Heart Failure (HF) is a complex clinical syndrome characterized by the inability of the heart to pump sufficient blood to meet the body’s metabolic demands, or its ability to do so only at elevated filling pressures. It represents a major public health concern associated with significant morbidity, mortality, and healthcare expenditure. For PharmD students, a thorough understanding of the pathophysiology, classification, diagnosis, and comprehensive management (both pharmacological and non-pharmacological) of heart failure, including its different phenotypes like HFrEF and HFpEF, is essential for optimizing patient outcomes and providing effective pharmaceutical care. This MCQ quiz will test your knowledge on the multifaceted aspects of Heart Failure.
1. Heart Failure with reduced Ejection Fraction (HFrEF) is typically defined as a left ventricular ejection fraction (LVEF) of:
- A. > 50%
- B. ≤ 40%
- C. 41-49%
- D. > 60%
Answer: B. ≤ 40%
2. Which neurohormonal system is chronically activated in heart failure and contributes to adverse cardiac remodeling, vasoconstriction, and sodium/water retention?
- A. The parasympathetic nervous system
- B. The Renin-Angiotensin-Aldosterone System (RAAS) and Sympathetic Nervous System (SNS)
- C. The natriuretic peptide system
- D. The kinin-kallikrein system
Answer: B. The Renin-Angiotensin-Aldosterone System (RAAS) and Sympathetic Nervous System (SNS)
3. B-type Natriuretic Peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are released from the ventricles in response to:
- A. Decreased wall stress and volume overload
- B. Increased myocardial wall stress and volume overload
- C. Sympathetic nervous system inhibition
- D. Activation of the RAAS only
Answer: B. Increased myocardial wall stress and volume overload
4. Which of the following is a common symptom of left-sided heart failure?
- A. Peripheral edema
- B. Jugular venous distension
- C. Dyspnea, orthopnea, and paroxysmal nocturnal dyspnea
- D. Hepatomegaly
Answer: C. Dyspnea, orthopnea, and paroxysmal nocturnal dyspnea
5. The New York Heart Association (NYHA) Functional Classification for heart failure assesses:
- A. Left ventricular ejection fraction
- B. The severity of symptoms and limitations to physical activity
- C. The underlying cause of heart failure
- D. Cardiac biomarker levels
Answer: B. The severity of symptoms and limitations to physical activity
6. Which class of drugs is considered a cornerstone of therapy for all symptomatic HFrEF patients to reduce morbidity and mortality, unless contraindicated?
- A. Loop diuretics
- B. Angiotensin-Converting Enzyme (ACE) Inhibitors or Angiotensin II Receptor Blockers (ARBs)
- C. Digoxin
- D. Calcium channel blockers
Answer: B. Angiotensin-Converting Enzyme (ACE) Inhibitors or Angiotensin II Receptor Blockers (ARBs)
7. Sacubitril/Valsartan, an Angiotensin Receptor-Neprilysin Inhibitor (ARNI), works by:
- A. Only blocking Angiotensin II receptors.
- B. Inhibiting neprilysin (increasing natriuretic peptides) and blocking Angiotensin II receptors.
- C. Directly stimulating beta-adrenergic receptors.
- D. Inhibiting aldosterone receptors.
Answer: B. Inhibiting neprilysin (increasing natriuretic peptides) and blocking Angiotensin II receptors.
8. Which three beta-blockers have been proven in large clinical trials to reduce mortality in patients with HFrEF?
- A. Atenolol, Propranolol, Labetalol
- B. Carvedilol, Metoprolol succinate (extended-release), Bisoprolol
- C. Esmolol, Sotalol, Acebutolol
- D. Nebivolol, Pindolol, Timolol
Answer: B. Carvedilol, Metoprolol succinate (extended-release), Bisoprolol
9. Aldosterone antagonists (e.g., spironolactone, eplerenone) are recommended in HFrEF patients (with LVEF ≤35-40% and NYHA class II-IV, or post-MI with LVEF ≤40% and HF symptoms/DM) to:
- A. Primarily provide symptomatic relief from congestion.
- B. Reduce mortality and hospitalizations by blocking deleterious effects of aldosterone.
