Heart Failure and Cardiogenic Shock Practice Questions

30 multiple-choice questions on Heart failure and cardiogenic shock for paramedic and EMT students, from Chapter 18 (Cardiovascular Emergencies). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

30 practice questions

1. A STEMI patient has a BP of 84/50, cool clammy skin, confusion and a high lactate, and has just been started on norepinephrine. Which SCAI cardiogenic shock stage best fits?

   1. A. Stage A, at risk
   2. B. Stage B, beginning shock
   3. C. Stage E, extremis
   4. D. Stage C, classic shock
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   Answer: D. Stage C, classic shock

   The SCAI staging system (A at risk, B beginning, C classic, D deteriorating, E extremis) defines stage C as hypoperfusion that needs intervention such as vasopressors, inotropes or mechanical support. Stage A has no hypotension or hypoperfusion, stage B has hypotension or tachycardia without hypoperfusion, and stage E is refractory collapse or ongoing CPR.

2. During transfer of a patient who had heart surgery yesterday, his chest tube drainage suddenly stops, his BP falls to 78/60 and his neck veins distend. What should you suspect?

   1. A. Normal recovery as the bleeding has stopped
   2. B. Tamponade from blood that cannot drain
   3. C. Tension pneumothorax on the opposite side
   4. D. Hypovolemia from too much chest tube output
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   Answer: B. Tamponade from blood that cannot drain

   After cardiac surgery, clotted chest tubes can let blood collect around the heart, causing tamponade with hypotension and distended neck veins; alert the receiving surgical team at once, since reopening may be needed. A sudden stop in drainage with shock is not normal recovery. A tension pneumothorax would cause one-sided breath sound changes, and hypovolemia causes flat, not distended, neck veins.

3. A heart failure patient on high doses of furosemide is newly confused, and the hospital reports a sodium of 121 mEq/L. What best explains the low sodium?

   1. A. Too much salt in her heart failure diet
   2. B. Aldosterone causing excess sodium loss
   3. C. Dehydration that concentrates the blood's sodium
   4. D. Diuretics plus ADH-driven water retention
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   Answer: D. Diuretics plus ADH-driven water retention

   In heart failure, low effective blood flow triggers ADH release, so the kidneys hold water out of proportion to sodium, and diuretics add sodium loss; the result is dilutional hyponatremia, a marker of severe disease that can cause confusion and seizures. Excess dietary salt raises, not lowers, sodium; aldosterone retains sodium; and simple dehydration tends to raise the sodium.

4. The most common cause of right-sided heart failure is:

   1. A. Chronic hypertension alone
   2. B. Left-sided heart failure
   3. C. Right coronary vasospasm
   4. D. Pulmonary embolism
   Show answer

   Answer: B. Left-sided heart failure

   Left ventricular failure raises pulmonary pressures, which eventually overloads the right ventricle. Pulmonary disease (cor pulmonale) and PE are other causes but are less common overall.

5. A 64-year-old had an MI 2 years ago and has an ejection fraction of 35%, but he has never had heart failure symptoms. Which ACC/AHA heart failure stage fits?

   1. A. Stage A (at risk for heart failure)
   2. B. Stage C (symptomatic heart failure)
   3. C. Stage B (pre-heart failure)
   4. D. Stage D (advanced heart failure)
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   Answer: C. Stage B (pre-heart failure)

   The ACC/AHA stages describe progression: A is at risk (for example, hypertension or diabetes), B is structural heart disease without symptoms (as here), C is structural disease with current or past symptoms, and D is advanced heart failure despite therapy. Unlike NYHA classes, the stages only move forward.

6. A heart failure patient's echo shows an ejection fraction of 45%. How is this classified under current AHA/ACC/HFSA guidance?

   1. A. Mildly reduced ejection fraction
   2. B. Heart failure with low ejection fraction
   3. C. Preserved ejection fraction
   4. D. Normal heart function
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   Answer: A. Mildly reduced ejection fraction

   Heart failure is classified as reduced ejection fraction (40% or less), mildly reduced (41% to 49%) or preserved (50% or more). An EF of 45% is mildly reduced; it is not low enough for the reduced category, not high enough for preserved, and the patient's symptoms show it is not normal function.

