Heart failure

True/false questions
1. Vasodilator therapy with vasodilators nitroprusside or nitroglycerin is often used for acute
severe failure with congestion and can be dramatically effective, especially in cases in
which increased afterload is a major factor.
A.True
B. False
2. Correction of potassium deficiency (caused, eg, by diuretic use) is of no value in chronic
digitalis intoxication.
A.True
B. False
3. Considerable evidence indicates that angiotensin antagonists, certain β-adrenoceptor
blockers, and the aldosterone antagonists spironolactone and eplerenone also have long-
term beneficial effects in congestive heart failure.
A.True
B. False
4. Chronic heart failure is best treated with loop diuretic; if severe, a prompt-acting positive
inotropic agent such as a β agonist or phosphodiesterase inhibitor and and vasodilators.
A.True
B. False
5. Beta blockers are of no value in acute failure and may be detrimental if systolic
dysfunction is marked.
A.True
B. False
6. Digitalis glycosides are first-line drugs in the treatment of heart failure.
A.True
B. False
7. Nesiritide, a recombinant form of brain natriuretic peptide, has vasodilating and diuretic
properties and has been heavily promoted for use in acute failure.
A.True
B. False
8. Phosphodiesterase inhibitors cause vasoconstriction, which may be responsible for a
major part of their beneficial effect.
A.True
B. False
9. Digitoxin is a very similar to digoxin but longer-acting molecule; it also comes from the
foxglove plant.
A.True
B. False
10. Clinical studies suggest that, like other diuretics, spironolactone and eplerenone
(aldosterone antagonist diuretics) does not have significant long-term benefits and does
not reduce mortality in chronic failure.
A.True
B. False
11. Severe acute digitalis toxicity (as in suicidal overdoses) usually causes marked
hyperkalemia and should not be treated with supplemental potassium.
A.True
B. False
12. Digoxin has an oral bioavailability of 60–75%, and a half-life of 36–40 h. Elimination is
by renal excretion (about 60%) and hepatic metabolism (40%).
A.True
B. False
13. Furosemide is not useful agent for immediate reduction of the pulmonary congestion and
severe edema associated with acute heart failure and for moderate or severe chronic
failure.
A.True
B. False
14. The increase in contractility evoked by digitalis results in increased ventricular ejection,
decreased end-systolic and end-diastolic size, increased cardiac output, and increased
renal perfusion.
A.True
B. False
15. Dobutamine and dopamine are not appropriate for chronic failure because of tolerance,
lack of oral efficacy, and significant arrhythmogenic effects.
A.True
B. False
16. Small increase in intracellular sodium by cardiac glycosides alters the driving force for
sodium/calcium exchange by the exchanger, so that more calcium is removed from the
cell.
A.True
B. False
17. Angiotensin Antagonists have been shown to reduce morbidity and mortality in chronic
heart failure
A.True
B. False
18. Phosphodiesterase Inhibitors milrinone, theophylline, aminophylline is used in chronic
heart failure because they have been shown to decrease morbidity and mortality.
A.True
B. False
19. The decrease in sympathetic tone is especially beneficial in chronic congestive heart
failure: reduced heart rate, preload, and afterload permit the heart to function more
efficiently.
A.True
B. False
20. Inhibition of P-glycoprotein of the cell membrane by digitalis is well documented and is
considered to be the primary biochemical mechanism of action
 A.True
B. False

Matching

1. Diuretic drug (duration of action 2-4 hours) which reduces preload, edema by powerful
diuretic action on thick ascending limb in nephron and with vasodilating effect on
pulmonary vessels. (Furosemide)
2. Antagonist of aldosterone in kidney with duration of action 24-48 h, which reduces
mortality rate and is available only in oral formulations. (Spironolactone)
3. Angiotensin-converting enzyme blocker with short half-life (but duration of large doses
12-24 hours). The main side effects of this drug are cough, renal damage, hyperkalemia.
(Captopril)
4. Inotropic agent for treatment of congestive heart failure and nodal arrhythmias. (Digoxin)
5. Prescribe β-blocker used for treatment of congestive heart failure (metoprolol)

Heart Failure
MSQ
Choose the ONE best answer.

1. Which drug may exacerbate HF?

A. Acetaminophen.
B. Cetirizine.
C. Chlorthalidone.
D. Ibuprofen.

2. Which best describes the action of ACE inhibitors on the failing heart?

A. ACE inhibitors increase vascular resistance.

B. ACE inhibitors decrease cardiac output.
C. ACE inhibitors reduce preload.
D. ACE inhibitors increase aldosterone.

3. What makes losartan different from other ARBs?

 A. Losartan is renally eliminated.
B. Losartan has an active metabolite.
C. Losartan has the shortest half-life.
D. Losartan has a small volume of distribution.

