1
ABFM
ABFM HEART DISEASE EXAM QUESTIONS
AND ANSWERS UPDATED (2024/2025)
(VERIFIED ANSWERS)
You see a 58-year-old male for a routine examination. According to the American
College of Cardiology/American Heart Association classification system, which
one of the following would meet the criteria for stage B heart failure, assuming he
has no additional complications?
A history of dyspnea on exertion
Well compensated heart failure
A grade 2/6 apical holosystolic murmur radiating to the axilla
Uncontrolled type 2 diabetes - ANS ✓C
A significant heart murmur, such as a grade 2/6 apical holosystolic murmur that
radiates to the axilla, is generally meaningful. The American College of
Cardiology/American Heart Association classification of heart failure includes
four stages. Stage A is defined as the absence of structural disease in a patient at
high risk for the development of heart failure. This includes patients with
hypertension, atherosclerotic disease, diabetes mellitus, obesity, metabolic
syndrome, or a family history of cardiomyopathy, as well as those using
cardiotoxins. Patients with stage B heart failure have evidence of structural heart
disease, such as a previous myocardial infarction, asymptomatic valvular disease,
or evidence of left ventricular remodelling such as left ventricular hypertrophy or
a low ejection fraction. Any patient with structural heart disease is at risk of
heart failure and should be managed aggressively to prevent complications in the
future. Stage C is defined as structural heart disease with prior or current
symptoms of heart failure. Patients with stage D heart failure have refractory
heart failure requiring specialized interventions.
A 61-year-old male sees you for a routine annual evaluation. A review of systems
is notable only for nocturia 1-2 times per night. He has a history of a non-ST-
ABFM HEART
, 2
ABFM
elevation myocardial infarction 2 years ago treated with a drug-eluting stent. His
current medications are metoprolol tartrate (Lopressor), 50 mg twice daily;
hydrochlorothiazide, 25 mg daily; atorvastatin (Lipitor), 40 mg daily; aspirin, 81
mg daily; and docusate as needed. He is a nonsmoker. His blood pressure is
132/82 mm Hg. A physical examination is normal. Which one of the following
medications is indicated at this time?
Diltiazem (Cardizem)
Enalapril (Vasotec)
Furosemide (Lasix)
Losartan (Cozaar)
Spironolactone (Aldactone) - ANS ✓B
Despite the absence of symptoms and a left ventricular ejection fraction within
the normal range, this patient's previous myocardial infarction (MI) is evidence
of structural heart disease, making his American College of Cardiology/American
Heart Association (ACC/AHA) heart failure classification stage B. Patients
without heart failure symptoms who have had an MI or who have evidence of left
ventricular remodelling are thought to be at considerable risk of developing
heart failure and intervention is warranted. Patients who are at risk of future
heart failure should take an ACE inhibitor if they can tolerate it.In addition to
optimal management of hyperlipidemia and hypertension, the AHA recommends
that ACE inhibitors and β-blockers such as carvedilol, metoprolol succinate, or
bisoprolol be used in all patients with a recent or remote history of MI,
regardless of ejection fraction or the presence of heart failure (SOR A). Two
large-scale studies have demonstrated that prolonged therapy with an ACE
inhibitor reduces the risk of a major cardiovascular event even when treatment
is initiated months or years after the MI.Furosemide is not recommended for use
in stage B patients, and calcium channel blockers such as diltiazem can lead to
worsening heart failure and should be avoided. The AHA recommends that
angiotensin receptor blockers be administered to post-MI patients without heart
failure who are intolerant of ACE inhibitors and have a low left ventricular
ejection fraction (SOR B). Aldosterone antagonists would not be the first-line
therapy for stage B heart failure.
