A patient develops acute moderate cardiac failure after myocardial injury. Which immediate hemodynamic pattern is most expected?

A. Increased output, venous unloading
B. Decreased output, venous damming
C. Increased output, arterial pooling
D. Decreased output, arterial dilation

B. Decreased output, venous damming

Early compensation for acute heart failure by the sympathetic nervous system produces which two major responses?

A. Increased contractility, vasoconstriction
B. Bradycardia, venodilation
C. Decreased afterload, natriuresis
D. Increased diuresis, vasodilation

A. Increased contractility, vasoconstriction

Which reflex is one of the major mechanisms that strongly stimulates sympathetic activity in acute heart failure?

A. Bainbridge reflex
B. Oculocardiac reflex
C. Baroreceptor reflex
D. Cushing triad

C. Baroreceptor reflex

Which additional mechanism can strongly activate the sympathetic nervous system in worsening heart failure?

A. Chemoreceptor reflex
B. Frank-Starling mechanism
C. Hering-Breuer reflex
D. Diving reflex

A. Chemoreceptor reflex

Severe circulatory compromise from heart failure can activate which powerful sympathetic response?

A. Bezold-Jarisch reflex
B. CNS ischemic response
C. Vasovagal response
D. Pupillary reflex

B. CNS ischemic response

In chronic heart failure, reduced cardiac output and blood pressure cause the kidneys to retain:

A. bicarbonate and calcium
B. glucose and phosphate
C. sodium and water
D. potassium and urea

C. sodium and water

Moderate fluid retention in chronic heart failure can be:

A. always harmful
B. beneficial
C. never compensatory
D. unrelated to output

B. beneficial

Excess fluid retention in heart failure can directly cause all of the following except:

A. pulmonary edema
B. peripheral edema
C. increased cardiac workload
D. improved cardiac reserve

D. improved cardiac reserve

Excessive ventricular stretching from fluid retention tends to:

A. strengthen the myocardium
B. increase coronary flow only
C. weaken the heart
D. prevent pulmonary edema

C. weaken the heart

In compensated heart failure, which statement is most accurate?

A. Pumping returns fully normal, reserves reduced
B. Cardiac reserves normalize
C. Output remains depressed, reserves reduced
D. Edema cannot occur

C. Output remains depressed, reserves reduced

Which best defines decompensated heart failure?

A. Normal output restored by SNS
B. No compensation can normalize output
C. Renal perfusion is excessive
D. Pumping exceeds metabolic demand

B. No compensation can normalize output

Decompensated heart failure can become fatal largely because the kidneys receive insufficient blood flow to:

A. filter proteins
B. secrete renin
C. activate vitamin D
D. excrete necessary fluid

D. excrete necessary fluid

The approximate cardiac output required to maintain normal fluid balance is:

A. 2 L/min
B. 3.5 L/min
C. 5 L/min
D. 7 L/min

C. 5 L/min

A patient with severe pulmonary edema from heart failure is most likely to have which auscultatory finding?

A. Wheezes
B. Rales
C. Pleural rub
D. Silent lungs

B. Rales

Severe pulmonary edema in heart failure commonly causes:

A. dysphagia
B. hemoptysis
C. dyspnea
D. stridor

C. dyspnea

Which is a major treatment option for decompensated heart failure?

A. Loop diuretic
B. Calcium channel blocker
C. Thiazide
D. Acetazolamide

A. Loop diuretic

Another major treatment option for decompensated heart failure is:

A. digoxin
B. atropine
C. adenosine
D. lidocaine

A. digoxin

In a normal heart, digitalis has what effect on contractile strength?

A. Large increase always
B. Little effect
C. Marked depression
D. Stops contraction

B. Little effect

In chronic heart failure, digitalis may increase myocardial contractile strength by approximately:

A. 10-20%
B. 25-40%
C. 50-100%
D. 150-200%

C. 50-100%

The primary cellular effect of digitalis that improves contraction is increased intracellular:

A. potassium
B. chloride
C. magnesium
D. calcium

D. calcium

Digitalis increases intracellular calcium largely by inhibiting the:

A. L-type calcium channel
B. sodium-potassium ATPase
C. ryanodine receptor
D. funny current channel

B. sodium-potassium ATPase

Inhibition of the sodium-potassium pump by digitalis raises intracellular sodium, which then reduces activity of the:

A. sodium-calcium exchanger
B. sodium-hydrogen exchanger
C. SERCA pump
D. potassium leak channel

A. sodium-calcium exchanger

In the failing heart, digitalis is especially useful because the sarcoplasmic reticulum cannot:

A. form gap junctions
B. accumulate normal calcium
C. generate ATP
D. repolarize membranes

B. accumulate normal calcium

Which type of heart failure is more common?

