Physician Assistant National Certifying Examination (PANCE) Cardiovascular System Syllabus

Cardiovascular System syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Cardiovascular System in Physician Assistant National Certifying Examination (PANCE), not a summary of it.

1. 1

   Coronary Heart Disease and Acute Coronary Syndromes

   4 topics

   • Stable angina pectoris
     • Pathophysiology of myocardial oxygen supply-demand mismatch
     • Stress testing and coronary angiography indications
     • Antianginal therapy: beta-blockers, nitrates, calcium channel blockers
   • Unstable angina and NSTEMI
     • Troponin kinetics and serial biomarker interpretation
     • TIMI and GRACE risk stratification
     • Antiplatelet and anticoagulation management
   • ST-elevation myocardial infarction
     • ECG localization of infarct territory
     • Reperfusion: PCI versus fibrinolysis timing
     • Post-MI complications and secondary prevention
   • Coronary risk factor modification
     • Statin intensity and lipid targets
     • Hypertension and diabetes control
2. 2

   Heart Failure and Cardiomyopathies

   4 topics

   • Heart failure with reduced ejection fraction
     • Guideline-directed medical therapy: ARNI, beta-blocker, MRA, SGLT2 inhibitor
     • Device therapy: ICD and CRT indications
   • Heart failure with preserved ejection fraction
   • Acute decompensated heart failure management
     • Diuresis and afterload reduction
     • Cardiogenic shock recognition
   • Dilated, hypertrophic, and restrictive cardiomyopathy
3. 3

   Arrhythmias and Conduction Disorders

   5 topics

   • Atrial fibrillation and flutter
     • Rate versus rhythm control strategies
     • CHA2DS2-VASc and anticoagulation decisions
   • Supraventricular tachycardias
     • AVNRT and AVRT mechanisms
     • Vagal maneuvers and adenosine
   • Ventricular tachycardia and fibrillation
   • Bradyarrhythmias and AV blocks
     • First, second, and third degree heart block
     • Pacemaker indications
   • Long QT and inherited channelopathies
4. 4

   Valvular and Structural Heart Disease

   4 topics

   • Aortic stenosis and regurgitation
     • Murmur characteristics and severity grading
     • Valve replacement timing (SAVR/TAVR)
   • Mitral stenosis and regurgitation
   • Infective endocarditis
     • Duke criteria
     • Prophylaxis indications
   • Rheumatic heart disease
5. 5

   Vascular Disease and Hypertension

   5 topics

   • Essential and secondary hypertension
     • Staging and lifestyle/pharmacologic management
     • Hypertensive urgency versus emergency
   • Aortic aneurysm and dissection
   • Peripheral arterial disease
     • Ankle-brachial index
     • Claudication management
   • Venous thromboembolism and chronic venous insufficiency
   • Lipid disorders and dyslipidemia

Cardiovascular System flashcards for Physician Assistant National Certifying Examination (PANCE)

22 of 50 cards from the Cardiovascular System deck — real questions with worked answers.

1. What clinical features define stable angina pectoris?

   Substernal chest pressure/discomfort that is (1) provoked by exertion or emotional stress, (2) relieved within minutes by rest or nitroglycerin, and (3) reproducible/predictable. It reflects fixed coronary stenosis causing demand-supply mismatch without myocyte necrosis (normal troponin).

2. What is the first-line antianginal and prognostic medication regimen for chronic stable angina?

   Symptom control: beta-blocker first-line (or calcium channel blocker if intolerant), plus sublingual nitroglycerin PRN. Prognosis/secondary prevention: high-intensity statin, antiplatelet (aspirin), and ACE inhibitor/ARB if diabetes, hypertension, CKD, or LV dysfunction.

3. How are unstable angina (UA) and NSTEMI distinguished from each other?

   Both are non-ST-elevation acute coronary syndromes with ischemic symptoms at rest/crescendo and possible ST depression or T-wave inversion. The difference is biomarkers: NSTEMI has elevated troponin (myocyte necrosis), whereas UA has normal troponin.

4. What is the initial medical management of UA/NSTEMI?

   Dual antiplatelet therapy (aspirin + P2Y12 inhibitor such as ticagrelor or clopidogrel), anticoagulation (heparin), beta-blocker, high-intensity statin, nitrates for symptoms, and oxygen only if $\text{SpO}_2 < 90\%$. Risk-stratify (TIMI/GRACE) for early invasive angiography.

5. What ECG criteria define ST-elevation myocardial infarction (STEMI)?

   New ST elevation at the J point in $\geq 2$ contiguous leads: $\geq 1\,\text{mm}$ in limb leads, and in $V_2\text{–}V_3$ $\geq 2\,\text{mm}$ in men ($\geq 2.5\,\text{mm}$ if age $<40$) or $\geq 1.5\,\text{mm}$ in women. New LBBB with ischemic symptoms is treated similarly.

6. Which coronary artery and infarct territory correspond to ST elevation in leads II, III, and aVF?

   Inferior wall MI, usually from the right coronary artery (RCA). Beware concurrent right ventricular infarction—obtain right-sided leads ($V_4R$) and avoid nitrates/preload-reducers if RV infarct is present.

7. What is the reperfusion goal time for STEMI with primary PCI versus fibrinolysis?

   Primary PCI is preferred with a door-to-balloon time $\leq 90$ minutes (or $\leq 120$ minutes if transfer needed). If PCI is unavailable within that window, give fibrinolytics within a door-to-needle time $\leq 30$ minutes.

