Heart Failure and Cardiomyopathies MCQs

Medicine · 87 free questions with answers & explanations.

1. A 55-year-old man with ischemic cardiomyopathy and EF 28% is on optimal doses of carvedilol, lisinopril, and furosemide. Despite this, he remains NYHA class III with dyspnea on minimal exertion. Serum creatinine is 1.2 mg/dL, K⁺ 4.0 mEq/L, and eGFR 65 mL/min. Which additional drug has the strongest evidence for reducing mortality in this patient?
2. A 45-year-old man presents with progressive dyspnea, exertional chest pain, and multiple syncopal episodes. On examination, there is a harsh systolic murmur at the left lower sternal border that increases with Valsalva maneuver and decreases with squatting. Echo shows asymmetric septal hypertrophy with septal-to-posterior wall ratio of 1.8 and dynamic LVOT obstruction with resting gradient 70 mmHg. What is the first-line pharmacological treatment?
3. A 52-year-old woman with newly diagnosed heart failure with reduced ejection fraction (HFrEF, LVEF 28%) is started on guideline-directed medical therapy. Despite optimized doses of ACE inhibitor and beta-blocker, her LVEF remains 30% and NYHA class remains III. She is in sinus rhythm at 78 bpm. QRS duration is 118 ms (narrow). NT-proBNP is 2,800 pg/mL. She has no history of syncope. What additional device therapy should be considered?
4. A 38-year-old man presents with exertional syncope and a 4th heart sound. His father died suddenly at age 42. Echocardiogram shows asymmetric septal hypertrophy (IVS 22 mm), systolic anterior motion of the mitral valve, and a LVOT gradient of 48 mmHg at rest increasing to 90 mmHg with Valsalva. He is in sinus rhythm. Which medication is CONTRAINDICATED in symptomatic hypertrophic obstructive cardiomyopathy (HOCM)?
5. A 65-year-old man has HFrEF (EF 32%), NYHA Class III, on optimised GDMT (ACEI, carvedilol, spironolactone). He remains symptomatic with NT-proBNP 3200 pg/mL. His carvedilol dose is maximal. What is the next medication to add per current guidelines?
6. A 28-year-old athlete has a family history of sudden cardiac death. Echo shows asymmetric septal hypertrophy (IVS 18 mm), LVOTO gradient 45 mmHg at rest, and systolic anterior motion (SAM) of mitral valve. He has syncope on exertion. Which investigation best risk-stratifies for SCD in hypertrophic obstructive cardiomyopathy (HOCM)?
7. A 55-year-old man with HFrEF (EF 30%) is on optimal medical therapy with metoprolol succinate, enalapril, and furosemide. His NT-proBNP is 3800 pg/mL. The PARADIGM-HF trial established which new therapeutic class that should be incorporated into his treatment?
8. A 28-year-old athlete collapses during a race. Resuscitated from ventricular fibrillation. Echocardiography shows asymmetric septal hypertrophy (IVS 22 mm), SAM (systolic anterior motion of MV), dynamic LVOT gradient of 65 mmHg. What is the first-line pharmacological treatment for symptomatic obstructive HCM?
9. The DAPA-HF trial and EMPEROR-Reduced trial demonstrated benefit of SGLT2 inhibitors (dapagliflozin and empagliflozin respectively) in patients with HFrEF. Which of the following best describes their mechanism of benefit in heart failure, DISTINCT from their glucose-lowering effect?
10. A 35-year-old man presents with exertional syncope and a family history of sudden cardiac death. Echocardiogram shows asymmetric septal hypertrophy with an interventricular septum of 22 mm, systolic anterior motion (SAM) of the mitral valve, and LVOT gradient of 65 mmHg at rest. The PRIMARY mechanism of syncope in this condition is:
11. The PARADIGM-HF trial established sacubitril/valsartan (ARNI) as superior to enalapril in HFrEF. Sacubitril inhibits neprilysin, leading to accumulation of natriuretic peptides. Importantly, this renders which biomarker unreliable for HF monitoring after initiating ARNI therapy?
