Page 22 of 25
IM1.1-27 | Heart Failure — Practice Quiz
Click any question card to reveal the correct answer.
A 58-year-old man with a history of anterior wall myocardial infarction two years ago presents with progressive dyspnoea on climbing one flight of stairs and bilateral ankle oedema. His echocardiogram shows an LVEF of 38%. Which category of heart failure does this patient have?
Correct. HFrEF is defined as heart failure with an LVEF of 40% or less. An LVEF of 38% places this patient firmly in the HFrEF category. This distinction is critical because disease-modifying therapies — ACE inhibitors/ARBs, beta-blockers, aldosterone antagonists, and SGLT2 inhibitors — have proven mortality benefit specifically in HFrEF.
HFrEF is LVEF 40% or less; HFmrEF is LVEF 41-49%; HFpEF is LVEF 50% or greater. An LVEF of exactly 40% = HFrEF. These thresholds must be memorised precisely.
The LVEF cut-offs are: HFrEF = LVEF 40% or less; HFmrEF = LVEF 41-49%; HFpEF = LVEF 50% or greater. An LVEF of 38% is at or below 40%, placing this patient in the HFrEF category. This classification determines which pharmacological therapies have evidence-based mortality benefit.
Click to reveal answer
A 65-year-old woman with dilated cardiomyopathy can walk on level ground without symptoms but becomes breathless when climbing one flight of stairs. She has no symptoms at rest. According to the NYHA classification, what is her functional class?
Correct. NYHA Class II describes patients who are comfortable at rest and during mild exertion but experience symptoms (dyspnoea, fatigue, palpitations) with ordinary physical activity such as climbing stairs. This patient has no symptoms at rest and symptoms only on moderate exertion, which is the definition of NYHA Class II.
NYHA Class II: symptoms with ordinary activity (e.g., stair-climbing), comfortable at rest and with mild exertion. NYHA Class III: symptoms with minimal exertion (e.g., walking short distances on flat ground).
NYHA Class I = no symptoms even with ordinary activity; Class II = symptoms with ordinary activity, comfortable at rest; Class III = symptoms with less-than-ordinary activity, comfortable only at rest; Class IV = symptoms at rest. This patient is comfortable at rest and on level ground but symptomatic on stair-climbing — that is ordinary activity, making her NYHA Class II.
Click to reveal answer
A patient with known heart failure is brought to the emergency department with acute decompensation. Which of the following is the MOST common precipitant of acute decompensated heart failure in a patient on optimised therapy?
Correct. Non-compliance with salt restriction or prescribed medications is the single most common precipitant of acute decompensated heart failure in patients who have established, previously compensated heart failure. Other important precipitants include new arrhythmias (especially atrial fibrillation), ischaemia, infections (especially pneumonia), anaemia, uncontrolled hypertension, and nephrotoxic drugs (especially NSAIDs).
Non-compliance (salt and medications) is the most common precipitant of ADHF. Arrhythmia (especially AF), ischaemia, infection, and anaemia are the next most important. NSAIDs cause sodium and water retention and reduce the efficacy of diuretics and ACE inhibitors — a drug-related precipitant often overlooked.
The most common precipitants of acute decompensation in established heart failure are: (1) non-compliance with medications or dietary sodium restriction — the single most common cause; (2) new atrial fibrillation or other arrhythmia; (3) myocardial ischaemia; (4) infection; (5) anaemia; (6) uncontrolled hypertension. Spontaneous worsening without a precipitant is uncommon.
Click to reveal answer
A 50-year-old man with a dilated left ventricle develops atrial fibrillation. His CHA2DS2-VASc score is: Congestive heart failure (1), Age 50 years (0), Diabetes mellitus (1), prior Stroke (2). What is his total CHA2DS2-VASc score, and what anticoagulation threshold does this reach?
Correct. The CHA2DS2-VASc score for this patient: C (CHF) = 1, H (Hypertension) = 0, A (Age 50, not 65-74 or 75+) = 0, D (Diabetes) = 1, S2 (prior Stroke/TIA) = 2, V (Vascular disease) = 0, A (Age category 2) = 0, Sc (Sex category female) = 0. Total = 4. A score of 2 or more in males (or 3 or more in females) indicates anticoagulation is recommended. A score of 4 is well above the threshold and anticoagulation is clearly indicated.
