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1. E.C. is a 72-year-old white man who is hospitalized for edema, shortness of breath, and
orthopnea. His medical history includes hypertension (HTN), hyperlipidemia, type 2
diabetesmellitus (T2DM), and coronary artery disease (CAD) with stent placement.
Which one of the following best summarizes the role of natriuretic peptides (NP) in
diagnosis and management of E.C.?
A. Serial measurements of NP should routinely be used to optimize medical treatment.
B. A baseline measurement of NP would yield diagnostic and prognostic
information.
C. A baseline measurement of NP is not helpful due to co-morbid conditions.
D. A baseline measurement of NT-proBNP of 600 pg/mL indicates likely heart failure
(HF).
Jawaban B
Karena untuk menentukan pasien masuk dalam kelas mana dan stage mana banyak
pertimbangan yang harus dilihat. Salah satu pengukuran yang membantu yaitu BNP atau
NT-proBNP yang mengindikasikan adanya peningkatan maupun penurunan kadar
tersebut dalam plasma. Namun, kadar tersebut tidak spesifik untuk mendiagnosis pasien
HF.
2. E.C. is diagnosed with heart failure reduced ejection fraction (HFrEF) and treated with
intravenous diuretics. Guideline directed management and therapy (GDMT) is initiated
before discharge. Ten days later, when seen in the HF clinic, E.C. states that he feels
“pretty good.” He has been “getting around okay” but can’t walk his dog as far as he did
before hospitalization without feeling tired. Which one of the following best categorizes
E.C.’s ACC Stage and NYHA class today?
A. ACC Stage C/ NYHA class IV
B. ACC Stage D/NYHA class II
C. ACC Stage C/NYHA class II
D. ACC Stage D/NYHA class IV
Jawaban : C. ACC Stage C/NYHA class II
Karena stage C memiliki gejala adanya limitasi atau keterbatasan aktivitas fisik yang
dimiliki oleh E.C. Pasien E.C masih terlihat baik-baik saja ketika kontrol ke klinik HF,
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namun tidak dapat berjalan terlalu jauh saat dengan anjingnya karena pasien akan
kelelahan dan sampai masuk RS seperti kejadian sebelumnya. Selain itu, stage C juga
memperlihatkan adanya gejala structural heart disease dengan sekarang maupun gejala
terdaulu dari HF, dimana pasien juga telah didiagnosis HFrEF yang mengindikasikan
adanya kegagalan sistolik. NYHA function class II memiliki ciri adanya sedikit
keterbatasan pasien HF seperti pasien E.C.
3. Which of the following patient profiles best fits a diagnosis of HFpEF?
A. 45-year-old woman, history includes HTN, peripheral edema; NT-proBNP 550
pg/mL; EF 55%
B. 45-year-old woman, history includes HTN, peripheral edema; NT-proBNP 250
pg/mL; EF 45%
C. 65-year-old man, history includes ST-elevation myocardial infarction; rales; NT-
proBNP 675 pg/mL; EF 40-45% D. 76-year-old woman, medical history
noncontributory; rales; NT-proBNP 550 pg/mL; EF 60%
Jawaban : A
Pasien berumur 45 tahun yang memiliki epidemiologi tidak terlalu tinggi terkena HF
seperti wanita atau pria yang berumur lebih dari 65 tahun. Pasien yang berumur 45 tahun
seharusnya memiliki nilai HFpEF 40-50% dengan nilai NT-proBNP normal sebesar 450
pg/mol. HFpEF ini mengindikasikan jika pasien mengalami kegagalan diastole jantung.
Pasien memiliki nilai LVEF lebih dari 50% dan nilai NT-proBNP lebih dari nilai normal
(450 pg/mol) yaitu 550 pg/mol.
Question 4 and 5 pertain to the following case.
K.S is a 67-year-old white man whose medical history includes HTN and CAD (stent
placed 6 years ago). He reports dysphea with less than normal activity and trace edema;
he has been diagnosed with HFrEF (Stage C, NYHA class II). Objective findings include:
EF 25%, BP 132/77 mm Hg, heart rate (HR) 79 beats/minute, BUN 19 mg/dL, SCr 0.9
mg/dL, and K is 3.8 mEq/L. His other lab values are within normal limints. K.S.’s home
drugs include aspirin 81 mg, atorvastatin 40 mg, amlodipine 5 mg daily, and
chlorthalidone 12.5 mg daily.