8. List the standard post-MI discharge medications proven to improve survival.

   Dual antiplatelet therapy (aspirin + P2Y12 inhibitor), high-intensity statin, beta-blocker, and ACE inhibitor/ARB (especially with reduced EF, HTN, DM, or anterior MI). Add aldosterone antagonist if $\text{EF} \leq 40\%$ with HF or diabetes.

9. What are the major modifiable coronary risk factors?

   Hypertension, dyslipidemia (high LDL/low HDL), diabetes mellitus, cigarette smoking, obesity, physical inactivity, and unhealthy diet. Smoking cessation is the single most cost-effective intervention.

10. What LDL and lifestyle targets are emphasized in coronary risk factor modification for a patient with established ASCVD?

    High-intensity statin to lower LDL $\geq 50\%$ (goal LDL $< 70\,\text{mg/dL}$, often $<55$ in very high risk); BP target generally $<130/80\,\text{mmHg}$; HbA1c individualized (often $<7\%$); complete smoking cessation; and $\geq 150$ minutes/week of moderate aerobic activity.

11. Define heart failure with reduced ejection fraction (HFrEF).

    Clinical heart failure syndrome with left ventricular ejection fraction $\leq 40\%$. It is characterized by impaired systolic contractility, eccentric (dilated) LV remodeling, and neurohormonal activation (RAAS and sympathetic).

12. What are the four pillars of guideline-directed medical therapy for HFrEF?

    (1) ARNI (sacubitril/valsartan) or ACEi/ARB, (2) beta-blocker (carvedilol, metoprolol succinate, or bisoprolol), (3) mineralocorticoid receptor antagonist (spironolactone/eplerenone), and (4) SGLT2 inhibitor (dapagliflozin/empagliflozin). All reduce mortality.

13. Define heart failure with preserved ejection fraction (HFpEF) and its core pathophysiology.

    Clinical heart failure with $\text{EF} \geq 50\%$. The problem is diastolic dysfunction—a stiff, poorly relaxing LV causing elevated filling pressures with normal contractility. Often associated with hypertension, obesity, diabetes, and aging.

14. What is the cornerstone treatment for HFpEF?

    Manage volume with diuretics, aggressively control blood pressure, treat comorbidities (AF, obesity, ischemia), and add an SGLT2 inhibitor (now shown to reduce HF hospitalization). Unlike HFrEF, most neurohormonal drugs have limited mortality benefit.

15. What is the initial management of acute decompensated heart failure with pulmonary congestion?

    Remember LMNOP: Loop diuretics (IV furosemide), Morphine (rarely used now), Nitrates (vasodilator to reduce preload/afterload), Oxygen/noninvasive positive-pressure ventilation, and Position (sit upright). Identify and treat the precipitant.

16. How does BNP/NT-proBNP help in acute dyspnea evaluation?

    Elevated B-type natriuretic peptide (BNP) or NT-proBNP supports a cardiac cause of dyspnea (HF), reflecting ventricular wall stretch. A low value has high negative predictive value to rule out HF. Levels are lower in obesity and higher in renal failure and AF.

17. Contrast the three main cardiomyopathies (dilated, hypertrophic, restrictive) by ventricular size and dysfunction.

    Dilated: enlarged chambers with systolic dysfunction (low EF). Hypertrophic: thick, non-dilated LV with diastolic dysfunction and possible LVOT obstruction (preserved/high EF). Restrictive: normal-sized, rigid walls with diastolic dysfunction and impaired filling (preserved EF).

18. What is the inheritance and key pathophysiology of hypertrophic cardiomyopathy (HCM)?

    Autosomal dominant mutation in sarcomere genes (e.g., beta-myosin heavy chain). Asymmetric septal hypertrophy can cause dynamic LV outflow tract obstruction and systolic anterior motion of the mitral valve; it is a leading cause of sudden cardiac death in young athletes.

19. How does the murmur of hypertrophic obstructive cardiomyopathy change with maneuvers?

    The harsh systolic murmur INCREASES with maneuvers that decrease preload/afterload (Valsalva strain, standing) and DECREASES with increased preload/afterload (squatting, handgrip, passive leg raise). Less LV volume worsens the outflow obstruction.

20. What is the CHA2DS2-VASc score used for, and what does it count?

    It estimates annual stroke risk in atrial fibrillation to guide anticoagulation. Points: CHF (1), Hypertension (1), Age $\geq 75$ (2), Diabetes (1), prior Stroke/TIA (2), Vascular disease (1), Age 65–74 (1), Sex female (1). Anticoagulate if score $\geq 2$ in men or $\geq 3$ in women.

21. Describe the ECG findings of atrial fibrillation versus atrial flutter.

    Atrial fibrillation: irregularly irregular rhythm with absent P waves and a fibrillatory baseline. Atrial flutter: regular sawtooth flutter waves (atrial rate $\approx 300\,\text{bpm}$) with a regular ventricular response, classically $2{:}1$ conduction giving $\approx 150\,\text{bpm}$.

22. What are the rate-control and rhythm-control options for atrial fibrillation?

    Rate control: beta-blockers or non-dihydropyridine calcium channel blockers (diltiazem/verapamil); digoxin as adjunct. Rhythm control: electrical/pharmacologic cardioversion (must anticoagulate or exclude thrombus with TEE if onset $>48$ h), antiarrhythmics (amiodarone, flecainide), or catheter ablation.

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