CHA2DS2-VASc components: CHF (1), Hypertension (1), Age 75+ (2), Diabetes (1), prior Stroke/TIA (2), Vascular disease (1), Age 65-74 (1), Sex category female (1). Target INR for AF with warfarin = 2-3 (NOT 2.5-3.5, which applies only to mechanical mitral valve replacement).
CHA2DS2-VASc: C=1 (CHF), H=0, A=0 (age 50 earns no point — age 65-74=1 point, 75+=2 points), D=1 (diabetes), S2=2 (prior stroke), V=0, A2=0, Sc=0. Total = 4. Anticoagulation is recommended when the score is 2 or more for males (or 3 or more for females). A score of 4 clearly indicates anticoagulation.
Click to reveal answer
A patient with heart failure secondary to rheumatic mitral valve disease undergoes mechanical mitral valve replacement. He is started on warfarin. What is the target INR range for this patient?
Correct. The target INR for patients with a mechanical mitral valve replacement is 2.5 to 3.5 — a higher range than for atrial fibrillation or bioprosthetic valves (where INR 2.0-3.0 is used). The mitral position is higher-risk for thromboembolism than the aortic position because of lower-velocity flow on the left side of the heart and the larger valve orifice area.
INR 2.0-3.0 = standard target for AF, deep vein thrombosis, pulmonary embolism, bioprosthetic valves. INR 2.5-3.5 = mechanical mitral valve replacement (higher thromboembolism risk). This distinction is a classic exam trap.
INR targets: AF or bioprosthetic valve = 2.0-3.0; mechanical mitral valve replacement = 2.5-3.5 (higher, due to greater thromboembolism risk in the mitral position); mechanical aortic valve (low risk) = 2.0-3.0. The mechanical mitral target of 2.5-3.5 is a commonly tested distinction from the standard AF range.
Click to reveal answer
A 62-year-old woman with heart failure has an echocardiogram showing LVEF of 55%, left ventricular hypertrophy, impaired relaxation (E/A ratio 0.8, E/e' 16), and elevated filling pressures. What type of heart failure does she have, and what is the primary pathophysiological mechanism?
Correct. An LVEF of 55% (above 50%) with symptoms of heart failure = HFpEF. The echocardiographic pattern of impaired relaxation (reduced E/A ratio) and elevated filling pressures (E/e' above 14) confirms diastolic dysfunction as the primary mechanism. The ventricle is stiff and fails to relax properly during diastole, causing elevated filling pressures despite preserved systolic function.
HFpEF (LVEF 50% or greater): the ventricle contracts well but is stiff. Diastolic dysfunction causes elevated filling pressures and pulmonary congestion symptoms despite normal LVEF. Common causes: hypertension (most common), diabetes, obesity, atrial fibrillation.
LVEF 55% (above 50%) = HFpEF. The primary mechanism is diastolic dysfunction — impaired ventricular relaxation and reduced compliance — which causes elevated filling pressures even though the systolic ejection fraction is preserved. E/A ratio below 0.8 and E/e' above 14 are Doppler markers of diastolic dysfunction. Hypertension is the most common cause of HFpEF.
Click to reveal answer
A 55-year-old man with ischaemic cardiomyopathy and LVEF 32% develops worsening orthopnoea. On auscultation you hear a low-pitched sound at the cardiac apex in early diastole, best heard with the patient in the left lateral decubitus position. What is this sound, and what does it indicate?
Correct. A third heart sound (S3) is a low-pitched early diastolic sound, best heard at the apex with the bell of the stethoscope, with the patient in the left lateral decubitus position. It reflects rapid ventricular filling in early diastole against a compliant but volume-overloaded ventricle. In adults over 40 years, S3 is pathological and has high specificity for elevated filling pressures and ventricular dysfunction. It is the highest-specificity physical sign for decompensated heart failure.
S3 gallop: low-pitched, early diastole, heard best at the apex with the bell, left lateral decubitus position. Reflects elevated ventricular filling pressures. Most specific physical sign for decompensated heart failure in adults. The three best signs for elevated LVFP: S3 gallop (highest specificity), displaced apex beat, and elevated JVP.
An early diastolic low-pitched sound at the apex in a patient with heart failure = S3 gallop. S3 occurs during rapid ventricular filling (protodiastole) and indicates elevated filling pressures and volume overload. S4 occurs in late diastole (presystole) due to atrial contraction against a stiff ventricle. An opening snap is high-pitched and heard best medially in mitral stenosis.