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4. K.S.’s physician plans to discontinue amlodipine and chlorthalidone and add furosemide
40 mg daily, and asks for a recommendation on starting GDMT. Which one of the
following is the best initial treatment plan to recommend for K.S.?
A. Begin lisinopril 5 mg daily.
B. Begin lisinopril 20 mg daily.
C. Begin carvedilol 3.125 mg twice daily.
D. Begin lisinopril 5 mg daily and carvedilol 3.125 mg twice daily.
Jawaban : C. memulai dengan carverdiol 3.125mg 2x1

Karena carveridol yang merupakan beta blocker cocok digunakan untuk pasien NYHA
nilai LVEF <40%. Pasien memiliki LVEF 25% dan sudah didiagnosis masuk dalam stage
NYHA class II sehingga digunakan carveridol sebagai terapi. Mekanisme kerja
carveridol adalah penurunan aritmia ventricular, hipertrofi cardiac, dan penurunan
vasokontriksi.
5. K.S. is seen in clinic and his HF regimen is adjusted over the following months. At his 4-
month visit, he is taking lisinopril 20 mg daily and carvedilol 25 mg twice daily, and
furosemide 20 mg three times weekly as needed based on daily weight. Relevant
objective findings: BP is 119/70 mm Hg, HR 70 beats/minute, BUN 14 mg/dL, SCr 1
mg/dL, and K 4 mEq/L. K.S. is clinically stable although he states that “he gets winded a
little easier than he used to.” Which of the following is best to recommend adding to
K.S.’s HF regimen?
A. Spironolactone 12.5 mg daily
B. n-3 PUFA 1 g daily
C. Valsartan 40 mg twice daily
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D. Digoxin 0.125 mg daily

D. Digoxin 0,125 mg per hari
Ketika psien mengalami keparahan gejala yang terlihat dari data lab pasien yang
menunjukkan adanya sesak dan penurunan kadar K yang drastis. Penurunan kadar K
yang drastic ini dapat menyebabkan bleeding mendadak pada pasien, dan penurunan ini
dapat disebabkan karena mekanisme dari furosemide. Jika dipilih jawaban A salah,
karena spironolakton merupakan aldosterone inhibitor yang dapat menurunkan kadar K
dalam tubuh sehingga dipilih digoxin sebagai penambahan terapi inotropic agent.
6. A 73-year-old African American man who has recently relocated is being seen in your
HF clinic for the first time. He was diagnosed with HFrEF 4 years ago (Stage C HFrEF;
EF 30%) His medical history includes HTN, T2DM, peripheral artery disease, chronic
kidney disease 4, and benign prostatic hyperplasia. Objective data: BP 112/66 mm Hg,
HR 86 beats/minute, BUN 15 mg/dL, SCr 3.1 mg/dL, eGFR 26 mL/min/1.73m2 (stable
over past 12 months), K 3.7 mEq/L. His home drugs include aspirin 81 mg daily,
atorvastatin 80 mg daily, carvedilol 12.5 mg 2 twice daily, clopidogrel 75 mg daily,
finasteride 5 mg daily, lisinopril 40 mg daily, and sitagliptin 25 mg daily. Which one of
the following is best to recommend for this patient?
A. Discontinue lisinopril based on renal function.
B. Discontinue lisinopril and titrate carvedilol to 25 mg twice daily.
C. Continue current regimen and titrate carvedilol to 25 mg twice daily.
D. Continue current regimen
Jawaban : B. lisinopril dihentikan dan dilanjutkan dengan titrasi carvedilol 25 mg 2x1
Hal ini dilakukan karena lisinopril memiliki KI dengan pasien gagal ginjal. Pasien A 73
tahun memiliki data lab EGFR hanya 26 mL/min/1.73 m2. Lisinopril di
kontraindikasikan dengan pasien yang memiliki kegagalan ginjal dengan nilai
GFR<60mL/min/1.73m2
7. A physician contacts you for help regarding changing a patient from losartan 100 mg
daily to sacubitril/valsartan. The patient is a 55-year-old white woman with HFrEF, stage
C, NYHA class III. She has a history of angioedema with lisinopril. She is also taking
carvedilol 25 mg twice daily, furosemide 40 mg twice daily, spironolactone 12.5 mg
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daily. Her BP is 120/70 mm Hg and HR 75 beats/minute. Her K is 5.0 mEq/L and SrCr is
1.2 mg/dL. Which one of the following is best to recommend for this patient?
