Study guide
High-Yield Cardiovascular Medicine for the PANCE
Cardiology is the single highest-weighted organ system on the current NCCPA PANCE blueprint (~13% of items), so mastery of ACS, heart failure, dysrhythmias, hypertension, and valvular disease yields the greatest score return. This guide distills the most-tested diagnostics, thresholds, and first-line therapies aligned to ACC/AHA (incl. the 2025 ACS and 2022 HF guidelines), CMDT, and Tintinalli.
Acute Coronary Syndrome & Stable Angina
- ◆STEMI = ST elevation ≥1 mm in ≥2 contiguous limb leads or ≥2 mm in precordial leads (≥1.5 mm women in V2-V3); new/presumed-new LBBB is NOT an automatic STEMI-equivalent — apply Sgarbossa criteria, but treat as STEMI if the clinical picture is convincing.
- ◆Reperfusion goals: primary PCI within 90 min of first medical contact (120 min if transfer); fibrinolytics within 30 min (door-to-needle) only when PCI is unavailable in <120 min.
- ◆Initial care: aspirin 162-325 mg chewed loading dose (mortality benefit), high-intensity statin, plus a P2Y12 inhibitor — the 2025 ACC/AHA guideline prefers ticagrelor OR prasugrel over clopidogrel (no preference between the two); nitrates and morphine are symptomatic only — avoid nitrates with RV infarct, hypotension, or PDE-5 use in 24-48 h, and use opioids sparingly (may blunt oral P2Y12 absorption).
- ◆NSTEMI = positive troponin without ST elevation; risk-stratify with HEART/TIMI and give anticoagulation (heparin) plus early invasive strategy for high-risk features.
- ◆Wall localization: inferior (II, III, aVF → RCA), anterior (V1-V4 → LAD), lateral (I, aVL, V5-V6 → LCx); get right-sided leads (V4R) for suspected RV infarct.
- ◆Prinzmetal (vasospastic) angina: transient ST elevation at rest, young patients, cocaine/smoking; treat with CCB and nitrates — beta-blockers can worsen spasm.
Heart Failure
- ◆HFrEF = EF ≤40%; guideline-directed quadruple therapy: ARNI (sacubitril-valsartan) or ACEI/ARB, beta-blocker (carvedilol, metoprolol succinate, bisoprolol), MRA (spironolactone/eplerenone), and SGLT2 inhibitor — all reduce mortality.
- ◆HFpEF = EF ≥50% with congestion; manage BP and volume with diuretics — SGLT2 inhibitors (empagliflozin/dapagliflozin) are Class I to reduce HF hospitalization/CV death, though a clear all-cause mortality benefit in HFpEF is not established; finerenone also reduces HF events.
- ◆BNP/NT-proBNP helps rule out HF in dyspnea; elevated in HF, lowered by obesity, raised by renal failure/age/AF.
- ◆Acute decompensation: IV loop diuretic (furosemide), nitrates, oxygen/noninvasive ventilation, upright positioning; treat hypertensive flash pulmonary edema with IV nitroglycerin.
- ◆Loop diuretics relieve symptoms but do NOT reduce mortality; avoid non-dihydropyridine CCBs and NSAIDs in HFrEF.
- ◆S3 gallop = volume overload/systolic dysfunction; JVD, bibasilar crackles, and displaced PMI are classic findings.
Dysrhythmias
- ◆Atrial fibrillation: irregularly irregular rhythm, no P waves; rate control (beta-blocker or diltiazem) is first-line for most; anticoagulate per CHA₂DS₂-VASc (≥2 men, ≥3 women) with a DOAC preferred over warfarin (except mechanical valves/moderate-severe mitral stenosis → warfarin).
- ◆Unstable tachyarrhythmia (hypotension, chest pain, altered mental status, shock) → synchronized cardioversion; pulseless VT/VF → unsynchronized defibrillation.
- ◆SVT (regular, narrow-complex, ~150-250): vagal maneuvers → adenosine 6 mg IV rapid push (then 12 mg); definitive treatment is catheter ablation.