12. Hypertrophic cardiomyopathy with dynamic LVOTO shows which specific echocardiographic finding related to mitral valve systolic anterior motion (SAM)?
13. Cardiac sarcoidosis should be suspected in young to middle-aged adults with unexplained complete heart block, ventricular tachycardia, or cardiomyopathy. Which imaging modality is now considered the reference standard for detecting cardiac sarcoidosis granulomas?
14. The PARADIGM-HF trial demonstrated superiority of sacubitril/valsartan over enalapril in HFrEF. The mechanism of sacubitril (a neprilysin inhibitor) involves:
15. A 35-year-old man is diagnosed with hypertrophic obstructive cardiomyopathy (HOCM). Echocardiogram shows asymmetric septal hypertrophy (septum 23 mm), systolic anterior motion (SAM) of the mitral valve, and LVOT gradient of 65 mmHg at rest. He is symptomatic with exertional dyspnoea. Which is the MOST appropriate pharmacotherapy?
16. A 45-year-old woman with newly diagnosed dilated cardiomyopathy (LVEF 22%) is initiated on guideline-directed medical therapy (GDMT). Which of the following is the CORRECT sequence of initiating GDMT based on contemporary evidence?
17. A 58-year-old man has HFrEF (LVEF 28%, NYHA Class III) on maximally tolerated ACE inhibitor and carvedilol. His eGFR is 48 mL/min, K+ 4.5 mEq/L, and there are no recent hospitalizations. According to the DAPA-HF and EMPEROR-Reduced trial evidence (AHA/ACC 2022 heart failure guidelines), the addition of which drug is now considered a fourth pillar of HFrEF therapy?
18. A 28-year-old man with hypertrophic cardiomyopathy (HCM) has an asymmetric septal hypertrophy of 24 mm (IVS), LVOT gradient 85 mmHg at rest, and syncope with exertion. He is on metoprolol 100 mg/day with partial response. A novel cardiac myosin inhibitor approved in 2022 for symptomatic obstructive HCM is:
19. A 55-year-old man has HFrEF (EF 28%) on maximally tolerated ARNI (sacubitril/valsartan), beta-blocker, and MRA. He remains NYHA Class III with BNP 1,200 pg/mL. His QRS is 155 ms with LBBB pattern. What is the next most evidence-based intervention?
20. Hypertrophic obstructive cardiomyopathy (HOCM) with dynamic left ventricular outflow tract obstruction (LVOTO) worsens with which maneuver during physical examination?
21. A 50-year-old woman has HFrEF (LVEF 28%) and is on maximally tolerated doses of sacubitril-valsartan, carvedilol, and spironolactone. Resting HR is 78 bpm in sinus rhythm. NT-proBNP remains elevated. What additional evidence-based therapy should be considered?
22. A 45-year-old man presents with progressive dyspnoea and syncope. Echo shows asymmetric septal hypertrophy (IVS 22 mm, posterior wall 10 mm), SAM of mitral valve, and peak LVOT gradient 80 mmHg at rest (>110 mmHg with Valsalva). Which drug is the MOST recently approved pharmacological option specifically reducing LVOT gradient through a novel mechanism?
23. A 50-year-old man with HFrEF (LVEF 28%) is on optimal guideline-directed medical therapy: ACE inhibitor, beta-blocker, MRA, and dapagliflozin. He remains NYHA Class III despite 3 months of optimization. QRS duration is 148 ms with LBBB morphology. LVEF remains <35%. What is the next recommended therapy?
24. A 35-year-old woman presents with exertional dyspnea and family history of sudden cardiac death. Echo shows asymmetric septal hypertrophy (28 mm), systolic anterior motion (SAM) of the anterior mitral leaflet, LVOT peak gradient 65 mmHg (obstruction), and preserved LVEF. What is the most appropriate first-line pharmacological therapy?
25. A 58-year-old man with HFrEF (EF 28%) is on maximally tolerated doses of bisoprolol, sacubitril/valsartan, and eplerenone. He remains in NYHA class III. Current SGLT2 inhibitor trials in HFrEF (DAPA-HF, EMPEROR-Reduced) demonstrated that adding dapagliflozin or empagliflozin reduced which primary composite outcome?