A. Start sacubitril/valsartan 49/51 mg twice daily 36 hours after the last dose of losartan.
B. Start sacubitril/valsartan 97/103 mg at the next dosing interval.
C. Do not start sacubitril/valsartan because of K 5.0 mEq/L.
D. Do not start sacubitril/valsartan because of history of angioedema with
angiotensin-converting enzyme inhibitor (ACEI).
Jawaban : D. pemberhentian sacubitri/valsartan karena pasien memiliki pengalaman
angioedema yang disebabkan karena ACEI
Valsartan merupakan golongan ARB yang dapat memberikan efek samping mirip dengan
ACEI yaitu angioedema dan KI terhadap pasien yang memiliki pengalaman
mengkonsumsi ACEI (pasien mengkonsumsi lisinopril) yang menyebabkan angioedema,
sehingga penggunaan valsartan dihentikan.
8. An 87-year-old white woman comes to the HF clinic. Her medical history includes
HFrEF (Stage C, NYHA class II, EF 15%–20%), atrial fibrillation, HTN, and
hypothyroidism. Objective findings: BP 120/83 mm Hg, HR 108 beats/minute, BUN 10
mg/dL, SCr 0.6 mg/dL, K 4.3 mEq/L, TSH 0.82 mIU/L and Free T4 0.97 ng/dL. Her
home drugs include ramipril 5 mg daily, carvedilol 12.5 mg twice daily, levothyroxine 25
mcg daily, apixaban 5 mg twice daily. The medical resident is considering adding
ivabradine to improve HR control. Which of the following is best to recommend for this
patient?
A. Initiate ivabradine 5 mg twice daily and stop carvedilol.
B. Initiate ivabradine 5 mg twice daily and continue carvedilol.
C. Do not start ivabradine; increase carvedilol to 25 mg twice daily.
D. Do not start ivabradine; continue carvedilol 12.5 mg twice daily and add digoxin
0.125 mg daily.
Jawaban : C. tidak memulai ivabradine dan meningkatkan dosis carvedilol menjadi 25
mg 2x1
Ivabradine memiliki mekanisme penghambatan CYP 450 pada liver shingga dapat
menyebabkan peningkatan kadar obat lain yang dapat menyebabkan toksisitas meningkat.
Pasien juga mengalami hipotiroid yang menyebabkan metabolisme terganggu yaitu
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penurunan metabolisme. Obat ini menyebabkan pemanjangan depolarisasi diastolic

sehingga dapat meningkatkan tekanan darah yang merupakan salah satu faktor resiko HF.
9. A patient with diabetic kidney disease, HFrEF, and K 5.8 mEq/L is undergoing dietary
changes. The primary care physician wants to know if patiromer is likely to improve
outcomes. The patient is taking valsartan 80 mg twice daily, metoprolol succinate 200 mg
daily, and bumetanide 2 mg twice daily. Which one of the following is the best response
to this question? A. Patiromer will take 2–3 days to reduce the K levels and will decrease
hospitalizations because the valsartan will not need to be discontinued.
B. Patiromer will improve HF outcomes because after K levels are normalized
valsartan can be increased to target dose.
C. Patiromer is effective at achieving normal K levels while maintaining stable doses of
RAAS inhibitors, but there are no data regarding hospitalizations or other HF outcomes.
D. Patiromer’s effectiveness at achieving normal K levels in HF patients while using
RAAS inhibitors is unknown.