4. How do β-blockers improve cardiac function in HF?

A. By decreasing cardiac remodeling.

B. By increasing heart rate.
C. By increasing renin release.
D. By activating norepinephrine.

5. BC is a 70-year-old female who is diagnosed with HFrEF. Her past medical history is significant for
hypertension and atrial fibrillation. She is taking hydrochlorothiazide, lisinopril, metoprolol tartrate, and
warfarin. BC says she is feeling “good” and has no cough, shortness of breath, or edema. Which is the most
appropriate medication change to make?

A. Discontinue hydrochlorothiazide.
B. Change lisinopril to losartan.
C. Decrease warfarin dose.
D. Change metoprolol tartrate to metoprolol succinate.

6. SC is a 75-year-old white male who has HF. He is seen in clinic today, reporting shortness of breath,
increased pitting edema, and a 5-pound weight gain over the last 2 days. His current medication regimen
includes losartan and metoprolol succinate. SC has no chest pain and is deemed stable for outpatient
treatment. Which of the following is the best recommendation?

A. Increase the dose of metoprolol succinate.

B. Start hydrochlorothiazide.
C. Start furosemide.
D. Discontinue losartan.

7. How is spironolactone beneficial in HF?

A. Promotes potassium secretion.

B. Agonizes aldosterone.
C. Prevents cardiac hypertrophy.
D. Decreases blood glucose.

8. Which is important to monitor in patients taking digoxin?

A. Chloride.
B. Potassium.
C. Sodium.
D. Zinc.
9. Which describes the mechanism of action of milrinone in HF?

A. Decreases intracellular calcium.

B. Increases cardiac contractility.
C. Decreases cAMP.
D. Activates phosphodiesterase.

10. What is the most common adverse effect associated with fixed-dose hydralazine/isosorbide dinitrate?

A. Diarrhea.
B. Drug-induced lupus.
C. Headache.
D. Heartburn.

11. A 73-year-old man with an inadequate response to other drugs is to receive digoxin for heart failure.
Which of the following is the best-documented mechanism of beneficial action of cardiac glycosides?

(A) A decrease in calcium uptake by the sarcoplasmic reticulum

(B) An increase in ATP synthesis
(C) A modification of the actin molecule
(D) An increase in systolic cytoplasmic calcium levels
(E) A block of cardiac β adrenoceptors

12. A 73-year-old man with an inadequate response to other drugs is to receive digoxin for heart failure. After
your patient has been receiving digoxin for 3 wk, he presents to the emergency department with an
arrhythmia. Which one of the following is most likely to contribute to the arrhythmogenic effect of
digoxin?

A. Increased parasympathetic discharge

B. Increased intracellular calcium
C. Decreased sympathetic discharge
D. Decreased intracellular ATP
E. Increased extracellular potassium

13. A patient who has been taking digoxin for several years for atrial fibrillation and chronic heart failure is
about to receive atropine for another condition. A common effect of digoxin (at therapeutic blood levels)
that can be almost entirely blocked by atropine is

A. Decreased appetite
B. Headaches
C. Increased atrial contractility
D. Increased PR interval on ECG
E. Tachycardia

14. A 65-year-old woman has been admitted to the coronary care unit with a left ventricular myocardial
infarction. She develops acute severe heart failure with marked pulmonary edema, but no evidence of
peripheral edema or weight gain. Which one of the following drugs would be most useful?
 A. Digoxin
B. Furosemide
C. Minoxidil
D. Propranolol
E. Spironolactone

15. An 82-year-old woman has long-standing heart failure. Which one of the following drugs has been shown
to reduce mortality in chronic heart failure?

A. Atenolol
B. Digoxin
C. Dobutamine
D. Furosemide
E. Spironolactone

16. Which row in the following table correctly shows the major effects of full therapeutic doses of digoxin on
the AV node and the ECG?

Row Row AV Refractory QT Interval T Wave

Period
A Increased Increased Upright
B Increased Decreased Inverted
C Decreased Increased Upright
D Decreased Decreased Upright
E Decreased Increased Inverted

17. Which one of the following drugs is associated with clinically useful or physiologically important positive
inotropic effect?

A. Captopril
B. Dobutamine
C. Enalapril
D. Losartan
E. Nesiritide

18. A 38-year-old man who has been running a marathon collapses and is brought to the emergency
department. He is found to have a left ventricular myocardial infarction and heart failure with significant
pulmonary edema. The first-line drug of choice in most cases of heart failure is

A. Atenolol
B. Captopril
C. Carvedilol
D. Digoxin
E. Diltiazem
F. Dobutamine
G. Enalapril
H. Furosemide
I. Metoprolol
 J. Spironolactone

19. Which of the following has been shown to prolong life in patients with chronic congestive failure in spite
of having a negative inotropic effect on cardiac contractility?

A. Carvedilol
B. Digoxin
C. Dobutamine
D. Enalapril
E. Furosemide

20. A 5-year-old child is brought to the emergency department with sinus arrest and a ventricular rate of 35
bpm. An empty bottle of his uncle’s digoxin was found where he was playing. Which of the following is the
drug of choice in treating a severe overdose of digoxin?