A. Right-sided failure
B. Equal frequency
C. Left-sided failure
D. Isolated biventricular failure

C. Left-sided failure

Left-sided heart failure tends to increase mean pulmonary filling pressure because blood shifts from the systemic to the:

A. coronary circulation
B. pulmonary circulation
C. portal circulation
D. lymphatic system

B. pulmonary circulation

The most important problem in left-sided heart failure is:

A. ascites
B. hepatomegaly
C. peripheral cyanosis
D. pulmonary edema

D. pulmonary edema

Cardiogenic shock is best defined as circulatory shock caused by:

A. systemic vasodilation
B. inadequate cardiac pumping
C. excessive renal diuresis
D. adrenal insufficiency

B. inadequate cardiac pumping

A major vicious-cycle feature of cardiogenic shock is that reduced blood pressure lowers:

A. cerebral venous drainage
B. coronary blood supply
C. portal vein flow
D. pulmonary venous tone

B. coronary blood supply

In cardiogenic shock with ventricular deterioration, the classic drug treatment is:

A. digoxin
B. mannitol
C. heparin
D. verapamil

A. digoxin

If cardiogenic shock is associated with coronary thrombosis, which treatment may be used?

A. insulin infusion
B. methimazole
C. streptokinase or tPA
D. protamine sulfate

C. streptokinase or tPA

Another revascularization option for clot-related cardiogenic shock is:

A. valve commissurotomy
B. coronary artery bypass graft
C. carotid endarterectomy
D. pacemaker insertion

B. coronary artery bypass graft

Severe acute cardiac failure often causes what change in peripheral capillary pressure?

A. Increased markedly
B. Decreased
C. Unchanged always
D. Becomes pulsus paradoxus

B. Decreased

Which develops first in acute left-sided heart failure?

A. Peripheral edema
B. Ascites
C. Pulmonary edema
D. Anasarca

C. Pulmonary edema

A patient with compensated heart failure feels stable at rest. Which hidden limitation still remains?

A. Increased cardiac reserves
B. Depressed cardiac reserves
C. Normal renal perfusion
D. No sympathetic tone

B. Depressed cardiac reserves

Which combination best fits decompensated rather than compensated heart failure?

A. Normal output, no edema
B. Full recovery, normal reserves
C. Severe edema, inadequate renal flow
D. Improved pumping, stable balance

C. Severe edema, inadequate renal flow

A patient with congestive heart failure develops worsening fluid retention. Which renal-hemodynamic pattern is most expected?

A. Increased GFR, suppressed RAAS
B. Decreased GFR, activated RAAS
C. Increased GFR, reduced aldosterone
D. Normal GFR, absent SNS tone

B. Decreased GFR, activated RAAS

In congestive heart failure, RAAS activation most directly increases secretion of:

A. Insulin
B. Thyroxine
C. Aldosterone
D. Glucagon

C. Aldosterone

Which additional neurohumoral response commonly accompanies congestive heart failure?

A. Sympathetic activation
B. Parasympathetic dominance
C. Suppressed catecholamines
D. Decreased renin release

A. Sympathetic activation

Atrial natriuretic peptide is released primarily when the:

A. Ventricles become ischemic
B. Atrial walls are stretched
C. Aortic valve closes
D. AV node depolarizes

B. Atrial walls are stretched

ANP helps protect against congestive symptoms of heart failure by increasing renal:

A. Potassium retention
B. Glucose reabsorption
C. Salt and water excretion
D. Calcium secretion

C. Salt and water excretion

A patient with acute pulmonary edema from left-sided heart failure receives a bedside intervention that traps blood in the veins of the limbs to reduce left-heart workload. This intervention is:

A. Intra-aortic balloon pump
B. Limb tourniquets
C. Trendelenburg positioning
D. Carotid massage

B. Limb tourniquets

Which drug may be given in pulmonary edema specifically to increase the strength of cardiac contraction?

A. Digoxin
B. Furosemide
C. Morphine
D. Nitroglycerin

A. Digoxin

Which of the following is one of the four main treatments for pulmonary edema due to left-sided heart failure?