Jawaban : B. Patiromer dapat meningkatkan hasil HF karena setelah K normal maka
dosis valsartan dapat ditingkatkan sesuai dosis target
Patiromer merupakan obat untuk hyperkalemia, dimana pasien mengalami diabetes
mellitus dengan data lab kalium tinggi sedangkan untuk HF tidak diperbolehkan memiliki
kadar kalium tinggi karenaa dapat meningkatkan vasokontriksi jantung.
10. A 70-year-old white woman is being seen in the clinic for routine follow-up. Her medical
history includes HTN, hyperlidemia, and HFpEF (Stage C, NYHA class III, EF 55%).
Objective data include BP 135/72 mm/Hg, HR 70 beats/minute, BUN 14 mg/dL, SCr 1.1
mg/dL, K 3.8 mEq/L, eGFR > 60, and NT-proBNP 600 pg/mL. Her home drugs include
amlodipine 5 mg daily, aspirin 81 mg, daily, atorvastatin 20 mg daily, candesartan 16 mg
daily, and furosemide 20 mg daily. Using information from the TOPCAT study, which
one of the following best assesses the use of spironolactone in this patient?
A. It has proven mortality benefit.
B. It may improve quality of life.
C. It does not affect HF hospitalizations but can be added for hypertension.
D. It should not be used.
Jawaban A.
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Pemberian spironolakton bagi pasien class C III dapat menurunkan mortalitas,

menurunkan MRS dan penurunan kematian dari cardiovascular disease karena MRS,
sehingga pemberian spironolakton dapat menurunkan mortalitas.
11. You are preparing an in-service for mid-level providers in your clinic. You plan to focus
on management of HFpEF because you have received several questions recently on this
topic. Which of the following statements is most important to include in the presentation?
A. For patients with HFpEF, the prognosis is notably worse than HFrEF due to less
clarity regarding medication interventions with mortality benefit. 3
B. For patients with HFpEF, a focus of care should be carefully managing BP to
achieve an appropriate target.
C. For patients with HFpEF, initiating spironolactone should be done as early as possible
in as many patients as possible.
D. For patients with HFpEF and T2DM, initiating empagliflozin should be considered as
first line management of T2DM.
Jawaban : B
Pasien yang memiliki penyakit HFpEF merupakan suatu penyakit dengan keadaan
sistolik yang tidak sesuai sehingga perawatan harus berhati-hati sampai mencapai BP
target karena sistolik merupakan salah satu bagian dari tekanan darah yang sangat mudah
untuk meningkat.
12. Questions 12 and 13 pertain to the following case.
K.J. is a 60-year-old woman with newly diagnosed HFrEF who is referred to the HF
clinic for evaluation. Her EF is 30%, and prior work-up was negative for coronary
disease. K.J. is taking lisinopril 10 mg daily and furosemide 20 mg daily. Her BP is
110/65 with a HR of 90 beats/minute. She has NYHA class III symptoms. Today’s
examination is benign except for tachycardia and mild LE edema. K.J.’s other lab values
include CrCl 80 mL/min and K 4.5 mEq/L.
12. Which one of the following is best to recommend for K.J.?
A. Change lisinopril to sacubitril/valsartan 49/51 mg twice daily.
B. Add carvedilol 12.5 mg twice daily.
C. Add bisoprolol 1.25 mg daily.
D. Add spironolactone 12.5 mg daily.
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Jawaban : C
Karena jika menambahkan spironolakton akan menyebabkan pasien terkena hypokalemia
dilihat dari nilai K yang hamper mendekati rendah. Jika pasien mendapatkan terapi ACEI
maka beta blocker diperlukan yaitu penambahan bisoprolol atau carvedilol. Namun,
carvedilol tidak dipilih karena dosisnya kurang sesuai (seharusnya 3.125 mg bid). Dilihat
dari pasien mengalami HFrEF sehingga terapi yang cocok yaitu ACEI/ARB+BB dan
diuretic. Pasien belum mendapatkan terapi beta blocker sehingga jawaban C paling tepat.
13. Six months later, after multiple medication adjustments and titrations, K.J. is now on a
regimen of sacubitril/valsartan 49/51 mg twice daily, metoprolol succinate 100 mg daily
(increased 2 weeks ago from 50 mg daily), spironolactone 12.5 mg daily, and furosemide
40 mg daily. K.J. currently complains of worsening fatigue, dyspnea, and weight gain (5
lb). Her BP is 100/60 mm Hg and HR 95 beats/minute. She has 1+ pitting edema to her
shin, + JVD, and her lungs are clear. Her renal function is stable and K is 5.1 mEq/L.