A 74-year-old female is discharged from the hospital after being treated for an
exacerbation of heart failure with volume overload. She has a previous history of
ABFM HEART
, 3
ABFM
coronary heart disease and hypertension. Her discharge medications include
furosemide (Lasix), 20 mg twice daily; lovastatin, 40 mg daily; ramipril (Altace),
5 mg daily; spironolactone (Aldactone), 12.5 mg twice daily; metoprolol
succinate (Toprol-XL), 75 mg daily; and aspirin, 81 mg daily. In addition, she is
instructed to avoid the use of ibuprofen and other NSAIDs and to add
metolazone, 2.5 mg daily, with 30 mL of 10% potassium chloride elixir on
mornings when her weight is more than 3 lb over her target weight of 130
lb.Which one of the following is the most common reason for medication
nonadherence in patients such as this?
Cost
Concerns regarding potential side effects
Conflicting instructions from different health care providers
Failure to understand - ANS ✓D
Medication compliance and understanding of how and why to take medications is
a crucial aspect of medical care in heart failure. A study of patients recently
discharged from the hospital following an exacerbation of heart failure found a
high rate of medication nonadherence, with only one-third of patients taking all
their medications as prescribed and not taking unprescribed medications. Of
those not taking medications as prescribed, the most common reason given was
not understanding discharge instructions (57%). Less common reasons include
confusion due to conflicting instructions from the discharging physician and the
primary care physician, medication cost, being unconvinced of the utility of the
medication, and concerns regarding potential side effects (SOR B).
Which one of the following is true regarding the use of clopidogrel (Plavix) with
aspirin in patients with coronary artery disease?
A loading dose of 150 mg of clopidogrel is recommended at the time acute
coronary syndrome is diagnosed
Clopidogrel should be given first because it has a faster onset of antiplatelet
activity
ABFM HEART
, 4
ABFM
Clopidogrel should be discontinued at least 5 days before coronary artery bypass
graft surgery and aspirin should be continued up to the day of surgery
When used with clopidogrel, aspirin can be given at a dosage of 325 mg daily
after cardiac stent placement - ANS ✓C
Clopidogrel should be discontinued at least 5 days before coronary bypass
surgery but aspirin should be continued. Clopidogrel is a thienopyridine
derivative that is used primarily as an adjunctive agent in patients with acute
coronary syndrome (ACS). It is used most commonly in conjunction with aspirin
but is an adequate alternative in patients who are aspirin intolerant. If
clopidogrel is used alone, initial treatment with heparin or possibly with a
glycoprotein IIb/IIIa inhibitor is especially important because of clopidogrel's
delayed onset of antiplatelet activity compared to that of aspirin. The CAPRIE
trial (Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events) found
clopidogrel to be comparable to aspirin in reducing ischemic events in patients
with a history of recent myocardial infarction, recent stroke, or symptomatic
peripheral artery disease. The CURE trial (Clopidogrel in Unstable angina to
prevent Recurrent Events) found the combination of aspirin and clopidogrel to
be more effective in reducing ischemic events than aspirin alone in patients with
ACS.Clopidogrel should be started with a loading dose of 300-600 mg, followed
by 75 mg daily. When clopidogrel is used with aspirin, the aspirin dosage should
be 75-162 mg daily. Because of an increased risk of bleeding, current guidelines
recommend that clopidogrel be discontinued at least 5 days, and preferably 7
days, before bypass graft surgery. In patients undergoing urgent cardiac
catheterization and percutaneous coronary intervention (PCI), a loading dose of
600 mg of clopidogrel should be administered either before or at the time of the
PCI. Clopidogrel should be continued at a dosage of 75 mg daily, along with
aspirin.
A 68-year-old male with a history of hypertension, diabetes mellitus, and heart
failure presents with a 6-week history of progressive fatigue, ankle swelling, and
dyspnea on exertion. His current medications include lisinopril (Prinivil, Zestril),
20 mg daily; atorvastatin (Lipitor), 40 mg daily; insulin glargine (Lantus), 10 U
subcutaneously at bedtime; and sitagliptin (Januvia), 100 mg daily.On
examination his pulse rate is 76 beats/min and regular, and his blood pressure is
130/80 mm Hg. He has jugular venous distention, a laterally displaced apex beat,
and 1+ pitting ankle edema. Lung auscultation reveals bibasilar crackles. Cardiac
auscultation reveals a regular rhythm with a soft S4. Echocardiography shows a
ABFM HEART
ABFM
ABFM HEART DISEASE EXAM QUESTIONS
AND ANSWERS UPDATED (2024/2025)
(VERIFIED ANSWERS)
You see a 58-year-old male for a routine examination. According to the American
College of Cardiology/American Heart Association classification system, which
one of the following would meet the criteria for stage B heart failure, assuming he
has no additional complications?