26. A 38-year-old woman presents with syncope during exertion and a harsh systolic murmur that increases with the Valsalva manoeuvre and decreases with squatting. Echocardiogram confirms hypertrophic obstructive cardiomyopathy (HOCM) with LVOT gradient 65 mmHg at rest. She remains symptomatic on maximum beta-blocker therapy. Which novel therapy, a cardiac myosin inhibitor, is now FDA-approved for HOCM with persistent symptoms?
27. In hypertrophic obstructive cardiomyopathy (HOCM), which medication is a recently approved first-in-class cardiac myosin inhibitor shown to reduce LVOT gradient in the EXPLORER-HCM trial?
28. The PARADIGM-HF trial established sacubitril/valsartan (ARNI) as superior to enalapril in HFrEF. The primary mechanism by which sacubitril provides benefit BEYOND ACE inhibition is:
29. Cardiac sarcoidosis is a cause of dilated cardiomyopathy and complete heart block. Which diagnostic investigation is now the gold standard for detecting active cardiac sarcoidosis with the highest sensitivity?
30. A 48-year-old woman is diagnosed with new-onset dilated cardiomyopathy. LVEF is 25%. She is initiated on guideline-directed medical therapy including beta-blocker, ACEi, and spironolactone. At 3 months, a genetic panel is planned. Which gene mutation is most commonly identified in familial dilated cardiomyopathy?
31. In hypertrophic obstructive cardiomyopathy (HOCM) with persistent symptoms (NYHA class III) and LVOT gradient ≥ 50 mmHg despite maximally tolerated beta-blocker and disopyramide, which intervention is preferred in an anatomically eligible patient with severe septal hypertrophy?
32. A 58-year-old man with heart failure with reduced EF (HFrEF; LVEF 28%) is optimised on carvedilol 25 mg BD, sacubitril-valsartan 97/103 mg BD, and spironolactone 50 mg. NYHA class II. NT-proBNP is 1200 pg/mL. Per ESC 2021 and AHA 2022 HF guidelines, which fourth foundational therapy should now be added?
33. A 35-year-old athlete has a family history of sudden cardiac death. Echocardiography shows asymmetric interventricular septal hypertrophy (24 mm), systolic anterior motion of the mitral valve, and a peak LVOT gradient of 68 mmHg at rest. He remains symptomatic (NYHA III) despite maximally tolerated metoprolol. Per 2022 ACC/AHA HCM guidelines, the most appropriate next pharmacological addition is:
34. A 55-year-old man with HFrEF (EF 28%) is on maximally tolerated doses of carvedilol and sacubitril/valsartan. Potassium is 4.8 mEq/L and eGFR is 38 mL/min. Which additional therapy is recommended by ACC/AHA 2022 guidelines with proven mortality benefit in this population?
35. A 30-year-old athlete is found to have asymmetric LV hypertrophy (maximum wall thickness 18 mm, septal-posterior ratio 1.6:1), LVOT gradient 50 mmHg at rest, systolic anterior motion of the mitral valve, and exertional syncope. Genetic testing confirms MYBPC3 mutation. Which is the most appropriate intervention for symptom control?
36. A 55-year-old man has HFrEF (LVEF 30%) on optimal tolerated ACEi and beta-blocker therapy. He remains NYHA Class III. The RALES trial informs adding which drug to his regimen?
37. A 45-year-old man with hypertrophic obstructive cardiomyopathy (HOCM) has gradient 65 mmHg at rest. He is symptomatic on maximum beta-blocker dose. Which of the following is the NEWEST FDA-approved drug specific to this condition?
