I85PREP
⌘ K
ABIM Advanced HF study materials
ABIM Advanced HF study resources

ABIM Advanced HF practice questions

One question at a time. Build your ABIM Advanced HF understanding.

First 50 of 199 questions. Each one lists the choices, the correct answer, and an explanation. The checker at the top of this page saves progress in this browser when it is available.

Continue in the practice tool above to load more questions, 50 at a time.

Question 1Heart Failure Diagnosis and Management

Which description best fits advanced (stage D) heart failure?

  1. Symptoms only with strenuous exertion and normal biomarkers
  2. Structural heart disease without symptoms or biomarker elevation
  3. Symptoms at rest or minimal exertion despite therapy Correct answer.
  4. NYHA class I symptoms with preserved ejection fraction

Explanation

Advanced heart failure is characterized by severe symptoms at rest or with minimal exertion despite optimized guideline-directed therapy, often with recurrent hospitalizations. Stage B is structural disease without symptoms, while stage C includes current or prior symptoms.

Question 2Heart Failure Diagnosis and Management

Which factor most commonly lowers NT-proBNP relative to the degree of heart failure?

  1. Atrial fibrillation
  2. Older age
  3. Chronic kidney disease
  4. Obesity Correct answer.

Explanation

Obesity reduces natriuretic peptide concentrations through decreased synthesis and increased clearance, so NT-proBNP may be lower than expected. Chronic kidney disease, atrial fibrillation, and older age tend to raise natriuretic peptide levels.

Question 3Heart Failure Diagnosis and Management

A patient with heart failure symptoms has an LVEF of 45%. Which category applies?

  1. Normal ejection fraction
  2. HFpEF
  3. HFmrEF Correct answer.
  4. HFrEF

Explanation

HFmrEF is defined by an LVEF of 41% to 49% with symptoms or signs of heart failure. HFrEF is an LVEF of 40% or less, and HFpEF is an LVEF of 50% or greater.

Question 4Heart Failure Diagnosis and Management

Before starting sacubitril/valsartan in a patient taking an ACE inhibitor, what washout period is recommended?

  1. 24 hours
  2. 36 hours Correct answer.
  3. 12 hours
  4. 6 hours

Explanation

An ARNI and an ACE inhibitor must not be used together because of the risk of angioedema. A 36-hour washout after stopping the ACE inhibitor is recommended before starting sacubitril/valsartan.

Question 5Heart Failure Diagnosis and Management

In acute decompensated heart failure with congestion and stable blood pressure, what is the best approach to beta-blocker initiation?

  1. Start carvedilol immediately at target dose
  2. Give intravenous metoprolol to all patients
  3. Initiate low-dose beta blocker before decongestion
  4. Defer until euvolemic and clinically stable Correct answer.

Explanation

Beta blockers are generally started once the patient is euvolemic and clinically stable, beginning at low dose with gradual titration. Starting during active congestion can worsen hemodynamics.

Question 6Heart Failure Diagnosis and Management

Which finding is a contraindication to starting spironolactone in HFrEF?

  1. LVEF 30% and NYHA II
  2. Systolic BP 110 mmHg
  3. eGFR 25 and potassium 5.3 Correct answer.
  4. eGFR 60 and potassium 4.2

Explanation

An MRA should not be initiated when eGFR is below 30 or potassium is above 5.0 because of the risk of hyperkalemia and renal worsening. Close monitoring is required when an MRA is used.

Question 7Heart Failure Diagnosis and Management

Which drug class reduces heart failure hospitalization in HFpEF?

  1. Ivabradine
  2. Digoxin
  3. SGLT2i Correct answer.
  4. Amlodipine

Explanation

SGLT2 inhibitors reduce heart failure hospitalization in HFpEF and are recommended in management. Ivabradine is used in HFrEF with sinus rhythm and elevated heart rate despite beta blockade.

Question 8Heart Failure Diagnosis and Management

Primary prevention ICD therapy in ischemic HFrEF is indicated with an LVEF of 35% or less despite at least 3 months of GDMT and which NYHA class?

