ABFM KSA HEART DISEASE EXAM
QUESTIONS & ANSWERS, UPDATED
2026/2027 EDITION, AMERICAN BOARD OF
FAMILY MEDICINE, 1-100 Q&A | INSTANT
DOWNLOAD PDF.
Core Domains
Acute Coronary Syndrome and Myocardial Infarction
Stable Ischemic Heart Disease and Chronic Coronary Disease
Heart Failure with Reduced and Preserved Ejection Fraction
Arrhythmias and ECG Interpretation
Hypertension and Dyslipidemia Management
Preventive Cardiology and Cardiovascular Risk Stratification
Valvular Heart Disease and Structural Cardiac Conditions
Cardiovascular Complications and Emergency Management
Introduction
The ABFM Knowledge Self-Assessment (KSA) in Heart Disease is a 60-
question, single-answer assessment designed to help family physicians identify
and close knowledge gaps in cardiovascular care. The activity focuses on
diagnosis and management of acute coronary syndrome, stable ischemic heart
disease, chronic and acute decompensated heart failure, arrhythmias, and
cardiovascular risk reduction. Questions are scenario-based and test applied
clinical decision-making consistent with current ACC/AHA guidelines. This
practice examination mirrors the format, difficulty, and content distribution of
the official KSA, covering coronary artery disease, heart failure, arrhythmias,
hypertension, preventive cardiology, and valvular conditions.
SECTION ONE: QUESTIONS 1–100
,Question 1
A 65-year-old female who had an ST-elevation myocardial infarction (STEMI)
treated with fibrinolytic therapy 2 days ago has sudden onset of chest pain
and shortness of breath. Clinical evaluation reveals pulmonary edema with
blood pressure 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 higher in the
pulmonary artery than in the right atrium. Which complication does the
patient most likely have?
A. Acute papillary muscle rupture
B. Ventricular septal rupture
C. Ventricular free wall rupture
D. Left ventricular aneurysm
E. Severe left ventricular failure
B. Ventricular septal rupture
RATIONALE: The oxygen saturation step-up from the right atrium to the
pulmonary artery is pathognomonic for ventricular septal rupture (VSR). VSR
typically presents 2-7 days post-MI with a new holosystolic murmur,
cardiogenic shock, and pulmonary edema. Papillary muscle rupture causes
severe mitral regurgitation but does not produce an oxygen step-up.
Question 2
A 56-year-old man with hypertension and type 2 diabetes presents for follow-
up. He has no chest pain. His LDL is 142 mg/dL, HDL 36 mg/dL, BP 136/78
mm Hg, nonsmoker. According to current guidelines, what is the most
appropriate next step?
A. Begin low-dose aspirin therapy
B. Start moderate- to high-intensity statin therapy
C. Begin ACE inhibitor for cardioprotection
D. No therapy is indicated at this time
, B. Start moderate- to high-intensity statin therapy
RATIONALE: Patients with diabetes between ages 40–75 should be
started on a statin regardless of baseline LDL, especially with additional
ASCVD risk factors. Aspirin is not recommended for primary prevention in
patients with diabetes without additional high-risk features.
Question 3
Which of the following is the most specific biomarker for diagnosing acute
myocardial infarction?
A. Creatine kinase-MB (CK-MB)
B. Myoglobin
C. Cardiac troponin I or T
D. Lactate dehydrogenase (LDH)
C. Cardiac troponin I or T
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 LDH is an older marker with poor specificity.
Question 4
A 58-year-old male with a history of hypertension presents to the emergency
department with acute onset of tearing chest pain radiating to the back. His
blood pressure is 180/100 mm Hg in the right arm and 100/60 mm Hg in the
left arm. What is the most appropriate initial diagnostic test?
A. ECG
B. Chest X-ray
C. CT angiography of the chest
D. Transthoracic echocardiogram
C. CT angiography of the chest
, RATIONALE: The presentation is classic for aortic dissection (tearing
chest pain radiating to the back with interarm blood pressure differential). CT
angiography is the definitive initial diagnostic study to confirm the diagnosis.
Question 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
A. Immediate PCI within 90 minutes
RATIONALE: STEMI with ST elevation in inferior leads (II, III, aVF)
requires immediate reperfusion therapy. Primary PCI within 90 minutes of
first medical contact is preferred over thrombolytics when available.
