Managing
2.5
ANCC/AACN
CONTACT HOURS
Follow the latest staging system
to recognize patients with this
disorder early and help delay
disease progression.
BY DONNA CHOJNOWSKI, RN, CRNP, MSN
T HE PREVALENCE OF
heart failure is increasing
as the number of older
Americans increases, more
people survive myocardial
infarction (MI), and more people
develop hypertension and coronary
artery disease (CAD), which are
risk factors for heart failure. About
5 million Americans have heart fail-
ure, and more than half a million
new cases are identified yearly. Yet
evidence-based guidelines for heart
failure treatment continue to be
underused.
Guidelines developed by the
American College of Cardiology
(ACC) and American Heart
Association (AHA), revised in
2005, provide management rec-
ommendations for heart failure
but also focus on identifying
patients at risk and adopting
strategies to prevent or slow ven-
36 Nursing2006, Volume 36, Number 7
systolic
tricular remodeling.
Heart failure can be caused by
diastolic or systolic dysfunction. In
this article, I’ll describe practice
guidelines for managing heart fail-
ure caused by systolic dysfunction.
Recognizing systolic trouble
Typically, heart failure is identi-
fied during a medical evaluation
for complaints of decreased exer-
cise tolerance, dyspnea, and fluid
retention. In asymptomatic
patients, heart failure may be
diagnosed when tests for other
conditions uncover abnormal left
ventricular (LV) function.
Obtain a thorough history and
perform a physical examination.
Documentation should include
the patient’s previous and current
medical conditions, surgeries,
treatments, substance use, expo-
sure to toxins, family history of
heart failure risk factors, and
medication reconciliation.
Ask the patient about current
symptoms, including onset. Have
him describe symptoms, frequen-
cy and patterns, treatments, and
whether treatments relieve symp-
toms.
Findings that may be related to
heart failure include:
• neurologic signs and symptoms
such as depression, syncope, diffi-
culty with concentration, confu-
sion, and panic attacks
• cardiovascular signs and symp-
toms such as fatigue, angina, syn-
cope, palpitations, orthostastic
hypotension, edema, and discol-
oration of the extremities
• pulmonary signs and symptoms
such as dyspnea at rest or with
exertion, cough, orthopnea,
paroxysmal nocturnal dyspnea,
hemoptysis, wheezing, frequent
www.nursing2006.com
heart failure

upper respiratory infections, and

sleep apnea
• gastroenterologic signs and symp-
toms such as abdominal discomfort
or tenderness, bloating, weight
loss or gain, nausea, anorexia, and
hepatomegaly
• genitourinary signs and symptoms
such as renal insufficiency, noc-
turia, oliguria, anuria, and sexual
dysfunction. If the patient is tak-
ing diuretics, ask about his pattern
of diuresis and if it’s changed.
• endocrine signs and symptoms,
such as those associated with thy-
roid disease, diabetes, or metabolic
JOHN BAVOSI/PHOTO RESEARCHERS, INC.

syndrome.

Testing, testing
The initial workup for a patient
with suspected heart failure in-
cludes lab tests, a chest X-ray,
electrocardiogram (ECG), and
echocardiogram. Let’s take a look