A history of dyspnea on exertion
Well compensated heart failure
A grade 2/6 apical holosystolic murmur radiating to the axilla
Uncontrolled type 2 diabetes - ANS ✓C
A significant heart murmur, such as a grade 2/6 apical holosystolic murmur that
radiates to the axilla, is generally meaningful. The American College of
Cardiology/American Heart Association classification of heart failure includes
four stages. Stage A is defined as the absence of structural disease in a patient at
high risk for the development of heart failure. This includes patients with
hypertension, atherosclerotic disease, diabetes mellitus, obesity, metabolic
syndrome, or a family history of cardiomyopathy, as well as those using
cardiotoxins. Patients with stage B heart failure have evidence of structural heart
disease, such as a previous myocardial infarction, asymptomatic valvular disease,
or evidence of left ventricular remodelling such as left ventricular hypertrophy or
a low ejection fraction. Any patient with structural heart disease is at risk of
heart failure and should be managed aggressively to prevent complications in the
future. Stage C is defined as structural heart disease with prior or current
symptoms of heart failure. Patients with stage D heart failure have refractory
heart failure requiring specialized interventions.
A 61-year-old male sees you for a routine annual evaluation. A review of systems
is notable only for nocturia 1-2 times per night. He has a history of a non-ST-
ABFM HEART
, 2
ABFM
elevation myocardial infarction 2 years ago treated with a drug-eluting stent. His
current medications are metoprolol tartrate (Lopressor), 50 mg twice daily;
hydrochlorothiazide, 25 mg daily; atorvastatin (Lipitor), 40 mg daily; aspirin, 81
mg daily; and docusate as needed. He is a nonsmoker. His blood pressure is
132/82 mm Hg. A physical examination is normal. Which one of the following
medications is indicated at this time?
Diltiazem (Cardizem)
Enalapril (Vasotec)
Furosemide (Lasix)
Losartan (Cozaar)
Spironolactone (Aldactone) - ANS ✓B
Despite the absence of symptoms and a left ventricular ejection fraction within
the normal range, this patient's previous myocardial infarction (MI) is evidence
of structural heart disease, making his American College of Cardiology/American
Heart Association (ACC/AHA) heart failure classification stage B. Patients
without heart failure symptoms who have had an MI or who have evidence of left
ventricular remodelling are thought to be at considerable risk of developing
heart failure and intervention is warranted. Patients who are at risk of future
heart failure should take an ACE inhibitor if they can tolerate it.In addition to
optimal management of hyperlipidemia and hypertension, the AHA recommends
that ACE inhibitors and β-blockers such as carvedilol, metoprolol succinate, or
bisoprolol be used in all patients with a recent or remote history of MI,
regardless of ejection fraction or the presence of heart failure (SOR A). Two
large-scale studies have demonstrated that prolonged therapy with an ACE
inhibitor reduces the risk of a major cardiovascular event even when treatment
is initiated months or years after the MI.Furosemide is not recommended for use
in stage B patients, and calcium channel blockers such as diltiazem can lead to
worsening heart failure and should be avoided. The AHA recommends that
angiotensin receptor blockers be administered to post-MI patients without heart
failure who are intolerant of ACE inhibitors and have a low left ventricular
ejection fraction (SOR B). Aldosterone antagonists would not be the first-line
therapy for stage B heart failure.
