Chronic Heart Failure (CHF) is a progressive clinical syndrome characterized by the heart’s inability to meet the body’s circulatory demands. Its management is complex, aiming to alleviate symptoms, improve quality of life, reduce hospitalizations, and prolong survival. Guideline-Directed Medical Therapy (GDMT), alongside non-pharmacological interventions and device therapies, forms the cornerstone of CHF management, particularly for Heart Failure with reduced Ejection Fraction (HFrEF). For PharmD students, a comprehensive understanding of these evolving management strategies for both HFrEF and Heart Failure with preserved Ejection Fraction (HFpEF) is crucial for optimizing patient outcomes and providing effective pharmaceutical care. This MCQ quiz will test your knowledge on the comprehensive management of chronic heart failure.
1. The primary goals of managing chronic heart failure include all of the following EXCEPT:
- A. Improving symptoms and quality of life
- B. Reducing hospitalizations
- C. Curing the underlying cardiac structural abnormalities completely
- D. Slowing disease progression and prolonging survival
Answer: C. Curing the underlying cardiac structural abnormalities completely
2. According to current guidelines, which four classes of medications are considered foundational (pillar) therapy for most patients with symptomatic HFrEF to reduce morbidity and mortality?
- A. Diuretics, Digoxin, Nitrates, Calcium Channel Blockers
- B. ARNI/ACEI/ARB, Evidence-Based Beta-Blocker, MRA, SGLT2 Inhibitor
- C. Statins, Aspirin, Clopidogrel, Anticoagulants
- D. Inotropes, Vasopressors, Antiarrhythmics, Theophylline
Answer: B. ARNI/ACEI/ARB, Evidence-Based Beta-Blocker, MRA, SGLT2 Inhibitor
3. When initiating an ACE inhibitor or ARB in a patient with HFrEF, it is important to monitor for:
- A. Hyperglycemia and weight gain
- B. Hypotension, hyperkalemia, and worsening renal function
- C. Bradycardia and bronchospasm
- D. QT prolongation and visual disturbances
Answer: B. Hypotension, hyperkalemia, and worsening renal function
4. Which of the following beta-blockers is NOT considered an evidence-based choice for reducing mortality in HFrEF?
- A. Carvedilol
- B. Metoprolol succinate (extended-release)
- C. Bisoprolol
- D. Atenolol
Answer: D. Atenolol
5. Mineralocorticoid Receptor Antagonists (MRAs) like spironolactone or eplerenone are recommended for HFrEF patients (NYHA class II-IV, LVEF ≤35-40%) primarily to:
- A. Provide rapid symptomatic relief of congestion.
- B. Reduce mortality and heart failure hospitalizations by blocking aldosterone’s deleterious effects.
- C. Increase heart rate and contractility.
- D. Lower LDL cholesterol.
Answer: B. Reduce mortality and heart failure hospitalizations by blocking aldosterone’s deleterious effects.
6. SGLT2 inhibitors (e.g., dapagliflozin, empagliflozin) have demonstrated benefit in HFrEF by:
- A. Primarily acting as potent positive inotropes.
- B. Reducing cardiovascular death and heart failure hospitalizations, even in patients without diabetes.
- C. Significantly increasing blood pressure.
- D. Replacing the need for beta-blockers.
Answer: B. Reducing cardiovascular death and heart failure hospitalizations, even in patients without diabetes.
7. Loop diuretics (e.g., furosemide) are used in chronic heart failure management primarily to:
- A. Improve long-term survival as monotherapy.
- B. Reduce preload and alleviate symptoms of fluid overload (congestion).
- C. Antagonize neurohormonal activation.
- D. Prevent cardiac remodeling.
Answer: B. Reduce preload and alleviate symptoms of fluid overload (congestion).
8. The combination of hydralazine and isosorbide dinitrate (H-ISDN) is specifically recommended as part of GDMT for which group of HFrEF patients?
- A. All patients with NYHA Class I symptoms
- B. Self-identified African American patients with NYHA class III-IV HFrEF on optimal therapy with ACEI/ARB and beta-blockers, or those who cannot tolerate ACEI/ARBs.
- C. Patients with severe renal impairment.
- D. Patients with preserved ejection fraction (HFpEF).
Answer: B. Self-identified African American patients with NYHA class III-IV HFrEF on optimal therapy with ACEI/ARB and beta-blockers, or those who cannot tolerate ACEI/ARBs.
9. Digoxin’s current place in the management of HFrEF is primarily for:
- A. First-line therapy to improve survival.
- B. Reducing symptoms and potentially hospitalizations in patients who remain symptomatic despite optimal GDMT, or for rate control in concomitant atrial fibrillation.
