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Cardiology PANCE (uworld) New Practice Exam
Complete Version 2025 / 2026 Questions and
Correct Answers | Graded A+
**1. Which cardiac drug works by blocking parasympathetic activity to increase heart rate? Atropine (increases heart rate by blocking muscarinic receptors at the SA node). Does not affect QRS complex width.
- This drug works by inhibiting the Na-K ATPase pump, increasing intracellular calcium, and slowing conduction through the SA node. What is it? Digoxin.
- Which drug is used in the treatment of ventricular tachycardia by blocking potassium channels and prolonging the action potential duration? This drug has a very long half-life and may cause thyroid and pulmonary toxicity. Class III antiarrhythmic drugs (amiodarone).
- What is the significance of paradoxical splitting of the second heart sound? Left bundle branch block (LBBB).
- Which connective tissue disorder is frequently associated with aortic root dilation? Ehlers-Danlos syndrome. May present with an early diastolic murmur of aortic regurgitation.
- What condition presents with a loud S 1 and a low-pitched diastolic rumble best heard at the cardiac apex? Mitral stenosis.
- Which heart sound is an abnormal finding in elderly patients with left ventricular stiffness? Fourth heart sound (S4) ā a high-pitched presystolic sound indicating reduced left ventricular compliance, as seen in hypertensive heart disease or aortic stenosis.**
**8. What is a common complication of ventricular septal rupture post-MI? Acute left-to-right shunt with pulmonary overcirculation. Presents with a new harsh holosystolic murmur at the left sternal border and rapid hemodynamic deterioration.
- A patient presents with the following findings: - Vertigo**
**- Tinnitus
- Visual disturbances
- Upper extremity claudication - Subclavian bruit *Affects the subclavian artery proximal to the vertebral artery origin What is the diagnosis? Subclavian steal syndrome. Blood is diverted from the vertebrobasilar circulation into the arm. Tx: surgical revascularization or angioplasty.
- What condition should be suspected in a patient with syncope and a prolonged QT interval on ECG? Torsades de pointes (polymorphic ventricular tachycardia). These patients will also have a prolonged corrected QT interval on ECG.
- Tachycardia, diaphoresis, distended jugular veins, bilateral crackles at the lung bases, and S 3 gallop are consistent with which diagnosis? Acute decompensated left heart failure. Fluid backs up into the pulmonary circulation, causing pulmonary edema.
- How is hypertension defined, and what is the initial treatment approach? Blood pressure greater than 140 / 90 mmHg on three separate occasions in a patient not on antihypertensive medication. Initiate lifestyle modification first, then add a thiazide diuretic, ACE inhibitor, ARB, or calcium channel blocker depending on comorbidities.
- A patient is having an acute MI and thrombolytics were administered but coronary flow is not restored. What is the next step? Perform rescue PCI. This is considered second-line therapy because thrombolytics may cause systemic bleeding and rebound thrombosis.
- Why are ACE inhibitors first-line for all post-MI patients without contraindications?**
**21. What is an early ECG finding in patients with hypertrophic obstructive cardiomyopathy? Left ventricular hypertrophy pattern with deep septal Q waves in lateral leads. Tx: echocardiography to confirm; initiate beta blocker.
- A patient sustains blunt chest trauma and develops bradycardia, ST elevation in multiple leads, and elevated troponin. What is the diagnosis? Myocardial contusion. The direct impact causes myocardial injury. ECG changes may mimic STEMI. ICU monitoring is required, as the patient may develop arrhythmias or cardiogenic shock.
- What is the most common cause of secondary hypertension presenting with hypokalemia and suppressed renin? Primary hyperaldosteronism. Defined by resistant hypertension with hypokalemia, suppressed renin, and an elevated aldosterone-to-renin ratio.
- What are some common causes of myocarditis?**
**- Viral infection (coxsackievirus B is the most common). - Autoimmune (giant cell myocarditis).
- Drug-induced (chemotherapy agents). - Chagas disease (endemic regions).
- Which condition causes impaired myocardial relaxation and filling, leading to fatigue, dyspnea on exertion, orthopnea, PND, and crackles? Restrictive cardiomyopathy. Low-voltage QRS on ECG or bundle branch block may be present.
- What is the significance of a narrow split S 2? Aortic stenosis, which delays aortic valve closure, reducing the normal physiologic split.
