USMLE Step 2 Quiz
Practice Heart Failure And Cardiomyopathies in USMLE Step 2 with focused quiz questions that help you check what you know, review explanations, and build confidence with test-style prompts.
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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?
This quiz focuses on Heart Failure And Cardiomyopathies, giving you a quick way to practice the rules, question types, and explanations that matter most for USMLE Step 2.
Try each quiz question before looking at the correct answer. Use the explanations to review missed ideas, then come back to similar questions until the pattern feels familiar.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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 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.
A 69-year-old woman with HFrEF (EF 32%) presents with dyspnea, fatigue, and edema. Exam shows JVD, rales, S3. BP 134/78. Labs: BNP 1700 pg/mL; troponin negative. CXR shows pulmonary edema. She has a new fever and productive cough; WBC 15,000/µL. Which of the following is the most appropriate next step in management?
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 infection, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for treating precipitants like infection alongside HF therapy, ensuring best patient outcomes. Choice B is incorrect due to overlooking infection, often seen when students attribute all symptoms to HF alone. 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.
A 57-year-old man with known HFrEF (EF 35%) presents with acute dyspnea, orthopnea, and edema. Exam: JVD, rales, S3. BP 164/96. Labs: BNP 1600 pg/mL; troponin negative. CXR shows pulmonary edema. He is started on IV loop diuretics. Which additional therapy is most appropriate to rapidly improve symptoms given his elevated blood pressure?
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 hypertensive decompensated HFrEF, which guides the management approach. The correct answer is A because it aligns with ACC/AHA guidelines for vasodilators in hypertensive acute HF, ensuring best patient outcomes. Choice B is incorrect due to contraindication in systolic HF, often seen when students confuse rate control with afterload 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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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.
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?
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 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.
A 34-year-old man with no significant past medical history presents to the emergency department with a 2-week history of worsening shortness of breath, fatigue, and a nonproductive cough. He reports having a flu-like illness with fever and myalgias about a month ago, from which he thought he had recovered. His temperature is 37.1°C (98.8°F), blood pressure is 105/70 mm Hg, pulse is 110/min, and respirations are 24/min. Physical examination reveals jugular venous distention, bibasilar crackles, and an S3 gallop. An ECG shows sinus tachycardia with nonspecific T-wave abnormalities. Troponin levels are slightly elevated.
What is the most likely etiology of this patient's condition?
Explanation: 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.
A 19-year-old college basketball player collapses during practice. He is immediately attended to by the team's medical staff. He regains consciousness after about 30 seconds but feels lightheaded. He denies any preceding symptoms. His father died suddenly at age 35 from a 'heart problem.' On examination, his vital signs are stable. A harsh crescendo-decrescendo systolic murmur is heard at the left lower sternal border, which increases in intensity with the Valsalva maneuver.
Which of the following is the most likely diagnosis?
Explanation: The presentation of syncope during exertion in a young athlete, combined with a family history of sudden death, is highly suggestive of hypertrophic cardiomyopathy (HCM). The physical exam finding of a harsh systolic murmur that increases with the Valsalva maneuver (which decreases preload) is classic for the dynamic left ventricular outflow tract obstruction seen in HCM. HCM is an autosomal dominant genetic disorder and is the most common cause of sudden cardiac death in young athletes.
A 66-year-old man presents to the outpatient clinic with a 2-month history of progressive shortness of breath on exertion and orthopnea. He has a history of hypertension. On examination, his pulse is 95/min and irregular. Bibasilar crackles and trace pedal edema are noted. The physician is concerned about new-onset heart failure.
Which of the following is the most appropriate initial diagnostic test to order in this setting?
Explanation: In a patient presenting with symptoms suggestive of heart failure (dyspnea, orthopnea, crackles), measuring a natriuretic peptide level (BNP or NT-proBNP) is the recommended initial diagnostic test. These peptides are released from the ventricles in response to increased wall stress. A normal level has a high negative predictive value, making heart failure unlikely. An elevated level strongly supports the diagnosis and indicates the need for further evaluation, typically with an echocardiogram.
A 58-year-old woman is diagnosed with new-onset heart failure based on her clinical symptoms and an elevated NT-proBNP level. Her physical exam is significant for an S3 gallop and bilateral pitting edema. She has no known history of coronary artery disease.
Which of the following diagnostic studies is most useful for determining the underlying etiology and classifying the type of heart failure in this patient?
Explanation: 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.
A 70-year-old man with a history of hypertension and dyslipidemia presents with exertional dyspnea. An echocardiogram reveals a left ventricular ejection fraction of 30%. Coronary angiography demonstrates multivessel coronary artery disease not amenable to revascularization. He is started on guideline-directed medical therapy.
Which of the following tests would be most appropriate to assess for myocardial viability to determine if the patient might still benefit from revascularization?
Explanation: In patients with ischemic cardiomyopathy, it is important to distinguish between myocardium that is irreversibly scarred and myocardium that is hibernating (viable but dysfunctional due to chronic ischemia). Cardiac MRI with delayed gadolinium enhancement is an excellent non-invasive tool for this purpose. Areas of non-viable scar tissue will show late gadolinium enhancement, while viable myocardium will not. The extent of viability can help determine if the patient might benefit from revascularization procedures like CABG.
A 59-year-old man with HFrEF (LVEF 30%) is being managed with lisinopril, carvedilol, and furosemide. Despite this therapy, he continues to have mild exertional dyspnea (NYHA Class II symptoms). His blood pressure is 115/70 mm Hg, heart rate is 65/min, creatinine is 1.1 mg/dL, and potassium is 4.5 mEq/L. His eGFR is 70 mL/min/1.73 m².
Which of the following medications would be the most appropriate addition to his regimen to further reduce morbidity and mortality?
Explanation: This patient is on an ACE inhibitor and a beta-blocker but remains symptomatic. The next step in GDMT for HFrEF is to add a mineralocorticoid receptor antagonist (MRA) like spironolactone or eplerenone. MRAs have been shown to provide significant mortality benefit in patients with NYHA class II-IV HFrEF and an LVEF of 35% or less, provided they have normal renal function and potassium levels. His current labs show no contraindications.