7. You are treating a 66-year-old with acute pulmonary edema. His BP is 82/50, skin is cool and mottled, and he is confused. Which intervention is contraindicated?

   1. A. Sublingual nitroglycerin
   2. B. Supplemental oxygen
   3. C. Cardiac monitoring
   4. D. Vasopressor per protocol
   Show answer

   Answer: A. Sublingual nitroglycerin

   Nitroglycerin lowers preload and can cause profound hypotension in a patient already in cardiogenic shock. Most protocols prohibit it when systolic BP is below about 90 to 100 mm Hg.

8. A heart failure patient without diabetes has dapagliflozin on his medication list. What is the most likely reason?

   1. A. He likely has undiagnosed type 2 diabetes
   2. B. It is used as a loop diuretic
   3. C. It is a standard heart failure medication
   4. D. It is a beta blocker for rate control
   Show answer

   Answer: C. It is a standard heart failure medication

   SGLT2 inhibitors such as dapagliflozin and empagliflozin are recommended heart failure medicines that reduce hospitalization and death, whether or not the patient has diabetes. Watch for dehydration and euglycemic ketoacidosis when such patients are ill. They are not a sign of hidden diabetes, they are not loop diuretics (though they have a mild diuretic effect), and they are not beta blockers.

9. A heart failure patient takes sacubitril/valsartan. An urgent care clinic also started lisinopril yesterday for his BP. What is the main concern?

   1. A. Angioedema from combining it with an ACE inhibitor
   2. B. Severe hypoglycemia from taking the two drugs together
   3. C. Low potassium from the two drugs together
   4. D. Bradycardia caused by the valsartan component
   Show answer

   Answer: A. Angioedema from combining it with an ACE inhibitor

   Sacubitril/valsartan combines an ARB with a neprilysin inhibitor; taking it with an ACE inhibitor greatly raises the risk of angioedema, so the two must not be combined (a 36-hour washout is required when switching). The pair raises rather than lowers potassium, and neither drug causes hypoglycemia or slows the heart rate.

10. A heart failure patient with an ejection fraction of 25% has an ICD, although he has never had a ventricular dysrhythmia. Why was it implanted?

    1. A. To shock atrial fibrillation back to sinus
    2. B. To pace his heart faster during exercise
    3. C. To strengthen each ventricular contraction
    4. D. To prevent sudden death from VT or VF
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    Answer: D. To prevent sudden death from VT or VF

    Patients with an ejection fraction of 35% or less from heart failure have a high risk of sudden death from VT or VF, so an ICD is often placed for primary prevention before any event. ICDs are not designed to treat atrial fibrillation, rate-responsive pacing is a pacemaker feature, and no ICD increases the force of contraction.

11. During prehospital lung ultrasound on a dyspneic patient, you see many vertical B-lines in both lungs. What does this finding suggest?

    1. A. A collapsed lung from a large tension pneumothorax
    2. B. Normal lungs with healthy, air-filled spaces
    3. C. Air trapping from a severe COPD exacerbation
    4. D. Fluid in the lung tissue, as in pulmonary edema
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    Answer: D. Fluid in the lung tissue, as in pulmonary edema

    Multiple B-lines in both lungs reflect fluid in the interstitium, supporting cardiogenic pulmonary edema when the history fits. A pneumothorax shows no lung sliding and no B-lines, normal lungs show horizontal A-lines with sliding, and COPD air trapping does not produce diffuse B-lines.

12. With a patient sitting at 45 degrees, you see the top of the internal jugular pulsation 8 cm above the sternal angle. How should you interpret this?

    1. A. A normal finding at this angle
    2. B. Low central venous pressure
    3. C. Raised jugular venous pressure
    4. D. A strong carotid pulsation
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    Answer: C. Raised jugular venous pressure

    The jugular venous pulse normally rises no more than about 3 to 4 cm above the sternal angle at 45 degrees; 8 cm indicates raised right-sided pressure, as in heart failure or fluid overload. It is not normal and does not suggest low pressure, and the soft, two-wave venous pulse should not be confused with the carotid.

13. A patient in cardiogenic shock has sinus tachycardia at 124/min. Your partner suggests IV metoprolol to slow the rate. What is the best response?

