心衰问答培训 优选ppt课件

Question 1Ten year survival after the onset of heart failure:A.A.80-90%B.B.60-79%C.C.40-59%D.D.20-39%E.E.Under 20%2020/10/181Question 1Ten year survival aPrognosis in Heart Failure Men over 45 years of AgeSurviving(%)Years from Diagnosis2020/10/182Prognosis in Heart Failure MePrognosis in Heart Failure Women over 45 years of AgeSurviving(%)Years from Diagnosis2020/10/183Prognosis in Heart Failure WoQuestion 2Potential underlying causes of heart failure include:A.A.Coronary artery diseaseB.B.HemochromatosisC.C.Mitral regurgitationD.D.Ventricular septal defectE.E.all of the above2020/10/184Question 2Potential underlyinHeart FailureThe Final Common Pathwayn nischemic diseasen nvalvular diseasen ncardiomyopathyn npericardial diseasen nhypertensionn ncongenital HeartFailure2020/10/185Heart FailureThe Final CommonQuestion 3The pathophysiology of heart failure can best be described as:A.A.a failure of protective mechanismsB.B.activation of harmful pathwaysC.C.introduction of pathogenic influencesD.D.inappropriate activation of normal mechanismsE.E.all of the above2020/10/186Question 3The pathophysiologyPhysiologic Response to Heart FailureLV Dysfunction Renal-AdrenalCarotid and LA Baroreceptors Renin-AngiotensinAldosteroneSympathetic OutputSodiumand fluidretentiontachycardiavasoconstriction2020/10/187Physiologic Response to Heart Question 4Physiologic effects of Angiotensin II include:A.A.vasoconstrictionB.B.activation of thirstC.C.sodium retentionD.D.aldosterone releaseE.E.all of the above2020/10/188Question 4Physiologic effectsRenin-Angiotensin SystemReninAngiotensin IAngiotensin II decreasedrenal perfusion decreasedNa deliverysympathetic activityAVP ReleasevasoconstrictionaldosteroneIncreased thirstNE releasesodium retentiondecreased GFR2020/10/189Renin-Angiotensin SystemReninAQuestion 5The following is a feature of the heart failure state:A.A.reduced circulating catecholaminesB.B.increased left ventricular end diastolic pressureC.C.reduced plasma volumeD.D.increased renal sodium excretionE.E.reduced pulmonary capillary wedge pressure2020/10/1810Question 5The following is a Compensatory Mechanisms in Heart Failuren nincreased preloadn nincreased sympathetic tonen nincreased circulating catecholaminesn nincreased Renin-angiotensin-aldosteronen nincreased vasopressinn nincreased atrial natriuretic factor2020/10/1811Compensatory Mechanisms in HeaQuestion 6Patients with early heart failure typically present with:A.A.No symptomsB.B.Dyspnea on exertion onlyC.C.Dyspnea with minimal activityD.D.Dyspnea at restE.E.Acute respiratory distress2020/10/1812Question 6Patients with earlyHeart Failure Clinical Manifestations SymptomsSymptomsn ndyspneadyspnean nfatiguefatiguen nexertional limitationexertional limitationn nweight gainweight gainn npoor appetitepoor appetiten ncoughcough SignsSignsn ntachycardia,tachypneatachycardia,tachypnean nedemaedeman njugular venous distensionjugular venous distensionn npulmonary ralespulmonary ralesn npleural effusionpleural effusionn nhepato/splenomegalyhepato/splenomegalyn nascitesascitesn ncardiomegalycardiomegalyn nS3 gallopS3 gallop2020/10/1813Heart Failure Clinical ManifeDyspnea Clinical Presentationsn nexertional shortness of breathn ncoughn northopnean nparoxyxmal nocturnal dyspnean nsevere respiratory distressn nrespiratory failure2020/10/1814Dyspnea Clinical PresentatioNYHA Functional Classificationn nClass IClass I:patients with cardiac disease but no patients with cardiac disease but no limitation of physical activitylimitation of physical activityn nClass IIClass II:ordinary activity causes fatigue,ordinary activity causes fatigue,palpitations,dyspnea or anginal painpalpitations,dyspnea or anginal painn nClass IIIClass III:less than ordinary activity causes less than ordinary activity causes fatigue,palpitations,dyspnea or angina fatigue,palpitations,dyspnea or angina n nClass IVClass IV:symptoms even at restsymptoms even at rest2020/10/1815NYHA Functional ClassificationQuestion 7Edema