CHF

Question 1

What is heart failure (definition)?

Answer 1

A progressive clinical syndrome where the heart cannot supply sufficient oxygen-rich blood due to structural/functional impairment of ventricular filling or ejection.

Question 2

Most common cause of HF etiology?

Answer 2

Ischemic heart disease (chronic CAD, prior MI).

Question 3

Key non-ischemic HF risk factors?

Answer 3

HTN, obesity, DM, dilated cardiomyopathy (familial/cardiotoxins/viral), thyroid disease, stress (Takotsubo), valvular disease.

Question 4

Cardiac output (CO) formula?

Answer 4

CO = SV × HR.

Question 5

Mean arterial pressure (MAP) relationship?

Answer 5

MAP = CO × SVR.

Question 6

Define preload.

Answer 6

Volume in ventricle just prior to contraction (stretch).

Question 7

Define afterload.

Answer 7

Resistance/tension LV must overcome to eject stroke volume.

Question 8

Normal LVEF range?

Answer 8

~55–70%.

Question 9

HFpEF EF cutoff?

Answer 9

> 50%.

Question 10

HFmrEF EF range?

Answer 10

41–49%.

Question 11

HFrEF EF cutoff?

Answer 11

≤40%.

Question 12

Diastolic HF equals what EF category?

Answer 12

HFpEF.

Question 13

Systolic HF equals what EF category?

Answer 13

HFrEF.

Question 14

Common HF signs/symptoms?

Answer 14

Dyspnea, fatigue, fluid overload, peripheral edema, pulmonary congestion, orthopnea.

Question 15

Physical exam HF findings (3 classic)?

Answer 15

Rales, S3 gallop, JVD (plus peripheral edema).

Question 16

What neurohormones drive compensatory responses in HF?

Answer 16

Angiotensin II, norepinephrine, aldosterone, vasopressin (ADH).

Question 17

Compensatory mechanism #1 in HF?

Answer 17

Tachycardia + increased contractility via norepinephrine.

Question 18

Why can tachycardia worsen CO at high HR?

Answer 18

Very high HR reduces diastolic filling time → SV drops.

Question 19

Chronic sympathetic activation leads to what receptor change?

Answer 19

Downregulation/decreased sensitivity of β1 receptors.

Question 20

Compensatory mechanism #2 in HF?

Answer 20

Fluid retention + increased preload via RAAS activation (reduced renal perfusion).

Question 21

Downside of excess preload on Frank-Starling curve?

Answer 21

After the flat portion, more preload causes congestion (pulmonary/systemic) without CO benefit.

Question 22

Compensatory mechanism #3 in HF?

Answer 22

Vasoconstriction → increased SVR → increased afterload (mediated by NE and angiotensin II).

Question 23

Why does increased afterload worsen HF?

Answer 23

Makes ejection harder → further reduces CO.

Question 24

BNP: normal cutoff?

Answer 24

<100 pg/mL.

Question 25

NT-proBNP: normal cutoff?

Answer 25

<300 pg/mL.

Question 26

BNP/NT-proBNP clinical uses?

Answer 26

Aid prevention, diagnosis, and prognosis in HF (affected by age/sex/body habitus/renal function).

Question 27

Key HF labs to assess?

Answer 27

CMP/electrolytes (Na/K/Ca/Mg), SCr/renal function, glucose, BNP/NT-proBNP, lipids, thyroid.

Question 28

Non-invasive tests used in HF workup?

Answer 28

Echo (EF/remodeling/valves), CXR (cardiomegaly/congestion), ECG (arrhythmias).

Question 29

ACC/AHA Stage A HF definition?

Answer 29

At risk: HTN, atherosclerotic disease, DM, obesity, metabolic syndrome (no structural disease yet).

Question 30

ACC/AHA Stage B HF definition?

Answer 30

Structural heart disease (prior MI, LV remodeling/LVH/low EF) but no HF symptoms.

Question 31

ACC/AHA Stage C HF definition?

Answer 31

Structural heart disease with prior/current symptoms (dyspnea, fatigue, reduced exercise tolerance); EF low or normal.

Question 32

ACC/AHA Stage D HF definition?

Answer 32

Refractory HF: marked symptoms at rest, recurrent hospitalizations despite GDMT.

Question 33

NYHA Class I?

Answer 33

No limitation of physical activity.

Question 34

NYHA Class II?

Answer 34

Slight limitation of physical activity.

Question 35

NYHA Class III?

Answer 35

Marked limitation of physical activity.

Question 36

NYHA Class IV?

Answer 36

Symptoms at rest or unable to do activity without symptoms.

Question 37

Overall HF treatment goals?

Answer 37

Improve QoL, stabilize, reduce morbidity/hospitalization + mortality, slow progression, prolong survival.

Question 38

Core nonpharm HF counseling points?

Answer 38

Smoking cessation, limit alcohol, sodium restriction (~2–3 g/day or less), weight reduction if obese, modest exercise, daily weights, fluid restriction if directed.

