The 4 Cardiology Concepts That Always Show Up on FNP Boards
Cardiology · 3 min read · October 7, 2026
Demystifying Heart Murmurs: Systolic vs. Diastolic
Cardiology is one of the most heavily tested categories on both the AANP and ANCC board exams. When it comes to heart murmurs, students often panic, but the secret to board success is recognizing patterns. Remember the golden rule: systolic murmurs happen between S1 and S2, while diastolic murmurs happen between S2 and S1.
Systolic murmurs include conditions like aortic stenosis and mitral regurgitation. Aortic stenosis is a harsh, crescendo-decrescendo systolic ejection murmur best heard at the right second intercostal space that radiates to the neck. Mitral regurgitation is a holosystolic murmur heard best at the apex that radiates to the axilla.
Diastolic murmurs, on the other hand, are almost always pathologic. Think of aortic regurgitation (a high-pitched, blowing decrescendo diastolic murmur at the left sternal border) and mitral stenosis (a low-pitched diastolic rumble with an opening snap heard best at the apex).
Board Pearl: Always listen to the carotid arteries when evaluating a systolic murmur at the base of the heart. If it radiates to the neck, think aortic stenosis.
Heart Failure: Classification and Management Priorities
Heart failure (HF) questions on boards generally test your understanding of classifications (HFrEF vs. HFpEF) and first-line pharmacotherapy that reduces mortality.
Heart Failure with Reduced Ejection Fraction (HFrEF) involves a systolic dysfunction where the ejection fraction is 40% or less. Your pharmacological toolkit here must include guideline-directed medical therapy (GDMT) that alters disease progression. This includes ACE inhibitors (or ARBs/ARNI), beta-blockers (specifically metoprolol succinate, carvedilol, or bisoprolol), and mineralocorticoid receptor antagonists (MRAs) like spironolactone, alongside SGLT2 inhibitors.
Heart Failure with Preserved Ejection Fraction (HFpEF) is a diastolic dysfunction where the ejection fraction is normal (greater than or equal to 50%), but the ventricles are stiff and unable to fill properly. Management here focuses heavily on controlling blood pressure, heart rate, and volume overload with diuretics.
Board Pearl: Never start a beta-blocker in acute, decompensated heart failure with active volume overload. Wait until the patient is euvolemic and stabilized.
Hypertension Guidelines and Risk Stratification
Hypertension management is a staple of primary care and a favorite topic for board question writers. You need to know the ACC/AHA staging benchmarks: Normal (<120/<80 mmHg), Elevated (120-129/<80 mmHg), Stage 1 (130-139 or 80-89 mmHg), and Stage 2 (≥140 or ≥90 mmHg).
When do you initiate pharmacotherapy? For Stage 1 hypertension, medication is only initiated if the patient has clinical cardiovascular disease (CVD) or a 10-year ASCVD risk of 10% or higher. For Stage 2 hypertension, initiate a two-drug combination of different classes along with lifestyle modifications.
First-line antihypertensive agents for the general non-black population include thiazide diuretics, CCBs, and ACE inhibitors or ARBs. For the Black population, initial therapy should include a thiazide diuretic or a calcium channel blocker.
Board Pearl: ACE inhibitors and ARBs are strictly contraindicated in pregnancy due to the risk of fetal renal damage and malformations. Always use a safe alternative like labetalol or nifedipine.
You have everything it takes to conquer cardiology and pass your FNP boards with flying colors. Trust your preparation, focus on the high-yield mechanics, and remember that every question brings you one step closer to your nurse practitioner career.