  1. NYHA I only
  2. NYHA IV ambulatory
  3. NYHA IV refractory
  4. NYHA II-III Correct answer.

Explanation

Primary prevention ICD therapy is indicated for LVEF of 35% or less with NYHA class II or III symptoms on optimal medical therapy. It is not intended for NYHA IV refractory symptoms unless other advanced therapies are planned.

Question 9Heart Failure Diagnosis and Management

Which variable is part of the H2FPEF score for HFpEF?

  1. Serum sodium
  2. Troponin level
  3. Atrial fibrillation Correct answer.
  4. Coronary artery disease

Explanation

The H2FPEF score incorporates heavy habitus, hypertension, atrial fibrillation, pulmonary hypertension, elder age, and elevated filling pressures. Coronary disease, sodium, and troponin are not components.

Question 10Heart Failure Diagnosis and Management

A patient with acute heart failure receives IV furosemide 40 mg and produces 300 mL of urine in 6 hours. What is the best next step?

  1. Add oral hydrochlorothiazide after discharge
  2. Stop diuretics and give fluids
  3. Escalate IV loop diuretic dosing Correct answer.
  4. Start beta blocker

Explanation

Poor urine output after an initial IV loop diuretic dose warrants escalating the loop diuretic dose or using a continuous infusion. Adjunctive thiazide therapy may be added if response remains inadequate.

Question 11Heart Failure Diagnosis and Management

A patient on sacubitril/valsartan and spironolactone has potassium 5.8 mmol/L and eGFR 35. What is the best management?

  1. Continue all and repeat in 1 week
  2. Add potassium supplement
  3. Hold MRA and consider potassium binder Correct answer.
  4. Start ACE inhibitor instead

Explanation

Marked hyperkalemia in a patient taking an MRA requires holding the MRA, reviewing dietary potassium, and considering a potassium binder. RAAS inhibitor therapy may be continued with close monitoring when appropriate.

Question 12Heart Failure Diagnosis and Management

Intravenous iron in HFrEF with iron deficiency most consistently improves which outcome?

  1. Mortality
  2. Left ventricular ejection fraction
  3. Quality of life Correct answer.
  4. Serum sodium

Explanation

IV iron improves symptoms and quality of life and reduces heart failure hospitalizations in iron-deficient HFrEF. A clear mortality benefit has not been established.

Question 13Heart Failure Diagnosis and Management

A 72-year-old with HFpEF, low voltage, increased LV wall thickness, and grade 2-3 Tc-PYP uptake needs which next test?

  1. Coronary angiography
  2. Light-chain testing Correct answer.
  3. Genetic testing only
  4. Endomyocardial biopsy always

Explanation

Tc-PYP uptake suggests transthyretin cardiac amyloidosis, but monoclonal light-chain disease must be excluded first. Serum free light chains and serum/urine immunofixation are required before confirming ATTR amyloidosis.

Question 14Heart Failure Diagnosis and Management

A patient with cardiogenic shock has BP 78/50 mmHg, cold extremities, and pulmonary congestion. What initial vasoactive strategy is most appropriate?

  1. High-dose furosemide alone
  2. Oral metoprolol
  3. Norepinephrine first Correct answer.
  4. Nitroprusside alone

Explanation

Norepinephrine is first-line for hypotension in cardiogenic shock, with an inotrope added if hypoperfusion persists. Vasodilators and beta blockers may worsen hypotension in this setting.

Question 15Heart Failure Diagnosis and Management

Which scenario best supports pulmonary artery catheter use in advanced heart failure?

  1. Guide diuretic dose in stable outpatients
  2. Mild HFpEF with stable symptoms
  3. Routine use in all decompensated HF
  4. Uncertain volume status in refractory shock Correct answer.

Explanation

Pulmonary artery catheterization is not routine but is useful when hemodynamics are uncertain, such as refractory or mixed shock. It can help distinguish cardiogenic from other shock states and guide therapy.