A. Hypertonic saline
B. Fluid bolus
C. Oxygen supplementation
D. β-blocker loading

C. Oxygen supplementation

The purpose of oxygen supplementation in pulmonary edema is best described as:

A. Raising preload rapidly, vasodilation
B. Reducing deterioration, vasodilation
C. Increasing renal sodium retention, vasodilation
D. Enhancing atrial stretch, vasodilation

B. Reducing deterioration, vasodilation

Cardiac reserve is best defined as the maximum percentage by which cardiac output can increase:

A. Below normal
B. Above normal
C. During systole only
D. During diastole only

B. Above normal

Normal cardiac reserve is approximately:

A. 50-100%
B. 100-200%
C. 300-400%
D. 500-600%

C. 300-400%

Cardiac reserve is usually how in patients with heart failure?

A. Increased
B. Unchanged
C. Diminished
D. Inverted

C. Diminished

The best test to diagnose low cardiac reserve is an:

A. Exercise test
B. Resting spirometry
C. Tilt table test
D. EEG

A. Exercise test

A patient with low cardiac reserve is most likely to show which combination during exertion?

A. Bradycardia, edema, confusion
B. Increased heart rate, dyspnea, fatigue
C. Decreased heart rate, cyanosis, syncope
D. Normal heart rate, weakness, cough

B. Increased heart rate, dyspnea, fatigue

Normal cardiac output is closest to:

A. 2 L/min
B. 3.5 L/min
C. 5 L/min
D. 8 L/min

C. 5 L/min

Normal right atrial pressure is closest to:

A. 0 mmHg
B. 4 mmHg
C. 8 mmHg
D. 12 mmHg

A. 0 mmHg

During an acute heart attack, right atrial pressure typically:

A. Decreases below zero
B. Rises to about 4 mmHg
C. Remains fixed at zero
D. Falls with venous pooling

B. Rises to about 4 mmHg

Decompensation in heart failure occurs because cardiac output never rises to the critical level needed to reestablish:

A. Coronary vasodilation
B. Normal AV conduction
C. Normal renal fluid excretion
D. Normal ventricular hypertrophy

C. Normal renal fluid excretion

The critical cardiac output needed to restore normal renal fluid balance is:

A. 2 L/min
B. 3 L/min
C. 4 L/min
D. 5 L/min

D. 5 L/min

After effective digitalis therapy, it takes several days for venous return to decrease because of increased:

A. Hemorrhage
B. Diuresis
C. Vasoconstriction
D. Bradycardia

B. Diuresis

On a Guyton-style heart failure graph, a point exactly at the critical cardiac output needed for normal fluid balance represents:

A. Cardiogenic shock
B. Acute MI
C. Compensated heart failure
D. Decompensated failure

C. Compensated heart failure

Beriberi heart disease is associated with greatly increased venous return because systemic vascular resistance is:

A. Increased
B. Diminished
C. Unchanged
D. Variable only

B. Diminished

The vitamin deficiency classically associated with beriberi heart disease is:

A. Vitamin B1
B. Vitamin B6
C. Vitamin B12
D. Vitamin C

A. Vitamin B1

In beriberi, despite high venous return, cardiac output may fall because the heart is:

A. Hypercontractile
B. Electrically blocked
C. Weakened
D. Severely hypertrophied

C. Weakened

An arteriovenous fistula overloads the heart primarily because it causes excessive:

A. Afterload
B. Venous return
C. Coronary resistance
D. Atrial refractoriness

B. Venous return

In the presence of a large arteriovenous fistula, total peripheral vascular resistance is expected to:

A. Increase
B. Stay unchanged
C. Decrease
D. Oscillate only

C. Decrease

In an arteriovenous fistula, venous return typically:

A. Decreases
B. Increases
C. Stops
D. Normalizes

B. Increases

A major hemodynamic consequence of arteriovenous fistula is increased:

A. Cardiac output and right atrial pressure
B. Pulmonary resistance and wedge pressure
C. Left atrial standstill and bradycardia
D. Coronary thrombosis and afterload

A. Cardiac output and right atrial pressure

Immediately after myocardial infarction, the pumping ability of the heart is:

A. Enhanced
B. Preserved
C. Depressed
D. Variable

C. Depressed

After MI, the immediate hemodynamic pattern includes reduced cardiac output and:

A. Reduced venous pressure
B. Damming of venous blood
C. Marked arterial vasodilation
D. Increased cardiac reserve

B. Damming of venous blood

Venous damming after MI leads most directly to increased:

A. Intracranial pressure
B. Right atrial pressure
C. Oncotic pressure
D. Oxygen extraction

B. Right atrial pressure

Which pairing is correct?