Question 6
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
B. Stable angina
RATIONALE: Stable angina is characterized by predictable chest pain
with exertion that is relieved by rest or nitroglycerin, with a stable pattern
QUESTIONS & ANSWERS, UPDATED
2026/2027 EDITION, AMERICAN BOARD OF
FAMILY MEDICINE, 1-100 Q&A | INSTANT
DOWNLOAD PDF.
Core Domains
Acute Coronary Syndrome and Myocardial Infarction
Stable Ischemic Heart Disease and Chronic Coronary Disease
Heart Failure with Reduced and Preserved Ejection Fraction
Arrhythmias and ECG Interpretation
Hypertension and Dyslipidemia Management
Preventive Cardiology and Cardiovascular Risk Stratification
Valvular Heart Disease and Structural Cardiac Conditions
Cardiovascular Complications and Emergency Management
Introduction
The ABFM Knowledge Self-Assessment (KSA) in Heart Disease is a 60-
question, single-answer assessment designed to help family physicians identify
and close knowledge gaps in cardiovascular care. The activity focuses on
diagnosis and management of acute coronary syndrome, stable ischemic heart
disease, chronic and acute decompensated heart failure, arrhythmias, and
cardiovascular risk reduction. Questions are scenario-based and test applied
clinical decision-making consistent with current ACC/AHA guidelines. This
practice examination mirrors the format, difficulty, and content distribution of
the official KSA, covering coronary artery disease, heart failure, arrhythmias,
hypertension, preventive cardiology, and valvular conditions.
SECTION ONE: QUESTIONS 1–100
,Question 1
A 65-year-old female who had an ST-elevation myocardial infarction (STEMI)
treated with fibrinolytic therapy 2 days ago has sudden onset of chest pain
and shortness of breath. Clinical evaluation reveals pulmonary edema with
blood pressure 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 higher in the
pulmonary artery than in the right atrium. Which complication does the
patient most likely have?
A. Acute papillary muscle rupture
B. Ventricular septal rupture
C. Ventricular free wall rupture
D. Left ventricular aneurysm
E. Severe left ventricular failure
B. Ventricular septal rupture
RATIONALE: The oxygen saturation step-up from the right atrium to the
pulmonary artery is pathognomonic for ventricular septal rupture (VSR). VSR
typically presents 2-7 days post-MI with a new holosystolic murmur,
cardiogenic shock, and pulmonary edema. Papillary muscle rupture causes
severe mitral regurgitation but does not produce an oxygen step-up.
Question 2
A 56-year-old man with hypertension and type 2 diabetes presents for follow-
up. He has no chest pain. His LDL is 142 mg/dL, HDL 36 mg/dL, BP 136/78
mm Hg, nonsmoker. According to current guidelines, what is the most
appropriate next step?
A. Begin low-dose aspirin therapy
B. Start moderate- to high-intensity statin therapy
C. Begin ACE inhibitor for cardioprotection
D. No therapy is indicated at this time
, B. Start moderate- to high-intensity statin therapy
RATIONALE: Patients with diabetes between ages 40–75 should be
started on a statin regardless of baseline LDL, especially with additional
ASCVD risk factors. Aspirin is not recommended for primary prevention in
patients with diabetes without additional high-risk features.
Question 3
Which of the following is the most specific biomarker for diagnosing acute
myocardial infarction?
A. Creatine kinase-MB (CK-MB)
B. Myoglobin
C. Cardiac troponin I or T
D. Lactate dehydrogenase (LDH)
C. Cardiac troponin I or T
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 LDH is an older marker with poor specificity.
Question 4
A 58-year-old male with a history of hypertension presents to the emergency
department with acute onset of tearing chest pain radiating to the back. His
blood pressure is 180/100 mm Hg in the right arm and 100/60 mm Hg in the
left arm. What is the most appropriate initial diagnostic test?
A. ECG
B. Chest X-ray
C. CT angiography of the chest
D. Transthoracic echocardiogram
C. CT angiography of the chest
, RATIONALE: The presentation is classic for aortic dissection (tearing
chest pain radiating to the back with interarm blood pressure differential). CT
angiography is the definitive initial diagnostic study to confirm the diagnosis.
Question 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
A. Immediate PCI within 90 minutes
RATIONALE: STEMI with ST elevation in inferior leads (II, III, aVF)
requires immediate reperfusion therapy. Primary PCI within 90 minutes of
first medical contact is preferred over thrombolytics when available.
Question 6
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
B. Stable angina
RATIONALE: Stable angina is characterized by predictable chest pain
with exertion that is relieved by rest or nitroglycerin, with a stable pattern
