levosimendan MOA?

A. Inhibits Na/K ATPase
B. Increases Ca2+ sensitivity
C. Inhibits phosphodiesterase 3
D. Activates β1 receptors

B. Increases Ca2+ sensitivity

A ventricular myocyte is exposed to strong β-adrenergic stimulation with high cAMP and active protein kinase A. Which phospholamban-SERCA state is expected?

A. Dephosphorylated; SERCA activated
B. Phosphorylated; SERCA inhibited
C. Dephosphorylated; SERCA inhibited
D. Phosphorylated; SERCA activated

D. Phosphorylated; SERCA activated

PKA phosphorylates phospholamban, which activates SERCA.

In a failing cardiomyocyte, phospholamban remains dephosphorylated. What is the most immediate consequence?

A. Inhibited SERCA reuptake
B. Increased calcium sensitivity
C. Enhanced NCX activity
D. Faster ventricular depolarization

A. Inhibited SERCA reuptake

During diastole, the sodium-calcium exchanger helps extrude calcium from cardiac myocytes. What is its ion stoichiometry?

A. 2 Na in, 1 Ca out
B. 3 Na out, 1 Ca in
C. 3 Na in, 1 Ca out
D. 1 Na in, 3 Ca out

C. 3 Na in, 1 Ca out

Digoxin MOA:

A. Inhibits Na/K ATPase
B. Activates SERCA directly
C. Blocks cardiac β1 receptors
D. Inhibits phosphodiesterase 3

A. Inhibits Na/K ATPase

Which form of cardiac dysfunction responds most optimally to inotropic drugs?

A. Constrictive pericarditis
B. Diastolic heart failure
C. Hypertrophic obstruction
D. Systolic heart failure

D. Systolic heart failure

Systolic failure responds best because the primary defect is inotropy.

Which direct effect best describes digitalis on cardiac muscle?

A. Negative inotropy
B. Positive inotropy
C. Negative lusitropy
D. Pure chronotropy

B. Positive inotropy

Digoxin toxicity:

A. Constipation, bloating, cramps
B. Melena, tenesmus, pain
C. Vomiting, nausea, diarrhea
D. Steatorrhea, ileus, jaundice

C. Vomiting, nausea, diarrhea

A patient on digoxin is found to have elevated serum potassium. How does hyperkalemia affect digitalis-induced arrhythmia risk?

A. Protective against arrhythmia
B. Conducive to arrhythmia
C. No meaningful change
D. Causes vagal excess only

A. Protective against arrhythmia

Hyperkalemia is protective against digitalis-induced arrhythmia.

A digoxin-treated patient also has hypercalcemia. What effect does the calcium abnormality have?

A. Stabilizes cardiac membranes
B. Reduces digoxin binding
C. No effect on toxicity
D. Conducive to arrhythmia

D. Conducive to arrhythmia

Hypercalcemia is conducive to digitalis-induced arrhythmia.

In the setting of digoxin use and hypercalcemia, increased magnesium would most likely:

A. Raise intracellular sodium
B. Blunt calcium’s toxic effect
C. Stimulate β1 signaling
D. Inhibit Na/K ATPase

B. Blunt calcium’s toxic effect

A patient in acute systolic failure receives milrinone. What is its mechanism?

A. PDE-3 inhibition
B. β1 receptor stimulation
C. Na/K ATPase inhibition
D. Calcium sensitization

A. PDE-3 inhibition

Milrinone belongs to which drug class?

A. Cardiac glycoside
B. Catecholamine
C. Bipyridine
D. Organic nitrate

C. Bipyridine

Besides improving inotropy, milrinone can reduce afterload through which additional action?

A. α1-mediated vasoconstriction
B. Nitric oxide donation
C. ACE inhibition
D. Vasodilation via MLCK inhibition

D. Vasodilation via MLCK inhibition

A patient with severe low-output heart failure is started on dobutamine. What is its primary mechanism?

