ABFM HEART DISEASE EXAM
1. A 65-year-old female who has heart failure with an ejection fraction
of 35% is found to have a TSH level of 13.8 µU/mL (N 0.3-4.82). Her T3
and T4 levels are normal, and her thyroid gland is normal to palpation.
You check her levels again in 2 months and they are unchanged. You
advise her that
hypothyroidism decreases her metabolic rate, which reduces the
stress on her heart
hypothyroidism is detrimental to her heart only if she develops
hypothyroid symptoms
subclinical hypothyroidism has negative effects on heart failure and
treatment should be considered
treatment of subclinical hypothyroidism would raise her LDL-
cholesterol lev- el: C
Clinical hypothyroidism has long been associated with cardiac dysfunction.
It has also been shown that subclinical hypothyroidism (TSH >4 µU/mL with
normal or bor- derline low thyroid hormone levels) can cause left
ventricular systolic and diastolic dysfunction, which improves with thyroid
replacement therapy. Patients with overt
or subclinical hypothyroidism should be treated with levothyroxine to
improve their cardiovascular function and decrease the potential risk of
,heart failure. Thyroxine in excess can exacerbate coronary artery disease,
and should be started at low doses and increased slowly in patients with
possible underlying coronary artery
disease. Results of meta-analyses indicate that therapy will lower, not raise,
serum
LDL-cholesterol levels.
2. A 58-year-old male is hospitalized with severe decompensated heart
failure refractory to intravenous inotropic therapy and guideline-
directed medical therapy. You are considering referral to a tertiary
care hospital for mechanical circulatory support to bridge to
transplantation.Which one of the following is true regarding
mechanical circulatory support bridge therapy?
It should be limited to patients who meet the criteria for heart
transplantation
It should only be used in patients with biventricular heart failure
It generally improves quality of life while waiting for transplantation
It greatly reduces quality of life while waiting for transplantation: c
Mechanical circulatory support (MCS) with a ventricular assist device has
contin- ued to evolve and has emerged as a viable therapeutic option for
patients with advanced stage D heart failure with reduced ejection fraction
refractory to guide- line-directed medical therapy and cardiac device
intervention. A variety of ventricular
,assist devices are now available. These devices may be either
intracorporeal or extracorporeal, and may be designed to assist the left
ventricle, right ventricle, or both.Bridge therapy refers to the use of left
ventricular assist devices to help a patient survive until a donor heart
becomes available for transplantation. Several devices are available, some
of which are implantable and allow patients to be discharged to their
homes. These devices can increase patient activity levels and quality of life.
Complications can occur, including stroke, infection, and death, but these
devices can be lifesaving in patients with refractory heart failure.The data
from the Interagency Registry for Mechanically Assisted Circulatory
Support indicates that cardiogenic shock, advanced age, and severe right
heart failure (manifested as ascites or increased bilirubin) are major risk
factors for death after MCS. This led to a recommendation that referral for
MCS be considered before severe right ventricular failure develops.
Possible indications for a bridge-to-candidacy ventricular assist device
include obesity, tobacco use, and severe pulmonary hypertension in
patients who might otherwise be candidates for transplantation.
3. An active 66-year-old female presents with intermittent chest pain
and dyspnea. She is currently pain free. A resting EKG is normal.If
found on the history and examination, which one of the following
symptoms is most likely to be associated with myocardial ischemia
as the cause of chest pain?
An episode of diaphoresis associated with the chest pain
Pain reproduced by chest wall palpation on the left side of the chest
, Pain that comes and goes with and without exertion
Intermittent pleuritic-type pain and dyspnea: A
Cardiac ischemia is classically defined as deep, poorly localized chest or
arm discomfort reproducibly associated with exertion or emotional stress. It
is relieved with rest and nitroglycerin. It can present in an atypical fashion,
and the discomfort can localize or radiate to the neck, lower jaw, throat,
shoulder, epigastrium, hands, or upper back. It may be entirely absent in
some cases. In older patients without chest pain, new-onset or unexplained
exertional dyspnea is the most common anginal equivalent, even with a
normal resting EKG.Although they may be present, pleuritic-type pain, pain
reproduced with movement or palpation of the chest wall
or arm, and sharp or stabbing pain are not characteristic features of
myocardial ischemia. Very brief episodes of pain, lasting a few seconds or
less, are also not characteristic of myocardial ischemia. In a meta-analysis
of symptoms useful in diagnosing acute coronary syndrome in a low-risk
setting, diaphoresis was found to be the strongest predictor of myocardial
infarction (MI) (likelihood ratio [LR] = 2.44), and the presence of chest wall
tenderness significantly reduced the possibility of
1. A 65-year-old female who has heart failure with an ejection fraction
of 35% is found to have a TSH level of 13.8 µU/mL (N 0.3-4.82). Her T3
and T4 levels are normal, and her thyroid gland is normal to palpation.
