Study guide
Cardiovascular and pulmonary complaints send patients to urgent care, emergency departments, and primary care offices every day, and the PANCE blueprint weights these two organ systems heavily. This chapter walks through the reasoning a physician assistant uses at the bedside: what to ask, what to look for, what tests to order, and how to treat the most commonly tested conditions. Educational content only, not medical advice.
Acute Coronary Syndromes and the Chest Pain Workup
Consider a 58-year-old man named Harold who arrives with crushing substernal chest pressure radiating to his left arm, diaphoresis, and nausea that began 45 minutes ago while shoveling gravel. The history and physical task area asks the examinee to recognize classic anginal equivalents: pressure rather than sharp pain, exertional onset, associated diaphoresis, and risk factors such as smoking, diabetes, hypertension, and family history of early coronary disease. The diagnostics task area centers on the 12-lead electrocardiogram, obtained within 10 minutes of arrival, and serial troponin measurements. ST-segment elevation in contiguous leads defines ST-elevation myocardial infarction, or STEMI, and demands immediate reperfusion, either percutaneous coronary intervention within 90 minutes or fibrinolytic therapy if PCI is unavailable. Non-ST-elevation myocardial infarction, or NSTEMI, and unstable angina share a similar initial approach but are distinguished by troponin elevation. Clinical intervention and pharmaceutical therapeutics converge on the mnemonic MONA-B modernized: aspirin 162 to 325 mg chewed, a P2Y12 inhibitor such as clopidogrel or ticagrelor, anticoagulation with heparin, a beta-blocker once the patient is hemodynamically stable, high-intensity statin therapy, and nitroglycerin for ongoing pain unless the patient has taken a phosphodiesterase inhibitor recently or has right ventricular infarction. Health maintenance extends beyond the acute event: cardiac rehabilitation, smoking cessation counseling, and secondary prevention with antiplatelet and lipid-lowering therapy reduce recurrence. Recognizing atypical presentations, including women, older adults, and patients with diabetes who may present with only fatigue or dyspnea, is a frequently tested clinical pearl.
Heart Failure and Valvular Disease
Heart failure questions often describe a patient with progressive dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and lower extremity edema. On physical exam, an S3 gallop, jugular venous distension, and bibasilar crackles support the diagnosis. Diagnostics include B-type natriuretic peptide, which rises with ventricular wall stress, and echocardiography to determine ejection fraction, distinguishing heart failure with reduced ejection fraction from heart failure with preserved ejection fraction. Chest radiography may show cardiomegaly, cephalization of pulmonary vessels, Kerley B lines, and pleural effusions. Pharmaceutical therapeutics for heart failure with reduced ejection fraction now centers on four pillars: an ACE inhibitor or angiotensin receptor-neprilysin inhibitor, a beta-blocker such as carvedilol or metoprolol succinate, a mineralocorticoid receptor antagonist like spironolactone, and a sodium-glucose cotransporter-2 inhibitor. Loop diuretics such as furosemide manage volume overload symptomatically but do not improve mortality. Acute decompensated heart failure calls for oxygen, diuresis, and identification of a precipitant such as dietary indiscretion, medication nonadherence, ischemia, or arrhythmia. Valvular disease is tested through auscultation findings: aortic stenosis produces a harsh crescendo-decrescendo systolic murmur radiating to the carotids, while mitral regurgitation produces a holosystolic murmur radiating to the axilla. Health maintenance for heart failure patients includes daily weight monitoring, sodium restriction, and vaccination against influenza and pneumococcus, since respiratory infections are common decompensation triggers.
Arrhythmias and Hypertension
Atrial fibrillation, the most commonly tested arrhythmia, presents on electrocardiogram as an irregularly irregular rhythm without discernible P waves. Management balances rate control, using beta-blockers or non-dihydropyridine calcium channel blockers, against rhythm control in select patients, alongside stroke prevention using the CHA2DS2-VASc score to guide anticoagulation decisions. A patient in atrial fibrillation with rapid ventricular response who becomes hypotensive or altered requires synchronized cardioversion. Ventricular tachycardia and fibrillation are life-threatening; pulseless ventricular tachycardia and ventricular fibrillation are treated with immediate defibrillation and advanced cardiac life support algorithms. Bradyarrhythmias, including third-degree atrioventricular block, may require atropine or transcutaneous pacing. Hypertension is tested both as a chronic disease and as a hypertensive emergency. Chronic hypertension is diagnosed by blood pressure readings at or above 130/80 mmHg on repeated measurement per current guidelines, though clinicians should note that threshold definitions have evolved and candidates should apply the values given in current national guidelines. First-line agents include thiazide diuretics, ACE inhibitors or angiotensin receptor blockers, and calcium channel blockers, with selection individualized by comorbidities such as diabetes or chronic kidney disease. Hypertensive emergency, defined as severely elevated blood pressure with acute end-organ damage such as encephalopathy, papilledema, or acute kidney injury, requires controlled intravenous reduction, typically no more than 25 percent in the first hour, using agents like nicardipine or labetalol to avoid precipitating ischemic injury from overly rapid correction.
