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Cardiac Medicine Subspecialty Certification Practice Test

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Exam Code: AACN-CMC
Exam Name: Cardiac Medicine Subspecialty Certification
Number of Questions: 90
Exam Type: Multiple-choice
Exam questions: 75 scored and 15 unscored
Passing Marks: 50 (out of 75 scored questions)
Time Allotted: 2 hours

I. CARDIOVASCULAR CONDITIONS (23%)
- Cardiac Conditions
- Acute coronary syndrome (e.g.- STEMI- NSTEMI- unstable angina)
- Cardiac tamponade
- Cardiomyopathies
- Dysrhythmias
- Heart failure
- Hypertensive urgency or emergency
- Inflammatory and infectious conditions
- Pericardial effusion
- Pulmonary edema
- Syncope
- Valvular disorders
- Vascular Conditions
- Acute arterial occlusion
- Acute venous thrombosis
- Aortic aneurysm or dissection
- Hyperlipidemia
- Post-intervention vascular complication

II. NON-CARDIOVASCULAR CONDITIONS (23%)
- Respiratory
- Acute pulmonary embolus
- Acute respiratory failure (e.g.- ARDS- ALI)
- Pleural space abnormalities (e.g.- pneumothorax)
- Pulmonary hypertension
- Sleep apnea
- Endocrine
- Adrenal disorders
- Diabetes mellitus
- Metabolic syndrome
- Thyroid disorders
- Hematology
- Coagulopathies
- Anemia
- Neurology
- Cerebrovascular accidents (stroke)
- Renal
- Acute kidney injury
- Chronic kidney disease
- Electrolyte imbalances
- Multisystem
- Multisystem organ dysfunction syndrome (MODS)
- Shock states
- Non-cardiac chest pain
- Behavioral and Psychosocial
- Substance use and withdrawal

III. THERAPEUTIC INTERVENTIONS (39%)
- Cardiac Procedures
- Right heart catheterization
- Left heart catheterization
- Percutaneous coronary interventions
- Pericardiocentesis
- Intra-aortic balloon pumps
- Left ventricular assist devices (LVADs)
- Percutaneous structural heart interventions
- Vascular Interventions
- Peripheral angiography and interventions
- Carotid angiography and interventions
- Endovascular grafts
- Catheter-directed thrombolysis
- Cardiovascular Pharmacology
- Antidysrhythmics
- Anticoagulants
- Diuretics
- Inotropes
- Platelet inhibitors
- Thrombolytics
- Vasoactive agents
- Electrophysiologic Interventions
- Temporary pacemakers
- Permanent pacemakers
- Cardiac resynchronization therapy
- Implantable cardioverter defibrillator
- External wearable defibrillator
- Ablation
- Cardioversion
- Defibrillation
- Respiratory
- Non-invasive ventilation
- Mechanical ventilation
- Renal
- Renal replacement therapy (e.g.- hemodialysis- CRRT- SCUF)
- Multisystem
- Targeted temperature management
- Palliative and end-of-life care

IV. MONITORING AND DIAGNOSTICS (16%)
- Cardiovascular
- Hemodynamic monitoring
- Echocardiography
- Electrocardiography (ECG)
- Laboratory testing
- Stress testing
- Remote cardiovascular monitoring (e.g.- dysrhythmia monitoring- pulmonary artery sensor)
- Respiratory
- Arterial blood gases (ABG)
- Mixed venous gases
- Pulse oximetry
- End-tidal capnography (EtCO2)
- Radiography

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Question: 640
A 62-year-old female with tricuspid regurgitation presents with ascites and peripheral edema.
Echocardiogram shows a regurgitant volume of 50 mL and right atrial enlargement. What is the most
appropriate management?
A. Watchful waiting
B. Surgical valve repair
C. Transcatheter valve replacement
D. Diuretic therapy
Answer: D
Explanation: Symptomatic tricuspid regurgitation with right heart failure (ascites, edema) is initially
managed with diuretics to reduce volume overload. Surgical or transcatheter repair is considered for
severe, refractory cases. Watchful waiting is inappropriate for symptomatic patients.