Click to reveal answer
A 48-year-old woman with dilated cardiomyopathy is on maximal medical therapy. Her physician adds an aldosterone antagonist to her ACE inhibitor, beta-blocker, and loop diuretic. Which of the following is the PRIMARY monitoring concern when adding spironolactone in this patient?
Correct. Aldosterone antagonists (spironolactone, eplerenone) are potassium-sparing and can cause dangerous hyperkalaemia, especially when combined with ACE inhibitors/ARBs (which also raise potassium by reducing angiotensin II-mediated aldosterone release) and when there is concurrent renal impairment. Serum potassium and renal function must be checked within 1-2 weeks of initiating therapy and regularly thereafter. Spironolactone should be avoided if eGFR is below 30 mL/min/1.73m2.
Four pillars of HFrEF pharmacotherapy: ACE inhibitor/ARB/ARNI + beta-blocker + aldosterone antagonist + SGLT2 inhibitor. Spironolactone monitoring: serum potassium and creatinine at 1-2 weeks, then regularly. Stop if potassium exceeds 5.5 mmol/L or creatinine rises significantly. Avoid if eGFR below 30.
Spironolactone and eplerenone block aldosterone and cause potassium retention (potassium-sparing effect), not potassium loss. The primary risk is hyperkalaemia, which is amplified by concurrent ACE inhibitor/ARB use and renal impairment. Regular monitoring of serum potassium and creatinine is mandatory after initiation.
Click to reveal answer
A 60-year-old man with chronic heart failure secondary to hypertensive cardiomyopathy has a BNP of 650 pg/mL. What does an elevated BNP indicate, and what is its clinical utility in this context?
Correct. Brain natriuretic peptide (BNP) and NT-proBNP are released by ventricular cardiomyocytes in response to increased wall stress (elevated filling pressures and volume overload). An elevated BNP in a patient presenting with dyspnoea supports the diagnosis of heart failure over non-cardiac causes, and the level correlates with severity and prognosis. BNP is not a marker of myocardial necrosis — that is troponin. A BNP below 35 pg/mL or NT-proBNP below 125 pg/mL makes heart failure unlikely.
BNP < 35 pg/mL or NT-proBNP < 125 pg/mL makes heart failure unlikely (high negative predictive value). BNP rises with increased ventricular wall stress, not necrosis. Elevated BNP also occurs in AF, pulmonary hypertension, and renal failure — so it is not specific to heart failure alone but is very useful in context.
BNP and NT-proBNP are natriuretic peptides released by ventricular myocytes in response to elevated wall stress and filling pressures. They are not markers of necrosis (that is troponin). Elevated BNP supports the diagnosis of heart failure and correlates with severity and prognosis. A normal BNP virtually excludes heart failure as the cause of dyspnoea.
Click to reveal answer
A 70-year-old woman with rheumatic heart disease presents with progressive dyspnoea. Auscultation reveals a mid-diastolic rumbling murmur at the cardiac apex, loudest in the left lateral decubitus position, with a presystolic accentuation. What is the most likely underlying valvular lesion, and what is its haemodynamic consequence?
Correct. Mitral stenosis produces a mid-diastolic rumbling (low-pitched) murmur at the cardiac apex, best heard in the left lateral decubitus position with the bell of the stethoscope. Presystolic accentuation is a characteristic feature when sinus rhythm is preserved. The haemodynamic consequence is obstruction to left ventricular filling, causing elevated left atrial pressure, pulmonary hypertension, right heart failure, and reduced cardiac output.
Mitral stenosis murmur: mid-diastolic, low-pitched rumble, apex, left lateral decubitus, presystolic accentuation (in sinus rhythm). Opening snap precedes the murmur. Causes: almost always rheumatic in India. Consequence: elevated LA pressure -> pulmonary hypertension -> right heart failure.
A mid-diastolic rumble at the apex with presystolic accentuation in a patient with rheumatic heart disease = mitral stenosis. This is caused by the narrowed mitral valve orifice obstructing blood flow from the left atrium to the left ventricle during diastole. The result is elevated left atrial pressure, pulmonary congestion, and — in advanced disease — right heart failure.
Click to reveal answer