A. Digoxin antibodies
B. Lidocaine infusion
C. Magnesium infusion
D. Phenytoin by mouth
E. Potassium by mouth

ANSWERS

1. Correct answer = D. NSAIDs, such as ibuprofen, lead to increased fluid retention and increased blood
pressure. If possible, NSAIDs should be avoided in HF patients in order to avoid exacerbations of HF.

2. Correct answer = C. ACE inhibitors decrease vascular resistance, decrease preload, decrease afterload, and
increase cardiac output. In addition, ACE inhibitors blunt aldosterone release.

3. Correct answer = B. Losartan is the only ARB that undergoes first-pass metabolism to convert to its active
metabolite. Most ARBs have once-daily dosing, and all (except candesartan) have large volumes of
distribution.

4. Correct answer = A. Although it seems counterintuitive to decrease heart rate in HF, β-blockers improve
cardiac functioning by slowing heart rate, decreasing renin release, and preventing the direct effects of
norepinephrine on cardiac muscle to decrease remodeling.

5. Correct answer = D. Metoprolol succinate should be used in HF, given that there is mortality benefit
shown with metoprolol succinate in landmark HF trials. Hydrochlorothiazide and warfarin are appropriate
based on the information given; there is no reason to change to an ARB since the patient has no cough or
history of angioedema.

6. Correct answer = C. As it is possible that SC is having a HF exacerbation, increasing the dose of the β-
blocker is not indicated at this time. There is no reason to stop losartan, based on the information we have.
Loop diuretics are preferred over thiazide diuretics when patients require dieresis immediately.

7. Correct answer = C. Spironolactone antagonizes aldosterone, which in turn prevents salt/water retention,
cardiac hypertrophy, and hypokalemia. Spironolactone has endocrine effects on hormones but not on
glucose.
8. Correct answer = B. Hypokalemia can lead to life-threatening arrhythmias and increases the potential of
cardiac toxicity with digoxin.

9. Correct answer = B. Milrinone is a phosphodiesterase inhibitor that leads to increased cAMP, increased
intracellular calcium, and therefore increased contractility.

10. Correct answer = C. While drug-induced lupus is a possibility with hydralazine, headache is the most
common adverse effect.

11. The answer is D. Digitalis does not decrease calcium uptake by the sarcoplasmic reticulum or increase
ATP synthesis; it does not modify actin. Cardiac adrenoceptors are not blocked. The most accurate
description of digitalis’s mechanism in this list is that it increases systolic cytoplasmic calcium indirectly by
inhibiting Na+/K+ ATPase and altering Na/Ca exchange.

12. The answer is B. The effects of digitalis include increased vagal action on the heart (not arrhythmogenic)
and increased intracellular calcium, including calcium overload, the most important cause of toxicity.
Decreased sympathetic discharge and increased extracellular potassium and magnesium reduce digitalis
arrhythmogenesis.

13. The answer is D. The parasympathomimetic effects of digitalis can be blocked by muscarinic blockers
such as atropine. The only parasympathomimetic effect in the list provided is increased PR interval,
representing slowing of AV conduction.

14. The answer is B. Acute severe congestive failure with pulmonary edema often requires a vasodilator that
reduces intravascular pressures in the lungs. Furosemide has such vasodilating actions in the context of
acute failure. Pulmonary edema also involves a shift of fluid from the intravascular compartment to the
lungs. Minoxidil would decrease arterial pressure and increase the heart rate excessively. Digoxin has a
slow onset of action and failure but not in acute pulmonary edema. Pulmonary vasodilation and removal of
edema fluid by diuresis are accomplished by furosemide.

15. The answer is E. Of the drugs listed, only spironolactone has been shown to reduce mortality in this
highly lethal disease. Digoxin, dobutamine, and furosemide are used in the management of symptoms.
16. The answer is B. Digitalis increases the AV node refractory period—a parasympathomimetic action. Its
effects on the ventricles include shortened action potential and QT interval, and a change in repolarization
with flattening or inversion of the T wave.

17. The answer is B. Although they are extremely useful in heart failure, ACE inhibitors (eg, captopril,
enalapril), and angiotensin receptor blockers (ARBs, eg, losartan) have no positive inotropic effect on the
heart. Nesiritide is a vasodilator with diuretic effects and renal toxicity.

18. The answer is H. In both systolic and diastolic heart failure, the initial treatment of choice is usually
furosemide.

19. The answer is A. Several β blockers, including carvedilol, have been shown to prolong life in heart failure
patients even though these drugs have a negative inotropic action on the heart. Their benefits presumably
result from some other effect, and at least one β blocker has failed to show a mortality benefit.
20. The answer is A. The drug of choice in severe, massive overdose with any cardiac glycoside is digoxin
antibody, Digibind. The other drugs listed are used in moderate overdosage associated with increased
automaticity.