- C. Increase heart rate and contractility.
- D. Replace the need for ACE inhibitors.
Answer: B. Reduce mortality and hospitalizations by blocking deleterious effects of aldosterone.
10. SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) have shown benefit in HFrEF patients, including those without diabetes, by:
- A. Primarily lowering blood glucose.
- B. Reducing cardiovascular death and HF hospitalizations through multiple proposed mechanisms (e.g., natriuresis, metabolic effects, anti-inflammatory effects).
- C. Increasing blood pressure.
- D. Acting as potent positive inotropes.
Answer: B. Reducing cardiovascular death and HF hospitalizations through multiple proposed mechanisms (e.g., natriuresis, metabolic effects, anti-inflammatory effects).
11. Loop diuretics (e.g., furosemide, bumetanide) are used in heart failure primarily for:
- A. Neurohormonal antagonism
- B. Improving long-term mortality as monotherapy
- C. Symptomatic relief of fluid retention (congestion)
- D. Increasing myocardial contractility
Answer: C. Symptomatic relief of fluid retention (congestion)
12. Which of the following is a common adverse effect of loop diuretic therapy that requires monitoring?
- A. Hyperkalemia
- B. Hypokalemia, hypomagnesemia, and dehydration
- C. Hypertension
- D. Bradycardia
Answer: B. Hypokalemia, hypomagnesemia, and dehydration
13. Digoxin exerts its positive inotropic effect by inhibiting which enzyme in cardiomyocytes?
- A. Adenylyl cyclase
- B. Na+/K+-ATPase pump
- C. Phosphodiesterase-3
- D. Soluble guanylyl cyclase
Answer: B. Na+/K+-ATPase pump
14. The combination of hydralazine and isosorbide dinitrate (H-ISDN) has shown particular benefit in reducing mortality and morbidity in which self-identified HFrEF patient population already on standard therapy?
- A. Elderly patients (>75 years)
- B. African Americans
- C. Patients with severe renal impairment
- D. Patients intolerant to beta-blockers
Answer: B. African Americans
15. Ivabradine is indicated for specific HFrEF patients who are in sinus rhythm with a resting heart rate ≥70 bpm despite maximally tolerated beta-blocker therapy. It works by inhibiting:
- A. The RAAS system
- B. The If current (“funny” current) in the sinoatrial node
- C. Aldosterone receptors
- D. Neprilysin
Answer: B. The If current (“funny” current) in the sinoatrial node
16. Heart Failure with preserved Ejection Fraction (HFpEF) is characterized by LVEF typically:
- A. ≤ 30%
- B. ≤ 40%
- C. ≥ 50%
- D. Between 41% and 49%
Answer: C. ≥ 50%
17. The management of HFpEF has historically focused on:
- A. Routine use of digoxin and inotropes.
- B. Evidence-based neurohormonal blockers that show clear mortality benefit (similar to HFrEF).
- C. Managing symptoms (e.g., congestion with diuretics) and treating comorbidities (e.g., hypertension, atrial fibrillation, obesity).
- D. Early cardiac transplantation.
Answer: C. Managing symptoms (e.g., congestion with diuretics) and treating comorbidities (e.g., hypertension, atrial fibrillation, obesity).
18. Which class of medications has more recently demonstrated benefits in reducing HF hospitalizations in patients with HFpEF?
- A. ACE inhibitors
- B. Beta-blockers
- C. SGLT2 inhibitors
- D. Aldosterone antagonists (evidence is less robust for broad mortality/morbidity benefit in all HFpEF compared to SGLT2i)
Answer: C. SGLT2 inhibitors
19. A common precipitating factor for Acute Decompensated Heart Failure (ADHF) is:
- A. Strict adherence to sodium and fluid restriction
- B. Medication non-adherence or inappropriate medication changes
- C. Regular moderate exercise
- D. Overuse of beta-blockers at stable doses
Answer: B. Medication non-adherence or inappropriate medication changes
20. In ADHF, a patient presenting as “warm and wet” (well-perfused but congested) would primarily benefit from which initial therapy?
