Assessment and Diagnosis
22%of exam
Planning and Implementation
35%of exam
Evaluation and Modification
18%of exam
Patient and Community Education
25%of exam
Quick Facts
- Exam
- ANCC CV-BC
- Credential
- Cardiac-Vascular Nurse, Board Certified
- Questions
- 150 total; 125 scored
- Time
- 3 hours
- Pass
- 350 scaled of 500
- Pass rate
- 67% first-time (2025)
- Fee
- $395; $295 ANA member
- Valid
- 5 years
- Retest
- 60 days; 3 yearly
- Renewal
- 75 CE hours
- Blueprint
- Dec 5, 2024
Infarct Lead Groups
II, III, aVF = inferior = right coronary
V1-V2: septalV3-V4: anteriorI, aVL, V5-V6: lateralV7-V9: posterior
STEMI vs NSTEMI
STEMI
- Complete occlusion
- Persistent ST elevation
- Immediate reperfusion
NSTEMI
- Partial occlusion
- ST depression or inversion
- Troponin positive
Elevation means immediate reperfusion
Chest Pain Triage
- New chest discomfort→12-lead within 10 minutes(First action)
- ST elevation present→Activate STEMI team(Start clock)
- Depression, troponin positive→NSTEMI pathway(Risk stratify)
- Normal ECG and troponin→Serial troponin, monitor(0/1-hour protocol)
- Inferior ST elevation→Add right-sided leads(Check V4R)
- Tearing pain, unequal pulses→Suspect aortic dissection(No fibrinolytics)
- Took PDE5 inhibitor→Withhold nitroglycerin(24 to 48 hours)
Hemodynamic Normals
- Cardiac output
- 4-8 L/min
- Cardiac index
- 2.5-4.0 L/min/m2Under 2.2 hypoperfusion
- CVP
- 2-8 mm HgRight preload
- PAOP / PCWP
- 6-12 mm HgOver 18 congestion
- PA pressure
- 15-30/8-15 mm Hg
- MAP
- 70-105 mm HgShock target 65
- SVR
- 800-1200 dynes-s/cm5
- Stroke volume index
- 33-47 mL/beat/m2
Acute Limb Ischemia
Pain, Pallor, Pulseless, Paresthesia, Paralysis, Poikilothermia
Pulseless: surgical emergencyParalysis: late signTime is limb
Stable vs Unstable Angina
Stable
- Predictable exertion trigger
- Relieved by rest
- Normal troponin
Unstable
- New or rest pain
- Not relieved by rest
- Normal troponin, still ACS
Pattern change means ACS
Infarct Leads
- V1-V2
- Septal; LAD
- V3-V4
- Anterior; LAD
- I, aVL, V5-V6
- Lateral; circumflex
- II, III, aVF
- Inferior; right coronary
- V7-V9
- Posterior; circumflex or RCA
- V4R
- Right ventricle; proximal RCAPreload dependent
- aVR elevation
- Left main or multivessel
Right vs Left Heart Failure
Right sided
- JVD, hepatomegaly
- Ascites, dependent edema
- Hepatojugular reflux
Left sided
- Crackles, orthopnea
- Exertional dyspnea
- Paroxysmal nocturnal dyspnea
Systemic vs pulmonary congestion
STEMI ECG Criteria
- Most leads
- 1 mm, two contiguous
- V2-V3, men 40+
- 2 mm elevation
- V2-V3, men under 40
- 2.5 mm elevation
- V2-V3, women
- 1.5 mm elevation
- Measured at
- J point
- Reciprocal change
- Depression in opposite wall
- New LBBB
- Not automatic STEMI; apply Sgarbossa
S3 vs S4
S3
- Early diastole
- Volume overload
- Decompensated heart failure
S4
- Late diastole
- Stiff ventricle
- Absent in atrial fibrillation
Volume vs stiffness
Heart Sounds
- S3
- Early diastole; volume overload
- S4
- Stiff ventricle; absent in AF
- Aortic stenosis
- Systolic; radiates to carotids
- Aortic regurgitation
- Diastolic; wide pulse pressure
- Mitral regurgitation
- Holosystolic; radiates to axilla
- Mitral stenosis
- Diastolic rumble; opening snap
- Mitral valve prolapse
- Mid-systolic click
- Pericardial rub
- Scratchy; better leaning forward
- Pulsus paradoxus
- Tamponade; drop over 10
Cardiac Labs
- hs-troponin
- Injury; needs rise or fall0/1-hour protocol
- BNP
- Wall stress; rules out HF