    1. A. Slowing the rate will raise his blood pressure soon
    2. B. Metoprolol will improve his pump function now
    3. C. The fast rate is compensating for low stroke volume
    4. D. The rate should be lowered below 60 at once
    Show answer

    Answer: C. The fast rate is compensating for low stroke volume

    In cardiogenic shock, stroke volume is low, so the heart rate rises to keep cardiac output up; slowing it with a beta blocker can cause collapse. Lowering the rate will not raise his BP, metoprolol depresses rather than improves contractility in the acute setting, and a rate below 60 would worsen perfusion.

14. A patient with acute severe mitral regurgitation has pulmonary edema and a BP of 132/80. How does nitroglycerin help him?

    1. A. It raises preload to better fill the left ventricle
    2. B. It slows the heart to lengthen filling
    3. C. It raises the pressure in the left atrium
    4. D. It lowers afterload so more blood goes forward
    Show answer

    Answer: D. It lowers afterload so more blood goes forward

    In mitral regurgitation, blood can leave the ventricle forward into the aorta or backward into the atrium. Lowering afterload with vasodilators lets more of it go forward and less backward, easing pulmonary congestion, as long as BP allows. Nitroglycerin lowers preload rather than raising it, does not slow the heart, and lowers rather than raises left atrial pressure.

15. A malnourished heavy drinker has warm extremities, bounding pulses, a heart rate of 120 and new heart failure. Which treatable deficiency should be considered?

    1. A. Vitamin C deficiency (scurvy)
    2. B. Vitamin D deficiency (rickets)
    3. C. Thiamine deficiency (wet beriberi)
    4. D. Vitamin K deficiency (bleeding disorder)
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    Answer: C. Thiamine deficiency (wet beriberi)

    Severe thiamine deficiency can cause wet beriberi, a high-output heart failure with vasodilation, warm skin and tachycardia, which responds to thiamine. Scurvy causes bleeding gums and poor wound healing, vitamin D deficiency affects bone, and vitamin K deficiency causes bleeding, not high-output failure.

16. A diabetic patient with heart failure was started on pioglitazone a month ago. She has gained 4 kg and has worse leg edema and dyspnea. What is the likely cause?

    1. A. Hypoglycemia from the pioglitazone
    2. B. An allergic reaction to pioglitazone
    3. C. Kidney stones caused by the pioglitazone
    4. D. Fluid retention caused by pioglitazone
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    Answer: D. Fluid retention caused by pioglitazone

    Thiazolidinediones such as pioglitazone cause sodium and fluid retention and carry a warning against use in symptomatic heart failure, so new edema and weight gain after starting one suggests a drug-induced exacerbation; report the new drug. They rarely cause hypoglycemia on their own, and allergic reactions and kidney stones do not explain fluid overload.

17. A heart failure patient on carvedilol, sacubitril/valsartan and spironolactone has a BP of 92/58. He is warm, alert, and says he feels his usual self. What is the best interpretation?

    1. A. He is in cardiogenic shock and needs vasopressors
    2. B. He needs a 2-liter fluid bolus right away
    3. C. This may be his usual BP on heart failure drugs
    4. D. His medicines should be stopped by EMS today
    Show answer

    Answer: C. This may be his usual BP on heart failure drugs

    Guideline-directed heart failure medicines lower BP, and many patients run systolic pressures in the 90s with good perfusion; compare with his usual readings and look for signs of hypoperfusion before treating. A warm, alert patient at baseline is not in shock, large fluid boluses can cause pulmonary edema, and EMS does not stop chronic medicines.

18. During transfer of a cardiogenic shock patient with an intra-aortic balloon pump, how does the balloon help the heart?

    1. A. It inflates in systole to push blood forward
    2. B. It inflates in diastole and deflates before systole
    3. C. It stays inflated to raise the blood pressure
    4. D. It deflates in diastole to help fill the coronaries
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    Answer: B. It inflates in diastole and deflates before systole

    The balloon sits in the descending aorta. Inflating in diastole pushes blood back toward the coronary arteries, raising coronary perfusion, and deflating just before systole lowers the pressure the ventricle must eject against. Inflating during systole or staying inflated would increase afterload, and deflating in diastole would remove the coronary benefit. Routine use in MI shock is not recommended in current guidance, but it is still used in selected patients.