Question: 641
A 52-year-old male with a history of cocaine use presents with chest pain and ST elevation in leads V1-
V3. His BP is 160/90 mm Hg, and troponin is 4.5 ng/mL. Coronary angiography shows no obstructive
lesions. The MOST LIKELY diagnosis is:
A. Myocarditis
B. Coronary artery spasm
C. Pericarditis
D. Takotsubo cardiomyopathy
Answer: B
Explanation: Cocaine-induced chest pain with ST elevation and non-obstructive coronaries suggests
coronary artery spasm (Prinzmetal angina). Myocarditis may cause troponin elevation but not focal ST
elevation. Pericarditis typically shows diffuse ST elevation. Takotsubo cardiomyopathy presents with
apical ballooning, not seen here. Calcium channel blockers are the treatment of choice.
Question: 642
A 59-year-old female undergoes a stress echocardiogram with no wall motion abnormalities at rest or
stress. Her blood pressure rises from 120/80 to 200/100 mmHg at peak stress. What is the most likely
diagnosis?
A. Coronary artery disease
B. Normal stress response
C. Left ventricular hypertrophy
D. Hypertensive response to exercise
Answer: D
Explanation: An exaggerated blood pressure rise to 200/100 mmHg without wall motion abnormalities
suggests a Hypertensive response to exercise, common in patients with underlying hypertension.
Coronary artery disease would show wall motion abnormalities. Left ventricular hypertrophy requires
echocardiographic confirmation. Normal stress response has a BP rise <190/90 mmHg.
Question: 643
A 55-year-old female with a history of rheumatic heart disease presents with atrial fibrillation and a
mitral valve area of 1.2 cm� on echocardiogram. Her BP is 110/70 mmHg, and HR is 140 bpm. What is
the most appropriate intervention?
A. Perform electrical cardioversion
B. Start heparin and warfarin
C. Administer metoprolol 5 mg IV
D. Initiate amiodarone 150 mg IV
Answer: C
Explanation: Mitral stenosis with atrial fibrillation and rapid ventricular rate requires rate control to
improve diastolic filling. Metoprolol IV is appropriate for acute rate control. Anticoagulation is needed
long-term but not immediately, cardioversion is risky without prior anticoagulation, and amiodarone is
for rhythm control.
Question: 644
A 58-year-old male with acute limb ischemia undergoes CDT for a popliteal artery occlusion. Post-
procedure, angiography shows incomplete thrombolysis with residual thrombus. What is the most
appropriate next step?
A. Continue CDT for an additional 24 hours
B. Perform mechanical thrombectomy
C. Start systemic anticoagulation alone
D. Switch to surgical embolectomy
Answer: B
Explanation: Incomplete thrombolysis with residual thrombus after CDT warrants mechanical
thrombectomy to rapidly restore vessel patency and prevent limb loss. Continuing CDT for an additional
24 hours increases bleeding risk without guaranteed success. Systemic anticoagulation alone is
insufficient for significant residual thrombus. Surgical embolectomy is more invasive and typically
reserved for CDT failure in specific scenarios.
Question: 645
A 70-year-old male presents with chest pressure and shortness of breath for 2 hours. ECG shows no ST-
elevation, but troponin I is 1.2 ng/mL. He is started on aspirin 325 mg and ticagrelor 180 mg. His
GRACE score is 140, indicating high risk. What is the NEXT best step in management?
A. Arrange for coronary angiography within 24 hours
B. Administer IV morphine 4 mg for pain relief
C. Perform a nuclear stress test
D. Start IV nitroglycerin infusion
Answer: A
Explanation: The patient has NSTEMI (elevated troponin, no ST-elevation) and a high-risk GRACE
score (>130), indicating a high likelihood of adverse cardiac events. AHA/ACC guidelines recommend
early invasive strategy (coronary angiography within 24-72 hours) for high-risk NSTEMI patients.
Morphine is used for pain but is not the next priority. A nuclear stress test is inappropriate in acute
NSTEMI. Nitroglycerin infusion is indicated for ongoing ischemia but not the next step over
angiography.
Question: 646
A 71-year-old female with heart failure is on lisinopril and develops a persistent dry cough. What is the
most likely cause, and what should the nurse anticipate?