38. A 58-year-old man with HFrEF (LVEF 28%) on maximally tolerated doses of ACEi + carvedilol + spironolactone has NYHA class III symptoms, QRS duration 158 ms (LBBB morphology), sinus rhythm, and LVEF remains 28% despite 3 months of optimal therapy. According to ESC 2021 guidelines, the device therapy with Level of Evidence A for this patient is:
39. A 42-year-old man presents with dyspnea and syncope on exertion. Echocardiogram reveals asymmetric septal hypertrophy (IVS 22 mm), systolic anterior motion (SAM) of the mitral valve, and LVOT gradient of 60 mmHg at rest increasing to 110 mmHg on Valsalva. Mitral regurgitation is moderate. The LVEF is 72%. The most appropriate medical management as first-line is:
40. A 55-year-old man with HFrEF (LVEF 32%) is on maximally tolerated doses of sacubitril/valsartan, carvedilol, and eplerenone. He remains NYHA Class III with persistent symptoms and LVEF 30% after 3 months of optimal medical therapy. His QRS duration is 165 ms with left bundle branch block morphology. Which device therapy has shown mortality benefit in this patient?
41. A 42-year-old woman with hypertrophic cardiomyopathy (HCM) has resting LVOTO gradient of 65 mmHg, septal thickness 22 mm, and persistent NYHA Class III dyspnoea despite metoprolol 200 mg/day and disopyramide 300 mg/day. She is not a candidate for surgical myectomy due to comorbidities. Echocardiography confirms systolic anterior motion (SAM) of the mitral valve. What is the recommended next intervention?
42. A 58-year-old man with HFrEF (LVEF 28%, NYHA III) is on optimized GDMT: sacubitril/valsartan 97/103 mg BD, carvedilol 25 mg BD, spironolactone 25 mg/day, and dapagliflozin 10 mg/day. QRS duration is 168 ms with LBBB morphology. The next intervention shown to further reduce mortality is:
43. A 42-year-old man with a recent flu-like illness presents with dyspnea and chest pain. Echo shows LVEF 30%, global hypokinesia, mildly dilated LV. Troponin I is elevated. CMR demonstrates diffuse mid-myocardial late gadolinium enhancement (LGE) in a non-ischemic pattern. Coronary angiography is normal. What is the diagnosis and immediate management priority?
44. A 62-year-old woman with HFrEF (EF 32%) is on maximally tolerated ACE inhibitor, beta-blocker, and spironolactone. Her NYHA class remains III despite 6 months of optimal medical therapy. Her BP is 92/60 mmHg and HR 72 bpm. What additional therapy should be considered to improve mortality based on PARADIGM-HF trial evidence?
45. A 50-year-old man presents with progressive breathlessness. Echo shows EF 60%, concentric LVH, abnormal diastolic relaxation, enlarged left atrium (volume index 46 mL/m²), and elevated E/e' ratio of 17. BNP is 420 pg/mL. The diagnosis is HFpEF. The EMPEROR-Preserved and DELIVER trials demonstrated benefit of which class of drug in HFpEF?
46. A 30-year-old athlete is found to have an asymmetric septal hypertrophy of 22 mm on echo during pre-participation screening. He reports occasional exertional chest pain. His father died suddenly at age 38. Genetic testing confirms a pathogenic MYBPC3 variant. He has a 48-hour Holter showing 3 non-sustained VT runs. What is his most important risk stratification tool and likely management?
47. A 60-year-old man with HFrEF (EF 28%) is on bisoprolol 10 mg, enalapril 10 mg BD, and spironolactone 25 mg. He remains NYHA Class III. eGFR is 55 mL/min/1.73 m². Which treatment addition has been shown to reduce ALL-CAUSE MORTALITY in this clinical scenario per the PARADIGM-HF trial?
48. A 35-year-old man presents with exertional dyspnoea and presyncope. Echo shows asymmetric septal hypertrophy (25 mm), systolic anterior motion of the mitral valve (SAM), and LVOT gradient of 65 mmHg at rest. He is on verapamil. Which drug is NEWLY FDA-approved (2022) for symptomatic obstructive HCM reducing LVOT gradient?
49. A 45-year-old man with heart failure has an EF of 30%, LBBB with QRS 158 ms, and sinus rhythm despite optimal GDMT for 3 months. Per ACC/AHA 2022 guidelines, which device therapy is indicated (Class I)?