- NT-proBNP
- Usable on sacubitril/valsartan
- D-dimer
- Sensitive, not specific
- INR
- Warfarin effect
- aPTT
- Unfractionated heparin monitoring
- Anti-Xa
- Heparin or LMWH level
- Potassium
- MRA and ACE inhibitor safety
- Creatinine clearance
- DOAC dosing
ABI Values
- Calculation
- Ankle divided by brachial
- 1.00-1.40
- Normal
- 0.91-0.99
- Borderline
- 0.90 or less
- Peripheral artery disease
- 0.40 or less
- Severe ischemia; rest pain
- Above 1.40
- Noncompressible; use toe pressure
HFrEF Four Pillars
ARNI + beta-blocker + MRA + SGLT2 inhibitor
ARNI: sacubitril/valsartanBeta-blocker: carvedilolMRA: spironolactoneSGLT2i: dapagliflozin
HFrEF vs HFpEF
HFrEF
- LVEF 40% or less
- Dilated, weak pump
- Four-pillar GDMT
HFpEF
- LVEF 50% or more
- Stiff, poor filling
- SGLT2i, diuretic, comorbidities
Weak pump vs stiff
STEMI Reperfusion Pathway
- At PCI-capable hospital→Primary PCI, 90 minutes
- Transfer under 120 minutes→Transfer for primary PCI
- PCI beyond 120 minutes→Fibrinolysis, 30 minutes
- Onset beyond 12 hours→PCI, not fibrinolysis
- Prior intracranial hemorrhage→Fibrinolysis contraindicated(Absolute)
- Cardiogenic shock→Immediate invasive strategy
- After reperfusion→DAPT, statin, beta-blocker
HFrEF Four Pillars
- ARNI
- Sacubitril/valsartan preferred
- Beta-blocker
- Carvedilol, metoprolol succinate, bisoprolol
- MRA
- Spironolactone or eplerenone
- SGLT2 inhibitor
- Dapagliflozin or empagliflozin
- Loop diuretic
- Congestion; no mortality benefit
- ARNI washout
- 36 hours off ACE inhibitor
- HFrEF
- LVEF 40% or less
- HFmrEF
- LVEF 41-49%
- HFpEF
- LVEF 50% or more
CHA2DS2-VASc Score
CHF, HTN, Age, Diabetes, Stroke, Vascular, Sex
Age 75 or older: 2Stroke or TIA: 2All others: 1 pointTreat 2 men, 3 women
Warfarin vs DOAC
Warfarin
- Routine INR monitoring
- Vitamin K interactions
- Vitamin K, 4F-PCC
DOAC
- No routine monitoring
- Renal and weight dosing
- Idarucizumab, andexanet alfa
Monitor INR vs renal dosing
Choosing HF GDMT
- LVEF 40% or less→Start four pillars
- Already on ACE inhibitor→Switch to ARNI(36-hour washout)
- ARNI not feasible→ACE inhibitor or ARB
- Potassium under 5.0→Add MRA(eGFR above 30)
- On other pillars→Add SGLT2 inhibitor(Diabetes not required)
- Volume overloaded→Add loop diuretic(Symptoms only)
- LVEF 35% after months→Refer for ICD(40 days post-MI)
- LBBB, QRS 150 ms→Add CRT
ACS Time Targets
- First ECG
- Within 10 minutes
- Primary PCI
- 90 minutes from contact
- Transfer for PCI
- 120 minutes from contact
- Fibrinolysis
- Door-to-needle 30 minutes
- Fibrinolysis window
- Within 12 hours onset
- Troponin protocol
- 0/1 or 0/2 hours
- Access preference
- Radial over femoral
- High-intensity statin
- Started during hospitalization
Cardioversion vs Defibrillation
Synchronized
- Pulse present
- AF, SVT, monomorphic VT
- Timed to R wave
Unsynchronized
- Pulseless patient
- VF, pulseless VT
- Polymorphic VT
Pulse means synchronize
AF Stroke Prevention
- New atrial fibrillation→Score CHA2DS2-VASc
- Score 2 men, 3 women→Anticoagulate(Risk 2% yearly)
- No mechanical valve→DOAC over warfarin
- Mechanical valve, rheumatic stenosis→Warfarin only
- AF beyond 48 hours→TEE or 3 weeks
- Unstable with rapid rate→Synchronized cardioversion
- Anticoagulation contraindicated→Consider appendage occlusion
Antithrombotics
- Aspirin
- Irreversible COX-1 blockade
- Clopidogrel
- P2Y12 prodrug; CYP2C19
- Ticagrelor
- Reversible P2Y12; dyspnea
- Prasugrel
- Avoid after stroke or TIA
- Unfractionated heparin
