PANCE, Medical exams, 11%

Cardiovascular System

The cardiovascular system is the single highest-weighted PANCE content area, covering disease of the heart, conduction system, and vasculature. Questions range from recognizing acute coronary syndromes and interpreting classic murmur findings to managing chronic conditions such as heart failure, hypertension, and lipid disorders.

Position: 1 of 15 content areas
Published weighting: 11% in the official framework
Topics covered: 8 topics in this guide

What is covered

Topics inside this content area.

These topics describe the scope students most often review for this part of PANCE. Treat them as a study checklist rather than an exhaustive list of what a single exam form can sample.

Coronary artery disease and acute coronary syndromes: Stable angina through STEMI: risk factors, ECG patterns, biomarkers, and initial management priorities.
Heart failure and cardiomyopathies: Reduced versus preserved ejection fraction, dilated, hypertrophic, and restrictive patterns, and staged therapy.
Conduction disorders and dysrhythmias: Atrial fibrillation, blocks, supraventricular and ventricular rhythms, and rate versus rhythm decisions.
Valvular disease: Classic murmur descriptions, maneuvers, and the natural history of stenotic and regurgitant lesions.
Hypertension and lipid disorders: Diagnosis thresholds, first-line agents, compelling indications, and secondary-cause red flags.
Vascular disease: Aortic aneurysm and dissection, peripheral arterial disease, venous thromboembolism, and vasculitis patterns.
Congenital heart disease: High-yield shunt and obstruction lesions with their characteristic exam and diagnostic findings.
Hypotension and shock: Distinguishing cardiogenic, hypovolemic, distributive, and obstructive physiology from vitals and history.

Study tips

How to practice Cardiovascular.

Section-specific guidance that follows from how this material is usually tested.

Drill murmur-to-lesion pairings with flashcards until recognition is automatic; they are classic single-step questions.
Practice reading rhythm strips daily in short sessions rather than in one long block.
Anchor heart-failure pharmacology to physiology so guideline updates stay easy to absorb.
Give this system the largest share of weekly review time; the blueprint weights it highest.

Where this fits

Cardiovascular System is 1 of 15 content areas in the PANCE guide, and it carries a published weighting of 11% in the official framework. Use the full guide to balance it against everything else you have to review.

Back to the PANCE guide Official exam information

Sample Cardiovascular questions

Practice questions, not yet expert-reviewed

Original practice questions written to the published framework for this section. No expert has reviewed them, and they are not taken from any official exam. Try each one before you open the answer.

Question 1Foundational
A 72-year-old man reports exertional syncope and dyspnea. Cardiac examination reveals a harsh crescendo-decrescendo systolic murmur heard best at the right upper sternal border that radiates to both carotid arteries. Which valvular lesion does this describe?
1. AAortic stenosis
2. BMitral regurgitation
3. CAortic regurgitation
4. DMitral stenosis
Show answer
Answer: A. Aortic stenosis
A harsh systolic ejection murmur at the right second intercostal space with carotid radiation, plus exertional syncope, angina, or dyspnea, is the classic description of aortic stenosis. Mitral regurgitation is also systolic but is holosystolic, loudest at the apex, and radiates to the axilla rather than the carotids.
Key insight: Systolic murmur radiating to the carotids with exertional syncope means aortic stenosis until proven otherwise.
Question 2Foundational
Which serum biomarker is the most sensitive and specific indicator of myocardial injury in a patient with suspected acute coronary syndrome?
1. AMyoglobin
2. BCreatine kinase-MB
3. CCardiac troponin
4. DB-type natriuretic peptide
Show answer
Answer: C. Cardiac troponin
Cardiac troponin I and T are structural proteins released almost exclusively by injured myocardium, which makes them the preferred biomarker for diagnosing myocardial infarction. Creatine kinase-MB rises and falls faster but is far less specific because skeletal muscle also contains it, and B-type natriuretic peptide reflects ventricular wall stress rather than myocyte necrosis.
Key insight: Troponin is the reference biomarker for myocardial necrosis; the others trade specificity for speed or measure a different process entirely.
Question 3Intermediate
Which validated scoring tool estimates annual stroke risk in nonvalvular atrial fibrillation and is used to decide whether to start oral anticoagulation?
1. AWells score
2. BCHA2DS2-VASc score
3. CHAS-BLED score
4. DTIMI risk score
Show answer
Answer: B. CHA2DS2-VASc score
The CHA2DS2-VASc score assigns points for congestive heart failure, hypertension, age, diabetes, prior stroke or thromboembolism, vascular disease, and sex, and the total estimates annual thromboembolic stroke risk. The HAS-BLED score is the tempting distractor because it is also used in atrial fibrillation, but it estimates major bleeding risk on therapy rather than stroke risk.
Key insight: CHA2DS2-VASc answers whether to anticoagulate; HAS-BLED only flags modifiable bleeding risk once you do.
Question 4Intermediate
A 65-year-old with long-standing hypertension develops abrupt severe tearing chest pain radiating to the back, and the systolic blood pressure differs by 25 mm Hg between the two arms. What is the most likely diagnosis?
1. AAcute pericarditis
2. BPulmonary embolism
3. CAortic dissection
4. DST-elevation myocardial infarction
Show answer
Answer: C. Aortic dissection
Abrupt tearing or ripping pain that radiates to the back, combined with a blood pressure differential between the arms, is the classic presentation of acute aortic dissection extending into a branch vessel. Myocardial infarction is the tempting alternative, but its pain builds rather than peaking instantly and it does not produce an interarm pressure difference.
Key insight: Maximal-at-onset tearing pain plus unequal arm pressures points to the aorta, not the coronary arteries.
Question 5Advanced
Which bedside maneuver decreases left ventricular preload and therefore makes the outflow murmur of hypertrophic obstructive cardiomyopathy louder?
1. APassive leg raise
2. BSustained handgrip
3. CSquatting from standing
4. DValsalva strain phase
Show answer
Answer: D. Valsalva strain phase
Straining against a closed glottis raises intrathoracic pressure, reduces venous return, and shrinks the left ventricular cavity, which worsens dynamic outflow obstruction and intensifies the murmur. Passive leg raise and squatting both increase preload, and sustained handgrip increases afterload, so all three make this murmur softer.
Key insight: Less blood in the ventricle means more obstruction: hypertrophic cardiomyopathy is the murmur that gets louder with Valsalva.

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Cardiovascular System