50. In the PARADIGM-HF trial, sacubitril/valsartan (an ARNI) was compared to enalapril in HFrEF. A KEY safety concern when transitioning a patient from an ACE inhibitor to sacubitril/valsartan is:
51. Hypertrophic obstructive cardiomyopathy (HOCM) causes dynamic LVOT obstruction. Which bedside manoeuvre INCREASES the LVOT gradient and therefore WORSENS the murmur intensity?
52. Mavacamten is a novel cardiac myosin inhibitor approved for symptomatic obstructive HOCM. Its mechanism of action and the key monitoring requirement during treatment are:
53. The EMPEROR-Reduced trial demonstrated that empagliflozin reduced the primary composite of CV death or HF hospitalisation in HFrEF. Which class of drugs now forms part of the 'fantastic four' (or foundational quadruple therapy) for HFrEF per ESC 2021 guidelines?
54. A 35-year-old man has hypertrophic obstructive cardiomyopathy (HOCM) with peak left ventricular outflow tract (LVOT) gradient 68 mmHg at rest, NYHA III symptoms despite maximum tolerated beta-blocker. What is the newer pharmacological agent targeting the cardiac sarcomere that is now approved for symptomatic HOCM?
55. A 60-year-old man with HFrEF (EF 30%) on optimal medical therapy (ACEi, beta-blocker, MRA, SGLT2i) has NYHA Class III symptoms, QRS 165 ms with LBBB, sinus rhythm, and HR 72 bpm. Which device-based therapy is indicated?
56. A 40-year-old woman presents with progressive dyspnea, pre-syncopal episodes, and a pansystolic murmur that increases with Valsalva (strain phase) and decreases with squatting. Echo shows asymmetric septal hypertrophy (28 mm), systolic anterior motion of the mitral valve, and LVOT gradient 65 mmHg at rest. The pharmacological treatment of choice is:
57. A 32-year-old woman develops sudden onset of chest pain, dyspnea and pulmonary edema 2 weeks after delivery of her first child. Echo shows EF 28%, dilated left ventricle, no regional wall motion abnormality. Coronary angiography is normal. Diagnosis is peripartum cardiomyopathy (PPCM). The management includes standard HFrEF therapy PLUS which specific agent that targets the proposed pathogenic mechanism?
58. A 45-year-old man with dilated cardiomyopathy (EF 28%) is on optimal medical therapy (ACEi, beta-blocker, MRA, SGLT2i). He has LBBB with QRS duration 158 ms and NYHA Class III symptoms. Which device therapy is most indicated?
59. A 30-year-old athlete collapses during a football match and is successfully resuscitated from ventricular fibrillation. Echo shows asymmetric septal hypertrophy (IVS 20 mm), SAM of the mitral valve, and LVOTO gradient of 55 mmHg at rest. What is the most likely genetic defect?
60. A 58-year-old man with HFrEF (EF 32%) is on optimal doses of carvedilol, sacubitril-valsartan and eplerenone. He has NYHA class II, sinus rhythm, HR 75 bpm, BP 110/70 mmHg. QRS duration is 158 ms with LBBB morphology. Which additional device or drug intervention has a Class I indication for mortality reduction in this patient?
61. A 42-year-old woman with hypertrophic obstructive cardiomyopathy (HOCM) has resting LVOT gradient 68 mmHg, exertional syncope and NYHA class III symptoms despite maximally tolerated beta-blocker. Septal wall thickness is 22 mm. Which therapy specifically reduces LVOT obstruction by targeting myosin ATPase and was approved in 2022 for HOCM?
62. A 62-year-old man with HFrEF (LVEF 32%) is already on maximally tolerated ACE inhibitor, beta-blocker, and aldosterone antagonist. He remains NYHA class III with eGFR 55 mL/min. Per 2022 AHA/ACC/HFSA Heart Failure guidelines, which agent should be added as the 4th pillar of GDMT (guideline-directed medical therapy)?