- aPTT titrated; reversible
- Enoxaparin
- Renally dosed LMWH
- Bivalirudin
- Direct thrombin inhibitor
- Argatroban
- Anticoagulant of choice, HIT
- DAPT duration
- At least 12 monthsTicagrelor alone after month
Radial vs Femoral Access
Radial
- Compression band
- Early ambulation
- Check hand perfusion
Femoral
- Supine bed rest
- Leg kept straight
- Watch retroperitoneal bleed
Radial bleeds less
Anticoagulation Targets
- AF or VTE
- INR 2.0-3.0
- Bioprosthetic valve
- INR 2.0-3.0
- Mechanical mitral valve
- INR 2.5-3.5
- Dabigatran reversal
- Idarucizumab
- Factor Xa reversal
- Andexanet alfa
- Warfarin reversal
- Vitamin K, 4F-PCC
- Heparin reversal
- Protamine sulfate
- DOAC monitoring
- Renal function, not INR
Procedures and Devices
- PCI
- Stent the culprit lesion
- CABG
- Bypass with graft conduits
- TAVR
- Transcatheter aortic valve replacement
- TEER
- Edge-to-edge mitral repair
- IABP
- Inflate diastole, deflate systole
- LVAD
- Continuous flow; Doppler MAP
- ECMO
- Temporary cardiopulmonary support
- ICD
- LVEF 35% or less40 days post-MI
- CRT
- LBBB with QRS 150 ms
- Severe aortic stenosis
- Mean gradient 40 mm Hg
- Severe mitral stenosis
- Valve area 1.5 cm2
Cath Access Care
- Radial access
- Band with patent hemostasis
- Radial checks
- Color, warmth, sensation, refill
- Femoral access
- Supine, leg straight, flat
- Hematoma
- Hold pressure; mark border
- Pseudoaneurysm
- Pulsatile mass; new bruit
- Retroperitoneal bleed
- Back or flank pain
- Contrast nephropathy
- Hydrate; trend creatinine
Tamponade Beck Triad
Hypotension + JVD + muffled heart sounds
Pulsus paradoxus over 10Narrow pulse pressurePericardiocentesis treats
Hypertensive Urgency vs Emergency
Urgency
- No target organ damage
- Oral agents
- Gradual outpatient lowering
Emergency
- Target organ damage
- IV titratable agent
- Lower 25% first hour
Organ damage decides
Hemodynamic Profiles
- Warm and dry→Compensated; continue GDMT
- Warm and wet→IV diuretic, vasodilator
- Cold and wet→Inotrope plus diuretic
- Cold and dry→Cautious fluid, then inotrope
- Index under 2.2, hypotensive→Cardiogenic shock pathway
- High CVP, clear lungs→Suspect right ventricular infarct
Drug Interactions
- Amiodarone + digoxin
- Halve the digoxin dose
- Amiodarone + warfarin
- INR climbs; reduce dose
- Nitrate + PDE5 inhibitor
- Profound refractory hypotension
- Sildenafil, vardenafil
- Hold nitrates 24 hours
- Tadalafil
- Hold nitrates 48 hours
- ACE inhibitor to ARNI
- 36-hour washout
- MRA + ACE inhibitor
- Hyperkalemia; recheck potassium
- Warfarin + vitamin K
- Consistency, not avoidance
- Statin + gemfibrozil
- Rhabdomyolysis risk
Adverse Events
- HIT
- Platelets fall 50%; thrombosisDay 5-10
- ACE inhibitor cough
- Switch to ARB
- ARNI angioedema
- Stop drug; secure airway
- Hyperkalemia
- Stop MRA above 5.5
- Digoxin toxicity
- Nausea, halos, arrhythmia
- Statin myopathy
- Muscle pain; check CK
- Amiodarone toxicity
- Thyroid, liver, lung, eye
- IV amiodarone
- In-line filter; central preferred
- Warfarin bleeding
- Hold; vitamin K
Emergency Thresholds
- Hypertensive emergency
- Lower 25% first hour
- Aortic dissection
- Systolic under 120 mm Hg
- Cardiogenic shock
- Systolic under 90; hypoperfusion
- Shock vasopressor
- Norepinephrine first line
- Stroke thrombolysis
- Within 4.5 hoursDoor-to-needle 60
- Thrombectomy window
- Up to 24 hours
- Post-arrest temperature
- 32-37.5 degrees CelsiusHold 36 hours
- Cardiac tamponade
- Beck triad; pulsus paradoxus