Question 16Heart Failure Diagnosis and Management

CRT is most clearly indicated in HFrEF with LVEF 35% or less, sinus rhythm, and which QRS pattern?

  1. QRS <120
  2. QRS 120-149 without LBBB
  3. QRS 120-149 with LBBB
  4. QRS ≥150 with LBBB Correct answer.

Explanation

The strongest CRT indication is sinus rhythm with LBBB and QRS duration of 150 ms or greater. LBBB with QRS 120-149 ms is a weaker consideration.

Question 17Heart Failure Diagnosis and Management

Ivabradine is most appropriate for which patient with HFrEF?

  1. Sinus rhythm with HR 58
  2. Sinus rhythm with HR 78 Correct answer.
  3. Second-degree AV block
  4. Atrial fibrillation with rapid ventricular response

Explanation

Ivabradine is indicated for HFrEF in sinus rhythm with a heart rate of 70 bpm or higher despite maximally tolerated beta blockade. It is not used in atrial fibrillation or in bradyarrhythmias.

Question 18Heart Failure Diagnosis and Management

Which patient with HFrEF is most likely to benefit from adding hydralazine/isosorbide dinitrate to guideline-directed therapy?

  1. Patient with severe aortic stenosis
  2. White patient with mild HF and normal BP
  3. Self-identified Black patient with NYHA III symptoms Correct answer.
  4. Patient with symptomatic hypotension from ARNI

Explanation

Hydralazine/isosorbide dinitrate improves survival in self-identified Black patients with HFrEF on standard therapy, particularly with NYHA III-IV symptoms. It is also used in patients who cannot tolerate ACE inhibitors or ARBs.

Question 19Heart Failure Diagnosis and Management

A 70-year-old with HFpEF, hypertension, atrial fibrillation, and obesity needs therapy with the best evidence to reduce heart failure hospitalization. Which agent is most appropriate?

  1. Routine nitrate
  2. Digoxin
  3. SGLT2 inhibitor Correct answer.
  4. Dihydropyridine calcium channel blocker

Explanation

SGLT2 inhibitors reduce heart failure hospitalization in HFpEF and are recommended. Management should also address congestion, hypertension, atrial fibrillation, and obesity.

Question 20Heart Failure Diagnosis and Management

A 45-year-old with HF, LVEF 35%, complete heart block, and myocardial FDG-PET uptake has suspected cardiac sarcoidosis. What is the best management?

  1. Continue standard HF therapy only
  2. Start high-dose NSAIDs
  3. Immediate heart transplant
  4. Refer for ICD/CRT and immunosuppression Correct answer.

Explanation

Cardiac sarcoidosis with AV block and active myocardial inflammation warrants immunosuppression plus device therapy because of the risk of ventricular arrhythmia and conduction disease. Transplantation is reserved for refractory advanced disease.

Question 21Heart Failure Diagnosis and Management

Which patient with advanced heart failure is most appropriate for durable LVAD evaluation?

  1. NYHA IV refractory to inotropes, irreversible end-organ failure, not transplant candidate
  2. Acute myocarditis with rapid recovery
  3. NYHA IIIB-IV on optimal therapy with recurrent admissions Correct answer.
  4. NYHA II with LVEF 40% and no hospitalizations

Explanation

Durable LVAD therapy is considered for advanced HF with high mortality despite optimal therapy, either as a bridge to transplant or as destination therapy. Significant irreversible end-organ failure makes LVAD support inappropriate.

Question 22Heart Failure Diagnosis and Management

Which is an absolute contraindication to heart transplantation?

  1. Treated hypertension
  2. Active poor-prognosis malignancy Correct answer.
  3. Age 68
  4. Diabetes without end-organ damage

Explanation

Active malignancy with a poor prognosis is an absolute contraindication to heart transplantation. Older age and well-controlled hypertension or diabetes without end-organ damage are relative considerations rather than absolute contraindications.