A. PDE-3 inhibition
B. Muscarinic activation
C. β1 agonism
D. Na/K ATPase blockade

C. β1 agonism

A stable outpatient with chronic heart failure is discharged on guideline-type long-term therapy. Which class is explicitly listed as first-line in your material?

A. Organic nitrates
B. ACE inhibitors
C. Class I antiarrhythmics
D. Endothelin antagonists

B. ACE inhibitors

A patient with chronic heart failure needs additional neurohormonal blockade. Which class is also listed as first-line?

A. Direct renin inhibitors
B. Sodium channel blockers
C. Thrombin inhibitors
D. Aldosterone antagonists

D. Aldosterone antagonists

A patient with chronic heart failure cannot tolerate one RAAS-blocking strategy and is switched to another listed first-line class. Which is it?

A. Central α2 agonists
B. Angiotensin receptor antagonists
C. Class III antiarrhythmics
D. Muscarinic antagonists

B. Angiotensin receptor antagonists

A volume-overloaded patient with heart failure needs a preferred diuretic class for symptomatic control. Which is favored?

A. Thiazides
B. Osmotics
C. Loop diuretics
D. Carbonic anhydrase inhibitors

C. Loop diuretics

Which sympathetic-modulating class is listed among first-line chronic heart failure therapies?

A. β-blockers
B. Fibrinolytics
C. Mixed α agonists
D. Adenosine analogs

A. β-blockers

A patient with chronic HFrEF is started on an aldosterone antagonist proven useful in heart failure. Which drug is indicated?

A. Eplerenone
B. Amiloride
C. Spironolactone
D. Triamterene

C. Spironolactone

A patient with chronic systolic heart failure is started on enalapril. Which pathologic process does this therapy help reduce over time?

A. Cardiac remodeling
B. AV nodal conduction
C. Coronary vasospasm
D. Ventricular preload

A. Cardiac remodeling

A patient with congestive heart failure is given enalapril. What is its hemodynamic effect on preload and afterload?

A. ↑ preload, ↓ afterload
B. ↑ preload, ↑ afterload
C. ↓ preload, ↑ afterload
D. ↓ preload, ↓ afterload

D. ↓ preload, ↓ afterload

A patient with acute decompensated heart failure receives nesiritide. What is its mechanism of action?

A. PDE-3 inhibitor
B. BNP analog
C. β1 agonist
D. ACE inhibitor

B. BNP analog

A patient with acute heart failure is treated with a drug that mimics BNP but has limited overall benefit in practice. Which drug is this?

A. Nesiritide
B. Dobutamine
C. Digoxin
D. Milrinone

A. Nesiritide

Nesiritide most common adverse effect?

A. Hyperkalemia
B. Reflex tachycardia
C. Excessive hypotension
D. Ventricular bigeminy

C. Excessive hypotension

A patient with heart failure is taking digoxin and a loop diuretic. Which complication is the greatest concern?

A. Hypernatremic seizures
B. Hypokalemic arrhythmia
C. Hypermagnesemic block
D. Metabolic alkalosis only

B. Hypokalemic arrhythmia

Why does loop diuretic therapy increase arrhythmia risk in a patient taking digoxin?

A. Raises digoxin metabolism
B. Blocks calcium extrusion
C. Increases vagal discharge
D. Low potassium enhances pump binding

D. Low potassium enhances pump binding

A patient with both HFrEF and atrial fibrillation needs a drug that can aid rate control while also supporting inotropy. Which drug fits?

A. Digoxin
B. Verapamil
C. Adenosine
D. Flecainide

A. Digoxin

In which setting is digoxin classically contraindicated because it may worsen conduction down an accessory pathway?

A. Ebstein anomaly
B. Atrial septal defect
C. Wolff-Parkinson-White syndrome
D. Tetralogy of Fallot

C. Wolff-Parkinson-White syndrome

Which β-blocker is noted here to be effective in both systolic and diastolic heart failure?