www.nursing2006.com Nursing2006, July 37

at what each will show:
• Lab work begins with an assess-
ment of renal and hepatic function
and evaluation for underlying dis-
orders, such as anemia and dia-
betes. Based on the patient’s history
and physical exam, he also may be
tested for B-type natriuretic pep-
tide (BNP) level, thyroid hormone
levels, and iron level (to rule out
hemochromatosis) and for drugs
or toxin levels.
• The chest X-ray provides infor-
mation on heart size and the pres-
ence of pulmonary abnormalities,
such as vascular congestion, effu-
sions, and interstitial edema.
• The ECG reveals cardiac rhythm
and rate, evidence of conduction
abnormality (such as left bundle-
branch block), atrial or ventricular
arrhythmias, evidence of ischemia
or infarction, chamber hypertrophy
or enlargement, and electrolyte
abnormalities such as hyper-
kalemia.
• The echocardiogram is the most
useful noninvasive diagnostic tool
for evaluating a patient with heart
failure. The two-dimensional
echocardiogram and Doppler flow
studies provide information on
chamber size and function, ven-
tricular wall thickness, valve func-
tion, systolic and diastolic func-
tion, presence of thrombus or
aneurysm, or other structural
problems as identified by wall
thickness and function.
Additional tests can be done to
confirm the diagnosis or determine
the level of disease, such as radio-
nuclide ventriculography, coronary
angiography, hemodynamic assess-
ment via right-sided heart catheter-
ization, cardiac exercise testing for
oxygen consumption, computed
tomography scan or angiography,
magnetic resonance imaging, and
endomyocardial biopsy.
According to the ACC/AHA
guidelines, coronary angiography
is indicated to determine the pres-
ence of CAD if the patient has
angina or unexplained abnormal
ventricular function or if a patient
38 Nursing2006, Volume 36, Number 7
with known CAD reports a change
in his symptoms.
Invasive hemodynamic assess-
ment via right-sided heart catheteri-
zation may be done in conjunction
with cardiac catheterization, but
also may be indicated alone. This
assessment of hemodynamic pres-
sures may provide additional infor-
mation about ventricular function.
If the patient is being given intra-
venous (I.V.) medications such as
positive inotropes or vasodilators to
manage acute heart failure, the
catheter may be left in place to
monitor his response to therapy.
Setting the stage
Now let’s look at treatment based
on the staging approach of the
ACC/AHA guidelines. (For a
description of the stages and a
comparison with the New York
Heart Association system, see
Staging heart failure.) The
ACC/AHA system is recognized as
the mainstay for treatment and
emphasizes prevention to slow or
reverse ventricular remodeling,
whether or not the patient has
symptoms of heart failure.
After baseline staging, the health
care provider should assess the
patient’s history and clinical status
at follow-up visits to monitor the
effectiveness of treatment and plan
ongoing therapy. He may also order
follow-up diagnostic testing to
monitor the disease process. At
each visit, review the patient’s func-
tional assessment, vital signs,
weight, fluid volume status, diet,
fluid intake, and use of alcohol and
reconcile his medications. Educate
and reinforce information with the
patient and family.
Stage A—at risk
Treatment for a patient in stage A
aims to control conditions (such as
dyslipidemia) that could further
compromise the heart and to retard
or delay disease progression.
Interventions should follow these
guidelines:
• Control hypertension. Several large
studies have shown that effectively
treating hypertension decreases the
incidence of heart failure. The
Seventh Report of the Joint Na-
tional Committee on Prevention,
Detection, Evaluation, and Treat-
ment of High Blood Pressure (JNC
7) guidelines recommend keeping
an adult’s BP below 140/90 (below
130/80 if he has diabetes or chron-
ic kidney disease).
Strategies and goals are influ-
enced by the patient’s age. Elevated
diastolic BP is a strong risk factor
until age 50. After age 50, however,
elevated systolic BP becomes a
greater concern because of its strong
link to stroke and cardiovascular
disease, including heart failure.
Follow the JNC 7 treatment
algorithm for managing hyperten-
sion in patients with diabetes, car-
diovascular disease, or a history of
MI. The recommended drugs—
thiazide diuretics, angiotensin-
converting enzyme (ACE) inhibi-
tors or angiotensin receptor block-
ers, and beta-blockers—reduce BP,
and some also are indicated for
treating heart failure.
• Control dyslipidemia. Follow the
guidelines established by the
Third Report of the National
Cholesterol Education Program
Expert Panel on Detection,
Evaluation, and Treatment of
High Blood Cholesterol in Adults.
• Deal with diabetes. Because
patients with diabetes are at
increased risk for cardiovascular
disease and heart failure, keeping
blood glucose under tight control
is crucial. Early treatment with an
ACE inhibitor or an angiotensin
receptor blocker can reduce the
patient’s risk of end organ damage
and cardiovascular events.
• Treat other underlying disorders.
Disorders that can predispose a
patient to heart failure if left
untreated include thyroid dis-
ease, atrial fibrillation, and per-
sistent sinus tachycardia.
• If your patient has had cancer,
find out what treatments he
received. Ionizing radiation to
www.nursing2006.com
 Staging heart failure

The American College of Cardiology/American Heart Association (ACC/AHA) staging system is based on the patient’s risk
factors, symptoms, and any cardiac structural defects, as determined by history, physical exam, and diagnostic testing. The
system aims to promote prevention as well as guide treatment.