Question 23Heart Failure Diagnosis and Management

A patient with prior mediastinal radiation has HFpEF, elevated JVP, a pericardial knock, and respiratory variation in mitral inflow on echocardiography. What is the most likely diagnosis?

  1. Restrictive cardiomyopathy
  2. Cardiac amyloidosis
  3. Constrictive pericarditis Correct answer.
  4. HFpEF from hypertension

Explanation

Constrictive pericarditis impairs diastolic filling and classically causes a pericardial knock, elevated JVP, and respiratory variation in mitral inflow velocities. Prior mediastinal radiation is an important risk factor.

Question 24Heart Failure Diagnosis and Management

A patient with acute heart failure has worsening creatinine after diuresis but adequate urine output and no hyperkalemia. What is the best approach?

  1. Fluid bolus
  2. Start dopamine
  3. Continue decongestion Correct answer.
  4. Stop diuretic

Explanation

A modest creatinine rise during effective decongestion is common and does not by itself require stopping diuresis. Decongestion should continue with monitoring if the patient remains congested and urine output is adequate.

Question 25Heart Failure Diagnosis and Management

A patient with NYHA IV heart failure, recurrent admissions, and no transplant or LVAD option wants symptom relief. What is most appropriate?

  1. Add palliative care alongside HF management Correct answer.
  2. Discontinue all HF medications
  3. Avoid discussing prognosis
  4. Refer only when death is imminent

Explanation

Palliative care should be integrated early in advanced heart failure to manage symptoms and align care with patient goals. It is provided alongside guideline-directed heart failure therapy rather than replacing it.

Question 26Heart Failure Diagnosis and Management

A 68-year-old woman with a BMI of 38 kg/m² and chronic dyspnea has a plasma BNP of 85 pg/mL. Which factor most likely lowers her BNP relative to her degree of congestion?

  1. Renal impairment
  2. Obesity Correct answer.
  3. Advanced age
  4. Atrial fibrillation

Explanation

Obesity reduces natriuretic peptide concentrations through increased clearance and decreased synthesis, so BNP can be lower than expected for the degree of congestion. Renal impairment, atrial fibrillation, and older age all tend to raise natriuretic peptide levels.

Question 27Heart Failure Diagnosis and Management

A patient with HFrEF is transitioning from lisinopril 20 mg daily to sacubitril/valsartan. How long should the ACE inhibitor be withheld before the first dose of sacubitril/valsartan?

  1. 24 hours
  2. 12 hours
  3. 72 hours
  4. 36 hours Correct answer.

Explanation

A 36-hour washout is required when switching from an ACE inhibitor to sacubitril/valsartan to avoid angioedema from overlapping bradykinin and neprilysin inhibition. Shorter intervals increase that risk, and a longer hold is unnecessary.

Question 28Heart Failure Diagnosis and Management

In patients with HFrEF, dapagliflozin most consistently reduces which outcome regardless of diabetes status?

  1. Myocardial infarction
  2. Ischemic stroke
  3. All-cause hospital admission
  4. CV death or worsening HF Correct answer.

Explanation

Dapagliflozin reduced the composite of cardiovascular death or worsening heart failure in HFrEF trials independent of diabetes. It has not shown consistent reductions in stroke or myocardial infarction.

Question 29Heart Failure Diagnosis and Management

A patient is admitted with acute decompensated HFrEF, orthopnea, and elevated JVP and is not taking a beta-blocker. When is initiation of a beta-blocker most appropriate?

  1. After decongestion and stabilization Correct answer.
  2. During the first 24 hours of diuresis
  3. Only after discharge
  4. Immediately on admission

Explanation

Beta-blockers should be started when the patient is euvolemic and clinically stable, not during acute decompensation when negative inotropy may worsen congestion. Initiation before stabilization can precipitate worsening heart failure.

Question 30Heart Failure Diagnosis and Management

Which laboratory pattern defines iron deficiency in HFrEF as used in intravenous iron trials?