63. A 50-year-old man presents with progressive exertional dyspnea, presyncope, and a harsh systolic murmur at the left sternal border that increases with Valsalva maneuver and decreases with squatting. Echo shows asymmetric septal hypertrophy (IVS 22 mm), LVOTO gradient of 50 mmHg at rest increasing to 90 mmHg with provocation, and systolic anterior motion (SAM) of the mitral valve. What is the mechanism of hemodynamic worsening with Valsalva?
64. A 35-year-old man with HFrEF (LVEF 25%) and NYHA class III symptoms is on optimal GDMT. He is in normal sinus rhythm, HR 74 bpm, QRS duration 155 ms (LBBB morphology). Which device therapy is indicated?
65. A 58-year-old man with HFrEF (EF 30%) is already on maximally tolerated ACE inhibitor, beta-blocker, and spironolactone. He remains symptomatic (NYHA III) and his NT-proBNP remains markedly elevated. Per PARADIGM-HF trial evidence and current guidelines, the most appropriate next drug class to add is:
66. A 40-year-old man presents with exertional dyspnoea, syncope during exercise, and a 4th heart sound. His father died suddenly at 42. ECG shows LVH and a septal Q wave in leads I and aVL. Echocardiography shows an asymmetric septal hypertrophy of 24 mm with systolic anterior motion of the mitral valve and an LVOT gradient of 65 mmHg at rest. The most appropriate initial pharmacological therapy is:
67. A 66-year-old man with HFrEF (EF 28%) is optimised on maximally tolerated doses of sacubitril/valsartan, bisoprolol, spironolactone, and dapagliflozin. He remains in NYHA Class III with LBBB (QRS 162 ms) on ECG. What intervention has the strongest evidence for further reducing mortality and morbidity?
68. A 35-year-old woman presents with gradually progressive exertional dyspnoea and syncope. Echocardiography shows asymmetric left ventricular hypertrophy (septal thickness 22 mm), systolic anterior motion (SAM) of the mitral valve, and a dynamic LVOT gradient of 62 mmHg at rest. She is on verapamil. What is the CURRENT preferred invasive treatment for medically refractory obstructive hypertrophic cardiomyopathy?
69. A 55-year-old man with HFrEF (LVEF 28%) is on maximally tolerated carvedilol, sacubitril/valsartan, and spironolactone. His resting heart rate is 78 bpm in sinus rhythm despite maximal beta-blocker. His NYHA class remains III. Which additional therapy has an indication-specific mortality benefit in this setting?
70. A 38-year-old man presents with exertional dyspnoea and presyncope during exercise. Examination reveals a harsh systolic ejection murmur at left lower sternal border that increases with standing and Valsalva manoeuvre and decreases with squatting. LV outflow gradient is 55 mmHg at rest. He is on bisoprolol. What is the current first-line pharmacological agent specifically approved for symptomatic obstructive HCM that targets cardiac myosin?
71. A 58-year-old man with HFrEF (LVEF 28%) is on maximally tolerated doses of ACEi, beta-blocker, and aldosterone antagonist. He remains NYHA class III with NT-proBNP of 2,400 pg/mL. QRS duration is 142 ms with LBBB morphology. Which additional device therapy has PROVEN mortality benefit?
72. A 35-year-old man undergoes genetic testing after his brother dies suddenly. He is found to carry a MYBPC3 mutation. Echocardiogram shows maximal wall thickness of 22 mm, LVOT gradient 42 mmHg at rest. He is asymptomatic. What is the primary risk stratification tool for sudden cardiac death (SCD) in HCM?
73. A 50-year-old man with HFrEF (EF 30%) is on optimal guideline-directed medical therapy (GDMT): carvedilol, sacubitril-valsartan, spironolactone, and dapagliflozin. ECG shows sinus rhythm with LBBB (QRS duration 152 ms). LVEF remains 30% after 3 months. Which device intervention has a Class I recommendation in this scenario?
