1.2 The CMC Test Plan: Four Domains and How to Study Them

How the Test Plan Is Built

The CMC test plan is derived from AACN's study of practice, a job analysis repeated at least every five years that validates the knowledge, skills and experience required for safe and effective practice in the direct care of acutely and critically ill adult cardiac patients. An expert CMC panel converts those findings into four content domains subdivided into 77 named sub-topics. The current plan applies to exams taken on or after June 1, 2022.

The handbook carries two disclaimers that should be read literally. "The sum of these percentages is not 100 due to rounding" explains the 101% in the table above; do not treat it as an error or try to reconcile it. "Order of content does not necessarily reflect importance" means Domain I is listed first because it is the natural organizing category, not because it is the most heavily sampled. It is not.

The Two Facts Candidates Miss

Fact 1: Therapeutic Interventions is the largest domain by a wide margin. At 39% it outweighs Cardiovascular Conditions (23%) and Monitoring and Diagnostics (16%) combined. Most candidates arrive from a CCRN mindset in which disease states dominate, and they over-invest in pathophysiology. CMC asks disproportionately about what is done to the cardiac patient and about the surveillance that follows: the right and left heart catheterization, the percutaneous coronary intervention, the intra-aortic balloon pump, the ventricular assist device, the ablation, the vasoactive infusion, the ventilator, the continuous renal replacement circuit, the end-of-life conversation.

Fact 2: Nearly a quarter of the exam is not cardiology. Domain II carries the same 23% weight as Cardiovascular Conditions and spans 19 sub-topics from acute respiratory distress syndrome to thyroid disease to alcohol withdrawal. A study plan assembled from a cardiology review book leaves roughly 17 scored items unaddressed, which is a larger deficit than most candidates can absorb.

The arithmetic behind both facts is unforgiving. Seventy-five scored items are spread across 77 named sub-topics, so on average each sub-topic is worth about one item. Encyclopedic mastery of atrial fibrillation cannot recover the point you lose on end-tidal capnography or on the wearable cardioverter-defibrillator. On CMC, breadth beats depth.

Domain I: Cardiovascular Conditions (23%, about 17 items)

A. Cardiac Conditions (11 sub-topics)

1. Acute coronary syndrome (STEMI, NSTEMI, unstable angina)
2. Cardiac tamponade
3. Cardiomyopathies
4. Dysrhythmias
5. Heart failure
6. Hypertensive urgency or emergency
7. Inflammatory and infectious conditions (pericarditis, myocarditis, endocarditis)
8. Pericardial effusion
9. Pulmonary edema
10. Syncope
11. Valvular disorders

B. Vascular Conditions (5 sub-topics)

1. Acute arterial occlusion
2. Acute venous thrombosis
3. Aortic aneurysm or dissection
4. Hyperlipidemia
5. Post-intervention vascular complication

Three of these deserve more attention than they usually get. Hyperlipidemia looks out of place on a critical-care blueprint, but it is a named line item: expect statin intensity, non-statin add-ons and post-ACS lipid management. Post-intervention vascular complication covers retroperitoneal hematoma, pseudoaneurysm, arteriovenous fistula, access-site bleeding and limb ischemia after femoral or radial access, and it is high-yield precisely because it is pure bedside nursing surveillance. Dysrhythmias is a single line in the plan but functionally three teaching units (atrial, ventricular, and bradycardia with atrioventricular block); weight it as three.

Domain II: Non-Cardiovascular Conditions (23%, about 17 items)

• A. Respiratory (5): acute pulmonary embolus; acute respiratory failure (ARDS, acute lung injury); pleural space abnormalities such as pneumothorax; pulmonary hypertension; sleep apnea.
• B. Endocrine (4): adrenal disorders; diabetes mellitus; metabolic syndrome; thyroid disorders.
• C. Hematology (2): coagulopathies; anemia.
• D. Neurology (1): cerebrovascular accident (stroke).
• E. Renal (3): acute kidney injury; chronic kidney disease; electrolyte imbalances.
• F. Multisystem (3): multisystem organ dysfunction syndrome (MODS); shock states; non-cardiac chest pain.
• G. Behavioral and Psychosocial (1): substance use and withdrawal.