  1. Ferritin <30 ng/mL regardless of transferrin saturation
  2. Ferritin <100 ng/mL or 100-299 ng/mL with TSAT <20% Correct answer.
  3. Ferritin >300 ng/mL with TSAT <20%
  4. TSAT <10% regardless of ferritin

Explanation

The standard trial definition is ferritin below 100 ng/mL, or ferritin 100-299 ng/mL with transferrin saturation below 20%. This identifies patients who may benefit from intravenous iron.

Question 31Heart Failure Diagnosis and Management

Which medication should be avoided in HFrEF because it can worsen systolic function and increase mortality?

  1. Metoprolol succinate
  2. Sacubitril/valsartan
  3. Diltiazem Correct answer.
  4. Spironolactone

Explanation

Non-dihydropyridine calcium-channel blockers such as diltiazem have negative inotropic effects and are associated with worse outcomes in HFrEF. Beta-blockers, ARNI, and mineralocorticoid receptor antagonists are guideline-directed therapies.

Question 32Heart Failure Diagnosis and Management

A patient with acute decompensated heart failure and volume overload has inadequate urine output on oral furosemide. What is the most appropriate initial step?

  1. Give IV loop diuretic Correct answer.
  2. Begin ultrafiltration
  3. Add oral hydrochlorothiazide
  4. Start oral metolazone

Explanation

Intravenous loop diuretic is the first step for acute congestion with inadequate response to oral therapy because it ensures reliable delivery and higher peak concentrations. Thiazides or ultrafiltration are considered if the response remains inadequate.

Question 33Heart Failure Diagnosis and Management

Which NYHA functional class describes a patient with heart failure symptoms at rest?

  1. Class I
  2. Class IV Correct answer.
  3. Class III
  4. Class II

Explanation

NYHA class IV denotes symptoms of heart failure at rest. Class I has no limitation, class II has symptoms with ordinary activity, and class III has symptoms with less than ordinary activity.

Question 34Heart Failure Diagnosis and Management

A patient with HFrEF and permanent atrial fibrillation has a resting ventricular rate of 110 bpm despite maximally tolerated metoprolol succinate. Which agent is most appropriate to add for rate control?

  1. Ivabradine
  2. Digoxin Correct answer.
  3. Diltiazem
  4. Amiodarone

Explanation

Digoxin can be added for ventricular rate control in HFrEF with atrial fibrillation when beta-blocker therapy is insufficient. Ivabradine acts only in sinus rhythm, diltiazem is avoided in HFrEF, and amiodarone is not first-line rate control.

Question 35Heart Failure Diagnosis and Management

A patient with HFpEF and increased LV wall thickness has low voltage on ECG. Which test is most important to exclude AL cardiac amyloidosis?

  1. Serum free light chains and protein electrophoresis Correct answer.
  2. Transthyretin genetic testing
  3. Endomyocardial biopsy
  4. Technetium-99m pyrophosphate scintigraphy

Explanation

AL amyloidosis must be excluded with serum free light chains and serum/urine protein electrophoresis before attributing amyloidosis to ATTR. Technetium-99m pyrophosphate scintigraphy and transthyretin genetic testing evaluate ATTR, not AL.

Question 36Heart Failure Diagnosis and Management

A woman develops HFrEF with LVEF 30% one month after delivery. Which medication should be avoided while she is breastfeeding?

  1. Metoprolol succinate
  2. Furosemide
  3. Enalapril
  4. Sacubitril/valsartan Correct answer.

Explanation

Sacubitril/valsartan is not recommended during breastfeeding because of insufficient safety data. Enalapril, metoprolol, and furosemide are considered compatible with breastfeeding.

Question 37Heart Failure Diagnosis and Management

A patient receiving trastuzumab for breast cancer has a fall in LVEF from 60% to 45% without symptoms. What is the most appropriate next step?