- C. Reversing cardiac remodeling.
- D. Preventing hyperkalemia.
Answer: B. Reducing symptoms and potentially hospitalizations in patients who remain symptomatic despite optimal GDMT, or for rate control in concomitant atrial fibrillation.
10. Ivabradine is indicated for specific HFrEF patients (LVEF ≤35%, sinus rhythm, on maximally tolerated beta-blocker) with a resting heart rate of:
- A. < 50 bpm
- B. 50-60 bpm
- C. ≥ 70 bpm
- D. Any heart rate, as long as LVEF is reduced.
Answer: C. ≥ 70 bpm
11. The primary management strategy for chronic Heart Failure with preserved Ejection Fraction (HFpEF) focuses on:
- A. Routine use of ARNIs, beta-blockers, and MRAs for mortality benefit in all HFpEF patients.
- B. Controlling congestion with diuretics and managing comorbidities such as hypertension, atrial fibrillation, and obesity.
- C. Long-term inotropic support.
- D. Early consideration for cardiac transplantation.
Answer: B. Controlling congestion with diuretics and managing comorbidities such as hypertension, atrial fibrillation, and obesity.
12. Which class of medication has recently shown consistent benefits in reducing heart failure hospitalizations for patients with HFpEF?
- A. ACE inhibitors
- B. Beta-blockers
- C. SGLT2 inhibitors
- D. Digoxin
Answer: C. SGLT2 inhibitors
13. Key non-pharmacological management strategies for chronic heart failure include:
- A. High-sodium diet to maintain intravascular volume.
- B. Sodium and fluid restriction (as appropriate), regular physical activity/cardiac rehabilitation, and daily weight monitoring.
- C. Strict bed rest to reduce cardiac workload.
- D. Avoidance of all vaccinations.
Answer: B. Sodium and fluid restriction (as appropriate), regular physical activity/cardiac rehabilitation, and daily weight monitoring.
14. An Implantable Cardioverter-Defibrillator (ICD) is recommended for primary prevention in HFrEF patients with LVEF ≤35% and NYHA Class II-III symptoms despite optimal medical therapy to:
- A. Improve ejection fraction.
- B. Reduce the risk of sudden cardiac death from ventricular arrhythmias.
- C. Lower blood pressure.
- D. Alleviate symptoms of congestion.
Answer: B. Reduce the risk of sudden cardiac death from ventricular arrhythmias.
15. Cardiac Resynchronization Therapy (CRT) is indicated for symptomatic HFrEF patients with LVEF ≤35% on GDMT who also have:
- A. Normal QRS duration.
- B. A wide QRS complex (e.g., ≥150 ms, especially with LBBB morphology), indicating ventricular dyssynchrony.
- C. Atrial fibrillation with rapid ventricular response.
- D. Severe valvular disease requiring surgery.
Answer: B. A wide QRS complex (e.g., ≥150 ms, especially with LBBB morphology), indicating ventricular dyssynchrony.
16. When titrating beta-blockers for HFrEF, it is crucial to start with low doses and increase gradually because:
- A. High initial doses are needed for rapid effect.
- B. Beta-blockers can initially worsen heart failure symptoms or cause hypotension/bradycardia if titrated too quickly.
- C. They are rapidly metabolized.
- D. Tolerance develops quickly.
Answer: B. Beta-blockers can initially worsen heart failure symptoms or cause hypotension/bradycardia if titrated too quickly.
17. A patient with chronic HFrEF on an ACE inhibitor, beta-blocker, and MRA presents with a serum potassium of 5.7 mEq/L. The most appropriate immediate action regarding the MRA would be:
- A. Increase the MRA dose.
- B. Continue the MRA at the current dose and recheck in 1 month.
- C. Hold or reduce the MRA dose and investigate/manage the hyperkalemia.
- D. Add a potassium supplement.
Answer: C. Hold or reduce the MRA dose and investigate/manage the hyperkalemia.
18. Patients with chronic heart failure should be educated to seek medical attention if they experience:
- A. A weight loss of 1 lb in a week.
- B. A sudden weight gain of >2-3 lbs in a day or >5 lbs in a week, or worsening dyspnea/edema.
- C. Decreased frequency of urination.
- D. An increase in their usual exercise capacity.
Answer: B. A sudden weight gain of >2-3 lbs in a day or >5 lbs in a week, or worsening dyspnea/edema.
19. “Diuretic resistance” in chronic heart failure can be managed by all of the following strategies EXCEPT:
- A. Increasing the dose of the current loop diuretic.
- B. Switching to a different loop diuretic or adding a thiazide-like diuretic (sequential nephron blockade).
