Cardiology on the ABFM: 10 High-Yield Topics You Must Know

Cardiology is the single largest content domain on the ABFM, representing roughly 11% of the exam. More importantly, cardiology questions tend to involve guideline thresholds — exactly the kind of content where "knowing it cold" vs. "kind of remembering it" separates points.

Here are the ten cardiology topics that show up on essentially every ABFM exam, each with the specific numbers and decisions you need fluency on.

1. Hypertension: Diagnosis and Treatment Targets

Use the ACC/AHA 2017 thresholds (reaffirmed since):

- Elevated BP: 120-129 / <80 - Stage 1 HTN: 130-139 / 80-89 - Stage 2 HTN: ≥140 / ≥90 - Treatment target: <130/80 for most adults, including those with diabetes, CKD, or established ASCVD

First-line agents: thiazide (chlorthalidone preferred), CCB, ACE inhibitor, or ARB. Beta blockers are not first-line for uncomplicated HTN unless a compelling indication exists (post-MI, HFrEF).

Black patients without HF or CKD: initial monotherapy with thiazide or CCB.

2. Hyperlipidemia: Statin Initiation

Four statin benefit groups per ACC/AHA:

- Clinical ASCVD - LDL-C ≥190 mg/dL - Diabetes, age 40-75, LDL-C 70-189 (moderate-intensity statin) - 10-year ASCVD risk ≥7.5% with LDL 70-189 (consider statin; ≥20% = initiate high-intensity)

For ASCVD or LDL ≥190: high-intensity statin (atorvastatin 40-80, rosuvastatin 20-40). Add ezetimibe if LDL remains 70 on maximal statin for secondary prevention. PCSK9 inhibitors for very high-risk patients not at goal.

3. Heart Failure: HFrEF GDMT

Four pillars of guideline-directed medical therapy for HFrEF (EF ≤40%):

1. ARNI (sacubitril/valsartan) — preferred over ACE/ARB; use ACE/ARB only if ARNI not tolerated 2. Beta blocker — metoprolol succinate, carvedilol, or bisoprolol 3. MRA (spironolactone or eplerenone) — add if K+ <5.0 and GFR 30 4. SGLT2 inhibitor — dapagliflozin or empagliflozin; beneficial regardless of diabetes status

Know that ivabradine is added for HR 70 on max beta blocker. Digoxin is for symptom control, not mortality benefit.

4. Atrial Fibrillation: Rate vs Rhythm, Anticoagulation

Rate control (generally preferred for older, asymptomatic patients): beta blocker or non-dihydropyridine CCB (diltiazem, verapamil). Target resting HR <110 (lenient) or <80 (strict) per AFFIRM/RACE II.

Anticoagulation based on CHA₂DS₂-VASc:

- Score ≥2 in men or ≥3 in women: anticoagulate - Score 1 in men or 2 in women: consider anticoagulation - Score 0: no anticoagulation

DOACs (apixaban, rivaroxaban, dabigatran, edoxaban) are preferred over warfarin for most non-valvular AFib. Warfarin still preferred for mechanical valves and moderate-to-severe mitral stenosis.

5. Stable Angina / CAD Management

- Antiplatelet: aspirin 81 mg daily (or clopidogrel if aspirin intolerant) - Statin: high-intensity - Beta blocker: first-line for anginal symptoms; goal HR ~60 - ACE inhibitor: especially if HTN, DM, CKD, or EF ≤40% - Nitrates: sublingual for acute; long-acting for chronic symptom control

Stress testing: exercise ECG for patients who can exercise with interpretable baseline ECG; pharmacologic stress (dobutamine, regadenoson) or imaging (echo, nuclear) for those who cannot.

6. ACS: Initial Management Approach

- Aspirin 325 mg chewed - Nitroglycerin sublingual (avoid if RV infarct, hypotension, or recent PDE5) - Heparin (unfractionated or LMWH) - P2Y12 inhibitor (ticagrelor, prasugrel, or clopidogrel) - Beta blocker within 24 hours if no contraindications - Statin high-intensity

STEMI: PCI within 90 minutes (or 120 minutes if transferred); fibrinolytics if PCI unavailable within 120 minutes.

7. Valvular Disease: Aortic Stenosis Key Points

- Classic triad: angina, syncope, heart failure (each shortens prognosis dramatically) - Workup: transthoracic echo - Severe AS criteria: peak velocity ≥4 m/s, mean gradient ≥40 mmHg, valve area ≤1.0 cm² - Intervention indicated: symptomatic severe AS, or asymptomatic severe AS with EF <50% or during other cardiac surgery - SAVR vs TAVR: increasingly TAVR for moderate-to-high surgical risk; SAVR for younger, lower-risk patients

8. Pre-Operative Cardiac Risk Assessment

Use the RCRI (Revised Cardiac Risk Index):

- High-risk surgery - Ischemic heart disease - Heart failure - Cerebrovascular disease - Insulin-dependent diabetes - Creatinine 2.0

Score ≥2 with functional capacity <4 METs: consider further testing. Continue beta blockers perioperatively; generally do not start them just for surgery.

9. PAD: Diagnosis and Management

ABI diagnosis:

- Normal: 1.0-1.4 - Borderline: 0.91-0.99 - Mild-moderate PAD: 0.41-0.90 - Severe PAD: ≤0.40 - Non-compressible (calcified): 1.4 — get toe-brachial index

Management: smoking cessation (the single biggest intervention), statin, antiplatelet (aspirin or clopidogrel), supervised exercise, cilostazol for claudication symptoms.

10. Syncope: Risk Stratification

Use San Francisco Syncope Rule (CHESS):

- CHF history - Hematocrit <30% - ECG abnormal - Shortness of breath - SBP <90 at triage

Any positive criterion = higher risk for short-term serious outcomes → admit/extended workup. Otherwise outpatient evaluation usually appropriate.

Common outpatient picks: orthostatics, basic labs, ECG, plus echo if structural disease suspected. Tilt-table testing has fallen out of favor for most cases.

How to Use This List

Don't memorize it as a block. Feed it into your question bank over the next several weeks and let spaced repetition do the cement work. Each of these topics will be tested more than once on any realistic ABFM attempt — fluency with the numbers is worth real exam points.

If you want a simple gut check before exam day: can you state, without looking, the statin indication thresholds, the HFrEF four pillars, and the CHA₂DS₂-VASc decision cutoffs? If yes, you have the core cardiology content handled.