A. ANP — sodium retention
B. Beriberi — increased SVR
C. AV fistula — decreased venous return
D. CHF — sympathetic activation

D. CHF — sympathetic activation

A patient has a massive myocardial infarction with a sharp drop in cardiac output. Which reflex is activated by the resulting fall in arterial pressure?

A. Chemoreceptor reflex
B. Baroreceptor reflex
C. Stretch reflex
D. Bainbridge reflex

B. Baroreceptor reflex

The baroreceptor reflex in severe post-MI low-output states is triggered by:

A. Diminished arterial pressure
B. Increased venous pressure
C. Elevated right atrial pressure
D. Increased pulse pressure

A. Diminished arterial pressure

Within seconds after a major MI with very low cardiac output, the reflex response is to:

A. Suppress sympathetics, increase vagal tone
B. Increase both autonomic limbs
C. Stimulate sympathetics, inhibit parasympathetics
D. Inhibit sympathetics, inhibit parasympathetics

C. Stimulate sympathetics, inhibit parasympathetics

In the early compensatory response after MI, sympathetic stimulation mainly helps the surviving myocardium by:

A. Depressing normal muscle activity
B. Stimulating intact myocardium
C. Blocking AV conduction
D. Reducing coronary extraction

B. Stimulating intact myocardium

Increased venous tone after MI raises the:

A. Ejection fraction
B. Mean systemic filling pressure
C. Pulmonary diffusion capacity
D. Coronary sinus pressure

B. Mean systemic filling pressure

Raising mean systemic filling pressure has what effect on blood flow from the veins back to the heart?

A. Greatly increases it
B. Slightly decreases it
C. Abolishes it
D. Makes it pulsatile only

A. Greatly increases it

Immediately after MI, the expected hemodynamic pair is:

A. Decreased RA pressure, increased CO
B. Increased RA pressure, increased CO
C. Increased RA pressure, decreased CO
D. Decreased RA pressure, decreased CO

C. Increased RA pressure, decreased CO

In the semichronic stage after MI, the kidneys mainly respond with:

A. Fluid excretion
B. Fluid retention
C. Glucose wasting
D. Protein retention

B. Fluid retention

If cardiac output falls extremely low, roughly below 50% to 60% of normal, severe renal hypoperfusion may cause:

A. Polyuria
B. Glycosuria
C. Anuria
D. Hematuria

C. Anuria

Renal fluid retention after MI directly causes an increase in:

A. Blood volume and venous return
B. Afterload and heart rate
C. Coronary resistance
D. Pulmonary compliance

A. Blood volume and venous return

Moderate renal fluid retention in cardiac failure increases the:

A. Mean systemic filling pressure
B. Ventricular refractory period
C. Pulmonary capillary membrane
D. Atrial conduction time

A. Mean systemic filling pressure

Moderate fluid retention also causes the veins to:

A. Contract
B. Distend
C. Calcify
D. Spasm

B. Distend

Venous distention from moderate fluid retention tends to ______ venous resistance.

A. increase
B. abolish
C. reduce
D. not change

C. reduce

The overall effect of moderate renal fluid retention in heart failure is to ______ venous return.

A. decrease
B. normalize instantly
C. block
D. increase

D. increase

Moderate fluid retention in cardiac failure is generally:

A. beneficial
B. lethal
C. irrelevant
D. maladaptive only

A. beneficial

In severe cardiac failure, excessive fluid retention is generally:

A. beneficial
B. neutral
C. detrimental
D. anti-edematous

C. detrimental

During recovery after myocardial infarction, the undamaged myocardium tends to:

A. atrophy
B. hypertrophy
C. calcify
D. fibrose completely

B. hypertrophy

Another adaptive change after MI is formation of new ______ blood supply around the infarct border.

A. portal
B. lymphatic
C. coronary sinus
D. collateral

D. collateral

Which sequence best summarizes the three stages after an acute moderate heart attack?