- C. Administering the loop diuretic as a continuous infusion.
- D. Significantly increasing dietary sodium intake to enhance diuretic action.
Answer: D. Significantly increasing dietary sodium intake to enhance diuretic action.
20. Which of the following ACC/AHA stages of heart failure describes patients with structural heart disease but NO signs or symptoms of heart failure?
- A. Stage A
- B. Stage B
- C. Stage C
- D. Stage D
Answer: B. Stage B
21. For patients with HFrEF who are intolerant to ACE inhibitors due to cough, what is the recommended alternative from the RAAS inhibitor class?
- A. Direct renin inhibitor (Aliskiren)
- B. Angiotensin II Receptor Blocker (ARB)
- C. No alternative RAAS inhibitor should be used.
- D. A higher dose of the ACE inhibitor.
Answer: B. Angiotensin II Receptor Blocker (ARB)
22. Fluid restriction (e.g., 1.5-2 L/day) in chronic heart failure is generally recommended for patients with:
- A. All stages of heart failure, regardless of symptoms.
- B. Significant hyponatremia or persistent severe fluid retention despite diuretic therapy.
- C. Only those with preserved ejection fraction.
- D. Only those awaiting cardiac transplantation.
Answer: B. Significant hyponatremia or persistent severe fluid retention despite diuretic therapy.
23. The mechanism by which SGLT2 inhibitors provide benefit in HFrEF is thought to involve:
- A. Only their glucose-lowering effect.
- B. Multiple factors including osmotic diuresis, natriuresis, improved cardiac metabolism and energetics, and reduction in inflammation/fibrosis.
- C. Direct positive inotropic effects.
- D. Inhibition of neprilysin.
Answer: B. Multiple factors including osmotic diuresis, natriuresis, improved cardiac metabolism and energetics, and reduction in inflammation/fibrosis.
24. In the management of chronic HFrEF, the target doses for ACE inhibitors, ARBs, and beta-blockers are:
- A. The lowest doses that control symptoms.
- B. The evidence-based doses used in clinical trials that demonstrated mortality and morbidity benefits, or maximally tolerated doses.
- C. Doses that maintain a heart rate above 80 bpm.
- D. Doses that keep blood pressure below 100/60 mmHg.
Answer: B. The evidence-based doses used in clinical trials that demonstrated mortality and morbidity benefits, or maximally tolerated doses.
25. Which comorbidity, if present in a heart failure patient, requires careful management as it can exacerbate HF symptoms and is an independent risk factor for poor outcomes?
- A. Seasonal allergies
- B. Atrial fibrillation
- C. Mild hyperlipidemia
- D. Gout
Answer: B. Atrial fibrillation
26. What is the role of regular exercise training (cardiac rehabilitation) in stable chronic heart failure patients?
- A. It is contraindicated as it worsens cardiac function.
- B. It can improve exercise capacity, quality of life, and may reduce hospitalizations.
- C. It primarily aims to increase LVEF significantly.
- D. It replaces the need for all pharmacological therapy.
Answer: B. It can improve exercise capacity, quality of life, and may reduce hospitalizations.
27. Patients with HFrEF and iron deficiency (with or without anemia) may benefit from:
- A. Routine blood transfusions
- B. Intravenous iron supplementation to improve symptoms, functional capacity, and quality of life
- C. Oral iron supplementation as first-line, which is highly effective
- D. Erythropoiesis-stimulating agents routinely
Answer: B. Intravenous iron supplementation to improve symptoms, functional capacity, and quality of life
28. What is a key consideration when prescribing digoxin in elderly patients with chronic heart failure?
- A. They require higher doses due to increased clearance.
- B. They are less susceptible to toxicity.
- C. They may have reduced renal clearance and increased sensitivity, often requiring lower doses and careful monitoring.
- D. Digoxin is contraindicated in all elderly patients.
Answer: C. They may have reduced renal clearance and increased sensitivity, often requiring lower doses and careful monitoring.
29. The use of NSAIDs in patients with chronic heart failure should generally be avoided or used with extreme caution because they can:
- A. Improve diuretic efficacy.
- B. Cause sodium and water retention, exacerbate HF, and antagonize the effects of diuretics and ACE inhibitors.
- C. Lower serum potassium levels.
- D. Reduce the risk of gastrointestinal bleeding.
Answer: B. Cause sodium and water retention, exacerbate HF, and antagonize the effects of diuretics and ACE inhibitors.
30. If a patient on an ARNI (sacubitril/valsartan) develops symptomatic hypotension, an initial management step could be:
- A. Adding another antihypertensive agent.