COPD, Asthma, and Pulmonary Embolism
Chronic obstructive pulmonary disease presents in long-term smokers with progressive dyspnea, chronic cough, and pursed-lip breathing. Spirometry showing a reduced FEV1/FVC ratio that does not fully reverse with bronchodilators confirms the obstructive pattern. Chronic management follows a stepwise approach: short-acting bronchodilators for mild disease, escalating to long-acting muscarinic antagonists and long-acting beta-agonists, with inhaled corticosteroids reserved for patients with frequent exacerbations or an eosinophilic phenotype. Acute exacerbations are treated with short-acting bronchodilators, systemic corticosteroids, and antibiotics when purulent sputum suggests bacterial infection. Asthma, by contrast, typically presents in younger patients with episodic wheezing, chest tightness, and a reversible obstructive pattern on spirometry after bronchodilator use. Management follows a stepwise algorithm from as-needed short-acting beta-agonists to combination inhaled corticosteroid-formoterol therapy. Pulmonary embolism should be suspected in a patient with sudden-onset pleuritic chest pain, dyspnea, and tachycardia, particularly with risk factors like recent surgery, immobility, or malignancy; the Wells score helps stratify pretest probability, guiding the choice between D-dimer testing and CT pulmonary angiography. Anticoagulation with a direct oral anticoagulant is first-line for hemodynamically stable patients, while massive pulmonary embolism with hypotension may warrant thrombolysis. Community-acquired pneumonia rounds out this cluster, presenting with fever, productive cough, and focal crackles or consolidation on chest imaging; the CURB-65 score helps determine whether outpatient, inpatient, or ICU-level care and empiric antibiotic selection are appropriate.
Key terms
- STEMI
- — ST-elevation myocardial infarction; complete coronary artery occlusion identified by ST-segment elevation on ECG, requiring emergent reperfusion.
- Troponin
- — A cardiac biomarker released from injured myocardium; serial measurements help diagnose and rule out myocardial infarction.
- B-type natriuretic peptide (BNP)
- — A hormone released from stretched ventricular myocardium, used to support the diagnosis of heart failure.
- Ejection fraction
- — The percentage of blood pumped out of the left ventricle with each contraction, used to classify heart failure type.
- CHA2DS2-VASc score
- — A clinical scoring tool estimating stroke risk in atrial fibrillation, used to decide whether anticoagulation is warranted.
- Hypertensive emergency
- — Severely elevated blood pressure accompanied by acute damage to the brain, heart, kidneys, or eyes, requiring controlled intravenous therapy.
- FEV1/FVC ratio
- — Spirometric measure comparing forced expiratory volume in one second to forced vital capacity; reduced in obstructive lung disease.
- Wells score
- — A clinical prediction tool estimating the pretest probability of pulmonary embolism based on history and exam findings.
- CURB-65
- — A pneumonia severity score using confusion, urea, respiratory rate, blood pressure, and age to guide site-of-care decisions.
- Synchronized cardioversion
- — Delivery of an electrical shock timed to the QRS complex to convert an unstable tachyarrhythmia to normal rhythm.
Exam tips
- When a vignette pairs chest pain with diaphoresis and exertional onset, work through the ECG and troponin sequence before jumping to a diagnosis.
- Distinguish heart failure with reduced versus preserved ejection fraction before selecting pharmacologic therapy; the four-pillar regimen applies to reduced ejection fraction.
- For atrial fibrillation vignettes, check hemodynamic stability first; unstable patients need cardioversion, not just rate control medication.
- Reversibility on spirometry after bronchodilator is the key distinguishing feature between asthma and COPD in exam vignettes.
- Note that specific blood pressure and lipid thresholds are periodically revised by national guideline committees; apply the values provided in the question stem or your current review source.