- High-risk PE
- Hypotension; consider thrombolysis
Smoking Cessation 5 A's
Ask, Advise, Assess, Assist, Arrange
Ask at every visitAssist: counseling plus drugArrange follow-up
ACC/AHA Stage vs NYHA Class
ACC/AHA stage
- Structural progression
- Stages A through D
- Never moves backward
NYHA class
- Functional symptoms
- Class I through IV
- Can improve or worsen
Structure vs symptoms
Education Barrier Picker
- Low health literacy→Teach-back, plain language
- Vision or dexterity limits→Pill organizer, large print
- Limited English proficiency→Qualified medical interpreter
- Cost barrier→Assistance program referral
- Recent MI or PCI→Refer cardiac rehabilitation
- Starting warfarin→Anticoagulation clinic referral
BP Categories
- Normal
- Under 120/80 mm Hg
- Elevated
- 120-129 systolic, under 80
- Stage 1
- 130-139 or 80-89
- Stage 2
- 140 or 90 higher
- Crisis
- Above 180/120 mm Hg
- Treatment goal
- Under 130/80 mm Hg
- Risk calculator
- PREVENT equations
Lifestyle Targets
- Aerobic activity
- 150 minutes weekly, moderate
- Vigorous activity
- 75 minutes weekly
- Strength training
- Two or more days
- Sodium limit
- Under 2,300 mg dailyOptimal 1,500 mg
- High-intensity statin
- Lowers LDL 50% or more
- Post-ACS LDL
- Add nonstatin at 70
- Smoking cessation
- Counseling plus pharmacotherapy
- Nonmodifiable risks
- Age, sex, race, family
Home Monitoring
- Daily weight
- Same scale, after voiding
- Report weight gain
- 2-3 pounds overnight, 5 weekly
- BP technique
- Rest 5 minutes, bare arm
- BP readings
- Two, one minute apart
- Nitroglycerin rule
- No relief 5 minutes, 911
- Symptom action plan
- Green, yellow, red zones
- Teach-back
- Patient explains in own words
Community Resources
- Cardiac rehab
- Up to 36 supervised sessions
- Rehab referral
- MI, PCI, CABG, valve
- HF rehab coverage
- LVEF 35% or less
- Anticoagulation clinic
- Dosing; time in range
- Home INR testing
- Fingerstick point-of-care meter
- Remote CIED check
- Lead, battery, fluid trends
- HF follow-up
- Visit within 7 days
Common Traps
Injury vs infarction
Troponin shows injury ≠ MI needs ischemic evidence
S3 vs S4
S3 is volume ≠ S4 is stiffness
Urgency vs emergency
Urgency spares organs ≠ Emergency damages organs
Sync vs defibrillate
Pulse means synchronize ≠ Pulseless means defibrillate
Rate vs rhythm control
Rate slows ventricles ≠ Rhythm restores sinus
Nitrates in RV infarct
RV is preload dependent ≠ Nitrates drop pressure abruptly
Vitamin K teaching
Consistency, not avoidance ≠ Report every diet change
BNP on ARNI
Sacubitril raises BNP ≠ NT-proBNP stays usable
Stage vs class
HF stage never reverses ≠ NYHA class can improve
Scored vs pretest
125 questions scored ≠ 25 pretest not scored
Last Minute
- 1.Planning 35% is largest domain
- 2.Education 25%; Assessment 22%
- 3.Evaluation and Modification is 18%
- 4.150 questions; only 125 scored
- 5.Pass = 350 scaled of 500
- 6.Primary PCI within 90 minutes
- 7.Fibrinolysis needle within 30 minutes
- 8.HFrEF pillars: ARNI, BB, MRA, SGLT2i
- 9.ACE to ARNI = 36-hour washout
- 10.Anticoagulate CHA2DS2-VASc 2 men, 3 women
- 11.INR 2-3; mechanical mitral 2.5-3.5
- 12.ABI 0.90 or less = PAD
- 13.BP treatment goal under 130/80
- 14.Report 2-3 pound overnight gain
- 15.Nitroglycerin: no relief 5 minutes, 911
- 16.Cardiac rehab: up to 36 sessions
- 17.Pulse = synchronize; pulseless = defibrillate
- 18.Hold nitrates after PDE5 inhibitors
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