- A. Intravenous inotropes
- B. Intravenous vasopressors
- C. Intravenous loop diuretics and potentially vasodilators
- D. Beta-blocker initiation
Answer: C. Intravenous loop diuretics and potentially vasodilators
21. Cardiac remodeling in heart failure refers to:
- A. The normal adaptive changes in the heart with aging.
- B. Pathological changes in the size, shape, structure, and function of the heart (e.g., ventricular hypertrophy, dilation).
- C. The surgical repair of heart valves.
- D. The formation of new coronary collateral vessels.
Answer: B. Pathological changes in the size, shape, structure, and function of the heart (e.g., ventricular hypertrophy, dilation).
22. What is the ACC/AHA Stage C of heart failure?
- A. At high risk for HF but without structural heart disease or symptoms of HF.
- B. Structural heart disease but without signs or symptoms of HF.
- C. Structural heart disease with prior or current symptoms of HF.
- D. Refractory HF requiring specialized interventions.
Answer: C. Structural heart disease with prior or current symptoms of HF.
23. Key non-pharmacological management strategies for heart failure include:
- A. High sodium diet and unrestricted fluid intake.
- B. Sodium restriction, fluid restriction (if hyponatremic or congested), regular exercise as tolerated, and daily weight monitoring.
- C. Complete bed rest for all patients.
- D. Avoidance of all vaccinations.
Answer: B. Sodium restriction, fluid restriction (if hyponatremic or congested), regular exercise as tolerated, and daily weight monitoring.
24. Which of the following is a sign of worsening heart failure that patients should be educated to monitor for at home?
- A. Decreased urination frequency
- B. Unexplained rapid weight gain (e.g., 2-3 lbs in a day or 5 lbs in a week)
- C. Reduced thirst
- D. Increased energy levels
Answer: B. Unexplained rapid weight gain (e.g., 2-3 lbs in a day or 5 lbs in a week)
25. The mechanism of action of hydralazine in the H-ISDN combination therapy for HFrEF is primarily as a(n):
- A. Venodilator
- B. Arterial vasodilator
- C. Beta-blocker
- D. Diuretic
Answer: B. Arterial vasodilator (Isosorbide dinitrate is the venodilator in the combo).
26. Gynecomastia is a potential adverse effect specifically associated with which aldosterone antagonist?
- A. Eplerenone
- B. Spironolactone
- C. Furosemide
- D. Metoprolol
Answer: B. Spironolactone (due to its non-selective binding to androgen and progesterone receptors).
27. Titration of beta-blockers in HFrEF should generally be done:
- A. Rapidly to the target dose within one week.
- B. Slowly and cautiously, starting at low doses and doubling approximately every 2 weeks as tolerated, monitoring for worsening HF, hypotension, or bradycardia.
- C. Only if the patient is hypertensive.
- D. Until the heart rate is above 100 bpm.
Answer: B. Slowly and cautiously, starting at low doses and doubling approximately every 2 weeks as tolerated, monitoring for worsening HF, hypotension, or bradycardia.
28. Which laboratory parameters should be closely monitored when initiating or titrating ACE inhibitors, ARBs, ARNIs, or aldosterone antagonists in heart failure?
- A. Liver function tests and platelet count
- B. Serum potassium and renal function (serum creatinine, eGFR)
- C. Serum calcium and phosphate
- D. Thyroid function tests
Answer: B. Serum potassium and renal function (serum creatinine, eGFR)
29. Vericiguat is a newer oral medication for HFrEF that works by:
- A. Inhibiting the If current in the SA node.
- B. Stimulating soluble guanylate cyclase (sGC), enhancing the cGMP pathway independent of NO.
- C. Blocking SGLT2 receptors in the kidney.
- D. Antagonizing vasopressin receptors.
Answer: B. Stimulating soluble guanylate cyclase (sGC), enhancing the cGMP pathway independent of NO.
30. The primary reason for the “washout period” when switching from an ACE inhibitor to an ARNI (Sacubitril/Valsartan) is to reduce the risk of:
- A. Severe hypertension
- B. Angioedema
- C. Hyperkalemia
- D. Acute kidney injury
Answer: B. Angioedema (due to concomitant inhibition of neprilysin and ACE leading to bradykinin accumulation).