A. Allergic reaction; administer antihistamine
B. Angioedema; discontinue lisinopril
C. Worsening heart failure; increase lisinopril
D. Bradykinin accumulation; switch to ARB
Answer: D
Explanation: Lisinopril, an ACE inhibitor, can cause a dry cough due to bradykinin accumulation. The
nurse should anticipate switching to an ARB (e.g., losartan), which has a lower incidence of cough. An
allergic reaction is less likely without systemic symptoms. Angioedema is a severe side effect but
typically involves swelling, not cough. Worsening heart failure is unrelated to cough.
Question: 647
A 63-year-old male with acute arterial occlusion undergoes thrombolysis. Post-procedure, his CK rises to
4,000 U/L, and serum myoglobin is 500 ng/mL. Urine dipstick is positive for blood, but microscopy
shows no RBCs. What is the most appropriate treatment?
A. Administer furosemide 40 mg IV
B. Transfuse packed RBCs
C. Start dialysis immediately
D. Initiate IV hydration with sodium bicarbonate
Answer: D
Explanation: Elevated CK, myoglobin, and urine dipstick positive for blood without RBCs indicate
rhabdomyolysis, likely from reperfusion injury. Initiate IV hydration with sodium bicarbonate alkalinizes
urine to prevent myoglobin-induced renal damage. Administer furosemide 40 mg IV is not indicated as it
may worsen dehydration. Start dialysis immediately is premature without evidence of severe renal
failure. Transfuse packed RBCs is irrelevant to rhabdomyolysis management.
Question: 648
A 55-year-old female with pulmonary edema is on BiPAP with IPAP 14 cmH2O and EPAP 6 cmH2O.
Her SpO2 is 88%, and ABG shows pH 7.30, PaCO2 50 mmHg, PaO2 60 mmHg. What is the most
appropriate adjustment?
A. Increase EPAP to 8 cmH2O
B. Start furosemide 40 mg IV
C. Intubate and initiate mechanical ventilation
D. Increase IPAP to 18 cmH2O
Answer: D
Explanation: Hypoxemia and hypercapnia on BiPAP suggest inadequate ventilation and oxygenation.
Increasing IPAP improves tidal volume and CO2 clearance. Increasing EPAP may help oxygenation but
not hypercapnia. Intubation is premature without optimizing BiPAP. Furosemide addresses volume but
not immediate ventilatory needs.
Question: 649
A 57-year-old female presents with BP 210/125 mmHg and seizures. Labs show creatinine 2.5 mg/dL
and lactate 3.5 mmol/L (normal <2). What is the most appropriate initial treatment?
A. IV lorazepam
B. IV labetalol
C. IV nicardipine
D. Oral clonidine
Answer: A
Explanation: The patient has a hypertensive emergency with seizures, indicating hypertensive
encephalopathy. IV lorazepam is the priority to control seizures and prevent further neurologic damage.
IV nicardipine or labetalol can follow for BP control, but seizure management is urgent. Oral clonidine is
inappropriate for acute management.
Question: 650
A 50-year-old patient with hypertrophic cardiomyopathy presents with syncope and chest pain. ECG
shows left ventricular hypertrophy and Q waves in inferior leads. BP is 100/60 mm Hg, HR 90 bpm, CO
3.5 L/min. The patient is started on metoprolol. What is the MOST appropriate additional therapy?
A. Initiate IV nitroprusside
B. Start amiodarone infusion
C. Administer IV fluids 1 L bolus
D. Begin verapamil therapy
Answer: D
Explanation: In hypertrophic cardiomyopathy, syncope and chest pain result from left ventricular outflow
tract obstruction. Metoprolol reduces heart rate and contractility, but verapamil (a non-dihydropyridine
calcium channel blocker) is often added to further reduce obstruction and Strengthen diastolic filling.
Nitroprusside worsens obstruction by reducing afterload. Amiodarone is used for arrhythmias, not
obstruction. IV fluids are not indicated without hypovolemia.
Question: 651
A 59-year-old male with an LVAD presents with a pump flow of 2.8 L/min, power of 7.2 W, and PI of
1.5. Labs show INR 2.2, LDH 1400 U/L, and hemoglobin 6.5 g/dL. What is the most appropriate next
step?