- Prolonged inspiration with stridor indicates what? Upper airway obstruction. Foreign body and epiglottitis are common causes in children and adults, respectively.
- Which calcium channel blockers are considered safe in patients with heart failure with reduced ejection fraction?**
Amlodipine and felodipine (dihydropyridines with minimal negative inotropic effect). Unsafe (negative inotropic effect):
- Verapamil
- Diltiazem
- Bepridil
- A patient presents with positional chest pain that is worse when lying flat and relieved by sitting up. What is the diagnosis? Pericarditis. A pericardial friction rub may be heard on auscultation. Fever and elevated ESR/CRP are common.
- A patient presents with the following findings:
- Hyperresonance to percussion
- Absent breath sounds
- Tracheal deviation away from the affected side What is the diagnosis? Tension pneumothorax.
- A patient presents with the following findings:
- Chest pain
- Hemoptysis
- Signs of DVT (swollen, tender calf) What is the most likely diagnosis? Pulmonary embolism.
- A patient presents with the following findings:
- Hypotension
- Kussmaul sign (JVP rises with inspiration)
- Clear lung fields What is the diagnosis? Right ventricular infarction.
- How do you manage new-onset atrial fibrillation in a hemodynamically unstable patient? Immediate synchronized DC cardioversion.
The mitral valve. Results in mitral stenosis, which presents with a diastolic rumble. Cardiac complications include atrial fibrillation and systemic embolism.
- A patient presents with rib notching on chest X-ray, upper extremity hypertension, and lower extremity hypotension. What is the diagnosis? Coarctation of the aorta (narrowing of the aorta distal to the left subclavian artery). Patients will have left ventricular hypertrophy and a blood pressure differential between the arms and legs.
- Which murmur decreases with squatting and increases with standing, and why? Hypertrophic obstructive cardiomyopathy (HOCM). Squatting increases preload, filling the ventricle and reducing outflow obstruction. Standing decreases preload, worsening obstruction. Aortic stenosis behaves oppositely (louder with squatting).
- What is the significance of a late diastolic murmur heard at the lower left sternal border? Tricuspid stenosis. Associated with a slow-rising y descent in the jugular venous pulse because blood drains slowly from the right atrium.
- A rise in systemic blood pressure by more than 10 mmHg during expiration is called what, and what is it associated with? Reverse pulsus paradoxus. Associated with hypertrophic obstructive cardiomyopathy (HOCM).
- Which diuretic causes hyperkalemia and gynecomastia as side effects? Spironolactone. These electrolyte abnormalities may lead to dangerous arrhythmias. If the patient is also on ACE inhibitors, the risk of hyperkalemia is additive.
- A patient has normal clinic blood pressure readings but elevated ambulatory blood pressure monitoring values. What is this condition and how is it managed? Masked hypertension. Initiate 24 - hour ambulatory blood pressure monitoring, especially if the patient has evidence of target organ damage. Blood pressure variability is an independent predictor of cardiovascular risk.
- A patient presents with the following findings:
- Life-threatening arrhythmias
- Visual disturbances (yellow-green halos)
- Nausea and vomiting
- Bradycardia with AV block What is the diagnosis? Digoxin toxicity.
- Which drug decreases the clearance of warfarin and can lead to bleeding if given concurrently? Amiodarone (also fluconazole, metronidazole, and ciprofloxacin). It is recommended that INR be closely monitored when starting amiodarone.
- Severe tearing mid-back pain radiating between the shoulder blades is most concerning for which diagnosis? Descending aortic dissection. These findings are often out of proportion to physical examination findings.
- A patient presents with the following risk factors:
- Hypertension
- Bicuspid aortic valve
- Turner syndrome All are causes of which condition? Coarctation of the aorta. There is typically a greater than 20 mmHg difference in systolic blood pressure between the upper and lower extremities.
- What is a common complication of descending aortic dissection involving the intercostal arteries? Spinal cord ischemia from interruption of intercostal artery blood supply, resulting in paraplegia (anterior spinal artery syndrome).
- When an aortic dissection propagates into the coronary ostia, what does the patient develop? Acute MI, most commonly inferior STEMI due to right coronary artery involvement. Presents with ST elevation, troponin elevation, hemodynamic instability, and cardiogenic shock.
- How do beta blockers help in chronic heart failure?
Kussmaul sign. Normally occurs in constrictive pericarditis but may also be present in right ventricular infarction and cardiac tamponade.