19. During transport with an intra-aortic balloon pump in place through the femoral artery, the patient's left radial pulse disappears. What problem should you suspect?

    1. A. The balloon has moved up and blocks the left subclavian
    2. B. The balloon has moved down and blocks the renal arteries
    3. C. The patient's left arm cuff is inflated too tightly
    4. D. The pump has improved flow so the pulse is not needed
    Show answer

    Answer: A. The balloon has moved up and blocks the left subclavian

    The balloon tip should sit just below the left subclavian artery; if it migrates upward it can block flow to the left arm, causing a lost or weak left radial pulse, so notify the transport team and the receiving center. Downward migration blocks the renal arteries, causing falling urine output rather than arm changes. A cuff problem would not explain lost pulses alone, and a lost pulse is never a sign of improved flow.

20. A patient with long-standing heart failure has marked JVD, leg edema and orthopnea, but his lungs sound clear. How should you interpret the clear lungs?

    1. A. Clear lungs rule out raised left-sided pressure
    2. B. Clear lungs prove the problem is purely in the liver
    3. C. Chronic high pressures can exist without crackles
    4. D. Crackles are required to diagnose heart failure
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    Answer: C. Chronic high pressures can exist without crackles

    In chronic heart failure, the lymphatics adapt and remove more fluid, so many patients with very high filling pressures have few or no crackles; rely on the whole picture (JVD, orthopnea, edema, weight gain). Clear lungs do not rule out congestion or show a purely liver problem, and crackles are not required to diagnose heart failure.

21. A 52-year-old's echo report describes an enlarged left ventricle with thin walls that contracts weakly. Which condition does this describe?

    1. A. Hypertrophic cardiomyopathy
    2. B. Dilated cardiomyopathy
    3. C. Constrictive pericarditis
    4. D. Restrictive cardiomyopathy
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    Answer: B. Dilated cardiomyopathy

    Dilated cardiomyopathy enlarges the ventricle and thins its walls, giving a low ejection fraction; causes include coronary disease, alcohol, viruses, toxins and genetics. Hypertrophic cardiomyopathy thickens the walls, constrictive pericarditis is a stiff pericardium around a normal-sized heart, and restrictive cardiomyopathy causes stiff walls with near-normal size.

22. A woman who had chest radiation for lymphoma years ago has leg edema and ascites. Her neck veins are distended, rise further with each breath in, and her lungs are clear. What should you suspect?

    1. A. Constrictive pericarditis
    2. B. Left heart failure with pulmonary edema
    3. C. Cirrhosis from alcohol use
    4. D. Acute asthma exacerbation
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    Answer: A. Constrictive pericarditis

    A stiff, scarred pericardium (from radiation, surgery or infection) limits filling of the heart, producing right-sided congestion with clear lungs and a paradoxical rise in neck veins on inspiration (Kussmaul sign). Left heart failure causes crackles, cirrhosis does not produce distended neck veins, and asthma does not explain the edema.

23. Why does a heart failure patient wake up short of breath a few hours after lying down, rather than as soon as she lies flat?

    1. A. Her blood pressure rises sharply once she is in deep sleep
    2. B. Her airways tighten as soon as she falls asleep
    3. C. Her heart rate speeds up during deep sleep
    4. D. Edema fluid from the legs slowly returns to the blood
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    Answer: D. Edema fluid from the legs slowly returns to the blood

    When a patient lies down, edema fluid from the legs and lower body is gradually reabsorbed into the circulation over hours, raising preload until the failing left ventricle cannot keep up and fluid backs into the lungs, causing paroxysmal nocturnal dyspnea. Blood pressure usually falls during sleep, airway narrowing is the asthma mechanism, and the heart usually slows in deep sleep.

24. A patient with a mechanical mitral valve missed her warfarin for 2 weeks. She now has sudden dyspnea, crackles, and the usual crisp valve click is no longer heard. What should you suspect?