  1. Continue trastuzumab and repeat echo in 3 months
  2. Hold trastuzumab and start HF therapy Correct answer.
  3. Start high-dose furosemide
  4. Refer for cardiac transplantation

Explanation

Trastuzumab should be held when LVEF falls to 45% or lower, or by 10% or more from baseline, and standard heart-failure therapy with an ACE inhibitor and beta-blocker should be started. Trastuzumab-related cardiotoxicity is often reversible.

Question 38Heart Failure Diagnosis and Management

Which sleep-disordered breathing pattern is most characteristic of HFrEF and often presents with Cheyne-Stokes respiration?

  1. Narcolepsy
  2. Obesity hypoventilation syndrome
  3. Obstructive sleep apnea
  4. Central sleep apnea Correct answer.

Explanation

Central sleep apnea with Cheyne-Stokes respiration is characteristic of HFrEF and reflects instability of ventilatory control. Obstructive sleep apnea also occurs but is not the pattern defined by Cheyne-Stokes respiration.

Question 39Heart Failure Diagnosis and Management

A patient with HFrEF and atrial fibrillation has a CHA2DS2-VASc score of 3. Which anticoagulation strategy is preferred?

  1. Warfarin with target INR 2-3
  2. No anticoagulation if rhythm controlled
  3. Aspirin alone
  4. Apixaban Correct answer.

Explanation

A direct oral anticoagulant such as apixaban is preferred over warfarin in eligible patients with atrial fibrillation and heart failure. Aspirin is inadequate for stroke prevention, and rhythm control does not remove the need for anticoagulation.

Question 40Heart Failure Diagnosis and Management

Which electrolyte abnormality most increases the risk of digoxin toxicity?

  1. Hypernatremia
  2. Hypocalcemia
  3. Hyperkalemia
  4. Hypokalemia Correct answer.

Explanation

Hypokalemia increases digoxin binding at the sodium-potassium ATPase and predisposes to toxicity, especially with diuretic use. Hyperkalemia can also be dangerous in acute digoxin toxicity but does not increase toxicity risk in the same way.

Question 41Heart Failure Diagnosis and Management

A patient with HFrEF remains congested despite high-dose intravenous furosemide and has developed diuretic resistance. Which combination is most appropriate to add?

  1. Loop diuretic plus spironolactone
  2. Loop diuretic plus beta-blocker
  3. Loop diuretic plus ACE inhibitor
  4. Loop diuretic plus thiazide Correct answer.

Explanation

Adding a thiazide produces sequential nephron blockade and can overcome distal sodium reabsorption in diuretic resistance. ACE inhibitors, beta-blockers, and spironolactone are guideline therapies but do not acutely augment diuresis.

Question 42Heart Failure Diagnosis and Management

A patient with HFrEF and recurrent symptomatic ventricular tachycardia despite optimal GDMT and revascularization is not a candidate for ICD. Which antiarrhythmic is safest?

  1. Verapamil
  2. Flecainide
  3. Amiodarone Correct answer.
  4. Sotalol

Explanation

Amiodarone is the preferred antiarrhythmic in structural heart disease because it has less proarrhythmic risk. Flecainide and verapamil are contraindicated in HFrEF, and sotalol carries a significant risk of torsades de pointes.

Question 43Heart Failure Diagnosis and Management

Which patient is most appropriate for implantation of a CardioMEMS pulmonary artery pressure sensor?

  1. NYHA III with prior HF admission on diuretic Correct answer.
  2. NYHA IV with cardiogenic shock
  3. NYHA I with no prior HF hospitalization
  4. HFpEF with normal natriuretic peptides

Explanation

CardioMEMS is indicated for patients with NYHA class III symptoms, a prior heart-failure hospitalization, and ongoing diuretic use. It is not for class I patients, cardiogenic shock, or those with normal natriuretic peptides.

Question 44Heart Failure Diagnosis and Management

Which intervention improves functional capacity and reduces HF hospitalization in stable HFrEF?