Which one of the following, in addition to increasing furosemide to 40 mg twice daily, is
best to recommend for K.J.?
A. Decrease metoprolol to 50 mg daily.
B. Continue other drugs as prescribed.
C. Increase sacubitril/valsartan to 97/103 mg twice daily.
D. Increase metoprolol to 150 mg daily.
Jawaban : A
Pasien mengalami TD yang sangat rendah sehingga sebaiknya metropolol dosisnya
diturunkan untuk menghindari terjadinya hipotensi pada pasien.
14. A 40-year-old man with HFrEF comes to the clinic for a routine follow-up visit. Two
weeks ago he was hospitalized for HF at another institution; this was attributed to not
following his low-sodium diet. The patient’s eplerenone was increased to 50 mg daily
(from 25 mg) on discharge, and he was continued on his home regimen of
sacubitril/valsartan 97/103 mg twice daily, carvedilol 25 mg twice daily, and furosemide
40 mg twice daily. He reports he is back to his baseline NYHA class II symptoms, is
back to following a low-sodium diet, and is trying to eat healthier overall to lose weight.
His BP is 140/80 mm Hg and HR is 70 beats/minute. Lab results have been stable over
the last few years; 1 month ago they were BUN 15 mg /dL, SCr 1.2 mg/dL, and K 4.5
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mEq/L. Which one of the following is the best plan to monitor this patient’s renal
function and potassium?
A. Check in 2 months, then every 3-4 months
B. Check in a week, 3 months, then every 6 months
C. Check today, then monthly for 90 days, then every 3-4 months
D. Check today, in 1 month, then every 3-4 months
Jawaban : D
Pasien dengan diagnosis HFrEF harus dipantau kadar BUN SCr dan K sehingga
diperlukan monitoring rutin. Nilai BUN SCr dan K pasien sudah normal karena telah
dimonitoring 1 bulan pertama. Untuk monitoring selanjutnya yaitu hari ini (bulan kedua),
1 bulan berikutnya dan selanjutnya setiap 3-4 bulan. Pengecekan K dan SrCr dapat
dilakukan 2-3 hari dan 7 hari ketika memulai terapi, dan dilanjutkan 3 bulan pertama
(tiap bulan), dan selanjutnya 3-4 bulan sehingga jawaban yang tepat adalah D.
15. The VAL-HeFT study randomized HF patients to treatment with valsartan 160 mg twice
daily or placebo. The mean EF of patients in the study was 27%; 93% of patients were
also receiving an ACEI, and 35% were receiving a β-blocker. In a post-hoc subset
analysis, the effects of valsartan on the outcome of mortality was examined by
background therapy. The table below provides relative risks and confidence intervals for
the effect of valsartan on mortality when used with or without ACEI and/or β-blocker.
Effect of Valsartan on Mortality ACEI β- Number of Relative 95% CIa
Subgroup Analysis by Background Blocker Patients Riska
Therapy
Yes No 3034 0.98 0.85-1.15
Yes Yes 1610 1.40 1.11-1.85
No No 226 0.58 0.35-1.05
No Yes 140 0.80 0.35-1.8
Which one of the following most accurately describes these results?
A. It is fairly certain than the addition of valsartan to a β-blocker without an ACEI
reduces mortality.
B. The greatest relative risk reduction was seen when valsartan was combined with an
ACEI only (no β-blocker).
C. Addition of valsartan to both an ACEI and β-blocker suggested an increased risk of
harm.
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D. In the subset of patients receiving neither an ACEI nor β-blocker, the 95% CI includes
1, suggesting an increased risk of harm in this subgroup.
Jawaban : kombinasi ACEI dan beta blocker dengan valsartan memperlihatkan nilai RR
(Relative Risk) yang paling tinggi, karena kombinasi tersebut meningkatkan RR hingga
1,40 dibandingkan obat tunggal, sehingga dapat meningkatkan mortalitas.