ABFM KSA HEART DISEASE EXAM
QUESTIONS & ANSWERS,
UPDATED 2026/2027 EDITION,
AMERICAN BOARD OF FAMILY
MEDICINE
Core Domains
Acute Coronary Syndrome and Myocardial Infarction
Heart Failure (Reduced and Preserved Ejection Fraction)
Cardiac Arrhythmias and Atrial Fibrillation
Valvular Heart Disease
Hypertension and Cardiovascular Risk Management
Preventive Cardiology and Lipid Disorders
Pericardial and Myocardial Diseases
Cardiovascular Pharmacology and Anticoagulation
Introduction
The ABFM Knowledge Self-Assessment (KSA) in Heart Disease evaluates a
family physician's competence in diagnosing, managing, and preventing
cardiovascular conditions encountered in primary care. The examination
assesses knowledge of acute coronary syndromes, heart failure, arrhythmias,
valvular disease, hypertension, and preventive cardiology. Candidates are
tested through clinically relevant multiple-choice and scenario-based questions
informed by current evidence-based guidelines. The examination emphasizes
real-world application, pharmacologic decision-making, risk stratification, and
the critical thinking required to deliver comprehensive cardiovascular care. A
passing score demonstrates the knowledge necessary for certification and
maintenance of certification.
,SECTION ONE: QUESTIONS 1–200
1. A 65-year-old female who had an ST-elevation myocardial infarction
(STEMI) treated with fibrinolytic therapy 2 days ago has a sudden onset
of chest pain and shortness of breath. Clinical evaluation reveals
pulmonary edema with a blood pressure of 86/50 mm Hg, wet rales, a
harsh holosystolic murmur along the left sternal border radiating
toward the base and apex, and an S3 gallop. A pulmonary artery
catheter is placed and oxygen saturation is found to be higher in the
pulmonary artery than in the right atrium. Which one of the following
complications does the patient most likely have?
A. Acute papillary muscle rupture
B. Ventricular septal rupture
C. Ventricular free wall rupture
D. Left ventricular aneurysm
RATIONALE: In a patient with STEMI, cardiogenic shock with pulmonary
edema and hypotension should raise concern for mechanical complications.
The key diagnostic clue is the oxygen saturation step-up from the right atrium
to the pulmonary artery, which is pathognomonic for ventricular septal
rupture. Papillary muscle rupture causes severe mitral regurgitation but does
not produce an oxygen step-up.
2. A 65-year-old African-American male presents with a 2-month history
of exertional dyspnea and ankle swelling. His past medical history is
notable for hypertension and angioedema related to a peanut allergy.
On examination his blood pressure is 155/98 mm Hg. His jugular veins
are mildly distended and bibasilar rales are noted. The cardiac
examination reveals a regular rhythm with a soft S3 and no murmur.
Examination of the lower extremities reveals 1+ pitting ankle edema.
Echocardiography shows an estimated left ventricular ejection fraction
,of 40%. Which one of the following medications should be AVOIDED in
this patient?
A. Amlodipine
B. Carvedilol
C. Enalapril
D. Furosemide
RATIONALE: Angioedema occurs in less than 1% of patients taking an
ACE inhibitor but is more common in African-Americans. The American
Heart Association recommends that ACE inhibitors not be initiated in any
patient with a history of angioedema. Calcium channel blockers, particularly
those with negative inotropic effects, can cause a worsening of heart failure
and should also be avoided.
3. Which of the following is the most specific biomarker for diagnosing
acute myocardial infarction?
A. Creatine kinase-MB
B. Myoglobin
C. Cardiac troponin I or T
D. Lactate dehydrogenase
RATIONALE: Troponins are the most specific and sensitive markers for
myocardial injury. They remain elevated longer than CK-MB (up to 10-14 days)
and have near-perfect specificity for cardiac tissue. Myoglobin is not cardiac-
specific and rises rapidly but also falls quickly.
4. A 55-year-old male presents with substernal chest pressure radiating
to his left arm that occurs with exertion and resolves with rest.
Symptoms have been stable for several months. An ECG during an
episode of pain shows ST depression. What is the most likely
diagnosis?
, A. Unstable angina
B. Stable angina
C. NSTEMI
D. STEMI
RATIONALE: Stable angina is characterized by predictable chest pain
with exertion that is relieved by rest or nitroglycerin, with a stable pattern
over time. ECG may show ST depression during pain. Unstable angina has a
changing pattern or occurs at rest.
5. A 62-year-old male with diabetes presents with crushing chest pain at
rest for 30 minutes. ECG shows ST elevation in leads II, III, and aVF.
Troponin I is elevated. What is the priority treatment?
A. Immediate PCI within 90 minutes
B. Thrombolytics within 24 hours
C. Medical management with aspirin and heparin only
D. Stress testing in 48 hours
RATIONALE: STEMI with ST elevation in inferior leads requires
immediate reperfusion therapy. Primary PCI within 90 minutes of first
medical contact is preferred over thrombolytics. Stress testing is
contraindicated in acute STEMI.
6. A 58-year-old female with stable angina is started on medical
therapy. Which medication is indicated for symptom relief but does
not reduce mortality?