  1. Strict bed rest
  2. Routine oxygen therapy
  3. Cardiac rehabilitation Correct answer.
  4. High-dose vitamin E

Explanation

Exercise-based cardiac rehabilitation improves functional capacity and reduces heart-failure hospitalization in stable HFrEF. Bed rest promotes deconditioning, routine oxygen is not beneficial with normal saturation, and vitamin E has no proven role.

Question 45Heart Failure Diagnosis and Management

A patient with advanced HFrEF has serum sodium 128 mmol/L despite decongestion. Which therapy has been shown to improve symptoms without a mortality benefit?

  1. Tolvaptan Correct answer.
  2. Hypertonic saline
  3. Demeclocycline
  4. Fluid restriction to 500 mL/day

Explanation

Vasopressin receptor antagonists such as tolvaptan improve hyponatremia and symptoms but have not reduced mortality in heart failure. Hypertonic saline, severe fluid restriction, and demeclocycline are not first-line for this indication.

Question 46Heart Failure Diagnosis and Management

A patient with HFpEF has mean pulmonary artery pressure 42 mmHg, PCWP 14 mmHg, and PVR 4 Wood units. Which diagnosis best explains these findings?

  1. Normal hemodynamics
  2. Pre-capillary pulmonary hypertension Correct answer.
  3. Cardiogenic shock
  4. Post-capillary pulmonary hypertension due to HFpEF

Explanation

A mean pulmonary artery pressure above 20 mmHg with a normal PCWP and elevated pulmonary vascular resistance defines pre-capillary pulmonary hypertension. A PCWP of 14 mmHg does not support a post-capillary cause.

Question 47Heart Failure Diagnosis and Management

A patient with HFrEF and severe secondary mitral regurgitation remains symptomatic after 3 months of maximally tolerated GDMT and CRT. Which treatment is most likely to improve outcomes?

  1. Balloon mitral valvuloplasty
  2. Transcatheter edge-to-edge mitral valve repair Correct answer.
  3. Mitral valve replacement with mechanical prosthesis
  4. Observation alone

Explanation

Transcatheter edge-to-edge repair improves outcomes in selected patients with severe secondary mitral regurgitation and HFrEF who remain symptomatic despite GDMT and CRT. Mechanical replacement and balloon valvuloplasty are not first-line for secondary MR.

Question 48Heart Failure Diagnosis and Management

A patient with cardiac amyloidosis and HFpEF develops symptomatic hypotension after starting an ACE inhibitor. Which mechanism best explains this intolerance?

  1. Restrictive physiology makes the ventricle preload-dependent Correct answer.
  2. Amyloidosis causes fixed high cardiac output
  3. ACE inhibitors increase amyloid production
  4. ACE inhibitors directly deposit amyloid fibrils

Explanation

Cardiac amyloidosis produces a restrictive, stiff ventricle that depends on preload; vasodilators can cause profound hypotension. ACE inhibitors do not deposit amyloid or increase its production.

Question 49Heart Failure Diagnosis and Management

A patient with a continuous-flow LVAD presents with melena. Which bleeding mechanism is most characteristic?

  1. Acquired von Willebrand syndrome Correct answer.
  2. Disseminated intravascular coagulation
  3. Immune thrombocytopenia
  4. Vitamin K deficiency

Explanation

Continuous-flow LVADs cause shear stress that degrades von Willebrand factor multimers, leading to acquired von Willebrand syndrome and gastrointestinal bleeding. This is the characteristic bleeding mechanism in LVAD patients.

Question 50Heart Failure Diagnosis and Management

A heart transplant recipient develops new HF symptoms and elevated natriuretic peptides 6 months after transplant. Which test is the gold standard for diagnosing acute cellular rejection?

  1. Donor-specific antibody assay
  2. Endomyocardial biopsy Correct answer.
  3. Cardiac MRI
  4. Coronary angiography

Explanation

Endomyocardial biopsy remains the gold standard for diagnosing acute cellular rejection after heart transplantation. Donor-specific antibody testing is used for antibody-mediated rejection, and angiography evaluates cardiac allograft vasculopathy.