- B. Increasing the dose of the ARNI.
- C. Reducing or temporarily holding concomitant diuretics or other vasodilators, or reducing the ARNI dose.
- D. Administering intravenous fluids rapidly.
Answer: C. Reducing or temporarily holding concomitant diuretics or other vasodilators, or reducing the ARNI dose.
31. Which class of antiarrhythmic drugs is generally avoided in patients with HFrEF due to potential for negative inotropic effects and increased mortality (except for amiodarone or dofetilide in specific circumstances for AFib)?
- A. Class III antiarrhythmics (e.g., amiodarone)
- B. Class I antiarrhythmics (e.g., flecainide, propafenone)
- C. Beta-blockers
- D. Digoxin
Answer: B. Class I antiarrhythmics (e.g., flecainide, propafenone)
32. Patients with Stage D heart failure (refractory HF) may require which advanced therapies?
- A. Only palliative care
- B. Mechanical circulatory support (e.g., LVAD), cardiac transplantation, or palliative/hospice care
- C. High-dose oral diuretics as the sole option
- D. Discontinuation of all GDMT
Answer: B. Mechanical circulatory support (e.g., LVAD), cardiac transplantation, or palliative/hospice care
33. The primary benefit of using an ARNI over an ACE inhibitor or ARB in eligible HFrEF patients, as shown in PARADIGM-HF, is:
- A. Better blood pressure control only.
- B. Further reduction in cardiovascular mortality and HF hospitalizations.
- C. Lower incidence of hyperkalemia.
- D. Less need for diuretic therapy.
Answer: B. Further reduction in cardiovascular mortality and HF hospitalizations.
34. What is the role of patient education in the chronic management of heart failure?
- A. It is of minimal importance as patients will follow prescriptions regardless.
- B. It is critical for promoting self-care behaviors, medication adherence, symptom recognition, and appropriate action.
- C. It should only be provided by physicians.
- D. It focuses solely on dietary restrictions.
Answer: B. It is critical for promoting self-care behaviors, medication adherence, symptom recognition, and appropriate action.
35. A common goal for titration of evidence-based beta-blockers in HFrEF is to achieve:
- A. The highest possible heart rate.
- B. The target dose used in clinical trials or the maximally tolerated dose, while monitoring for side effects.
- C. A systolic blood pressure below 90 mmHg.
- D. Complete resolution of all symptoms within one week.
Answer: B. The target dose used in clinical trials or the maximally tolerated dose, while monitoring for side effects.
36. Which symptom is particularly indicative of worsening fluid retention in a chronic heart failure patient?
- A. Increased thirst
- B. Progressive dyspnea on exertion, orthopnea, or new/worsening peripheral edema
- C. Palpitations
- D. Dizziness upon standing
Answer: B. Progressive dyspnea on exertion, orthopnea, or new/worsening peripheral edema
37. For patients with chronic HFrEF, vaccination against which infections is generally recommended?
- A. Only seasonal influenza
- B. Influenza and pneumococcal disease
- C. Only pneumococcal disease
- D. No vaccinations are recommended due to immunosuppression.
Answer: B. Influenza and pneumococcal disease
38. Managing sleep-disordered breathing (e.g., obstructive or central sleep apnea) in HF patients is important because it can:
- A. Improve renal function.
- B. Worsen cardiac hemodynamics, increase sympathetic activity, and contribute to HF progression if untreated.
- C. Directly lower LDL cholesterol.
- D. Eliminate the need for diuretics.
Answer: B. Worsen cardiac hemodynamics, increase sympathetic activity, and contribute to HF progression if untreated.
39. Vericiguat, an oral soluble guanylate cyclase stimulator, is considered for which group of HFrEF patients?
- A. All newly diagnosed HFrEF patients as first-line therapy.
- B. High-risk HFrEF patients with worsening chronic HF who have had a recent HF hospitalization or need for IV diuretics.
- C. Patients with HFpEF only.
- D. Patients intolerant to all other GDMT.
Answer: B. High-risk HFrEF patients with worsening chronic HF who have had a recent HF hospitalization or need for IV diuretics.
40. A key difference in the pharmacological targets of ARNIs versus ACE inhibitors is that ARNIs:
- A. Only block angiotensin II receptors.
- B. Enhance the natriuretic peptide system via neprilysin inhibition in addition to RAAS blockade (via the ARB component).
- C. Primarily target beta-adrenergic receptors.
- D. Inhibit aldosterone synthesis directly.
Answer: B. Enhance the natriuretic peptide system via neprilysin inhibition in addition to RAAS blockade (via the ARB component).