Question 39

Stage A management focus?

Answer 39

Control risk factors/comorbidities; treat HTN/HLD; consider ACEi/ARB in DM/vascular disease.

Question 40

Stage B therapy for MI/ACS + EF ≤40% (and EF ≤40%)?

Answer 40

ACEi/ARB + beta blocker.

Question 41

HFpEF (Stage C) general strategy?

Answer 41

Control HTN, control tachycardia, manage AF per guidelines; diuretics PRN; consider ARNi/ACEi/ARB/MRA as appropriate.

Question 42

HFrEF (Stage C) cornerstone approach?

Answer 42

GDMT (“4 pillars”) + diuretics for congestion; add-on therapies as indicated.

Question 43

Stage D advanced therapies?

Answer 43

IV inotropes (dobutamine/milrinone), mechanical support (LVAD), transplant, palliative/hospice.

Question 44

Name the “4 pillars” of HFrEF therapy.

Answer 44

ARNI (or ACEi/ARB), evidence-based beta blocker, MRA, SGLT2 inhibitor.

Question 45

Loop diuretics role in GDMT?

Answer 45

Symptom relief of congestion/volume overload (does not provide the same mortality benefit as the pillars).

Question 46

When are ARNIs preferred over ACE/ARB?

Answer 46

HFrEF with NYHA II–III: ARNI preferred; replace ACE/ARB with ARNI if tolerated.

Question 47

If ARNI not feasible, what next?

Answer 47

Use ACE inhibitor.

Question 48

If ARNI not feasible AND ACE intolerance (cough/angioedema), what next?

Answer 48

Use ARB.

Question 49

Why aren’t neprilysin inhibitors combined with ACE inhibitors?

Answer 49

Increased risk of angioedema (must separate therapy).

Question 50

Required washout when switching from ACE inhibitor to ARNI?

Answer 50

36 hours.

Question 51

ARNI major contraindications (high-yield)?

Answer 51

Use within 36h of ACEi, history of angioedema, pregnancy, severe hepatic impairment (Child-Pugh C), aliskiren with DM.

Question 52

ARNI monitoring parameters?

Answer 52

BP, potassium, kidney function (CrCl/eGFR), reassess q1–2 weeks during titration.

Question 53

Evidence-based beta blockers in HFrEF (name 3)?

Answer 53

Bisoprolol, carvedilol, metoprolol succinate ER.

Question 54

Beta blocker titration pearls?

Answer 54

Double dose about every 2 weeks as tolerated; better when patient “dry”; avoid starting/increasing if decompensated.

Question 55

Beta blocker monitoring?

Answer 55

HR, BP, and signs of congestion/fluid retention.

Question 56

MRA agents used in HFrEF?

Answer 56

Spironolactone or eplerenone.

Question 57

MRA eligibility cutoffs?

Answer 57

K+ <5.0 mEq/L AND eGFR >30 mL/min/1.73m2.

Question 58

MRA key adverse effect to remember?

Answer 58

Hyperkalemia; spironolactone can cause gynecomastia.

Question 59

MRA monitoring schedule (high-yield)?

Answer 59

Check K+/renal function shortly after start and after titrations; then frequent monitoring (monthly early, then spaced out).

Question 60

SGLT2 inhibitor benefit in HFrEF applies to which patients?

Answer 60

Symptomatic chronic HFrEF patients regardless of diabetes status.

Question 61

SGLT2 eGFR cutoffs (per slides) for dapagliflozin and empagliflozin?

Answer 61

Dapagliflozin if eGFR >30; empagliflozin if eGFR >20 (for HF use per slide set).

Question 62

SGLT2 typical HF dose for dapagliflozin/empagliflozin?

Answer 62

10 mg PO once daily (start = target).

Question 63

SGLT2 contraindication to memorize?

Answer 63

Type 1 DM (ketoacidosis risk) and dialysis.

Question 64

SGLT2 notable risks/cautions?

Answer 64

Volume depletion, mycotic infections, urosepsis/pyelo (hold if severe), AKI/renal issues (hold), rare Fournier’s gangrene.

Question 65

Loop diuretic PO equivalence (normal renal function): bumetanide 1 mg equals what?

Answer 65

≈ torsemide 20 mg ≈ furosemide 40 mg ≈ ethacrynic acid 50 mg.

Question 66

Loop diuretic titration goal?

Answer 66

Relieve congestion over days–weeks; adjust based on symptoms/weight/volume status.

Question 67

When might you need to decrease loop diuretic dose?

Answer 67

When increasing ARNI/ACEi/ARB doses or after starting SGLT2 inhibitor (less congestion).

Question 68

“High dose” loop definition from slides?

Answer 68

Equivalent to furosemide 80 mg PO BID.

Question 69

If loop dose keeps rising, next steps?

Answer 69

Switch to different loop and/or add thiazide diuretic (sequential nephron blockade) + monitor labs/BP.

Question 70

Hydralazine/isosorbide dinitrate: who gets it?