Stage
A—Patient is at high risk for developing heart
failure because of hypertension, atheroscle-
rotic disease, dyslipidemia, diabetes, smok-
ing, history of cardiotoxic drug use, or family
history, but at this point, the patient doesn’t
have cardiac structural disorder or any signs
and symptoms of heart failure.
B—Patient has no heart failure symptoms,
but has structural heart disease, such as
abnormal left ventricular function, left ventric-
ular hypertrophy, myocardial infarction, or
valvular disease, and is at risk for progression
to heart failure.
C—Patient has past or current heart failure
symptoms associated with structural cardiac
disease such as advanced ventricular remod-
eling.
D—Patient has advanced refractory heart
failure and is symptomatic at rest or with mini-
mal exertion despite maximal medical therapy.
Treatment
• Treat underlying hypertension or diabetes.
• Control conditions that may cause cardiac injury.
• Regular exercise regimen
• Angiotensin-converting enzyme (ACE) inhibitor if indicated (such as
for patients with diabetes or vascular disease)
• Encourage smoking cessation.
• All stage A therapies
• ACE inhibitor unless contraindicated
• Beta-blocker unless contraindicated
• Implantable cardioverter-defibrillator (ICD) in select patients
• All stage A and B therapies
• Sodium-restricted diet
• Diuretic
• Digoxin
• Avoid or withdraw antiarrhythmics, most calcium channel blockers,
and nonsteroidal anti-inflammatory drugs.
• Consider aldosterone antagonist, angiotensin receptor blocker,
hydralazine, and nitrates.
• ICD and biventricular pacing in select patients
• All therapies for stages A, B, and C
• Mechanical assist device such as left ventricular assist device
(permanent or bridge to transplant)
• Continuous inotropic therapy
• Heart transplant
• Hospice care

The New York Heart Association (NYHA) functional classification, also widely used, is a subjective ranking based on the patient’s
functional ability. In contrast to the ACC/AHA system, in the NYHA system, the patient’s classification can change if symptoms
improve or worsen with therapy. The four NYHA classes are:
• Class I—no limitation of physical activity. Ordinary activity doesn’t cause the patient undue fatigue, dyspnea, palpitations, or
anginal pain.
• Class II—slight limitation of physical activity. The patient is comfortable at rest, but ordinary physical activity causes heart fail-
ure symptoms, including fatigue, dyspnea, palpitations, or anginal pain.
• Class III—marked limitation of physical activity. The patient is comfortable at rest, but less-than-ordinary physical activity caus-
es heart failure symptoms.
• Class IV—severe limitation. The patient has symptoms of heart failure at rest. Any physical activity increases this discomfort.

the mediastinum can lead to
restrictive cardiomyopathy and
heart failure. Chemotherapeutic
drugs such as athracyclines and
trastuzumab (a monoclonal anti-
body) can cause irreversible
myocardial damage.
• Encourage healthy living. If the
patient smokes, he should stop,
and he should avoid alcohol and
substance abuse. Regular exer-
cise and a low-fat, low-sodium
diet can help him maintain his
health and reduce his risk of
dyslipidemia, diabetes, and
hypertension.
Stage B—structural trouble
The treatment goals for a patient
in this stage are slowing disease
progression, improving survival,
and minimizing risk factors. In
addition to all stage A therapies,
all patients in stage B should take
an ACE inhibitor and a beta-
blocker unless contraindicated.
• Angiotensin-converting enzyme
inhibitors stop the conversion of
angiotensin I to angiotensin II, a
potent vasoconstrictor. This ther-

