USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 1
USMLE STEP 2 CK
HIGH-YIELD CARDIOLOGY REVIEW 2026
Complete Study Guide · 40-Question Qbank · Exam-Day Success
Curated by a 3rd-Year Internal Medicine Resident
Grounded in Current Clinical Practice | UpToDate® & ACC/AHA Guidelines 2025–2026
,USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 2
SECTION 1: CORONARY ARTERY DISEASE (CAD)
1.1 Stable Angina (Chronic Coronary Syndrome)
Clinical Vignette Cues
• Classic buzzwords: Chest pressure/tightness with exertion, relieved by rest or nitroglycerin
within 1–5 min; reproducible pattern.
• Risk factors: HTN, DM, hyperlipidemia, smoking, family history (1st-degree male <55, female
<65), obesity.
• Physical exam: Often NORMAL; may have S4 (reduced LV compliance), signs of heart failure
if severe.
• Atypical presentations: Women, diabetics, elderly — may present as jaw/arm pain, dyspnea,
or fatigue alone.
Diagnostic Approach
Step Action / Rationale
Initial test Resting 12-lead ECG (normal at rest in ~50%) + fasting lipids,
BMP, CBC
Next step (if ECG normal, able to Exercise stress ECG (Duke Treadmill Score)
exercise)
Next step (unable to exercise OR Pharmacologic stress test with imaging (nuclear/echo) —
baseline ECG abnormal) preferred if LBBB, paced rhythm, or prior ECG changes
Gold standard / anatomic Coronary CT Angiography (CCTA) — preferred initial anatomic
test per 2023 ACC/AHA CCS guidelines
Invasive gold standard Cardiac catheterization / Coronary angiography — if noninvasive
testing inconclusive or revascularization planned
Fractional Flow Reserve (FFR) Measured during catheterization; FFR ≤0.80 = hemodynamically
significant stenosis requiring revascularization
Management Hierarchy
1. Step 1 — Lifestyle: Smoking cessation, Mediterranean diet, exercise 30–60 min/day, weight
loss, BP <130/80, LDL <70 mg/dL (very high risk).
2. Step 2 — Medical therapy (ALL stable CAD patients): (a) Antiplatelet: Aspirin 81 mg/day OR
clopidogrel if aspirin intolerant. (b) Statin: High-intensity (atorvastatin 40–80 mg or rosuvastatin
20–40 mg). (c) Beta-blocker: First-line anti-anginal if tolerated. (d) ACE inhibitor/ARB: If DM,
CKD, EF <40%, or HTN.
3. Step 3 — Add anti-anginal if symptoms persist: Long-acting nitrates (isosorbide
mononitrate), calcium channel blockers (amlodipine), ranolazine.
4. Step 4 — Revascularization: PCI for 1–2 vessel disease. CABG preferred for LM disease, 3-
vessel disease with DM, or 3-vessel disease with reduced EF (per SYNTAX trial).
,USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 3
Common Pitfalls
• Pitfall: Ordering stress test without first checking resting ECG — ST changes at rest (LBBB,
WPW, digoxin effect) make exercise ECG uninterpretable; go straight to imaging modality.
• Pitfall: Choosing PCI over CABG in a diabetic with 3-vessel disease — FREEDOM trial showed
CABG superiority in this group.
• Pitfall: Stopping aspirin before elective surgery in a stent patient within 6 months — risk of stent
thrombosis outweighs bleeding risk.
, USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 4
1.2 Acute Coronary Syndromes (ACS)
ACS Spectrum — Quick Differentiator
Feature Unstable Angina (UA) NSTEMI STEMI
Troponin Normal Elevated Elevated
ECG ST depression / T- ST depression / T- ST elevation ≥1mm in
wave changes OR wave changes ≥2 contiguous leads
normal OR new LBBB
Mechanism Plaque rupture + partial Partial occlusion with Complete occlusion;
occlusion; no necrosis myocardial necrosis transmural infarction
Reperfusion goal Medical management ± Invasive within 2h Primary PCI within 90
early invasive (high-risk) or 24-72h min (door-to-balloon)
(intermediate)
STEMI Management Algorithm
5. Immediate (within minutes): MONA-B — Morphine (if pain unrelieved), Oxygen (if SpO2
<90%), Nitroglycerin (SL ×3, then IV if persistent pain; CONTRAINDICATED if inferior MI with
RV involvement, hypotension, or recent PDE5 inhibitor use), Aspirin 325 mg chew, Beta-blocker
(oral if hemodynamically stable).