A. Renal retention, hypertrophy, sympathetic loss
B. Immediate damage, sympathetic compensation, chronic recovery/fluid retention
C. Sympathetic compensation, infarction, renal failure
D. Chronic dilation, acute recovery, vagal rebound

B. Immediate damage, sympathetic compensation, chronic recovery/fluid retention

In compensated heart failure, maximal pumping ability of the partly recovered heart is:

A. supranormal
B. normal
C. still depressed
D. absent

C. still depressed

In compensated heart failure, cardiac output may be normal at rest, but the right atrial pressure is usually:

A. slightly increased
B. markedly negative
C. exactly zero
D. decreased

A. slightly increased

The slightly increased right atrial pressure in compensated heart failure helps maintain:

A. coronary perfusion
B. normal cardiac output
C. normal ejection fraction
D. normal arterial oxygen

B. normal cardiac output

A patient with compensated heart failure becomes dyspneic with heavy exercise because:

A. RA pressure falls too low
B. the heart cannot increase pumping enough
C. the kidneys immediately fail
D. vagal tone becomes excessive

B. the heart cannot increase pumping enough

The major functional reserve reduced in compensated heart failure is the:

A. pulmonary reserve
B. renal reserve
C. cardiac reserve
D. metabolic reserve

C. cardiac reserve

Failure of the heart to pump enough blood for the kidneys to excrete the needed fluid is a major cause of:

A. compensated heart failure
B. decompensated heart failure
C. isolated right heart strain
D. primary valvular stenosis

B. decompensated heart failure

Decompensated heart failure commonly leads to severe:

A. bradycardia and bradypnea
B. edema and death
C. hypertension and renal collapse
D. erythrocytosis and heart collapse

B. edema and death

Which statement best distinguishes compensated from decompensated heart failure?

A. Compensated HF has no renal role
B. Decompensated HF maintains normal fluid balance
C. Compensated HF has normal reserve
D. Decompensated HF cannot sustain renal excretion

D. Decompensated HF cannot sustain renal excretion

In the first minute after an acute moderate MI, the dominant compensation is:

A. renal sodium retention
B. sympathetic activation
C. myocardial hypertrophy
D. collateral vessel growth

B. sympathetic activation

Which combination best fits beneficial compensation in moderate cardiac failure?

A. Moderate fluid retention, increased venous return
B. Severe edema, reduced renal flow
C. Increased vagal tone, lower contractility
D. Distended veins, higher venous resistance

A. Moderate fluid retention, increased venous return

In decompensated heart failure, the fundamental renal problem is failure of the heart to pump enough:

A. oxygen
B. blood
C. lymph
D. plasma

B. blood

Because renal perfusion is inadequate in decompensated heart failure, the kidneys fail to:

A. filter glucose
B. excrete enough fluid
C. secrete potassium
D. retain sodium

B. excrete enough fluid

In decompensated heart failure, cardiac output remains ______ normal, promoting ongoing renal fluid retention.

A. above
B. equal to
C. below
D. independent of

C. below

Continued renal fluid retention in decompensated heart failure most directly causes increased:

A. blood volume and RA pressure
B. GFR and urine output
C. contractility and reserve
D. aortic pressure and EF

A. blood volume and RA pressure

Heart failure that progressively worsens because compensation cannot restore adequate output is called:

A. compensated failure
B. isolated right failure
C. acute valvular failure
D. decompensated failure

D. decompensated failure

A classic clinical feature of decompensated heart failure is progressive:

A. edema
B. bradycardia
C. cyanosis
D. hypertension

A. edema

Lung auscultation in decompensated heart failure commonly reveals bubbling:

A. wheezes
B. rales
C. stridor
D. rubs

B. rales

The “air hunger” symptom in decompensated heart failure is:

A. orthopnea
B. pleurisy
C. dyspnea
D. hemoptysis

C. dyspnea

A standard treatment combination for decompensated heart failure includes:

A. digoxin and diuretic
B. insulin and nitrate
C. adenosine and steroid
D. atropine and β-blocker

A. digoxin and diuretic

In this setting, digitalis is used mainly to:

A. slow renal filtration
B. strengthen cardiac pumping
C. dilate pulmonary veins
D. suppress aldosterone

B. strengthen cardiac pumping

Diuretics help decompensated heart failure mainly by:

A. increasing fluid retention
B. reducing edema
C. increasing SVR
D. depressing contractility

B. reducing edema

Digitalis increases intracellular calcium primarily by first inhibiting the:

A. calcium ATPase
B. sodium-calcium exchanger
C. sodium-potassium pump
D. funny current channel

C. sodium-potassium pump

Inhibition of the sodium-potassium pump by digitalis raises intracellular sodium, which slows the:

A. sodium-calcium exchanger
B. chloride-bicarbonate pump
C. calcium ATPase
D. potassium leak channel

A. sodium-calcium exchanger

The final ionic change that strengthens contraction with digitalis is increased intracellular:

A. potassium
B. chloride
C. calcium
D. magnesium

C. calcium

Isolated left-sided heart failure causes increased mean ______ filling pressure.