31. An S3 gallop heart sound in an adult patient with dyspnea is often indicative of:
- A. Aortic stenosis
- B. Left ventricular systolic dysfunction and volume overload (common in HFrEF)
- C. Well-controlled hypertension
- D. Atrial fibrillation
Answer: B. Left ventricular systolic dysfunction and volume overload (common in HFrEF)
32. Which of the following common OTC medications should generally be avoided or used with caution in patients with heart failure due to the risk of sodium/water retention and exacerbation?
- A. Acetaminophen
- B. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen or naproxen
- C. Vitamin C
- D. Antihistamines like loratadine
Answer: B. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen or naproxen
33. “Cardiac cachexia” seen in advanced heart failure refers to:
- A. Rapid weight gain due to fluid retention.
- B. Severe, unintentional weight loss including loss of muscle mass and adipose tissue.
- C. The development of diabetes mellitus.
- D. An increase in bone density.
Answer: B. Severe, unintentional weight loss including loss of muscle mass and adipose tissue.
34. Device therapy such as an Implantable Cardioverter-Defibrillator (ICD) is indicated for primary prevention in certain HFrEF patients to:
- A. Improve exercise tolerance.
- B. Reduce the risk of sudden cardiac death due to ventricular arrhythmias.
- C. Lower blood pressure.
- D. Reverse cardiac remodeling.
Answer: B. Reduce the risk of sudden cardiac death due to ventricular arrhythmias.
35. Cardiac Resynchronization Therapy (CRT) involves pacing both ventricles (and often the right atrium) and is beneficial for HFrEF patients who have:
- A. Normal QRS duration and NYHA Class I symptoms.
- B. LVEF ≤ 35%, NYHA Class II-IV symptoms despite GDMT, and evidence of ventricular dyssynchrony (e.g., wide QRS, often LBBB).
- C. Predominantly right-sided heart failure.
- D. Severe valvular heart disease as the primary problem.
Answer: B. LVEF ≤ 35%, NYHA Class II-IV symptoms despite GDMT, and evidence of ventricular dyssynchrony (e.g., wide QRS, often LBBB).
36. Eplerenone is preferred over spironolactone in some HFrEF patients because eplerenone:
- A. Is more effective at lowering blood pressure.
- B. Has greater selectivity for the mineralocorticoid receptor, leading to a lower incidence of gynecomastia and other antiandrogenic/progestogenic side effects.
- C. Does not require monitoring of serum potassium.
- D. Is administered once weekly.
Answer: B. Has greater selectivity for the mineralocorticoid receptor, leading to a lower incidence of gynecomastia and other antiandrogenic/progestogenic side effects.
37. The term “diuretic resistance” in heart failure refers to:
- A. An allergic reaction to diuretics.
- B. A diminished natriuretic and diuretic response to a given dose of diuretic.
- C. The development of hyperkalemia with diuretic use.
- D. The diuretic causing an increase in blood pressure.
Answer: B. A diminished natriuretic and diuretic response to a given dose of diuretic.
38. For a patient with HFrEF and atrial fibrillation, digoxin may be used for:
- A. Primary reduction of mortality.
- B. Ventricular rate control and potentially to improve symptoms, though its role for inotropy in sinus rhythm is limited to specific scenarios.
- C. Reversal of cardiac remodeling.
- D. Prevention of stroke as monotherapy.
Answer: B. Ventricular rate control and potentially to improve symptoms, though its role for inotropy in sinus rhythm is limited to specific scenarios.
39. Which symptom is more characteristic of right-sided heart failure than isolated left-sided heart failure?
- A. Orthopnea
- B. Paroxysmal nocturnal dyspnea
- C. Peripheral pitting edema and ascites
- D. Pulmonary rales
Answer: C. Peripheral pitting edema and ascites
40. The “Frank-Starling mechanism” describes how:
- A. The heart rate increases in response to sympathetic stimulation.
- B. Increased preload (ventricular stretch) initially leads to an increased stroke volume, up to a certain point.
- C. Neurohormonal antagonists improve cardiac function.
- D. Myocardial cells hypertrophy in response to pressure overload.