- ◆Torsades de pointes: polymorphic VT with prolonged QT → IV magnesium; correct hypokalemia/hypomagnesemia and stop QT-prolonging drugs.
- ◆Bradycardia/heart block: symptomatic → atropine 1 mg IV, then transcutaneous pacing; Mobitz II and third-degree block need a pacemaker. Wenckebach (Mobitz I) = progressive PR lengthening then dropped beat, usually benign.
- ◆WPW with AF: delta wave, short PR — AVOID AV nodal blockers (adenosine, beta-blockers, CCB, digoxin); use procainamide and cardiovert if unstable.
Hypertension & Lipids
- ◆Stage 1 HTN = 130-139/80-89, Stage 2 = ≥140/90 (ACC/AHA); diagnose with ≥2 readings on ≥2 visits or ambulatory monitoring.
- ◆First-line agents: thiazide, ACEI/ARB, or dihydropyridine CCB; in Black patients without HF/CKD start with thiazide or CCB; ACEI/ARB preferred with diabetes or CKD/proteinuria.
- ◆Hypertensive emergency = severe BP + acute end-organ damage → lower MAP ~10-20% in the first hour with IV agents (labetalol, nicardipine); asymptomatic 'urgency' does not need rapid parenteral lowering.
- ◆Secondary HTN clues: hypokalemia/resistant HTN (primary aldosteronism), abdominal bruit (renal artery stenosis), episodic spells (pheochromocytoma), OSA.
- ◆High-intensity statin for clinical ASCVD, LDL ≥190, or diabetes age 40-75; use the pooled-cohort 10-year risk (≥7.5%) to guide primary prevention.
- ◆Statins are first-line for lipids; add ezetimibe then a PCSK9 inhibitor if LDL remains ≥70 in very-high-risk ASCVD patients.
Valvular Disease
- ◆Aortic stenosis: harsh crescendo-decrescendo systolic murmur radiating to carotids, weak/delayed pulses (pulsus parvus et tardus); triad of angina, syncope, dyspnea → valve replacement (SAVR/TAVR) once symptomatic.
- ◆Mitral regurgitation: holosystolic blowing murmur at apex radiating to axilla; common cause is mitral valve prolapse (mid-systolic click).
- ◆Aortic regurgitation: early diastolic decrescendo murmur, wide pulse pressure, bounding (water-hammer) pulses; consider acute AR with aortic dissection/endocarditis.
- ◆Mitral stenosis: opening snap + low-pitched diastolic rumble at apex; associated with rheumatic heart disease, causes AF and left atrial enlargement.
- ◆Left-sided murmurs intensify with expiration, right-sided with inspiration; handgrip increases MR/AR/VSD, while Valsalva and standing increase HCM and MVP murmurs.
- ◆Infective endocarditis: new murmur + fever → blood cultures + echo (modified Duke criteria); prophylaxis only for highest-risk cardiac conditions before dental/respiratory procedures.
Pericardial, Aortic & Venous Emergencies
- ◆Acute pericarditis: pleuritic chest pain relieved by sitting forward, friction rub, diffuse ST elevation with PR depression; treat with NSAIDs + colchicine.
- ◆Cardiac tamponade: Beck triad (hypotension, JVD, muffled heart sounds), pulsus paradoxus, electrical alternans → urgent pericardiocentesis.
- ◆Aortic dissection: tearing chest/back pain, pulse/BP differential between arms, widened mediastinum; type A (ascending) → surgery, type B → IV beta-blocker (esmolol/labetalol) to target HR <60 before adding vasodilators.
- ◆Abdominal aortic aneurysm: pulsatile mass; one-time ultrasound screening in men 65-75 who ever smoked (USPSTF); repair at ≥5.5 cm or rapid growth.
- ◆DVT/PE: Wells score guides workup; D-dimer rules out low-probability disease, CT pulmonary angiography confirms PE; treat with a DOAC, and thrombolyse massive PE with hypotension.
- ◆PAD: claudication, ABI <0.90; first-line is exercise therapy, statin, antiplatelet, and smoking cessation, with cilostazol for symptom relief.