A. systemic
B. pulmonary
C. portal
D. coronary

B. pulmonary

Left-sided failure raises pulmonary filling pressure because blood backs up into the:

A. kidneys
B. systemic veins
C. lungs
D. liver

C. lungs

Pulmonary edema is likely when pulmonary capillary pressure rises above about:

A. 14 mm Hg
B. 21 mm Hg
C. 28 mm Hg
D. 35 mm Hg

C. 28 mm Hg

Average pulmonary capillary pressure is closest to:

A. 7 mm Hg
B. 14 mm Hg
C. 21 mm Hg
D. 28 mm Hg

A. 7 mm Hg

Low cardiac output from acute MI causing inadequate tissue perfusion is:

A. septic shock
B. hypovolemic shock
C. cardiogenic shock
D. neurogenic shock

C. cardiogenic shock

Cardiogenic shock worsens progressively in part because reduced arterial pressure lowers:

A. cerebral venous return
B. coronary blood supply
C. portal resistance
D. lymphatic drainage

B. coronary blood supply

Reduced coronary perfusion during cardiogenic shock causes:

A. stronger contraction
B. further myocardial weakening
C. immediate renal recovery
D. pulmonary vasodilation

B. further myocardial weakening

In a healthy heart, cardiac deterioration begins at ______ coronary arterial pressures than in a heart with major coronary blockage.

A. higher
B. equal
C. more variable
D. lower

D. lower

In a heart with major coronary vessel blockage, deterioration may begin when coronary pressure falls to about:

A. 20–30 mm Hg
B. 45 mm Hg
C. 80–90 mm Hg
D. 120–130 mm Hg

C. 80–90 mm Hg

In cardiogenic shock with ventricular damage, a classic medication used to prevent worsening deterioration is:

A. digoxin
B. lidocaine
C. atropine
D. nitroprusside

A. digoxin

Blood transfusion in cardiogenic shock is used mainly to increase:

A. potassium excretion and arterial pressure
B. blood and arterial pressure
C. vagal tone and arterial pressure
D. ventricular compliance and arterial pressure

B. blood and arterial pressure

Raising arterial pressure in cardiogenic shock helps by improving:

A. coronary perfusion
B. atrial depolarization
C. pulmonary compliance
D. venous capacitance

A. coronary perfusion

If cardiogenic shock is caused by coronary thrombosis, another treatment is:

A. clot removal
B. insulin infusion
C. dialysis
D. adenosine

A. clot removal

In acute heart failure, aortic pressure typically ______ while right atrial pressure ______.

A. increases, decreases
B. decreases, increases
C. decreases, decreases
D. increases, increases

B. decreases, increases

Acute cardiac failure does not immediately cause:

A. pulmonary edema
B. decreased aortic pressure
C. immediate peripheral edema
D. increased RA pressure

C. immediate peripheral edema

Severe acute cardiac failure often causes a ______ in peripheral capillary pressure rather than a rise.

A. plateau
B. surge
C. fall
D. delay

C. fall

Because peripheral capillary pressure initially falls in acute heart failure, immediate peripheral edema is:

A. prominent
B. absent
C. unilateral
D. hemorrhagic

B. absent

Over the long term, cardiac failure causes ______ peripheral capillary pressure because of renal fluid retention.

A. decreased
B. oscillating
C. increased
D. normalized

C. increased

In chronic heart failure, renal fluid retention is the major reason peripheral edema eventually develops. The key organ driving this is the:

A. liver
B. spleen
C. lungs
D. kidneys

D. kidneys

Long-term cardiac failure causes a ______ glomerular filtration rate and a ______ urine output.

A. increased, increased
B. decreased, decreased
C. increased, decreased
D. decreased, increased

B. decreased, decreased

One mechanism for the reduced GFR in long-term heart failure is:

A. dilation of afferent arterioles
B. increased renal venous oxygen
C. reduced arterial pressure
D. decreased aldosterone

C. reduced arterial pressure

Another mechanism contributing to reduced GFR in long-term heart failure is:

A. constriction of afferent arterioles
B. dilation of efferent arterioles only
C. increased renal plasma flow
D. reduced sympathetic tone

A. constriction of afferent arterioles

In long-term cardiac failure, reduced renal perfusion commonly causes activation of the:

A. kallikrein-kinin system
B. renin-angiotensin system
C. complement cascade
D. fibrinolytic pathway

B. renin-angiotensin system

Activation of the renin-angiotensin system in long-term heart failure promotes increased renal reabsorption of:

A. glucose and phosphate
B. calcium and chloride
C. water and salt
D. urea and potassium

C. water and salt

Long-term heart failure often causes increased secretion of:

A. cortisol
B. aldosterone
C. insulin
D. thyroxine

B. aldosterone

Increased aldosterone contributes to peripheral edema primarily because sodium retention secondarily increases:

A. bicarbonate loss
B. calcium excretion
C. water retention
D. protein synthesis

C. water retention

Long-term cardiac failure is associated with ______ of the sympathetic nervous system.