www.nursing2006.com Nursing2006, July 39

apy reduces the effects of sodium
and water retention, vasoconstric-
tion, and myocardial remodeling.
The drug also decreases the de-
gradation of bradykinin, enhanc-
ing its action and promoting
vasodilation and natriuresis.
Start an ACE inhibitor at a low
dose when the patient is euvole-
mic and gradually titrate the dose
upward as ordered. During the
first 1 to 2 weeks of therapy, and
regularly after that, monitor his
vital signs, postural BP, renal
function, and potassium level.
Adverse reactions to ACE in-
hibitors include angioedema,
cough secondary to increased
bradykinin, hyperkalemia, wors-
ening renal function, hypoten-
sion, azotemia, rash, and alopecia.
Contraindications to ACE
inhibitor therapy include bilateral
renal artery stenosis, pregnancy,
hyperkalemia, and renal insuffi-
ciency with a creatinine level
greater than 3 mg/dl.
A patient who can’t take or tol-
erate ACE inhibitors may be treat-
ed with an angiotensin receptor
blocker along with adequate beta-
blocker therapy. Adverse reac-
tions to angiotensin receptor
blockers include hypotension,
hyperkalemia, and azotemia.
These drugs also are contraindi-
cated in patients with elevated
serum creatinine.
• Beta-blockers, which inhibit
chronic activation of the sympa-
thetic nervous system, are the
other mainstay of drug therapy for
heart failure. Beta-blockers have
been so effective at reducing
symptoms, improving clinical sta-
tus, and reducing mortality and
hospitalizations that the guide-
lines identify them as the most
significant pharmacologic addi-
tion for heart failure management.
In the United States, two beta-
blockers are specifically approved
for heart failure: carvedilol and
long-acting metoprolol.
Start beta-blocker therapy at a
low dose and slowly titrate the
40 Nursing2006, Volume 36, Number 7
Getting in sync
Atrial lead
Right
ventricular lead
Biventricular pacing, which uses a 3-lead placement (above),
can restore ventricular synchrony in patients with heart failure and
conduction defects.
dosage up. Monitor for adverse
reactions, which include fluid
retention, worsening heart failure
symptoms, and fatigue.
Patient education and close
patient monitoring are key to suc-
cessful beta-blocker therapy.
Monitor vital signs and watch for
weight gain, which may require
an adjustment in diuretic therapy.
If the patient develops sympto-
matic bradycardia or heart block,
reduce or discontinue the beta-
blocker dosage as ordered.
Stage C—start of symptoms
Care for a patient in this stage
builds on treatments from stages A
and B and adds therapies to slow
disease progression, decrease
symptoms, and improve survival.
Let’s look at the additions:
• Diuretics are indicated for pa-
tients with fluid retention. (Some
patients are placed on diuretics in
stage A to treat hypertension.)
These drugs interfere with heart-
failure-induced sodium retention,
inhibiting sodium or chloride reab-
sorption in the renal tubules. Loop
diuretics, which affect the loop of
Left ventricular
lead
Henle, are the preferred diuretics
for heart failure because they
increase sodium excretion by up to
25% and they remain effective until
renal function is severely impaired.
Loop diuretics include bumeta-
nide, furosemide, and torsemide.
Whether given orally or I.V.,
diuretics can produce results rapid-
ly (within hours or days), improv-
ing cardiac function, decreasing
symptoms, and improving the
patient’s functional ability and
exercise tolerance.
Adverse reactions to loop diuret-
ics include hypotension, electrolyte
depletion (particularly of potassi-
um and magnesium), arrhythmias,
and impaired renal function.
By using diuretics appropriately,
the clinician can maximize ACE
inhibitor and beta-blocker therapy.
Concomitant use of ACE inhibi-
tors also may help balance the
potassium depletion caused by
loop diuretics.
• Digoxin increases myocardial
contractility and reduces sodium
reabsorption by the renal tubules.
Given as a low-dose maintenance
drug (serum concentration in the
www.nursing2006.com
range of 0.5 to 1 ng/ml), digoxin
can be effective without the toxici-