- What is the main side effect of direct renin inhibitors such as aliskiren? Hyperkalemia and renal impairment. Should not be combined with ACE inhibitors or ARBs.
- Sudden-onset ventricular fibrillation is most commonly caused by what? Myocardial ischemia. The ECG for VF shows chaotic, irregular waveforms with no identifiable QRS complexes.
- What are the pulmonary side effects of amiodarone? Pulmonary fibrosis and organizing pneumonia. Hypothyroidism and hyperthyroidism can also be caused by the iodine content of amiodarone. Amiodarone is typically reserved for those with severe or refractory ventricular arrhythmias. Corneal microdeposits are also a known side effect.
- What is S 3 , and what does it indicate? S 3 occurs just after S 2 and indicates volume overload or a dilated, poorly contracting ventricle (as in heart failure or mitral regurgitation). The sound is created by rapid ventricular filling striking the ventricular wall.
- A descending thoracic aortic aneurysm classically presents with what symptom? Dull, throbbing back pain, as opposed to the sharp, tearing pain of aortic dissection.
- What does tricuspid valve prolapse sound like on auscultation? A mid-systolic click heard best at the lower left sternal border, accentuated on inspiration.
- Post-MI pericarditis occurring within the first 1 - 3 days after the MI is called what, and how is it treated? Early post-MI pericarditis. Presents with pleuritic chest pain and a pericardial friction rub. Treat with high-dose aspirin and colchicine. Avoid NSAIDs and anticoagulation if possible.
- What is the treatment for atrial flutter with rapid ventricular response?
Ibutilide or DC cardioversion. Classic sawtooth flutter waves at 300 bpm on ECG. Patients usually have a regular ventricular rate of 150 bpm (2:1 block is most common).
- A patient presents with the following findings:
- Distended jugular veins
- Pulsatile and tender splenomegaly
- Peripheral cyanosis
- Bilateral leg edema What is the diagnosis? Right ventricular failure secondary to pulmonary arterial hypertension. A loud P 2 and right-sided S 3 may be present.
- A holosystolic murmur heard at the lower left sternal border, increasing with inspiration, indicates involvement of which valve? The tricuspid valve (tricuspid regurgitation).
- A systolic ejection murmur best heard at the upper right sternal border radiating to the carotids indicates which diagnosis? Aortic valve stenosis. Often degenerative in elderly patients or related to a congenital bicuspid valve in younger patients. Eventually causes left ventricular hypertrophy, angina, and syncope.
- Under which physiological condition is the mitral regurgitation murmur best heard? Decreased afterload (vasodilation).
- A neonate presents with a palpable thrill and a continuous machine-like murmur at the upper left sternal border. What is the diagnosis? Patent ductus arteriosus (PDA). If large, it presents with a continuous machine-like murmur. Smaller PDAs may have only a systolic component.
- When is BNP (B-type natriuretic peptide) released, and what is its physiological role? BNP is released from ventricular cardiomyocytes in response to increased wall stress and volume overload. Elevated BNP indicates elevated filling pressures and is useful for diagnosing and monitoring heart failure. BNP promotes natriuresis, vasodilation, and inhibits the RAAS. Nesiritide is a recombinant BNP used in acute decompensated heart failure.
- A patient with severe hypertension presents with papilledema and encephalopathy. What is the diagnosis and underlying mechanism? Hypertensive emergency. End-organ damage is caused by fibrinoid necrosis of arteriolar walls. Microangiopathic hemolytic anemia (schistocytes on peripheral smear) may be seen. Urinalysis will show hematuria and red cell casts.
- What are the current screening guidelines for abdominal aortic aneurysm (AAA) in non-smokers? Men aged 65 - 75 who have never smoked do NOT require routine screening ultrasound. Repair is advised for AAAs 5. 5 cm or greater in men and 5. 0 cm or greater in women.
- A patient presents with the following findings:
- Fixed split S 2 that does not vary with respiration
- Systolic ejection murmur at the upper left sternal border What is the diagnosis? Atrial septal defect (ASD), usually congenital. Mild forms present with exertional dyspnea in adulthood. Severe forms lead to pulmonary hypertension and right heart failure (Eisenmenger syndrome).