A. Aspirin
B. High-intensity statin
C. Beta-blocker
D. Sublingual nitroglycerin
QUESTIONS & ANSWERS,
UPDATED 2026/2027 EDITION,
AMERICAN BOARD OF FAMILY
MEDICINE
Core Domains
Acute Coronary Syndrome and Myocardial Infarction
Heart Failure (Reduced and Preserved Ejection Fraction)
Cardiac Arrhythmias and Atrial Fibrillation
Valvular Heart Disease
Hypertension and Cardiovascular Risk Management
Preventive Cardiology and Lipid Disorders
Pericardial and Myocardial Diseases
Cardiovascular Pharmacology and Anticoagulation
Introduction
The ABFM Knowledge Self-Assessment (KSA) in Heart Disease evaluates a
family physician's competence in diagnosing, managing, and preventing
cardiovascular conditions encountered in primary care. The examination
assesses knowledge of acute coronary syndromes, heart failure, arrhythmias,
valvular disease, hypertension, and preventive cardiology. Candidates are
tested through clinically relevant multiple-choice and scenario-based questions
informed by current evidence-based guidelines. The examination emphasizes
real-world application, pharmacologic decision-making, risk stratification, and
the critical thinking required to deliver comprehensive cardiovascular care. A
passing score demonstrates the knowledge necessary for certification and
maintenance of certification.
,SECTION ONE: QUESTIONS 1–200
1. A 65-year-old female who had an ST-elevation myocardial infarction
(STEMI) treated with fibrinolytic therapy 2 days ago has a sudden onset
of chest pain and shortness of breath. Clinical evaluation reveals
pulmonary edema with a blood pressure of 86/50 mm Hg, wet rales, a
harsh holosystolic murmur along the left sternal border radiating
toward the base and apex, and an S3 gallop. A pulmonary artery
catheter is placed and oxygen saturation is found to be higher in the
pulmonary artery than in the right atrium. Which one of the following
complications does the patient most likely have?
A. Acute papillary muscle rupture
B. Ventricular septal rupture
C. Ventricular free wall rupture
D. Left ventricular aneurysm
RATIONALE: In a patient with STEMI, cardiogenic shock with pulmonary
edema and hypotension should raise concern for mechanical complications.
The key diagnostic clue is the oxygen saturation step-up from the right atrium
to the pulmonary artery, which is pathognomonic for ventricular septal
rupture. Papillary muscle rupture causes severe mitral regurgitation but does
not produce an oxygen step-up.
2. A 65-year-old African-American male presents with a 2-month history
of exertional dyspnea and ankle swelling. His past medical history is
notable for hypertension and angioedema related to a peanut allergy.
On examination his blood pressure is 155/98 mm Hg. His jugular veins
are mildly distended and bibasilar rales are noted. The cardiac
examination reveals a regular rhythm with a soft S3 and no murmur.
Examination of the lower extremities reveals 1+ pitting ankle edema.
Echocardiography shows an estimated left ventricular ejection fraction
,of 40%. Which one of the following medications should be AVOIDED in
this patient?
A. Amlodipine
B. Carvedilol
C. Enalapril
D. Furosemide
RATIONALE: Angioedema occurs in less than 1% of patients taking an
ACE inhibitor but is more common in African-Americans. The American
Heart Association recommends that ACE inhibitors not be initiated in any
patient with a history of angioedema. Calcium channel blockers, particularly
those with negative inotropic effects, can cause a worsening of heart failure
and should also be avoided.
3. Which of the following is the most specific biomarker for diagnosing
acute myocardial infarction?
A. Creatine kinase-MB
B. Myoglobin
C. Cardiac troponin I or T
D. Lactate dehydrogenase
RATIONALE: Troponins are the most specific and sensitive markers for
myocardial injury. They remain elevated longer than CK-MB (up to 10-14 days)
and have near-perfect specificity for cardiac tissue. Myoglobin is not cardiac-
specific and rises rapidly but also falls quickly.
4. A 55-year-old male presents with substernal chest pressure radiating
to his left arm that occurs with exertion and resolves with rest.
Symptoms have been stable for several months. An ECG during an
episode of pain shows ST depression. What is the most likely
diagnosis?
, A. Unstable angina
B. Stable angina
C. NSTEMI
D. STEMI
RATIONALE: Stable angina is characterized by predictable chest pain
with exertion that is relieved by rest or nitroglycerin, with a stable pattern
over time. ECG may show ST depression during pain. Unstable angina has a
changing pattern or occurs at rest.
5. A 62-year-old male with diabetes presents with crushing chest pain at
rest for 30 minutes. ECG shows ST elevation in leads II, III, and aVF.
Troponin I is elevated. What is the priority treatment?
A. Immediate PCI within 90 minutes
B. Thrombolytics within 24 hours
C. Medical management with aspirin and heparin only
D. Stress testing in 48 hours
RATIONALE: STEMI with ST elevation in inferior leads requires
immediate reperfusion therapy. Primary PCI within 90 minutes of first
medical contact is preferred over thrombolytics. Stress testing is
contraindicated in acute STEMI.
6. A 58-year-old female with stable angina is started on medical
therapy. Which medication is indicated for symptom relief but does
not reduce mortality?
A. Aspirin
B. High-intensity statin
C. Beta-blocker
D. Sublingual nitroglycerin