    1. A. Normal wear of the mechanical valve
    2. B. A pulmonary embolism from a leg clot
    3. C. Heart failure from a missed diuretic
    4. D. A clot on the mechanical valve
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    Answer: D. A clot on the mechanical valve

    Mechanical valves make a crisp click, and patients need lifelong anticoagulation; a subtherapeutic INR can let a clot form on the valve, blocking its motion and causing sudden heart failure, shock or stroke, and loss of the click is a red flag. Normal wear does not cause sudden failure, and a PE or a missed diuretic could cause dyspnea but would not silence the valve click.

25. In a patient with cardiogenic shock, which hemodynamic pattern is expected?

    1. A. High cardiac output with low vascular resistance
    2. B. Low cardiac output with high vascular resistance
    3. C. Low cardiac output with low vascular resistance
    4. D. Normal cardiac output with high venous pressure
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    Answer: B. Low cardiac output with high vascular resistance

    In cardiogenic shock the failing pump produces low output, and compensatory vasoconstriction raises systemic vascular resistance, producing cool, clammy skin. High output with low resistance is typical of early septic shock.

26. Which is the most common cause of cardiogenic shock?

    1. A. Acute bacterial endocarditis
    2. B. Untreated chronic hypertension
    3. C. Stable atrial fibrillation
    4. D. A large acute MI
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    Answer: D. A large acute MI

    Loss of a large portion of left ventricular muscle from MI is the leading cause of cardiogenic shock. Mortality remains high, and these patients benefit from rapid transport to a PCI-capable center.

27. A heart failure patient takes bumetanide 2 mg daily. Bumetanide is about 40 times as potent as furosemide by weight. About how much furosemide is this equivalent to?

    1. A. 2 mg of furosemide
    2. B. 20 mg of furosemide
    3. C. 80 mg of furosemide
    4. D. 160 mg of furosemide
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    Answer: C. 80 mg of furosemide

    Bumetanide 1 mg is roughly equal to furosemide 40 mg, so 2 mg x 40 = 80 mg; knowing the home loop diuretic dose helps the hospital choose an IV dose (often equal to or double the home dose). 2 mg ignores the potency difference, 20 mg uses a factor of 10, and 160 mg doubles the correct answer.

28. A patient with an RV infarction is still hypotensive at 80/50 after 1.5 liters of fluid, and his neck veins are now markedly distended. What is the best next step?

    1. A. Give another 2 liters of fluid as fast as possible
    2. B. Give nitroglycerin to relieve the neck veins
    3. C. Give furosemide to remove the extra fluid
    4. D. Stop fluids and start an inotrope or vasopressor
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    Answer: D. Stop fluids and start an inotrope or vasopressor

    RV infarction needs preload, but once the right ventricle is full (rising neck veins without BP response), more fluid only dilates it and pushes the septum into the left ventricle, so support with an inotrope or vasopressor per protocol. Another 2 liters of fluid can worsen output, and nitroglycerin and furosemide reduce preload and can cause collapse.

29. A heart failure patient has a BP of 100/82. His proportional pulse pressure (pulse pressure divided by systolic BP) is 18%. What does this suggest?

    1. A. A normal output, since the systolic BP is 100
    2. B. A high output from sepsis or a fever
    3. C. Aortic regurgitation with a large stroke volume
    4. D. A low cardiac output (below 25% is concerning)
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    Answer: D. A low cardiac output (below 25% is concerning)

    Proportional pulse pressure = (100 - 82) / 100 = 18%; a value below about 25% predicts a low cardiac index in heart failure and suggests a 'cold' profile despite an acceptable systolic BP. A normal-looking systolic pressure can hide low output, while sepsis and aortic regurgitation widen rather than narrow the pulse pressure.

30. A 78-year-old with severe aortic stenosis has exertional chest pain, yet a recent cath showed normal coronary arteries. What best explains the angina?

    1. A. A coronary spasm triggered by the stiff aortic valve
    2. B. Pericarditis spreading from the aortic valve
    3. C. Pain referred from the esophagus behind the valve
    4. D. The thick ventricle needs more oxygen than it gets
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    Answer: D. The thick ventricle needs more oxygen than it gets

    In aortic stenosis the left ventricle hypertrophies to push past the narrow valve; the thick muscle needs more oxygen while coronary perfusion is limited, so angina can occur even with normal coronaries. Coronary spasm, pericarditis and esophageal pain do not explain exertional angina linked to the valve.