B. Higher Risk For Renal Failure: Mol/l

1.
65-year-old man with ischemic cardiomyopathy and systolic heart failure comes to the
physician for follow-up. The patient has New York Heart Association functional class II symptoms
and shows no signs of fluid overload. His daily medications include furosemide, carvedilol,
lisinopril, atorvastatin, and low-dose aspirin. The patient's blood pressure is 155/90 mm Hg and
pulse is 60/min. His potassium level is 4.2 mmol/L and serum creatinine level is 70 µmol/L
Adding losartan to this patient's current regimen is most likely to result in which of the
following?
A. Higher risk for heart failure-associated hospital admission
B. Higher risk for renal failure
C. Lower risk for all-cause mortality
D. Lower risk for arrhythmia
E. Lower risk for hyperkalemia
Explanation
Blockade of the renin-angiotensin system with ACE inhibitors or angiotensin receptor blockers (ARBs)
significantly improves cardiovascular outcomes and overall mortality in patients with congestive heart
failure due to left ventricular systolic dysfunction. However, dual blockade with both ACE inhibitors (eg,
lisinopril) and ARBs (eg, losartan) has not been shown to provide any significant improvement in
cardiovascular or all-cause mortality compared to monotherapy alone (Choice C). In addition, dual
therapy is associated with an increased risk for hyperkalemia (Choice E), symptomatic hypotension, and
worsening renal function and therefore is not recommended.
In contrast, addition of an aldosterone antagonist (spironolactone, eplerenone) to existing beta-blocker

and ACE inhibitor therapy is recommended in certain patients with heart failure.
(Choice A) While not improving mortality or total admissions, dual blockade of the renin-angiotensin
system with ACE inhibitors and ARBs is associated with a reduction in the risk of heart failure-associated
hospital admissions.
(Choice D Dual therapy is not associated with any significant change in the risk of arrhythmia compared
to monotherapy alone.
Educational objective:
Dual blockade of the renin-angiotensin system with both ACE inhibitors and ARBs does not provide any
significant benefit in cardiovascular or all-cause mortality compared to ACE inhibitors alone, and is
associated with an increased risk for hyperkalemia, hypotension, and worsening renal function.
2. A 56-year-old male who has heart failure with reduced ejection fraction sees you for follow-up.
He is stable but over the past year has noted an increase in dyspnea with moderate activity. His
blood pressure is well controlled today. His current medications include carvedilol, losartan and
escitalopram.
Which one of the following additions to his current medication regimen has the best evidence
for reducing his risk of mortality from heart failure?
A) Aspirin
B) Atorvastatin
C) Furosemide
D) Hydrochlorothiazide
E) Spironolactone
Explanation
This patient has symptomatic New York Heart Association class II heart failure, and an escalation in
therapy is warranted. Both -blockers and aldosterone antagonists have been shown to reduce mortality
in patients with symptomatic heart failure (SOR A). Management of associated cardiovascular disease
such as hyperlipidemia and hypertension is important to prevent disease progression, but of the
medications listed (aspirin, atorvastatin, furosemide, hydrochlorothiazide, and spironolactone)
spironolactone is the best choice to reduce heart failure–related mortality.
3. Which one of the following is most appropriate for the initial management of volume overload due to
an acute exacerbation of heart failure with preserved ejection fraction?
A) Carvedilol
B) Furosemide
C) Lisinopril
D) Sacubitril/valsartan (Entresto)
E) Spironolactone
Explanation
The management of heart failure with preserved ejection fraction includes treatment with diuretics,
including loop diuretics such as furosemide, for relief of symptoms when volume overload is present
(SOR B). Studies of other medication classes with proven benefit for heart failure with reduced ejection
fraction, including ACE inhibitors, -blockers, spironolactone, and the angiotensin receptor–neprilysin
inhibitor sacubitril/valsartan, have not shown the same effects in the setting of heart failure with
preserved ejection fraction. For patients with heart failure with preserved ejection fraction, the use of
these other medication classes should be limited to the treatment of other comorbid conditions, such as
hypertension, coronary artery disease, atrial fibrillation, or chronic kidney disease.
4. A 76-year-old man is seen in the emergency department with cough and worsening dyspnea over the
last 2 days. He has known coronary artery disease with a prior myocardial infarction. Blood pressure is
166/100 mm Hg and pulse is 95/min. On examination, the patient is morbidly obese and appears
uncomfortable. Lungs show bibasilar crackles and scattered bilateral wheezes. There is 1+ pitting ankle
edema seen bilaterally. Serum chemistries are normal except for sodium of 125mmol/L, creatinine of
140 umol/L, and blood urea nitrogen of 10.7mmol/L. Chest x-ray reveals prominent vascular markings
and blunting of costophrenic angles. Echocardiogram shows a diffusely hypokinetic left ventricle with
ejection fraction of 35%. Brain natriuretic peptide level is 96 pg/mL (normal <100 pg/mL).
Which of the following explains the normal brain natriuretic peptide value in this patient?
A. Decreased renal function

B. Hyponatremia
C. Non cardiac cause of dyspnea
D. Obesity
E. Older Age
Explanation
Elevated BNP> 400 - Likely CCF

- Sepsis
- Hematologic malignancy
Intermediate - Possible CCF
BNP 100-400 - Pulmonary HTN (PE, cor pulmonale)
- AKI/CKD
- Advanced age
- Stroke, intracranial hemorrhage
Normal - Non cardiac dyspnea
- Obesity
5. A 31-year-old woman with known moderate rheumatic mitral stenosis comes to the emergency
department with palpitations and is diagnosed with atrial fibrillation. The patient's arrhythmia resolves
spontaneously. She has normal renal function and has no history of bleeding.
Which of the following is the best treatment option for this patient?
A. Aspirin
B. Aspirin and clopidogrel
C. Rivaroxaban
D. Ticagrelor
E. Warfarin
This patient has paroxysmal atrial fibrillation (AF) in the setting of rheumatic mitral stenosis (MS). The
risk of systemic thromboembolism is quite high in this setting, with some studies reporting a stroke risk
as high as 10%-15% per year. CHADS2 or CHA2DS2-VASc risk stratification criteria should not be used to
assess thromboembolic risk in patients with valvular AF.
Current guidelines recommend long-term oral anticoagulation with warfarin to a target
International Normalized Ratio of 2.5 (range 2.0-3.0) in patients with MS and the following:
Paroxysmal, persistent, or permanent AF
Prior embolic event
Left atrial thrombus

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1.

A. Higher risk for heart failure-associated hospital admission

B. Higher risk for renal failure

C. Lower risk for all-cause mortality

D. Lower risk for arrhythmia

E. Lower risk for hyperkalemia

In contrast, addition of an aldosterone antagonist (spironolactone, eplerenone) to existing beta-blocker

A. Decreased renal function

Elevated BNP> 400 - Likely CCF

B. Aspirin and clopidogrel

Current guidelines recommend long-term oral anticoagulation with warfarin to a target

Paroxysmal, persistent, or permanent AF

Prior embolic event

Left atrial thrombus

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