41. If a patient with HFrEF is initiated on an SGLT2 inhibitor, the pharmacist should counsel on potential side effects including:
- A. Hypertension and hyperkalemia
- B. Genital mycotic infections, volume depletion, and euglycemic diabetic ketoacidosis (rare, especially in non-diabetics, but a warning)
- C. Weight gain and edema
- D. Bradycardia and bronchospasm
Answer: B. Genital mycotic infections, volume depletion, and euglycemic diabetic ketoacidosis (rare, especially in non-diabetics, but a warning)
42. Transitions of care (e.g., from hospital to home) are critical periods for HF patients. Effective management includes:
- A. Discontinuing all HF medications to simplify regimen.
- B. Ensuring clear medication reconciliation, patient education, scheduled follow-up, and communication between providers.
- C. Advising complete bed rest for one month post-discharge.
- D. Increasing dietary sodium to improve strength.
Answer: B. Ensuring clear medication reconciliation, patient education, scheduled follow-up, and communication between providers.
43. The long-term management of HFpEF often involves a strong emphasis on:
- A. Titrating ARNIs to maximum doses for mortality benefit.
- B. Aggressive management of contributing factors and comorbidities like hypertension, obesity, and atrial fibrillation.
- C. Routine use of digoxin for inotropic support.
- D. ICD implantation for all HFpEF patients.
Answer: B. Aggressive management of contributing factors and comorbidities like hypertension, obesity, and atrial fibrillation.
44. Which of the following is generally NOT a first-line drug class for chronic HFrEF due to lack of mortality benefit and potential harm in some cases?
- A. ACE inhibitors
- B. Beta-blockers (evidence-based ones)
- C. Non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) in HFrEF
- D. Mineralocorticoid receptor antagonists
Answer: C. Non-dihydropyridine calcium channel blockers (e.g., verapamil, diltiazem) in HFrEF
45. The use of fixed-dose combination of isosorbide dinitrate and hydralazine is particularly beneficial due to their complementary mechanisms which include:
- A. Beta-blockade and ACE inhibition
- B. Nitric oxide-mediated venodilation (from ISDN) and direct arterial vasodilation (from hydralazine), reducing preload and afterload
- C. Diuresis and potassium-sparing
- D. Inhibition of SGLT2 and neprilysin
Answer: B. Nitric oxide-mediated venodilation (from ISDN) and direct arterial vasodilation (from hydralazine), reducing preload and afterload
46. Palliative care consultation should be considered in chronic heart failure management:
- A. Only in the last few days of life.
- B. For patients with advanced, refractory symptoms (Stage D HF) to improve quality of life, manage symptoms, and assist with advance care planning.
- C. For all patients with newly diagnosed Stage A HF.
- D. To primarily facilitate cardiac transplantation.
Answer: B. For patients with advanced, refractory symptoms (Stage D HF) to improve quality of life, manage symptoms, and assist with advance care planning.
47. A common challenge in achieving target doses of GDMT for HFrEF is:
- A. Patient refusal due to lack of perceived benefit.
- B. Development of adverse effects such as hypotension, bradycardia, hyperkalemia, or worsening renal function.
- C. High cost of generic medications.
- D. Universal contraindications in elderly patients.
Answer: B. Development of adverse effects such as hypotension, bradycardia, hyperkalemia, or worsening renal function.
48. Regular assessment of volume status is critical in chronic HF management. This typically involves evaluating:
- A. Serum cholesterol levels
- B. Patient weight, presence of edema, JVD, orthopnea, and lung sounds
- C. Blood glucose levels
- D. Liver function tests only
Answer: B. Patient weight, presence of edema, JVD, orthopnea, and lung sounds
49. For patients with chronic HFrEF, which of the following is a key performance measure indicating quality of care?
- A. Prescription of an antibiotic at each visit
- B. Documentation of LVEF and prescription of appropriate GDMT (e.g., ACEI/ARB/ARNI, beta-blocker)
- C. Achieving a heart rate > 100 bpm
- D. Maintaining a systolic blood pressure > 160 mmHg
Answer: B. Documentation of LVEF and prescription of appropriate GDMT (e.g., ACEI/ARB/ARNI, beta-blocker)
50. The stepwise approach to initiating and uptitrating GDMT in HFrEF emphasizes:
- A. Starting all four pillar drugs simultaneously at target doses.
- B. Prioritizing one drug class to maximum dose before starting another.
- C. Initiating drugs from the four main classes as tolerated, often starting at low doses and titrating upwards, with frequent monitoring.
- D. Focusing only on diuretics for long-term management.
Answer: C. Initiating drugs from the four main classes as tolerated, often starting at low doses and titrating upwards, with frequent monitoring.