ty that’s more likely at higher
doses, especially in older adults.
Because of digoxin’s narrow
risk/benefit ratio, however, the
guidelines committee recommends
that this drug be considered only
in patients who are still sympto-
matic despite therapy with ACE
inhibitors, beta-blockers, and
diuretics.
• Aldosterone antagonists such as
spironolactone also may play an
increasing role in treating heart fail-
ure. Aldosterone has direct deleteri-
ous effects on the myocardium.
Although ACE inhibitors and
angiotensin receptor blockers
reduce circulating levels of aldo-
sterone, the degree of suppression
isn’t predictable. Patients in stage C
should be considered for spirono-
lactone therapy, in addition to the
mainstay regimen of ACE inhibitor,
beta-blocker, and diuretic.
Carefully monitor a patient
who’s starting this therapy because
spironolactone can cause hyper-
kalemia and worsening renal func-
tion in patients with heart failure
who are also taking ACE inhibitors
or angiotensin receptor blockers.
Eplerenone, a new aldosterone
antagonist, has been shown to
reduce mortality in post-MI pa-
tients with decreased LV function.
The drug is in clinical trials, but no
studies have been done with it in
patients with heart failure.
• Vasodilators such as hydralazine
and isosorbide may be indicated in
patients who continue to be symp-
tomatic despite ACE inhibitor and
beta-blocker therapy or who can’t
tolerate ACE inhibitors. Hydrala-
zine and isosorbide originally were
given as combination therapy
because of their complementary
effects on vasodilation, until ACE
inhibitors and beta-blockers were
found to be more effective. A recent
study found this combination to be
effective for African-Americans
when given in addition to ACE
inhibitors and beta-blockers.
www.nursing2006.com
Perhaps paving the way for more
treatments influenced by genetics,
the Food and Drug Administration
recently approved BiDil, a combina-
tion of hydralazine and isosorbide,
to treat heart failure in African-
Americans. This is the first heart
failure drug approved for a specific
ethnic group. Studies found the
combination dramatically improved
survival, decreased hospitalizations,
and improved quality of life in
African-Americans.
• Avoid or discontinue medications
that could conflict with heart failure
therapy, such as nonsteroidal anti-
inflammatory drugs (NSAIDs),
calcium channel blockers, and
antiarrhythmics. The NSAIDs have
been associated with increased
incidence of heart failure, decom-
pensation, and hospitalizations for
heart failure.
Device therapy is also an essen-
tial element in heart failure man-
agement. Between 15% and 30% of
patients with heart failure also have
conduction system disease, such as
left bundle-branch block with a
wide QRS complex. Cardiac resyn-
chronization therapy, also called
biventricular pacing, can improve
symptoms and functional ability,
reverse remodeling, improve quali-
ty of life, and decrease hospitaliza-
tions in patients with heart failure
and a wide QRS complex who are
on optimal medical therapy.
Biventricular pacing provides
electromechanical coordination
and improves ventricular syn-
chrony. Pacing wires are placed in
the right atrium, right ventricle,
and through the coronary sinus
into a cardiac vein on the lateral
wall of the left ventricle (see
Getting in sync). This therapy can
also reverse remodeling by decreas-
ing heart size and ventricular vol-
umes, improving ejection fraction,
and decreasing mitral regurgita-
tion. Strong evidence supports
considering biventricular therapy
for patients with symptomatic
heart failure and a QRS duration
greater than 120 milliseconds
despite adequate optimal medical
therapy.
Patients with heart failure are at
high risk for sudden cardiac death.
This risk can be reduced with beta-
blocker and aldosterone agonist
therapy and may be further re-
duced with use of an implantable
cardioverter-defibrillator, which is
indicated for patients with a histo-
ry of sudden cardiac death, life-
threatening arrhythmias, or mild to
moderate heart failure and an ejec-
tion fraction below 30%.