in heart failure takes the following form:A.A.Peripheral edemaB.B.Sacral edemaC.C.Abdominal distentionD.D.anasarcaE.E.Any of the above2020/10/1816Question 7Edema in heart failEdema Clinical Presentationsn nwhere-peripheral,sacral,generalizedn nobjective weight gainn nbloatingn nabdominal distension2020/10/1817Edema Clinical PresentationsQuestion 8Signs of right heart failure include all the following except:A.A.Peripheral edemaB.B.Pulmonary ralesC.C.Elevated jugular veinsD.D.hepatomegalyE.E.Pleural effusions2020/10/1818Question 8Signs of right hearLeft vs Right Heart FailureLeft Heart FailureLeft Heart Failuren npulmonary congestionpulmonary congestionRight Heart FailureRight Heart Failuren nperipheral edemaperipheral edeman nsacral edemasacral edeman nelevated JVPelevated JVPn nascitesascitesn nhepatomegalyhepatomegalyn nsplenomegalysplenomegalyn npleural effusionpleural effusion2020/10/1819Left vs Right Heart FailureLefQuestion 9A diagnosis of heart failure is best extablished on the basis of the following:A.A.Dyspnea at rest,increased heart size on chest X Dyspnea at rest,increased heart size on chest X ray and elevated jugular veinsray and elevated jugular veinsB.B.Dyspnea with stair climbing,increased heart size Dyspnea with stair climbing,increased heart size on chest X ray and heart rate of 105on chest X ray and heart rate of 105C.C.Rest dyspnea,interstitial edema on chest X ray,Rest dyspnea,interstitial edema on chest X ray,and elevated jugular veinsand elevated jugular veinsD.D.Orthopnea,flow redistribution on chest X Ray,Orthopnea,flow redistribution on chest X Ray,and crackles in lung basesand crackles in lung basesE.E.PND,bilateral pleural effusions and crackles in PND,bilateral pleural effusions and crackles in lung baseslung bases2020/10/1820Question 9A diagnosis of hearCriteria for Diagnosis of CHFHISTORYHISTORY PointsPoints rest dyspnea rest dyspnea4 4 orthopnea orthopnea4 4 PND PND3 3 dyspnea walking on level dyspnea walking on level2 2 dyspnea on climbing dyspnea on climbing1 1CHEST X-RayCHEST X-Ray alveolar pulmonary edema alveolar pulmonary edema4 4 interstitial pulm edema interstitial pulm edema3 3 bilateral pleural effusion bilateral pleural effusion3 3 CT ratio 0.50 CT ratio 0.503 3 flow redistribution flow redistribution2 2PHYSICALPHYSICAL PointsPoints HR 91-110 HR 91-1101 1 HR 110 HR 1102 2 JVP 6 cm JVP 6 cm2 2 JVP 6 cm&hepatom JVP 6 cm&hepatom3 3 lung crackles in base lung crackles in base1 1 lung crackles above base lung crackles above base2 2 wheezing wheezing3 3 S3 S33 38-12 points-definite CHF5-7 points -possible CHF 5 points -unlikely CHF2020/10/1821Criteria for Diagnosis of CHFHQuestion 10All the following medications can precipitate heart failure in susceptible patient except:A.A.metoprololB.B.spironolactoneC.C.procainamideD.D.diltiazemE.E.rosiglitazone2020/10/1822Question 10All the following Precipitating Causes of Heart Failure1.ischemia2.change in diet,drugs or both3.increased emotional or physical stress4.cardiac arrhythmias(eg.atrial fib)5.infection6.concurrent illness7.uncontrolled hypertension8.New high output state(anemia,thyroid)9.pulmonary embolism10.Mechanical disruption(sudden MR,VSD,AR)2020/10/1823Precipitating Causes of Heart Question 11The following investigations should always be carried out in patient presenting with heart failure except:A.A.Renal function testsB.B.A ventilation-perfusion scanC.C.Blood countsD.D.ElectrocardiogramE.E.Echocardiogram2020/10/1824Question 11The following inveInvestigations for Heart Failure n nEKGEKGuuevidence of ischemia,infarction,LVH,RVHevidence of ischemia,infarction,LVH,RVHuurhythm analysisrhythm analysisn nChest X-RayChest X-Rayuucardiac sizecardiac sizeuuevidence of pulmonary vascularityevidence of pulmonary vascularityn nBlood workBlood workuuCBC,renal function,electrolytesCBC,renal function,electrolytesn nAssessment of LV FunctionAssessment of LV Function2020/10/1825Investigations for Heart FailuQuestion 12Patient A.B.presents with clear signs