You check her levels again in 2 months and they are unchanged. You
advise her that
hypothyroidism decreases her metabolic rate, which reduces the
stress on her heart
hypothyroidism is detrimental to her heart only if she develops
hypothyroid symptoms
subclinical hypothyroidism has negative effects on heart failure and
treatment should be considered
treatment of subclinical hypothyroidism would raise her LDL-
cholesterol lev- el: C
Clinical hypothyroidism has long been associated with cardiac dysfunction.
It has also been shown that subclinical hypothyroidism (TSH >4 µU/mL with
normal or bor- derline low thyroid hormone levels) can cause left
ventricular systolic and diastolic dysfunction, which improves with thyroid
replacement therapy. Patients with overt
or subclinical hypothyroidism should be treated with levothyroxine to
improve their cardiovascular function and decrease the potential risk of
,heart failure. Thyroxine in excess can exacerbate coronary artery disease,
and should be started at low doses and increased slowly in patients with
possible underlying coronary artery
disease. Results of meta-analyses indicate that therapy will lower, not raise,
serum
LDL-cholesterol levels.
2. A 58-year-old male is hospitalized with severe decompensated heart
failure refractory to intravenous inotropic therapy and guideline-
directed medical therapy. You are considering referral to a tertiary
care hospital for mechanical circulatory support to bridge to
transplantation.Which one of the following is true regarding
mechanical circulatory support bridge therapy?
It should be limited to patients who meet the criteria for heart
transplantation
It should only be used in patients with biventricular heart failure
It generally improves quality of life while waiting for transplantation
It greatly reduces quality of life while waiting for transplantation: c
Mechanical circulatory support (MCS) with a ventricular assist device has
contin- ued to evolve and has emerged as a viable therapeutic option for
patients with advanced stage D heart failure with reduced ejection fraction
refractory to guide- line-directed medical therapy and cardiac device
intervention. A variety of ventricular
,assist devices are now available. These devices may be either
intracorporeal or extracorporeal, and may be designed to assist the left
ventricle, right ventricle, or both.Bridge therapy refers to the use of left
ventricular assist devices to help a patient survive until a donor heart
becomes available for transplantation. Several devices are available, some
of which are implantable and allow patients to be discharged to their
homes. These devices can increase patient activity levels and quality of life.
Complications can occur, including stroke, infection, and death, but these
devices can be lifesaving in patients with refractory heart failure.The data
from the Interagency Registry for Mechanically Assisted Circulatory
Support indicates that cardiogenic shock, advanced age, and severe right
heart failure (manifested as ascites or increased bilirubin) are major risk
factors for death after MCS. This led to a recommendation that referral for
MCS be considered before severe right ventricular failure develops.
Possible indications for a bridge-to-candidacy ventricular assist device
include obesity, tobacco use, and severe pulmonary hypertension in
patients who might otherwise be candidates for transplantation.
3. An active 66-year-old female presents with intermittent chest pain
and dyspnea. She is currently pain free. A resting EKG is normal.If
found on the history and examination, which one of the following
symptoms is most likely to be associated with myocardial ischemia
as the cause of chest pain?
An episode of diaphoresis associated with the chest pain
Pain reproduced by chest wall palpation on the left side of the chest
, Pain that comes and goes with and without exertion
Intermittent pleuritic-type pain and dyspnea: A
Cardiac ischemia is classically defined as deep, poorly localized chest or
arm discomfort reproducibly associated with exertion or emotional stress. It
is relieved with rest and nitroglycerin. It can present in an atypical fashion,
and the discomfort can localize or radiate to the neck, lower jaw, throat,
shoulder, epigastrium, hands, or upper back. It may be entirely absent in
some cases. In older patients without chest pain, new-onset or unexplained
exertional dyspnea is the most common anginal equivalent, even with a
normal resting EKG.Although they may be present, pleuritic-type pain, pain
reproduced with movement or palpation of the chest wall
or arm, and sharp or stabbing pain are not characteristic features of
myocardial ischemia. Very brief episodes of pain, lasting a few seconds or
less, are also not characteristic of myocardial ischemia. In a meta-analysis
of symptoms useful in diagnosing acute coronary syndrome in a low-risk
setting, diaphoresis was found to be the strongest predictor of myocardial
infarction (MI) (likelihood ratio [LR] = 2.44), and the presence of chest wall
tenderness significantly reduced the possibility of
