Heart Failure Practice Questions With
complete Answers
PJ is a 63-year-old woman presenting with NYHA class III HF, a recent 5-pound weight gain and
worsening dyspnea on exertion. Her current medications include lisinopril 20 mg daily, carvedilol
25 mg twice daily, furosemide 40 mg twice daily, celecoxib 100 mg twice daily, metformin 1000
mg twice daily, and levothyroxine 125 mcg daily. Today, PJ's vital signs are stable and her labs
include potassium 2.9 mmol/L and serum creatinine 0.7 mg/dL. Utilizing a mutually beneficial
pharmacodynamic drug-drug interaction, which of the following is the best treatment option to
manage PJ's hypokalemia and fluid overload as well as advance her guideline-directed medical
therapy for HF? Select all that apply.
A: Continue furosemide 40 mg twice daily.
B: Increase furosemide to 80 mg twice daily
C: Initiate spironolactone 25 mg once daily.
D: Initiate hydrochlorothiazide 25 mg daily. - ANS Answers b and c are correct. Increasing
the furosemide dose alone is inappropriate, as it will further decrease PJ's low serum
potassium. The addition of spironolactone along with the increased diuretic dose would provide
additional mortality benefit as well as potassium retention. When added to standard HF therapy
in patients with NYHA class II to IV symptoms, spironolactone has been shown to reduce
mortality. Spironolactone monotherapy at the low doses used to reduce mortality in HF does not
commonly result in clinically meaningful diuresis. It is important to recognize that spironolactone
alone may be insufficient to maintain adequate serum potassium levels, and close monitoring is
indicated as the addition of a potassium supplement may be required.
JC is a 64-year-old African American man with recently diagnosed HFrEF presenting with a
2-week history of SOB which limits his normal daily activities and increased lower extremity
edema. His weight has recently increased by 10 pounds. His physical examination is notable for
BP 148/72 mm Hg, HR 68 bpm, RR 24 breaths/min rales, and 3+ lower extremity edema.
Pertinent laboratory values include: sodium 138 mmol/L, potassium 5.4 mmol/L, BUN 35 mg/dL,
and creatinine 0.9 mg/dL. Past medical history is significant for HTN and COPD. Current
medications include lisinopril 20 mg daily, metoprolol XL 50 mg daily, and salmeterol/fluticasone
250/50 two puffs twice daily. In addition to counseling on salt and fluid restriction, which of the
following pharmacologic options is most appropriate for managing JC's fluid overload?
A: Initiate hydrochlorothiazide 50 mg daily.
B: Initiate furosemide 40 mg twice daily.
C: Initiate metolaz - ANS Answer b is correct. Loop diuretics, such as furosemide, are the
treatment of choice for managing volume overload in HF patients.
In which of the following scenarios should spironolactone be avoided? Select all that apply.
,A: Serum potassium <3.5 mmol/L
B: Creatinine clearance <30 mL/min
C: Concomitant sacubitril/valsartan therapy
D: NYHA class III to IV despite standard HF therapy
E: Serum potassium >5 mmol/L - ANS Answers b and e are correct. Aldosterone
antagonists (ARA) such as spironolactone can cause hyperkalemia and renal dysfunction and
thus should be avoided in patients with a serum potassium greater than 5 mmol/L (Answer e).
Patients with creatinine clearance less than30 mL/min (Answer b) are at higher risk of
hyperkalemia and thus is a contraindication to ARA therapy.
RH is a 45-year-old woman with nonischemic cardiomyopathy (presumed viral origin). She
presents to the clinic in a euvolemic state with vital signs of BP 92/63 mm Hg and HR 95 bpm.
She has been hospitalized twice in the past 3 months. Unfortunately, these hospitalizations have
been associated with episodes of acute on chronic renal failure and her renal function now
fluctuates significantly. Current medications include bumetanide 4 mg daily, metolazone 5 mg
every other day, sacubitril/valsartan 49/51 mg twice daily, and metoprolol XL 150 mg daily.
Which of the following would reduce the likelihood of RH being readmitted to the hospital?
A: Increase metoprolol XL to 200 mg daily.
B: Increase sacubitril/valsartan to 97/103 mg twice daily.
C: Initiate digoxin 0.125 mg daily.