Patients who are at risk for CAD
should be screened for CAD and
MI. Revascularization, if indicated,
may improve cardiac symptoms,
cardiac function, and survival.
Other surgical considerations for
cardiac structural disease and heart
failure include mitral valve repair,
removal of infarction areas, and
techniques to modify cardiac
geometry, reduce myocardial wall
stress, and support the heart.
Stage D—end-stage disease
Patients in stage D are sympto-
matic at rest and with minimal
exertion. These patients are hospi-
talized frequently for clinical dete-
rioration. A patient at this stage
usually requires intermittent I.V.
diuretics; inotropic support with
milrinone, dobutamine, or
dopamine; vasodilators such as
nitroprusside or nitroglycerin; and
a synthetic BNP such as nesiritide.
Many need their ACE inhibitor
and beta-blocker doses decreased
because of hypotension and wors-
ening renal failure.
Treatment strategies for this
patient group are to improve cardiac
performance, facilitate diuresis, and
promote clinical stability. Goals for
therapy during this time will need
to be reassessed, in consultation
with the patient and his family, as
the patient’s condition requires dis-
cussion of his prognosis.
At this advanced stage of heart
failure, specialized treatment is
considered, such as ventricular
assist devices (VADs), heart trans-
Nursing2006, July 41
plant, or continuous I.V. inotropes.
End-of-life or hospice care also
may be indicated at this stage.
Heart transplant offers the best
chance for survival in patients
with end-stage heart failure, but
the limited availability of donor
hearts and the complex posttrans-
plant regimen mean that only a
few patients will meet the criteria
for transplantation.
While a candidate awaits a trans-
plant, his condition may be stabi-
lized with inotrope therapy or a
VAD as a bridge therapy. A patient
who’s not a transplant candidate
may receive permanent VAD thera-
py, palliative home inotrope thera-
py, or hospice.
Patient teaching
Educate a patient in any stage of
heart failure about the disorder
and its treatments. Stress that
adhering to the medication regi-
self early in the morning (before
eating and dressing) and take his
vital signs at the same time each
day. He should limit sodium to 2
grams/day and fluids to 2
liters/day. If necessary, urge him
to stop smoking and lose weight;
refer him to support programs as
appropriate. Stress the importance
of properly managing his general
health. His primary care provider
should help him manage other
chronic disorders, such as dia-
betes or hypertension. Also make
sure he’s immunized for influenza
and pneumococcal disease.
Once, patients with heart fail-
ure were encouraged to avoid
exercise, but several studies have
demonstrated the value of exer-
cise for these patients. We now
know that inactivity promotes
physical deconditioning, which
can exacerbate symptoms, so the
guidelines recommend exercise
ure and the role of genetics, new
drugs and new approaches to man-
aging heart failure will evolve. By
understanding how the latest
guidelines fit in, you can focus on
early intervention and educate and
encourage your patient to get opti-
mal treatment.‹›
SELECTED REFERENCES
Bristow MR, et al. Comparison of Medical
Therapy, Pacing, and Defibrillation in Heart
Failure (COMPANION) Investigators. Cardiac-
resynchronization therapy with or without im-
plantable defibrillator in advanced chronic
heart failure. The New England Journal of Medi-
cine. 350(21):2140-2150, May 20, 2004.
Chobanian AV, et al. The seventh report of the
Joint National Committee on Prevention, De-
tection, Evaluation, and Treatment of High
Blood Pressure: The JNC 7 report. JAMA.
289(19):2560-2572, May 21, 2003.
Hunt SA, et al. ACC/AHA 2005 guideline up-
date for the diagnosis and management of
chronic heart failure in the adult: Summary ar-
ticle. Journal of the American College of Cardiol-
ogy. 112(12):1825-1852, September 20, 2005.
Prahash A, Lynch T. B-type natriuretic peptide:
A diagnostic, prognostic, and therapeutic tool
in heart failure. American Journal of Critical
Care. 13(1):46-55, January 2004.