of left heart failure and responds quickly to standard therapy.Follow-up assessment reveals normal LV systolic function.The most likely underlying cause of this patients heart failure is:A.A.Diastolic dysfunctionB.B.Mitral valve disruptionC.C.Pulmonary embolismD.D.Dilated cardiomyopathyE.E.Ischemic heart disease2020/10/1826Question 12Patient A.B.preseHeart Failure with Normal LV systolic function between symptomatic episodesn nischemian nsudden increase in myocardial demandsn ndiastolic LV dysfunction2020/10/1827Heart Failure with Normal LV sQuestion 13The following mechanisms contribute to myocardial dysfunction in heart failure patients:A.A.Increased circulating epinephrineB.B.Increased circulating norepinephrineC.C.Increased aldosterone productionD.D.Increased angiotensin productionE.E.all of the above2020/10/1828Question 13The following mechRationale for Treatment of Heart FailureLV dysfunctionsympathetic activation Renin-angiotensin Adrenalstimulation epinephrinenorepinephrineangiotensin Ialdosteroneangiotensin II2020/10/1829Rationale for Treatment of HeaQuestion 14All of the following have been shown to improve prognosis in patients with heart failure except:A.A.digoxinB.B.carvedilolC.C.enalaprilD.D.metoprololE.E.ramipril2020/10/1830Question 14All of the followiMedical Management of Heart FailureDrugs that improve symptomsDrugs that improve symptomsn nfurosemidefurosemiden nthiazide diureticsthiazide diureticsn nspironolactonespironolactonen ndigoxindigoxinn nACE InhibitorsACE Inhibitorsn nbeta blockersbeta blockersn naldosterone aldosterone antagonistsantagonistsDrugs that improve Drugs that improve prognosisprognosisn nACE inhibitorsACE inhibitorsn nbeta blockersbeta blockersn nspironolactone*spironolactone*2020/10/1831Medical Management of Heart FaRationale for Treatment of Heart FailureLV dysfunctionsympathetic activation Renin-angiotensin Adrenalstimulation epinephrinenorepinephrineangiotensin Ialdosteroneangiotensin IIBABsACEIsARBsspironolactone2020/10/1832Rationale for Treatment of HeaBeta Blocker TrialsMortality per year2020/10/1833Beta Blocker TrialsMortality pEnalapril vs Placebo in Symptomatic CHFCONSENSUSProbability of DeathMonths2020/10/1834Enalapril vs Placebo in SymptoQuestion 15The following are all adverse effects of beta blockers except:A.A.bronchospasmB.B.bradycardiaC.C.hypotensionD.D.depressionE.E.anxiety2020/10/1835Question 15The following are Beta BlockersAdverse Effectsn nexcessive fatiguen nbradycardia,heart blockn nhypotensionn nreactive airwaysn nmood disturbances,depressionn nintermittent claudicationn nimpotence 2020/10/1836Beta BlockersAdverse EffectseBeta Blockers in Heart FailurePractical Tipsn nstart with low doses start with low doses(3.125-6.25 mg carvedilol bid(3.125-6.25 mg carvedilol bid or 6.25-12.5 mg metoprolol bid)or 6.25-12.5 mg metoprolol bid)n nincrease dose slowly at intervals of 2 weeks or increase dose slowly at intervals of 2 weeks or moremoren navoid in patients with bronchospasm or advanced avoid in patients with bronchospasm or advanced heart block without pacemakerheart block without pacemakern nimprovement symptomatically and objectively improvement symptomatically and objectively may be slowmay be slown navoid abrupt withdrawlavoid abrupt withdrawl 2020/10/1837Beta Blockers in Heart FailureQuestion 16The following are all adverse effects of ACE Inhibitors except:A.A.Renal dysfunctionB.B.bradycardiaC.C.hypotensionD.D.coughE.E.hyperkalemia2020/10/1838Question 16The following are ACE InhibitorsAdverse Effectsn nhypotensionn nrenal dysfunctionn nhyperkalemian ncoughn nskin rashn ntaste disturbancen nangioneurotic edema 2020/10/1839ACE InhibitorsAdverse EffectsQuestion 17Current evidence supports the following approach with respect to digoxin:A.A.Should be used in all patients with LV dysfunctionShould be used in all patients with LV dysfunctionB.B.Should be used chronically in patients with Should be used chronically in patients with controlled heart failure to improve