Every one of these is examined in the cardiac patient, and reframing them that way converts Domain II from an unmanageable second exam into a manageable set of intersections. Thyroid disorders means amiodarone-induced thyrotoxicosis and hypothyroidism, thyroid storm with rate control, and myxedema with low cardiac output, not a general endocrinology review. Coagulopathies means heparin-induced thrombocytopenia after cardiac surgery or PCI, warfarin and direct oral anticoagulant reversal, and bleeding on dual antiplatelet therapy. Anemia means transfusion thresholds in acute coronary syndrome and the relationship between hemoglobin and oxygen delivery when cardiac output is fixed. Sleep apnea means obstructive sleep apnea as a driver of atrial fibrillation, resistant hypertension and heart failure readmission. Stroke means cardioembolic stroke in atrial fibrillation, periprocedural stroke after transcatheter aortic valve replacement or carotid intervention, and blood pressure management after thrombolysis. Substance use means cocaine and methamphetamine chest pain, which the handbook's own sample question tests through cocaine-induced coronary vasospasm, and alcohol withdrawal on a telemetry unit.

Domain III: Therapeutic Interventions (39%, about 29 items)

• A. Cardiac Procedures (7): right heart catheterization; left heart catheterization; percutaneous coronary interventions; pericardiocentesis; intra-aortic balloon pumps; left ventricular assist devices; percutaneous structural heart interventions.
• B. Vascular Interventions (4): peripheral angiography and interventions; carotid angiography and interventions; endovascular grafts; catheter-directed thrombolysis.
• C. Cardiovascular Pharmacology (7): antidysrhythmics; anticoagulants; diuretics; inotropes; platelet inhibitors; thrombolytics; vasoactive agents.
• D. Electrophysiologic Interventions (8): temporary pacemakers; permanent pacemakers; cardiac resynchronization therapy; implantable cardioverter defibrillator; external wearable defibrillator; ablation; cardioversion; defibrillation.
• E. Respiratory (2): non-invasive ventilation; mechanical ventilation.
• F. Renal (1): renal replacement therapy (hemodialysis, CRRT, SCUF).
• G. Multisystem (2): targeted temperature management; palliative and end-of-life care.

Read that list for what it implies about your study plan. Electrophysiologic interventions alone carry 8 of the 31 sub-topics, more than cardiovascular pharmacology does. External wearable cardioverter-defibrillators, post-ablation care and temporary transvenous or epicardial pacing are named blueprint items rather than footnotes, yet they are absent from most self-built plans. Equally, non-invasive and invasive ventilation, renal replacement therapy, targeted temperature management, and palliative and end-of-life care are explicitly on a "cardiac" exam, because that is the actual work of a cardiac intensive care unit. If your review book has no chapter on withdrawal of life-sustaining therapy or on continuous renal replacement, it is not a CMC review book.

Domain IV: Monitoring and Diagnostics (16%, about 12 items)

• A. Cardiovascular (6): hemodynamic monitoring; echocardiography; electrocardiography; laboratory testing; stress testing; remote cardiovascular monitoring, including ambulatory dysrhythmia monitoring and implantable pulmonary artery pressure sensors.
• B. Respiratory (5): arterial blood gases; mixed venous gases; pulse oximetry; end-tidal capnography (EtCO2); radiography.

Domain IV is the smallest domain but the most concentrated: about 12 items across 11 named topics means nearly every topic appears. Know normal and abnormal pulmonary artery catheter values and waveform morphology, arterial line dynamic response and square-wave testing, mixed venous versus central venous oxygen saturation interpretation (SvO2 60-80%, ScvO2 roughly 5 points higher), capnography waveform patterns during cardiac arrest and after intubation, and what a portable chest radiograph shows about line, tube and device position.

Two Handbook Details That Change How You Study

Generic drug names only. AACN Certification Corporation is transitioning to the use of generic names only for medications in exams and practice exam products, and states that during the transition candidates may continue to see items that include both generic and trade names. Study by generic name (furosemide, eptifibatide, milrinone, nicardipine) and be able to recognize the trade names you will still occasionally meet in a stem.

The CMC Exam Bibliography. AACN publishes, inside the handbook itself, the list of references used for item validation, including Cardiovascular Nursing Practice by Jacobson, Marzlin and Webner, Bojar's Manual of Perioperative Care in Adult Cardiac Surgery, Lough's Hemodynamic Monitoring, Pagana's Mosby's Diagnostic and Laboratory Test Reference, and the American Heart Association emergency cardiovascular care guidelines. Two implications follow: the bibliography is the best-value reading list available for this exam, and where a very recent trial conflicts with mainstream nursing-textbook practice, the exam key reflects the guideline-level standard rather than the newest headline.

Building the Plan

Allocate study time to the published weights rather than to your comfort zone. A defensible 60-hour plan spends 23 hours on procedures, devices, infusions, ventilation, renal replacement and end-of-life care; 14 hours on cardiac and vascular conditions; 14 hours on the non-cardiovascular intersections; and 10 hours on monitoring and diagnostics. Then run a sub-topic audit: read all 77 lines of the test plan and mark every one you could not teach for two minutes. Those marks, not your practice-test percentage, are your real study list.