men, recommended diet, and
other guidelines can improve his
functional ability, leading to a bet-
ter quality of life.
Teach the patient to weigh him-
training as an adjunct to therapy.
Future directions
As researchers learn more about
the complex cascade of heart fail-
Donna Chojnowski is a heart failure/transplant nurse
practitioner and clinical manager of the heart failure
and cardiac transplant program at the Hospital of the
University of Pennsylvania in Philadelphia, Pa.
The author has disclosed that she has no significant
relationship with or financial interest in any commer-
cial companies that pertain to this educational activity.

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42 Nursing2006, Volume 36, Number 7 www.nursing2006.com

 2.5
ANCC/AACN CONTACT HOURS

Managing systolic heart failure

GENERAL PURPOSE To familiarize nurses with the current practice guidelines for managing heart failure. LEARNING OBJECTIVES After reading the pre-
ceding article and taking this test, you should be able to: 1. Identify the diagnostic studies commonly used for heart failure. 2. Identify the treatment goals
based on heart failure staging.

1. The most useful noninvasive diagnostic tool 7. Which statement is correct about beta- b. is effective in treating heart failure after an MI.
for evaluating a patient with heart failure is blockers? c. is specifically indicated for patients who are
a. a computed tomography scan. a. They’re considered a mainstay of drug therapy symptomatic at rest.
b. an ECG. for heart failure. d. helps balance the potassium depletion caused by
c. an echocardiogram. b. They activate the sympathetic nervous system. loop diuretics.
d. a chest X-ray. c. Adverse reactions include excessive diuresis.
d. If bradycardia develops, the dose may need to 13. Which drug usually doesn’t conflict with
2. A patient with heart failure and angina be increased. heart failure therapy?
should have which test to evaluate for CAD? a. NSAIDs
a. cardiac exercise test 8. Which isn’t a goal of treatment for stage C b. thiazide diuretics
b. magnetic resonance imaging heart failure? c. antiarrhythmics
c. right-sided heart catheterization a. improve survival d. calcium channel blockers
d. coronary angiogram b. decrease symptoms
c. slow disease progression 14. Benefits of biventricular pacing include
3. Which of the following best describes d. prepare the patient for end–of-life care or hospice decreasing heart size and
stage B heart failure? a. synchronizing left atrial with LV contractions.
a. LV hypertrophy without heart failure symptoms 9. Which statement is correct about digoxin? b. increasing mitral regurgitation.
b. past heart failure symptoms with ventricular a. Digoxin is never used to treat heart failure. c. increasing ejection fraction.
remodeling b. It’s a first-line drug for heart failure. d. increasing ventricular volume.
c. LV hypertrophy with heart failure symptoms c. It’s indicated for symptomatic patients despite
d. heart failure symptoms at rest despite treatment treatment with ACE inhibitors, beta-blockers, and 15. A patient with symptomatic stage C heart
diuretics. failure and a QRS duration greater than 120
4. According to the JNC 7 guidelines, which d. It impedes the conversion of angiotensin I to milliseconds despite optimal medical treat-
BP falls within current recommendations for angiotensin II. ment is a good candidate for
a patient with type 2 diabetes? a. stopping treatment with ACE inhibitors.
a. 128/78 c. 138/88 10. Which drug is an aldosterone antagonist? b. a VAD.
b. 132/84 d. 140/90 a. spironolactone c. furosemide c. heart transplant.
b. bumetanide d. torsemide d. biventricular pacing.
5. To control BP and limit end organ damage
in a patient with diabetes and stage A heart 11. BiDil is a combination of 16. Teach a patient with heart failure that
failure, administer a. an ACE inhibitor and beta-blocker. a. fluid restriction isn’t necessary if he’s taking
a. digoxin. c. calcium channel blockers. b. furosemide and eplerenone. diuretics.
b. ACE inhibitors. d. aldosterone antagonists. c. digoxin and torsemide. b. he should weigh himself weekly and limit sodi-
d. hydralazine and isosorbide. um to 4 grams/day.
6. ACE inhibitor–induced cough is thought to c. stopping smoking and losing weight most likely
be secondary to increased endogenous 12. The main significance of BiDil is that it won’t improve heart failure.
a. leukotrienes. c. bradykinin. a. is the first heart failure medication approved for d. following a 2-gram/day sodium diet and exercis-
b. histamine. d. nitric oxide. a specific ethnic group. ing will improve his quality of life.

✄ENROLLMENT FORM Nursing2006, July, Managing systolic heart failure

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a b c d a b c d a b c d a b c d
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2. ❍ ❍ ❍ ❍ 6. ❍ ❍ ❍ ❍ 10. ❍ ❍ ❍ ❍ 14. ❍ ❍ ❍ ❍
3. ❍ ❍ ❍ ❍ 7. ❍ ❍ ❍ ❍ 11. ❍ ❍ ❍ ❍ 15. ❍ ❍ ❍ ❍
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