A 74-year-old female is discharged from the hospital after being treated for an
exacerbation of heart failure with volume overload. She has a previous history of
ABFM HEART
, 3
ABFM
coronary heart disease and hypertension. Her discharge medications include
furosemide (Lasix), 20 mg twice daily; lovastatin, 40 mg daily; ramipril (Altace),
5 mg daily; spironolactone (Aldactone), 12.5 mg twice daily; metoprolol
succinate (Toprol-XL), 75 mg daily; and aspirin, 81 mg daily. In addition, she is
instructed to avoid the use of ibuprofen and other NSAIDs and to add
metolazone, 2.5 mg daily, with 30 mL of 10% potassium chloride elixir on
mornings when her weight is more than 3 lb over her target weight of 130
lb.Which one of the following is the most common reason for medication
nonadherence in patients such as this?
Cost
Concerns regarding potential side effects
Conflicting instructions from different health care providers
Failure to understand - ANS ✓D
Medication compliance and understanding of how and why to take medications is
a crucial aspect of medical care in heart failure. A study of patients recently
discharged from the hospital following an exacerbation of heart failure found a
high rate of medication nonadherence, with only one-third of patients taking all
their medications as prescribed and not taking unprescribed medications. Of
those not taking medications as prescribed, the most common reason given was
not understanding discharge instructions (57%). Less common reasons include
confusion due to conflicting instructions from the discharging physician and the
primary care physician, medication cost, being unconvinced of the utility of the
medication, and concerns regarding potential side effects (SOR B).
Which one of the following is true regarding the use of clopidogrel (Plavix) with
aspirin in patients with coronary artery disease?
A loading dose of 150 mg of clopidogrel is recommended at the time acute
coronary syndrome is diagnosed
Clopidogrel should be given first because it has a faster onset of antiplatelet
activity
ABFM HEART
, 4
ABFM
Clopidogrel should be discontinued at least 5 days before coronary artery bypass
graft surgery and aspirin should be continued up to the day of surgery
When used with clopidogrel, aspirin can be given at a dosage of 325 mg daily
after cardiac stent placement - ANS ✓C
Clopidogrel should be discontinued at least 5 days before coronary bypass
surgery but aspirin should be continued. Clopidogrel is a thienopyridine
derivative that is used primarily as an adjunctive agent in patients with acute
coronary syndrome (ACS). It is used most commonly in conjunction with aspirin
but is an adequate alternative in patients who are aspirin intolerant. If
clopidogrel is used alone, initial treatment with heparin or possibly with a
glycoprotein IIb/IIIa inhibitor is especially important because of clopidogrel's
delayed onset of antiplatelet activity compared to that of aspirin. The CAPRIE
trial (Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events) found
clopidogrel to be comparable to aspirin in reducing ischemic events in patients
with a history of recent myocardial infarction, recent stroke, or symptomatic
peripheral artery disease. The CURE trial (Clopidogrel in Unstable angina to
prevent Recurrent Events) found the combination of aspirin and clopidogrel to
be more effective in reducing ischemic events than aspirin alone in patients with
ACS.Clopidogrel should be started with a loading dose of 300-600 mg, followed
by 75 mg daily. When clopidogrel is used with aspirin, the aspirin dosage should
be 75-162 mg daily. Because of an increased risk of bleeding, current guidelines
recommend that clopidogrel be discontinued at least 5 days, and preferably 7
days, before bypass graft surgery. In patients undergoing urgent cardiac
catheterization and percutaneous coronary intervention (PCI), a loading dose of
600 mg of clopidogrel should be administered either before or at the time of the
PCI. Clopidogrel should be continued at a dosage of 75 mg daily, along with
aspirin.
A 68-year-old male with a history of hypertension, diabetes mellitus, and heart
failure presents with a 6-week history of progressive fatigue, ankle swelling, and
dyspnea on exertion. His current medications include lisinopril (Prinivil, Zestril),
20 mg daily; atorvastatin (Lipitor), 40 mg daily; insulin glargine (Lantus), 10 U
subcutaneously at bedtime; and sitagliptin (Januvia), 100 mg daily.On
examination his pulse rate is 76 beats/min and regular, and his blood pressure is
130/80 mm Hg. He has jugular venous distention, a laterally displaced apex beat,
and 1+ pitting ankle edema. Lung auscultation reveals bibasilar crackles. Cardiac
auscultation reveals a regular rhythm with a soft S4. Echocardiography shows a
ABFM HEART