74. A 45-year-old woman presents with progressive dyspnoea and syncope. Echo shows asymmetric septal hypertrophy (29 mm), systolic anterior motion (SAM) of the mitral valve, and LVOT gradient of 72 mmHg at rest. She is already on metoprolol 200 mg/day with persistent symptoms. According to ACC/AHA 2020 HCM guidelines, the next pharmacological agent approved for LVOT obstruction reduction is:
75. The PARADIGM-HF trial demonstrated superiority of sacubitril/valsartan (ARNI) over enalapril in heart failure with reduced ejection fraction. The primary endpoint of this trial was:
76. A 45-year-old man presents with sudden onset exertional syncope and dyspnoea. Echocardiogram shows asymmetric septal hypertrophy (IVS = 22 mm, posterior wall = 11 mm), systolic anterior motion of the mitral valve, and LVOT gradient of 70 mmHg at rest. Which drug should be avoided in this condition?
77. A 35-year-old man with dilated cardiomyopathy (LVEF 28%) is on optimal medical therapy (sacubitril/valsartan, carvedilol, spironolactone, dapagliflozin). After 3 months, LVEF remains ≤35% with LBBB morphology and QRS ≥150 ms. What additional device therapy should be considered?
78. A 55-year-old man with HFrEF (EF 28%) on optimal beta-blocker and ACE inhibitor therapy has NYHA class III symptoms, sinus rhythm, QRS 158 ms with LBBB morphology. Which device therapy offers the greatest survival benefit?
79. A 35-year-old woman presents with dyspnoea, exertional syncope, and loud S4. Echocardiography shows asymmetric hypertrophy of the interventricular septum (26 mm), systolic anterior motion of the mitral valve, and outflow tract gradient of 65 mmHg at rest. She is on bisoprolol 10 mg. What is the next appropriate intervention for refractory obstructive HCM?
80. A 55-year-old man with HFrEF (EF 30%) is already on maximally tolerated ACE inhibitor and beta-blocker. He has persistent NYHA Class III symptoms, eGFR 55, K+ 4.2 mEq/L. Which additional drug improves mortality most significantly in this patient?
81. A 42-year-old man presents with exertional syncope and a harsh crescendo-decrescendo systolic murmur at the left sternal border that increases with Valsalva manoeuvre and decreases with squatting. Echocardiography shows asymmetric septal hypertrophy 22 mm and LVOTO gradient of 70 mmHg at rest. What is the most appropriate first-line pharmacological treatment?
82. A 58-year-old man with HFrEF (LVEF 30%), NYHA class III, already on maximally tolerated doses of ACE inhibitor, carvedilol, and mineralocorticoid antagonist, has NT-proBNP 3400 pg/mL. He is euvolemic. The PARADIGM-HF trial demonstrated benefit of which add-on treatment?
83. A 38-year-old woman develops severe biventricular heart failure (LVEF 15%) in the last month of her first pregnancy. Echo shows dilated LV with no regional wall motion abnormalities. The most likely diagnosis and the drug that is CONTRAINDICATED in her management is:
84. A 45-year-old man presents with progressive exertional dyspnea and palpitations. Echo shows asymmetric septal hypertrophy (IVS 20 mm, PW 9 mm), LVEF 70%, and dynamic LVOT obstruction with peak gradient 65 mmHg at rest. He is on maximal beta-blocker therapy. What is the next management step?
85. A 52-year-old man with HFrEF (LVEF 30%) is on maximally tolerated beta-blocker, ACE inhibitor, and mineralocorticoid receptor antagonist. He remains in NYHA class III. eGFR is 55, potassium 4.2 mEq/L. What is the next evidence-based therapy to add?
86. A 38-year-old woman presents with syncope during exercise. Echocardiography reveals asymmetric septal hypertrophy of 24 mm, systolic anterior motion of the mitral valve, and a resting LVOT gradient of 50 mmHg. She has a family history of sudden cardiac death at age 35 in her brother. What is the most appropriate first-line symptomatic management?
87. A 44-year-old man with newly diagnosed dilated cardiomyopathy and LVEF 22% presents with non-sustained VT on Holter and an NYHA class II status after 6 weeks of optimal medical therapy. What is the threshold for primary prevention ICD implantation?