Answer: B. Increased preload (ventricular stretch) initially leads to an increased stroke volume, up to a certain point. (In HF, this mechanism can become dysfunctional).
41. Which of the “quadruple therapy” pillars for HFrEF has a mechanism that involves enhancing beneficial endogenous vasoactive peptides like natriuretic peptides?
- A. Beta-blockers
- B. Aldosterone antagonists
- C. SGLT2 inhibitors
- D. ARNIs (Angiotensin Receptor-Neprilysin Inhibitors)
Answer: D. ARNIs (Angiotensin Receptor-Neprilysin Inhibitors) (via neprilysin inhibition by sacubitril component).
42. What is a common initial approach to managing congestion in a patient hospitalized with ADHF who is already on chronic oral loop diuretic therapy?
- A. Discontinue all diuretics.
- B. Administer intravenous loop diuretics, often at a higher dose than their oral home dose.
- C. Add an oral thiazide diuretic only.
- D. Start an SGLT2 inhibitor as the primary diuretic.
Answer: B. Administer intravenous loop diuretics, often at a higher dose than their oral home dose.
43. In the pathophysiology of HFpEF, which factor is often a key contributor to diastolic dysfunction?
- A. Reduced ventricular contractility
- B. Increased ventricular compliance and chamber size
- C. Impaired ventricular relaxation and increased ventricular stiffness
- D. Severe bradycardia
Answer: C. Impaired ventricular relaxation and increased ventricular stiffness
44. When initiating an ARNI like sacubitril/valsartan in a patient previously on an ACE inhibitor, it is crucial to:
- A. Start the ARNI immediately after the last ACE inhibitor dose.
- B. Allow a 36-hour washout period after stopping the ACE inhibitor before starting the ARNI.
- C. Administer both concurrently for at least one week.
- D. Double the ARNI dose if previously on a high ACE inhibitor dose.
Answer: B. Allow a 36-hour washout period after stopping the ACE inhibitor before starting the ARNI.
45. The most common cause of heart failure worldwide is:
- A. Valvular heart disease
- B. Ischemic heart disease (coronary artery disease)
- C. Hypertensive heart disease
- D. Cardiomyopathies (non-ischemic)
Answer: B. Ischemic heart disease (coronary artery disease) (Though hypertension is also a major contributor).
46. Which of the following is NOT a primary goal of HFrEF management?
- A. Improving symptoms and quality of life
- B. Reducing hospitalizations
- C. Prolonging survival
- D. Curing heart failure and completely reversing all remodeling
Answer: D. Curing heart failure and completely reversing all remodeling (While some reversal of remodeling can occur, a “cure” is generally not the expectation for chronic HFrEF).
47. A patient with HFrEF develops a dry cough after starting lisinopril. What is a common next step if the cough is bothersome?
- A. Discontinue lisinopril and switch to an Angiotensin II Receptor Blocker (ARB).
- B. Add a cough suppressant and continue lisinopril.
- C. Increase the dose of lisinopril.
- D. Discontinue lisinopril and start digoxin.
Answer: A. Discontinue lisinopril and switch to an Angiotensin II Receptor Blocker (ARB).
48. A key educational point for patients with heart failure regarding diet is to limit the intake of:
- A. Potassium
- B. Sodium
- C. Protein
- D. Fiber
Answer: B. Sodium
49. For patients with advanced HFrEF who remain symptomatic despite optimal GDMT, options might include:
- A. Discontinuing all medications.
- B. Consideration for cardiac transplantation or left ventricular assist device (LVAD).
- C. Increasing the dose of loop diuretics indefinitely.
- D. Adding a non-dihydropyridine calcium channel blocker.
Answer: B. Consideration for cardiac transplantation or left ventricular assist device (LVAD).
50. What is the pharmacist’s role in the interprofessional management of heart failure patients?
- A. To only dispense medications as prescribed.
- B. To optimize drug therapy, monitor for efficacy and adverse effects, manage drug interactions, educate patients on medications and self-care, and promote adherence.
- C. To perform echocardiograms.
- D. To make all dietary recommendations independently.
Answer: B. To optimize drug therapy, monitor for efficacy and adverse effects, manage drug interactions, educate patients on medications and self-care, and promote adherence.