whether they have diabetes. Given this patient has HFrEF and co-existing type 2 diabetes, adding an SGLT2 inhibitor would provide both glycemic control and significant cardiovascular benefits.
15. A 60-year-old man with HFrEF (EF 25%) presents with dyspnea, orthopnea, fatigue, and edema. Exam: JVD, rales, S3. BP 146/88. Labs: BNP 1800 pg/mL; troponin negative. CXR shows pulmonary edema. Echo shows EF 25%. He improves after IV diuresis. Which of the following is the most appropriate next step in management before discharge regarding vaccination?
    Answer: Recommend influenza and pneumococcal vaccination if not up to date This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest stabilized decompensated HFrEF, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for vaccinations to prevent infections in HF, ensuring best patient outcomes. Choice B is incorrect due to misguided risk assessment, often seen when students invent contraindications without evidence. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
16. A 76-year-old man with HFrEF (EF 30%) presents with dyspnea, fatigue, and edema. Exam shows JVD, rales, S3. BP 140/82. Labs: BNP 1500 pg/mL; troponin negative. CXR shows pulmonary congestion. He asks why his BNP is elevated. Which statement best explains BNP in this setting?
    Answer: It rises with ventricular wall stretch from volume overload This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF with elevated BNP, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines explaining BNP physiology in HF, ensuring best patient outcomes. Choice B is incorrect due to confusion with troponin, often seen when students mix biomarkers for ischemia and congestion. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
17. A 62-year-old man with HFrEF (EF 28%) presents with dyspnea, fatigue, and edema. Exam shows JVD, rales, S3. BP 122/70. Labs: BNP 1450 pg/mL; troponin negative. CXR shows pulmonary congestion. After diuresis, he asks how to monitor himself at home to detect early fluid retention. What lifestyle modification should be recommended to this patient?
    Answer: Daily morning weights and call for rapid gain This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF amenable to self-monitoring, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for patient education on weight monitoring, ensuring best patient outcomes. Choice B is incorrect due to potential discouragement of adherence, often seen when students underestimate the value of simple monitoring tools. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
18. A 66-year-old man with known HFrEF (EF 35%) presents with dyspnea, orthopnea, fatigue, and new ankle edema. Exam shows JVD, bibasilar rales, S3, and irregularly irregular rhythm. BP 132/78, HR 146. Labs: BNP 1200 pg/mL; troponin negative. CXR shows pulmonary congestion. Echo shows EF 35% without acute change. ECG shows atrial fibrillation with rapid ventricular response. Which of the following is the most appropriate next step in management?
    Answer: Give IV loop diuretic and control rate with beta-blocker carefully This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest decompensated HFrEF with new atrial fibrillation, which guides the management approach. The correct answer is B because it aligns with ACC/AHA guidelines for treating volume overload and cautious rate control in HFrEF, ensuring best patient outcomes. Choice A is incorrect due to the risk of negative inotropy in systolic dysfunction, often seen when students select calcium channel blockers without considering HF type. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
19. A 75-year-old man with HFrEF (EF 20%) presents with dyspnea, fatigue, and edema. Exam shows JVD, rales, S3. BP 118/70. Labs: BNP 2300 pg/mL; troponin negative. CXR shows pulmonary edema. Echo shows EF 20% with left bundle branch block on ECG and QRS 170 ms. After stabilization on guideline-directed therapy, which of the following is the most appropriate next step in management?
    Answer: Cardiac resynchronization therapy evaluation This question tests the ability to manage heart failure and cardiomyopathies by applying clinical guidelines and evidence-based practices. Heart failure management requires understanding the type of failure (systolic vs diastolic) and selecting appropriate therapies. In the given scenario, the patient's echocardiogram and symptoms suggest heart failure with reduced ejection fraction (HFrEF) with left bundle branch block (LBBB) and wide QRS complex, which guides the management approach. The correct answer is Choice A because it aligns with ACC/AHA guidelines for treating HFrEF patients with EF ≤35%, NYHA class II-IV symptoms, LBBB, and QRS ≥150 ms, ensuring best patient outcomes through cardiac resynchronization therapy (CRT) evaluation. Choice C is incorrect due to the common misconception that beta-blockers should be avoided in low EF, often seen when students overlook that beta-blockers are a cornerstone of guideline-directed medical therapy (GDMT) for HFrEF to improve survival and symptoms. Teaching strategies include reinforcing the differences between heart failure types, emphasizing the importance of guideline adherence, and practicing the application of evidence-based management in clinical scenarios.
20. Which of the following diagnostic studies is most useful for determining the underlying etiology and classifying the type of heart failure in this patient?
    Answer: Transthoracic echocardiogram A transthoracic echocardiogram is the single most important diagnostic tool in the evaluation of a patient with heart failure. It provides crucial information, including the left ventricular ejection fraction (which classifies heart failure as HFrEF, HFmrEF, or HFpEF), assessment of diastolic function, evaluation of ventricular size and wall thickness, assessment of valvular function, and estimation of pulmonary pressures. This information is essential for both diagnosis and guiding management.

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