A. Administer IV fluids
B. Perform urgent pump exchange
C. Initiate heparin therapy
D. Transfuse packed red blood cells
Answer: C
Explanation: Low flow (2.8 L/min), high power (7.2 W), low PI (1.5), and elevated LDH (1400 U/L)
indicate pump thrombosis, causing hemolysis and anemia. Heparin therapy is the most appropriate initial
step to address thrombosis while maintaining anticoagulation (INR 2.2 is borderline). Fluids or
transfusion may be supportive but do not address the underlying issue. Pump exchange is considered if
medical therapy fails.
Question: 652
A 75-year-old patient with chronic kidney disease (GFR 25 mL/min) and heart failure presents with
pulmonary edema. Hemodynamics: BP 140/90 mm Hg, HR 100 bpm, CI 2.2 L/min/m�, PAOP 30 mm
Hg. Serum potassium is 5.8 mEq/L. What is the MOST appropriate initial therapy?
A. Administer IV furosemide 80 mg
B. Perform urgent hemodialysis
C. Initiate dobutamine infusion
D. Start nitroprusside infusion
Answer: B
Explanation: The patient has pulmonary edema (PAOP 30 mm Hg) and hyperkalemia (potassium 5.8
mEq/L) with severe CKD (GFR 25 mL/min). Urgent hemodialysis is the most appropriate to address
fluid overload and hyperkalemia, as diuretics (furosemide, A) are less effective in advanced CKD.
Nitroprusside risks hypotension, and dobutamine doesn�t address volume or potassium.
Question: 653
A 65-year-old male undergoes ablation for atrial fibrillation. Post-procedure, he develops neurological
deficits. CT scan confirms an embolic stroke. What is the most likely procedural complication?
A. Air embolism during ablation
B. Left atrial thrombus dislodgement
C. Pericardial effusion
D. Pulmonary vein stenosis
Answer: B
Explanation: Neurological deficits and embolic stroke post-atrial fibrillation ablation are most likely due
to Left atrial thrombus dislodgement, a known complication of left-sided ablation procedures. Air
embolism during ablation could cause stroke but is less common with proper technique. Pericardial
effusion presents with hemodynamic instability, not neurological deficits. Pulmonary vein stenosis causes
pulmonary symptoms, not stroke.
Question: 654
A 65-year-old patient with a history of MI presents with chest pain and ECG showing new Q waves in
leads V1-V3. Hemodynamics: BP 90/60 mm Hg, HR 100 bpm, CI 1.8 L/min/m�, PAOP 25 mm Hg.
Echocardiogram shows anterior wall akinesis. What is the MOST LIKELY complication?
A. Ventricular septal defect
B. Papillary muscle rupture
C. Cardiac tamponade
D. Ventricular aneurysm
Answer: D
Explanation: New Q waves in V1-V3, anterior wall akinesis, and heart failure (PAOP 25 mm Hg, CI 1.8
L/min/m�) post-MI suggest a ventricular aneurysm, a late complication causing wall motion abnormalities
and reduced cardiac output. Papillary muscle rupture presents with acute mitral regurgitation and a
murmur. Tamponade shows pericardial effusion. VSD elevates PAP and PAOP equally.
Question: 655
A 68-year-old male presents to the cardiac ICU post-myocardial infarction (MI) with a 12-lead ECG
showing ST-elevation in leads V1-V4 and a left ventricular ejection fraction (LVEF) of 30%. He
develops hypotension (BP 85/50 mmHg) and tachycardia (HR 120 bpm). A pulmonary artery catheter
reveals a cardiac index (CI) of 1.8 L/min/m� and a pulmonary capillary wedge pressure (PCWP) of 22
mmHg. Which intervention is most appropriate?
A. Start intra-aortic balloon pump (IABP) counterpulsation at 1:1 ratio
B. Initiate norepinephrine 0.01 mcg/kg/min to maintain MAP > 65 mmHg
C. Administer dobutamine 5 mcg/kg/min and titrate to a CI > 2.2 L/min/m�
D. Bolus 500 mL normal saline over 15 minutes to increase preload
Answer: C
Explanation: The patient is in cardiogenic shock post-MI, as indicated by hypotension, tachycardia, low
CI (<2.2 L/min/m�), and elevated PCWP (>18 mmHg), suggesting left ventricular dysfunction.