- Under which physiological condition does the harsh systolic murmur of aortic stenosis decrease in intensity? When there is decreased blood in the left ventricle (e.g., standing, Valsalva maneuver). This maneuver is used to differentiate aortic stenosis from HOCM, as the HOCM murmur increases with the same maneuvers.
- What is the treatment for cardiac tamponade presenting with Beck triad (hypotension, muffled heart sounds, and distended neck veins)? Pericardiocentesis.
- How do you manage stable versus unstable SVT? Stable SVT: pharmacotherapy with adenosine or vagal maneuvers (carotid sinus massage, Valsalva). Unstable SVT: synchronized direct current cardioversion. Unstable is defined as hypotension, altered consciousness, or ischemic discomfort.
- When is synchronized cardioversion indicated?
Unstable atrial flutter, atrial fibrillation, SVT, and stable monomorphic ventricular tachycardia with a pulse. Synchronized shock avoids induction of ventricular fibrillation.
- Exertional chest pain relieved by rest and sublingual nitroglycerin within 5 minutes is consistent with which diagnosis? Stable angina pectoris. Rapid relief after sublingual nitroglycerin is characteristic.
- What is the difference between a positive lusitropic effect and a positive chronotropic effect? An increased stroke volume is a positive lusitropic (relaxation) effect. An increased heart rate is a positive chronotropic effect.
- What are the cardiac manifestations of Lyme disease? Lyme carditis is caused by the spirochete Borrelia burgdorferi, transmitted by the Ixodes tick. Patients may develop AV conduction block (the most common cardiac manifestation) or myopericarditis with cardiomegaly and transient congestive heart failure.
- How is asymptomatic carotid stenosis defined, and when is intervention indicated? Asymptomatic carotid stenosis is the absence of TIA or stroke in the distribution of the affected artery within the previous 6 months. CEA may be considered for stenosis greater than 70 % in good surgical candidates.
- How is symptomatic carotid stenosis defined, and what is the management? Symptomatic carotid stenosis is defined as carotid atherosclerosis with a recent TIA or stroke. Current guidelines recommend dual antiplatelet therapy and high-intensity statin therapy in all patients.
- A patient presents with the following findings:
- S 3 gallop
- Elevated BNP
- Loud P 2 What is the most likely diagnosis and initial workup? Left ventricular systolic dysfunction (heart failure with reduced ejection fraction, HFrEF). A transthoracic echocardiogram should be obtained in all patients with new-onset heart failure to confirm and guide therapy.
Arterial calcification (non-compressible vessels), as seen in advanced diabetes or chronic kidney disease. This may falsely elevate the ABI; a toe-brachial index should be used instead.
- A patient presents with the following findings:
- Exertional dyspnea
- Orthopnea
- Holosystolic murmur over the cardiac apex radiating to the axilla
- S 3 gallop What is the diagnosis? Left ventricular dysfunction presenting as severe mitral regurgitation. The most common symptoms are exertional dyspnea and fatigue, caused by elevated left atrial pressure and reduced cardiac output. Pulmonary venous congestion results in orthopnea and paroxysmal nocturnal dyspnea.
- What are the common causes of tricuspid regurgitation? Rheumatic heart disease, infective endocarditis (especially in IV drug users), or right ventricular dilation from pulmonary hypertension. Other causes include carcinoid syndrome and Ebstein anomaly.
- A descending thoracic aortic aneurysm may be associated with which valvular abnormality if it extends to involve the aortic root? Aortic regurgitation, which would result in a diastolic murmur.
- A patient presents with exertional dyspnea, elevated jugular venous pressure, a pericardial knock, and a square root sign on cardiac catheterization. What is the diagnosis? Constrictive pericarditis.
- How do you differentiate a systolic from a diastolic murmur in terms of clinical significance? Key diastolic murmurs are:
- Aortic regurgitation (decrescendo, heard at left upper sternal border).
- Tricuspid stenosis (rumble, lower left sternal border). Key systolic murmurs are:
- Mitral regurgitation (holosystolic at apex).
- Aortic stenosis (crescendo-decrescendo at right upper sternal border).
- What is the most common cause of aortic stenosis in patients under 65 years of age? Bicuspid aortic valve. Presents with a systolic murmur radiating to the carotids.
- What is the acute treatment for ventricular fibrillation? Defibrillation (unsynchronized shock). These patients require CPR and full ACLS protocol. Epinephrine is given every 3 - 5 minutes, and amiodarone is used for refractory VF.