A. activation
B. suppression
C. denervation
D. exhaustion

A. activation

Sympathetic activation can worsen edema by constricting afferent arterioles and thereby:

A. increasing GFR
B. decreasing GFR
C. increasing filtration fraction
D. increasing renal plasma flow

B. decreasing GFR

Sympathetic stimulation increases tubular salt and water reabsorption in part by activating:

A. beta-2 receptors
B. muscarinic receptors
C. alpha receptors
D. nicotinic receptors

C. alpha receptors

Another way sympathetic activation promotes edema is by stimulating:

A. calcitonin release and beta receptors
B. renin and angiotensin II
C. ANP secretion and alpha receptors
D. NO release and angiotensin II

B. renin and angiotensin II

Sympathetic activation also promotes fluid retention by stimulating release of:

A. ADH
B. prolactin
C. glucagon
D. ANP

A. ADH

Atrial natriuretic peptide is released when the atrial walls become:

A. calcified
B. constricted
C. stretched
D. ischemic

C. stretched

In severe heart failure, blood levels of ANP may rise approximately:

A. 1- to 2-fold
B. 5- to 10-fold
C. 10- to 20-fold
D. 40 to 50-fold

B. 5- to 10-fold

ANP levels rise in severe heart failure mainly because the atria are:

A. underfilled
B. ischemic
C. stretched by pressure
D. denervated

C. stretched by pressure

ANP acts on the kidneys to greatly ______ excretion of salt and water.

A. decrease
B. increase
C. normalize
D. delay

B. increase

ANP serves an important protective role in heart failure by helping prevent:

A. arrhythmias
B. valve calcification
C. congestive symptoms
D. myocardial rupture

C. congestive symptoms

Acute progressive pulmonary edema may occur in a patient with longstanding heart failure after an event that further depresses:

A. right atrial function
B. left ventricular function
C. AV nodal conduction
D. renal tubular function

B. left ventricular function

In this setting, reduced blood oxygen levels in peripheral tissues trigger:

A. vasoconstriction
B. fibrinolysis
C. vasodilation
D. bradycardia

C. vasodilation

Peripheral vasodilation during acute progressive pulmonary edema tends to increase:

A. venous return
B. renal filtration
C. systemic resistance
D. coronary thrombosis

A. venous return

Increased venous return in this situation further raises pulmonary capillary pressure and thereby:

A. improves oxygenation
B. reduces edema formation
C. worsens pulmonary edema
D. lowers atrial pressure

C. worsens pulmonary edema

This sequence of worsening hypoxemia, vasodilation, venous return, and edema represents a:

A. compensatory reflex
B. protective adaptation
C. closed-loop recovery
D. vicious cycle

D. vicious cycle

A patient with longstanding heart failure develops sudden severe pulmonary edema after extreme emotional stress. Which mechanism best explains the rapid progression?

A. Hypoxemia causes vasodilation
B. ANP suppresses salt loss
C. Hyperoxia increases preload
D. ADH falls abruptly

A. Hypoxemia causes vasodilation

An emergency bedside maneuver to reduce left-heart workload in acute pulmonary edema is:

A. carotid massage
B. limb tourniquets
C. Trendelenburg position
D. abdominal binder

B. limb tourniquets

Rapidly acting diuretics help acute progressive pulmonary edema by causing rapid:

A. sodium infusion
B. arterial vasospasm
C. fluid loss
D. platelet inhibition

C. fluid loss

Giving pure oxygen in this setting mainly helps reverse:

A. hyperkalemia
B. oxygen desaturation
C. renal ischemia
D. aldosterone release

B. oxygen desaturation

Oxygen therapy also helps reduce further progression by countering peripheral:

A. vasodilation
B. thrombosis
C. fibrosis
D. bradycardia

A. vasodilation

A rapidly acting cardiotonic drug such as digitalis is used here primarily to:

A. lower venous tone
B. strengthen the heart
C. inhibit ANP release
D. suppress diuresis

B. strengthen the heart

Which of the following is one of the four major acute treatments for progressive pulmonary edema in longstanding heart failure?