Dobutamine, an inotrope, improves cardiac contractility and output, targeting a CI > 2.2 L/min/m�.
Norepinephrine is less effective for cardiogenic shock as it primarily increases afterload. IABP may be
considered but is not first-line without further deterioration. Fluid bolus is contraindicated due to
elevated PCWP, indicating adequate or excessive preload.
Question: 656
A 62-year-old patient with acute decompensated heart failure (ADHF) presents with severe dyspnea and
hypoxemia. An arterial blood gas (ABG) is drawn while the patient is on 4 L/min nasal cannula oxygen.
The results show pH 7.32, PaCO2 48 mmHg, PaO2 65 mmHg, HCO3- 24 mEq/L. What is the most
appropriate interpretation of this ABG?
A. Compensated metabolic acidosis
B. Uncompensated respiratory acidosis
C. Uncompensated metabolic acidosis
D. Compensated respiratory acidosis
Answer: B
Explanation: The ABG results indicate a pH of 7.32 (below normal range of 7.35�7.45), suggesting
acidosis. The PaCO2 is 48 mmHg (elevated, normal 35�45 mmHg), indicating a respiratory cause of
acidosis due to hypoventilation, likely from pulmonary edema in ADHF. The HCO3- is 24 mEq/L
(normal 22�26 mEq/L), showing no significant compensation. Thus, this is uncompensated respiratory
acidosis. Compensated respiratory acidosis would show an elevated HCO3- to normalize pH, while
metabolic acidosis would involve a low HCO3-. Uncompensated metabolic acidosis is ruled out due to
normal HCO3- and elevated PaCO2.
Question: 657
A 67-year-old male with a history of CABG develops fever and hypotension (BP 80/50 mm Hg) 96
hours post-op. His WBC is 20,000/�L, lactate 4.2 mmol/L, CVP 8 mm Hg, CO 7.0 L/min. The MOST
appropriate next action is:
A. Start norepinephrine 0.1 mcg/kg/min
B. Administer a 1 L fluid bolus
C. Initiate broad-spectrum antibiotics
D. Order a TEE for endocarditis
Answer: C
Explanation: Fever, hypotension, and high CO with elevated lactate suggest septic shock, likely from a
postoperative infection. Broad-spectrum antibiotics are the priority to address the source, per Surviving
Sepsis guidelines. Norepinephrine and fluids are supportive, but antibiotics are critical. TEE is premature
without specific endocarditis signs.
Question: 658
A 45-year-old female presents with cardiac tamponade and undergoes pericardiocentesis. During the
procedure, 500 mL of serous fluid is removed, and the intrapericardial pressure drops from 20 mmHg to
5 mmHg. Post-procedure, the patient�s blood pressure is 90/60 mmHg, and echocardiography shows a
small residual effusion. What is the most critical next step?
A. Perform repeat pericardiocentesis
B. Initiate dobutamine for inotropic support
C. Administer IV fluids to increase preload
D. Start heparin to prevent clot formation
Answer: C
Explanation: Post-pericardiocentesis, the patient�s hypotension (90/60 mmHg) suggests inadequate
preload due to rapid fluid removal or underlying cardiac dysfunction. Administering IV fluids to increase
preload is the most critical step to stabilize hemodynamics. Dobutamine may be considered if
contractility is impaired, but there�s no evidence of this yet. Repeat pericardiocentesis is unnecessary
with only a small residual effusion and normalized intrapericardial pressure. Heparin is contraindicated in
the acute setting due to bleeding risk.
Question: 659
A 72-year-old female with a history of pulmonary hypertension is admitted with right heart failure. Her
pulmonary artery pressure is 60/30 mmHg, and right atrial pressure is 15 mmHg. Which medication is
most appropriate?
A. Furosemide 40 mg IV
B. Sildenafil 20 mg orally three times daily
C. Dobutamine 5 mcg/kg/min
D. Nitroglycerin 10 mcg/min IV
Answer: B
Explanation: Sildenafil, a phosphodiesterase-5 inhibitor, reduces pulmonary vascular resistance in
pulmonary hypertension, improving right heart function. Furosemide addresses fluid overload but not
pulmonary hypertension, dobutamine is for cardiogenic shock, and nitroglycerin may worsen
hypotension.
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