- A narrow complex arrhythmia with an irregularly irregular rhythm is best treated how? Rate control with a beta blocker or diltiazem, followed by anticoagulation assessment per CHA 2 DS 2 - VASc score.
- Dull, pressure-like pain provoked by exertion and relieved by rest is most consistent with which etiology? Cardiac origin. Stable angina occurs predictably with exertion. Acute coronary syndrome occurs at rest or with minimal exertion.
- Nocturnal dyspnea that awakens a patient from sleep is most often caused by what? Paroxysmal nocturnal dyspnea (PND) from left heart failure.
- In infective endocarditis in non-IV drug users, which valve is most commonly affected, and what are the complications? The mitral valve. Valve destruction causes mitral regurgitation and left heart failure. Systemic emboli may cause stroke, splenic infarction, or renal infarction.
- Mobitz type I (Wenckebach) second-degree heart block is associated with which conditions? Vagal excess or AV nodal ischemia, particularly in the setting of inferior MI.
- A patient presents with the following findings:
- AV block
- Erythema migrans rash
- Migratory arthritis What is the diagnosis?
IV nitroglycerin to reduce preload and afterload. IV furosemide is added for diuresis. Beta blockers should be avoided acutely in decompensated heart failure.
- What is the stabilization protocol for acute decompensated heart failure with reduced EF prior to definitive therapy?
- Supplemental O 2 for hypoxia or dyspnea (CPAP if needed).
- IV furosemide for diuresis.
- IV nitroglycerin for vasodilation (if SBP greater than 90 mmHg).
- Hold beta blockers if hemodynamically unstable.
- Hold ACE inhibitors if SBP less than 90 mmHg.
- Inotropic support (dobutamine) if cardiogenic shock is present.
- Swan-Ganz catheter if diagnosis is uncertain.
- What is a potential early complication of anthracycline chemotherapy (e.g., doxorubicin)? Dilated cardiomyopathy from direct myocardial toxicity, which may present during or shortly after treatment. Baseline echocardiography is required before initiation. Tx: guideline-directed heart failure therapy (ACE inhibitor plus beta blocker).
- A crescendo-decrescendo murmur heard at the upper right sternal border radiating to the carotids is most consistent with which diagnosis? Aortic stenosis.
- Under which hemodynamic condition is pulmonary capillary wedge pressure (PCWP) decreased? Distributive shock (septic or anaphylactic). Systemic vasodilation leads to reduced venous return and decreased left-sided filling pressures.
- Absent P waves with a narrow QRS and a regular ventricular rate of 150 bpm is most consistent with which arrhythmia? Atrial flutter with 2:1 AV block. Requires rate control or cardioversion. Refer for electrophysiology evaluation.
- Fibrinolytic therapy is absolutely contraindicated in which situations? Active internal bleeding or prior intracranial hemorrhage.
- What is the imaging modality of choice for suspected cardiac tamponade?
Bedside echocardiography (transthoracic or transesophageal).
- An elevated D-dimer with acute chest pain is most concerning for which diagnoses? Pulmonary embolism or aortic dissection. These patients will also have tachycardia, hypoxia, and risk factors for thrombosis.
- Chest pain that is reproducible on pressing the costochondral junction is most consistent with which diagnosis? Costochondritis.
- What is the diagnostic modality of choice for suspected pericarditis? Transthoracic echocardiogram to assess for pericardial effusion. The patient typically feels worse when lying down or during deep inspiration.
- When does early post-MI pericarditis occur, and how is it treated? Early post-MI pericarditis occurs within the first 24 - 72 hours after MI. The patient presents with pain that worsens with deep inspiration and improves when leaning forward. Tx: high-dose aspirin and colchicine. Avoid NSAIDs and anticoagulation if possible.
- A patient presents with the following findings:
- Jaundice
- Peripheral neuropathy
- Cardiomegaly
- Nephrotic syndrome (proteinuria) What is the diagnosis? Hemochromatosis ā deposition of iron in various organs including the heart, liver, and pancreas. Causes dilated or restrictive cardiomyopathy. Phlebotomy is the treatment of choice.
- Atrial flutter that is refractory to pharmacologic rate control should be treated with what? Catheter ablation targeting the cavotricuspid isthmus, which is where the reentrant circuit is located.
- A reentrant circuit around the mitral annulus results in which arrhythmia?