symptom statuscontrolled heart failure to improve symptom statusC.C.Should be used chronically in patients with Should be used chronically in patients with controlled heart failure to improve prognosiscontrolled heart failure to improve prognosisD.D.Should be used acutely in patients with new onset Should be used acutely in patients with new onset heart failureheart failureE.E.Digoxin has no role in heart failure patientsDigoxin has no role in heart failure patients2020/10/1840Question 17Current evidence sDigitalis and other Inotropic DrugsRecommendationsn nto improve symptoms and reduce hospitalizations to improve symptoms and reduce hospitalizations in patients in sinus rhythm who remain in patients in sinus rhythm who remain symptomatic on ACEIssymptomatic on ACEIsn npatients in atrial fibrillation and LV failurepatients in atrial fibrillation and LV failuren nparenteral use of dopaminergic agents or parenteral use of dopaminergic agents or phosphodiesterase inhibitors not recommended phosphodiesterase inhibitors not recommended routinely,but may be used in select patients with routinely,but may be used in select patients with intractable heart failure intractable heart failure 2020/10/1841Digitalis and other Inotropic Question 18Current evidence supports the following approach with respect to Angiotensin receptor antagonists:A.A.Should be used in all patients with LV dysfunctionShould be used in all patients with LV dysfunctionB.B.Should be used chronically in patients with Should be used chronically in patients with controlled heart failure to improve symptom statuscontrolled heart failure to improve symptom statusC.C.Should be used chronically in patients with Should be used chronically in patients with controlled heart failure to improve prognosiscontrolled heart failure to improve prognosisD.D.Should be used in patients unable to tolerate ACE Should be used in patients unable to tolerate ACE InhibitorsInhibitorsE.E.Have no role in heart failure patientsHave no role in heart failure patients2020/10/1842Question 18Current evidence sAngiotensin Receptor BlockersIndicationsn nmay be considered for patients unable to tolerate ACEIs2020/10/1843Angiotensin Receptor BlockersAngiotensin Receptor BlockersAdverse Effectsn nhypotensionn nrenal dysfunctionn nhyperkalemia 2020/10/1844Angiotensin Receptor BlockersQuestion 19Current evidence supports the following approach with respect to Aldosterone antagonists:A.A.Should be used in all patients with LV dysfunctionShould be used in all patients with LV dysfunctionB.B.Should be used chronically in patients with Should be used chronically in patients with controlled heart failure to improve symptom statuscontrolled heart failure to improve symptom statusC.C.Should be used chronically in patients with Should be used chronically in patients with controlled heart failure to improve prognosiscontrolled heart failure to improve prognosisD.D.Should be used in patients with severe heart failure Should be used in patients with severe heart failure to improve symptomsto improve symptomsE.E.Should be used in patients with severe heart failure Should be used in patients with severe heart failure to improve symptoms and prognosisto improve symptoms and prognosis2020/10/1845Question 19Current evidence sAldosterone Antagonists in Heart FailureEvidencen nRALES trialRALES trialn n1663 patients with class III-IV heart failure 1663 patients with class III-IV heart failure already on ACEI randomized to spironolactone already on ACEI randomized to spironolactone(25 mg od)vs placebo(25 mg od)vs placebon nafter 2 years,30%reduction in mortality in after 2 years,30%reduction in mortality in treatment group treatment group 2020/10/1846Aldosterone Antagonists in HeaAldosterone Antagonists in Heart FailureIndicationsn nPatients with severe symptomatic heart failure who are already on standard medications 2020/10/1847Aldosterone Antagonists in HeaQuestion 20Current evidence supports the following approach with respect