Answer 70

Persistently symptomatic Black patients with NYHA III–IV on full GDMT (ARNI/ACE/ARB + BB + MRA + SGLT2).

Question 71

Hydralazine/isosorbide main counseling/monitoring?

Answer 71

Monitor BP/HR; dizziness/headache possible; titrate toward target.

Question 72

Ivabradine indication (all must be true)?

Answer 72

HFrEF EF <35%, NYHA II–III, on maximally tolerated beta blocker, sinus rhythm, resting HR >70.

Question 73

Ivabradine key “does NOT do” benefit?

Answer 73

Lowers HR without lowering BP (in sinus rhythm).

Question 74

Ivabradine: when NOT to use (big ones)?

Answer 74

HFpEF, acute decompensated HF, persistent AF/flutter, BP <90/50, resting HR <60, significant conduction disease without pacemaker.

Question 75

Ivabradine starting dose (age <75 vs >75)?

Answer 75

<75: 5 mg BID with food; >75: 2.5 mg BID with food.

Question 76

Ivabradine titration rule based on HR?

Answer 76

HR <50 or brady sx: decrease (or stop if already low); HR 50–60: keep; HR >60: increase by 2.5 mg BID up to 7.5 mg BID.

Question 77

Digoxin role in modern HFrEF?

Answer 77

Consider if symptomatic despite GDMT or can’t tolerate GDMT; often when also needing AF rate control (esp if low BP).

Question 78

Digoxin dosing considerations?

Answer 78

Use ideal body weight; consider age, renal function, interacting meds.

Question 79

Vericiguat: which patients qualify?

Answer 79

Selected high-risk HFrEF with recent worsening HF already on GDMT; NYHA II–IV; LVEF <45%; recent HF hospitalization or IV diuretics or elevated natriuretic peptides.

Question 80

Vericiguat dosing/titration?

Answer 80

Start 2.5 mg daily with food; double every 2 weeks to target 10 mg daily with food.

Question 81

Potassium binders in HFrEF: when considered?

Answer 81

Hyperkalemia (e.g., K+ >5.5) on RAASi where you want to continue GDMT; options: patiromer or sodium zirconium cyclosilicate.

Question 82

ICD indication pearl from slides?

Answer 82

Prevent sudden death in prior cardiac arrest/sustained ventricular arrhythmias; prior MI with LVEF <35% (per slide note).

Question 83

CRT is what type of therapy?

Answer 83

Pacemaker-based cardiac resynchronization therapy.

Question 84

Stage D mechanical support example?

Answer 84

Ventricular assist device (VAD/LVAD) as bridge to transplant/support.

Question 85

HF readmissions: common cause highlighted?

Answer 85

Dietary and medication non-adherence.

Question 86

Drugs to avoid in HF: NSAIDs why?

Answer 86

Promote sodium/water retention → worsen congestion.

Question 87

Antiarrhythmics: which are proven safe in HF?

Answer 87

Amiodarone and dofetilide (others in class I/III often avoided).

Question 88

Antiarrhythmics to avoid: class Ic examples?

Answer 88

Flecainide, propafenone (avoid).

Question 89

Which calcium channel blockers are avoided in HF (esp HFrEF)?

Answer 89

Non-dihydropyridines: diltiazem, verapamil (negative inotropy).

Question 90

Thiazolidinediones (pioglitazone): why avoid?

Answer 90

Fluid retention.

Question 91

Corticosteroids: why avoid?

Answer 91

Promote sodium/water retention.

Question 92

DPP-4 inhibitors to avoid in HF per slides?

Answer 92

Saxagliptin and alogliptin (↑ HF hospitalization risk).

Question 93

What electrolyte is most “impacted” across HF pharmacotherapy?

Answer 93

Potassium (arrhythmia/conduction implications).

Question 94

HFrEF GDMT “sequence” mindset?

Answer 94

Initiate/add/switch → titrate → address adherence/cost/access → manage comorbidities/complexities/end-of-life.

Question 95

Target dose vs dose optimization difference?

Answer 95

Target dose = trial-proven dose; optimization = target or highest tolerated by patient.

Question 96

What’s the main “bothersome” ACE inhibitor side effect and why?

Answer 96

Cough due to bradykinin accumulation.

Question 97

Best fix for ACE inhibitor cough?

Answer 97

Switch to an ARB.

Question 98

When are ACEi/ARB titrations better tolerated (per slides)?

Answer 98

When patient is “wet”/congested.

Question 99

When are beta blocker starts/titrations better tolerated?

Answer 99

When patient is “dry” (not edematous).

Question 100

Loop diuretic PO vs IV conversion: furosemide 40 mg PO equals what IV dose?

Answer 100

20 mg IV.

Question 101

Loop diuretic PO vs IV conversion: torsemide 20 mg PO equals what IV dose?

Answer 101

20 mg IV.

Question 102

Loop diuretic PO vs IV conversion: bumetanide 1 mg PO equals what IV dose?

Answer 102

1 mg IV.