MCQs on Heart Failure

Written by Dr. Daniel Fraser (MBBS, FRACP) – Physician

Question 1

A 72-year-old woman presents with progressive shortness of breath and ankle swelling over several months. She has a history of hypertension and type 2 diabetes. On examination, her blood pressure is 150/90 mmHg, pulse is 78 bpm and regular, and she has bilateral basal crackles and pitting oedema in the lower limbs. Echocardiogram shows preserved ejection fraction (EF 60%) with evidence of concentric left ventricular hypertrophy and impaired relaxation on Doppler.

Which of the following best explains the likely pathophysiology of this patient’s heart failure?

A) Reduced contractility of the left ventricle
B) Volume overload due to mitral regurgitation
C) Decreased compliance of the left ventricle
D) Increased right atrial pressure due to pulmonary hypertension
E) Atrial fibrillation with rapid ventricular response

Correct Answer: C) Decreased compliance of the left ventricle

Explanation:
This patient presents with heart failure with preserved ejection fraction (HFpEF), often seen in elderly patients with hypertension and left ventricular hypertrophy. The key pathophysiological mechanism in HFpEF is diastolic dysfunction, particularly reduced ventricular compliance and impaired relaxation, which leads to elevated filling pressures despite preserved systolic function.

A) Reduced contractility refers to systolic heart failure (HFrEF), which is not consistent with the preserved EF.
B) Volume overload from mitral regurgitation can contribute to heart failure, but the echo findings and hypertensive background point more to diastolic dysfunction.
D) Increased right atrial pressure due to pulmonary hypertension may be secondary but is not the primary pathophysiology here.
E) Atrial fibrillation is not mentioned and would not alone account for the preserved EF with impaired relaxation pattern.

Question 2

Tom, a 68-year-old man with known chronic heart failure, presents for follow-up. He reports that he is able to do light housework and walk around the house without issues. However, he gets breathless when walking up a flight of stairs or walking briskly outdoors. He has no symptoms at rest.

According to the New York Heart Association (NYHA) functional classification, which class of heart failure does Tom fall into?

A) NYHA Class I
B) NYHA Class II
C) NYHA Class III
D) NYHA Class IV
E) Unable to classify due to insufficient data

Correct Answer: B) NYHA Class II

Explanation:
The NYHA functional classification is used to assess symptom severity and functional limitation in heart failure:

Class I: No limitation of physical activity.
Class II: Mild limitation; symptoms with ordinary activity (e.g. stairs, brisk walking).
Class III: Marked limitation; symptoms with less than ordinary activity (e.g. slow walking).
Class IV: Symptoms at rest or minimal activity.

Tom is asymptomatic at rest and with light activity, but becomes symptomatic with ordinary physical exertion. This is consistent with Class II.

A) Class I would be correct if he had no symptoms at all with ordinary exertion.
C) Class III would be appropriate if symptoms occurred with minimal exertion.
D) Class IV applies to those with symptoms at rest.
E) Insufficient data is not correct here, as the description clearly supports classification.

Question 3

John, a 64-year-old man with a history of chronic obstructive pulmonary disease (COPD), presents with progressive swelling of his legs and abdominal fullness over several weeks. He denies any orthopnoea or paroxysmal nocturnal dyspnoea. On examination, he has elevated jugular venous pressure, hepatomegaly, ascites, and bilateral pitting oedema up to the knees. His chest is clear to auscultation.

Which of the following features is most consistent with right-sided heart failure?

A) Orthopnoea
B) Paroxysmal nocturnal dyspnoea
C) Bilateral pitting oedema
D) Basal lung crackles
E) Fine inspiratory crepitations

Correct Answer: C) Bilateral pitting oedema

Explanation:
Right-sided heart failure is characterised by systemic venous congestion, leading to signs such as peripheral oedema, ascites, hepatomegaly, and raised JVP. This patient’s presentation is classic for isolated or predominant right-sided failure, which may result from pulmonary hypertension due to COPD (cor pulmonale).

A) Orthopnoea and
B) Paroxysmal nocturnal dyspnoea are symptoms of left-sided heart failure, due to pulmonary congestion.
D) Basal crackles and
E) Fine inspiratory crepitations also reflect pulmonary oedema, which is typical in left-sided or biventricular failure, but not in isolated right-sided failure.

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2. Cardiology Module

2.1 ECG

2.2 Acute Coronary Syndrome

2.3 Heart Failure

2.4 Hypertension

2.5 Valvular Heart Diseases

2.6 Other CVS Disorders

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