A. pure oxygen
B. fluid bolus
C. beta-blocker loading
D. vasopressin infusion

A. pure oxygen

Which mechanism does not promote edema in long-term heart failure?

A. increased aldosterone
B. ANP-mediated natriuresis
C. sympathetic activation
D. angiotensin activation

B. ANP-mediated natriuresis

In severe heart failure, atrial stretch is most directly caused by blood:

A. moving rapidly into capillaries
B. backing up from ventricles
C. bypassing the lungs
D. pooling in arteries only

B. backing up from ventricles

Which treatment list best matches acute progressive pulmonary edema in chronic heart failure?

A. tourniquets, diuretic, oxygen, digitalis
B. insulin, dialysis, oxygen, aspirin
C. nitrates, heparin, atropine, bicarbonate
D. steroids, calcium, fluids, lidocaine

A. tourniquets, diuretic, oxygen, digitalis

The dyspnea seen with low cardiac reserve is mainly due to:

A. excess oxygen delivery
B. insufficient tissue perfusion
C. airway obstruction
D. increased hemoglobin

B. insufficient tissue perfusion

Muscle fatigue in low cardiac reserve is best explained by:

A. glycogen depletion
B. muscle ischemia
C. electrolyte excess
D. increased lactate clearance

B. muscle ischemia

An acute myocardial infarction most immediately causes the cardiac output curve to:

A. shift upward
B. flatten only
C. disappear
D. shift downward

D. shift downward

Within approximately how many seconds after MI do sympathetic reflexes become very active?

A. 5 seconds
B. 15 seconds
C. 60 seconds
D. 30 seconds

D. 30 seconds

Early sympathetic activation after MI tends to:

A. lower cardiac output and venous return
B. raise cardiac output and venous return
C. suppress both curves
D. affect only arterial pressure

B. raise cardiac output and venous return

Over the next days to weeks after MI, cardiac output and venous return curves rise further mainly due to:

A. valve replacement and renal retention
B. reduced preload and renal retention
C. myocardial recovery and renal retention
D. vagal dominance and renal retention

C. myocardial recovery and renal retention

Renal retention of salt and water after MI increases the:

A. ejection fraction
B. mean systemic filling pressure
C. coronary resistance
D. pulmonary compliance

B. mean systemic filling pressure

In decompensated heart failure, the ______ curve fails to reach the critical level.

A. venous return
B. pulmonary pressure
C. cardiac output
D. arterial oxygen

C. cardiac output

Because the cardiac output curve never reaches the critical level in decompensation, the kidneys continue to:

A. excrete excess fluid
B. retain fluid
C. normalize GFR
D. increase filtration

B. retain fluid

Continued renal retention in decompensated heart failure progressively increases the:

A. stroke volume
B. arterial compliance
C. heart rate
D. venous return curve

C. heart rate

Treatment of decompensated heart failure with digitalis primarily causes the ______ curve to rise.

A. venous return
B. cardiac output
C. pulmonary resistance
D. renal filtration

B. cardiac output

When digitalis raises cardiac output to the critical level, the kidneys respond by:

A. retaining more sodium
B. decreasing filtration
C. eliminating more fluid
D. increasing aldosterone

C. eliminating more fluid

An arteriovenous fistula can lead to which type of heart failure?

A. low-output
B. right-sided only
C. diastolic only
D. high-output

D. high-output

The mechanism of heart failure in an arteriovenous fistula is:

A. reduced contractility
B. excessive venous return
C. coronary occlusion
D. valve stenosis

B. excessive venous return

In arteriovenous fistula–induced heart failure, the intrinsic pumping ability of the heart is:

A. depressed
B. absent
C. normal
D. hypercontractile

C. normal

Beriberi heart disease is another cause of:

A. low-output failure
B. obstructive shock
C. restrictive cardiomyopathy
D. high-output failure

D. high-output failure

In beriberi, weakening of the heart leads to decreased blood flow to the:

A. lungs
B. brain
C. kidneys
D. liver

C. kidneys

Reduced renal perfusion in beriberi causes the kidneys to:

A. excrete excess fluid
B. retain fluid
C. reduce sodium reabsorption
D. increase GFR

B. retain fluid

Fluid retention in beriberi contributes to an increase in:

A. venous return
B. pulmonary diffusion
C. arterial elasticity
D. cardiac reserve

A. venous return