Heart Failure And Cardiomyopathies

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USMLE Step 2 CK › Heart Failure And Cardiomyopathies

Questions 1 - 10
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?

Start verapamil for afterload reduction

Noninvasive positive-pressure ventilation and IV diuresis

Give isotonic saline to improve preload

Stop diuretics to prevent worsening creatinine

Immediate IV beta-blocker bolus for tachycardia

Explanation

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 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?

Treat with antibiotics for presumed myocarditis

Stop beta-blocker permanently due to low EF

Cardiac resynchronization therapy evaluation

Immediate coronary angiography despite no ischemic symptoms

Start verapamil for conduction system support

Explanation

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.

3

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?

Increase alcohol intake to reduce stress

Use NSAIDs for edema-related pain control

Stop diuretics once breathing improves

Avoid vaccines due to fluid retention risk

Low-sodium diet, medication adherence, and close follow-up

Explanation

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.

4

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?

Start verapamil and discharge if symptoms improve

Start IV diltiazem for rate control

Administer large-volume IV fluids for tachycardia

Immediate electrical cardioversion without anticoagulation assessment

Give IV loop diuretic and control rate with beta-blocker carefully

Explanation

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.

5

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?

Stop all medications if urine output increases

Avoid weighing to reduce anxiety

Drink extra fluids when legs swell

Daily morning weights and call for rapid gain

Increase sodium intake before exercise

Explanation

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.

6

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?

Start verapamil to improve diastolic filling

Begin high-dose beta-blocker titration immediately

Switch to oral diuretics and discharge

Stop diuretics and give IV fluids for renal perfusion

Add a thiazide-type diuretic for sequential nephron blockade

Explanation

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.

7

A 71-year-old woman with HFrEF (EF 30%) presents with dyspnea, orthopnea, fatigue, and edema. Exam shows JVD, rales, S3. BP 116/68. Labs: BNP 1900 pg/mL; troponin negative. CXR shows pulmonary edema. She is placed on IV diuretics. Which of the following lab abnormalities is most important to monitor closely during diuresis?

Serum vitamin B12 level

Serum bilirubin level

Serum potassium level

Serum amylase level

Serum uric acid level only

Explanation

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 requiring diuresis monitoring, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for preventing hypokalemia during diuresis, ensuring best patient outcomes. Choice B is incorrect due to irrelevance to diuresis complications, often seen when students monitor unrelated labs. 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.

8

A 62-year-old man with HFrEF (EF 28%) presents with dyspnea, orthopnea, and edema. Exam: JVD, rales, S3. BP 128/74. Labs: BNP 1600 pg/mL; troponin negative. CXR shows pulmonary edema. He is on furosemide and carvedilol but not on an SGLT2 inhibitor. After stabilization, which medication addition is most appropriate to reduce heart failure hospitalization risk?

Add dapagliflozin

Add verapamil

Add dobutamine as chronic outpatient infusion

Add short-acting nifedipine

Add ibuprofen

Explanation

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 without SGLT2i, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for adding SGLT2 inhibitors to reduce hospitalizations in HFrEF, ensuring best patient outcomes. Choice B is incorrect due to contraindication in systolic HF, often seen when students select therapies for diastolic HF. 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.

9

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?

Avoid vaccines due to risk of fluid overload

Recommend live vaccines only for heart failure patients

Delay all vaccines until EF normalizes

Vaccines are contraindicated with elevated BNP

Recommend influenza and pneumococcal vaccination if not up to date

Explanation

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.

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?

Carvedilol

Furosemide

Lisinopril

Spironolactone

All heart failure medications permanently

Explanation

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.

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