D: Initiate ivabradine 5 mg twice daily. - ANS Answer d is correct. RH's β-blocker dose
cannot be up-titrated to target dose (200 mg daily) due to low BP. Given the patient is in normal
sinus rhythm with HR greater than 70 bpm despite maximally tolerated β-blocker, ivabradine is
indicated. While ivabradine does not reduce mortality, it does reduce hospitalizations.
A patient calls the pharmacy and reports that her physician recently increased her metoprolol
succinate from 100 mg to 150 mg to treat her NYHA class II HF. She asks if she may continue to
use the 100-mg tablets she has at home. What is the most appropriate recommendation?
A: Recommend that she contact her physician because metoprolol succinate cannot be split in
half.
B: Recommend taking 1.5 of the 100 mg tablets because metoprolol succinate tablets can be
split in half.
C: Recommend she speak to her provider about switching to metoprolol tartrate as this is the
preferred formulation for patients with HF.
D: Recommend she speak to her provider about switching to atenolol as this is an
evidence-based β-blocker for patients with HF. - ANS Answers b is correct. While
metoprolol succinate is controlled/extended release, it is a scored tablet and can be split. It
cannot be crushed or chewed.
RJ is a 61-year-old woman with a history of ischemic cardiomyopathy who presents to clinic with
symptoms consistent with NYHA class IV HF. Past medical history includes hyperlipidemia,
diabetes mellitus, MI, and hypothyroidism. RJ complains of progressive weight gain (∼6 pound
increase since her last visit 3 months ago), SOB at rest, 2 pillow orthopnea, and occasional
paroxysmal nocturnal dyspnea (PND). Her physical examination is positive for 1+ pitting edema
, in her ankles and minimal jugular vein distention (JVD). Vital signs include BP 105/70 mm Hg
and HR 91 bpm. Laboratory results include: potassium 3.6 mmol/L, BUN 39 mg/dL, and
creatinine 1.4 mg/dL (baseline creatinine 1.2-1.6 mg/dL). RJ's current medications include
levothyroxine 50 mcg daily, furosemide 40 mg twice daily, lisinopril 20 mg daily, atorvastatin 40
mg daily, aspirin 81 mg daily, insulin glargine 46 units at bedtime, and insulin aspart 6 units befo
- ANS Answer b is correct. Given the mortality benefit associated with β-blockers in HF, this
medication should be part of the patient's medical regimen. β-Blockers should be initiated at the
lowest dose (eg, metoprolol succinate 12.5 mg or 25 mg daily) and then slowly up-titrated.
However, β-blockers should only be initiated once euvolemia is achieved.
Which of the following therapies decreases HR via inhibition of the If current in the sinoatrial
node?
A: Metoprolol succinate
B: Carvedilol
C: Digoxin
D: Ivabradine - ANS Answer d is correct.Ivabradine inhibits If current in the sinoatrial node,
leading to reductions in HR without affecting myocardial contractility.
CM is a 54-year old African American female with HFrEF (NYHA class III-IV) receiving
bumetanide 2 mg twice daily, enalapril 10 mg twice daily, metoprolol XL 150 mg daily, and
spironolactone 25 mg daily. Her vital signs include BP 129/78 mm Hg and HR 86 bpm. The
medical team would like to initiate combination hydralazine and ISDN in CM. Which of the
following statements are true regarding ISDN? Select all that apply.
A
Initiate therapy in African American patients with NYHA class III-IV HFrEF.
B
Discontinue background ACE inhibitor/ARB therapy.
C
Lower doses may be used in patients who develop a headache with therapy.
D
Discontinue background β-blocker therapy. - ANS Answers a and c are correct. In African
American patients with NYHA class III-IV HFrEF, hydralazine and ISDN should be initiated to
reduce morbidity and mortality. Headache is a common adverse effect of ISDN that usually
responds to initiating lower doses or temporarily reducing the dose.
IH is a 44-year-old African American man with NYHA class II HF presenting with dizziness and
orthostatic hypotension. His laboratory values reveal the following: potassium 5.8 mmol/L, BUN
60 mg/dL (baseline 18 mg/dL), serum creatinine 2.0 mg/dL (baseline 0.9 mg/dL). IH's
medications include furosemide 80 mg twice daily, ramipril 5 mg twice daily, and metoprolol XL
50 mg daily. Which of the following immediate medication adjustments are appropriate? Select
all that apply.
A
Temporarily hold furosemide.
B