to diuretics:A.A.Should be used in all patients with LV dysfunctionShould be used in all patients with LV dysfunctionB.B.Should be used only in patients with active heart Should be used only in patients with active heart failurefailureC.C.Should be used all patients who have had Should be used all patients who have had symptomatic heart failure to prevent recurrencessymptomatic heart failure to prevent recurrencesD.D.Should be used in all patients with severe LV Should be used in all patients with severe LV dysfunction dysfunction E.E.Have no role in heart failure patientsHave no role in heart failure patients2020/10/1848Question 20Current evidence sDiuretics in Heart Failuren nvery useful for management of acute congestive staten nproduce rapid symptom reliefn nhave no prognostic advantage in stable patients2020/10/1849Diuretics in Heart FailureveryDiuretics in Heart FailureAgents Usedn nfurosemiden nhydrochlorthiaziden nmetolazone2020/10/1850Diuretics in Heart FailureAgeQuestion 21The following are all adverse effects of furosemide except:A.A.renal dysfunctionB.B.skin rashC.C.hypotensionD.D.hyponatremiaE.E.hyperkalemia2020/10/1851Question 21The following are Diuretics in Heart FailureAdverse Effectsn nelectrolyte disturbances(K,Na)n nhypotensionn nrenal dysfunctionn nrashn nototoxicity(ethacrynic acid,furosemide)2020/10/1852Diuretics in Heart FailureAdvQuestion 22The following are all options to consider in patients with highly symptomatic and refractory heart failure except:A.A.revascularizationB.B.resynchronization therapyC.C.cardiac transplantationD.D.plasmapheresisE.E.dialysis2020/10/1853Question 22The following are Patients with:hypertension CAD DM risk for CMPPatients with:prior MI LV systolic dysfunction asymptomatic valve diseasePatients with:known structural heart disease SOB fatigue exercise tolerancePatients with:marked symptoms despite full therapyTherapytreat RFsencourage exercisediscourage alcoholTherapyall for Stage AACEIsBABsTherapyall for Stages A and Bdirueticsdigoxindietary restrictionsTherapyall for ABCassist devices transplantation Structural heart diseaseSymptoms of Heart FailureRefractory SymptomsSTAGE ASTAGE BSTAGE CSTAGE DAt risk2020/10/1854Patients with:Patients with:PaQuestion 23The following all support the diagnosis of acute pericarditis except:A.A.typical chest discomfortB.B.ST elevation on EKGC.C.history of a preceding viral illnessD.D.S4 gallopE.E.pericardial friction rub2020/10/1855Question 23The following all Acute Pericarditis Diagnostic Criterian nchest painn npericardial friction rubn nEKG changes2020/10/1856Acute Pericarditis DiagnostiQuestion 24The earliest EKG changes seen in acute pericarditis:A.A.ST segment depressionB.B.ST segment elevation C.C.hyperacute T wavesD.D.T wave depression E.E.PR depression2020/10/1857Question 24The earliest EKG cEKG in Acute Pericarditis1.Diffuse ST segment elevation(except aVR and V1)+PR segment depression(except aVR and V1)+PR segment depression2.ST normalizes,T waves flatten3.T waves invert where STs were elevated4.Return to normal pattern2020/10/1858EKG in Acute Pericarditis1.Question 25Pericardial tamponade should be suspected in the following situations:A.A.enlarged heart shadow on chest X rayB.B.unexplained hypotensionC.C.unexplained severe dyspneaD.D.exaggerated inspiratory decline in BPE.E.all of the above2020/10/1859Question 25Pericardial tamponPericardial TamponadePhysical Examination Findingsn nhypotensionn ntachycardian ntachypnean ndistant heart soundsn nelevated JVPn npulsus paradoxus2020/10/1860Pericardial TamponadePhysicalQuestion 26Causes of pericardial effusions include all of the following except:A.A.hypertensive crisisB.B.breast cancerC.C.myocarditisD.D.lymphomaE.E.renal failure2020/10/1861Question 26Causes of pericardPericarditis-causesn nidiopathicidiopathicn ninfectious(viral,bacterial,TB)infectious(viral,bacterial,TB)n npost MI(acute,Dresslers syndrome)post MI(acute,Dresslers syndrome)n nneoplastic diseaseneoplastic diseasen nuremi