A. Metoprolol
B. Carvedilol
C. Propranolol
D. Nebivolol

D. Nebivolol

The additional vasodilatory property of nebivolol is primarily attributed to activity at which receptor?

A. β1 receptor
B. β3 receptor
C. α1 receptor
D. M2 receptor

B. β3 receptor

A patient arrives with acute pulmonary edema from acute heart failure. Which diuretic is preferably given intravenously?

A. Furosemide
B. Hydrochlorothiazide
C. Spironolactone
D. Acetazolamide

A. Furosemide

Which drug is first-line and indicated in both acute HFrEF and acute HFpEF for symptomatic volume overload?

A. Digoxin
B. Enalapril
C. Furosemide
D. Nesiritide

C. Furosemide

In heart failure, preload is usually increased primarily because of:

A. Increased blood volume and reduced venous tone
B. Increased blood volume and venous tone
C. Enhanced lymphatic return and venous tone
D. Reduced atrial filling pressures and venous tone

B. Increased blood volume and venous tone

Increased preload in heart failure most directly increases myocardial oxygen demand by increasing:

A. Fiber length at filling
B. Coronary flow reserve
C. Sodium channel opening
D. Sinoatrial automaticity

A. Fiber length at filling

Which electrolyte abnormality most facilitates the toxic actions of cardiac glycosides?

A. Hypocalcemia
B. Hypermagnesemia
C. Increased calcium levels
D. Hypernatremia

C. Increased calcium levels

Cardiac glycosides (like digoxin) work by inhibiting the Na+/K+-ATPase pump, which leads to a secondary increase in intracellular calcium levels to enhance cardiac contractility.

A 58-year-old man has long-standing hypertension and diabetes but no structural heart disease and no heart-failure symptoms. Which stage best fits?

A. Stage C
B. Stage A
C. Stage D
D. Stage B

B. Stage A

An asymptomatic patient is found to have reduced ejection fraction after a prior silent myocardial infarction. Which heart-failure stage is this?

A. Stage D
B. Stage A
C. Stage B
D. Stage C

C. Stage B

A patient has known dilated cardiomyopathy and dyspnea that improves with standard heart-failure therapy. Which stage applies?

A. Stage C
B. Stage B
C. Stage A
D. Stage D

A. Stage C

A patient with end-stage heart failure remains symptomatic despite ordinary therapy and is being evaluated for transplant. Which stage is this?

A. Stage A
B. Stage C
C. Stage B
D. Stage D

D. Stage D

A patient with heart failure also has atrial fibrillation with rapid ventricular response. Which drug from your material is specifically indicated in this setting?

A. Digoxin
B. Hydralazine
C. Nesiritide
D. Furosemide

A. Digoxin

In chronic heart failure, digoxin is usually added only after which therapies fail to adequately control symptoms?

A. β-blockers and nitrates
B. Diuretics and ACE inhibitors
C. ARBs and hydralazine
D. Calcium blockers and diuretics

B. Diuretics and ACE inhibitors

A patient in cardiogenic shock has severe hypotension and needs a rapidly acting positive inotrope. Which pair is especially useful?

A. Digoxin and nesiritide
B. Enalapril and furosemide
C. Dopamine and dobutamine
D. Spironolactone and milrinone

C. Dopamine and dobutamine

A patient has left-ventricular dysfunction but no edema. According to your material, which drug class should be used first?

A. ACE inhibitors
B. Loop diuretics
C. Cardiac glycosides
D. Aldosterone blockers

A. ACE inhibitors

An African American patient remains symptomatic from heart failure despite ACE-inhibitor therapy. Which add-on combination is specifically recommended?

A. Verapamil and nitrate
B. Digoxin and amiloride
C. Isosorbide dinitrate and hydralazine
D. Losartan and spironolactone

C. Isosorbide dinitrate and hydralazine