6. Anticoagulation: Unfractionated heparin (UFH) bolus + infusion for PCI route; bivalirudin
alternative.
7. P2Y12 inhibitor loading: Ticagrelor 180 mg OR prasugrel 60 mg (preferred over clopidogrel for
PCI); clopidogrel 600 mg if others unavailable or if fibrinolysis used.
8. Reperfusion: Primary PCI <90 min from first medical contact (FMC) if capable cath lab
available. Fibrinolysis (tPA/TNK) if PCI cannot be performed within 120 min of FMC — must
give within 12h of symptom onset.
9. Fibrinolysis contraindications (absolute): Prior hemorrhagic stroke, ischemic stroke <3
months, intracranial neoplasm, active internal bleeding, suspected aortic dissection, significant
closed-head trauma <3 months.
NSTEMI/UA Management Algorithm
10. HEART score / TIMI score: Risk-stratify immediately. High-risk features: dynamic ST changes,
elevated troponin, hemodynamic instability, recurrent ischemia, signs of HF.
11. High-risk → Early invasive strategy: Cath within 2 hours (very high risk: ongoing ischemia,
hemodynamic instability) OR within 24 hours (high-risk).
12. Intermediate-risk → Ischemia-guided: Cath within 72 hours OR noninvasive stress testing if
stabilized.
13. Medical management (same as STEMI minus emergent reperfusion): Dual antiplatelet
(aspirin + P2Y12), anticoagulation (UFH, LMWH, or bivalirudin), high-intensity statin, beta-
blocker, ACEi.
USMLE STEP 2 CK
HIGH-YIELD CARDIOLOGY REVIEW 2026
Complete Study Guide · 40-Question Qbank · Exam-Day Success
Curated by a 3rd-Year Internal Medicine Resident
Grounded in Current Clinical Practice | UpToDate® & ACC/AHA Guidelines 2025–2026
,USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 2
SECTION 1: CORONARY ARTERY DISEASE (CAD)
1.1 Stable Angina (Chronic Coronary Syndrome)
Clinical Vignette Cues
• Classic buzzwords: Chest pressure/tightness with exertion, relieved by rest or nitroglycerin
within 1–5 min; reproducible pattern.
• Risk factors: HTN, DM, hyperlipidemia, smoking, family history (1st-degree male <55, female
<65), obesity.
• Physical exam: Often NORMAL; may have S4 (reduced LV compliance), signs of heart failure
if severe.
• Atypical presentations: Women, diabetics, elderly — may present as jaw/arm pain, dyspnea,
or fatigue alone.
Diagnostic Approach
Step Action / Rationale
Initial test Resting 12-lead ECG (normal at rest in ~50%) + fasting lipids,
BMP, CBC
Next step (if ECG normal, able to Exercise stress ECG (Duke Treadmill Score)
exercise)
Next step (unable to exercise OR Pharmacologic stress test with imaging (nuclear/echo) —
baseline ECG abnormal) preferred if LBBB, paced rhythm, or prior ECG changes
Gold standard / anatomic Coronary CT Angiography (CCTA) — preferred initial anatomic
test per 2023 ACC/AHA CCS guidelines
Invasive gold standard Cardiac catheterization / Coronary angiography — if noninvasive
testing inconclusive or revascularization planned
Fractional Flow Reserve (FFR) Measured during catheterization; FFR ≤0.80 = hemodynamically
significant stenosis requiring revascularization
Management Hierarchy
1. Step 1 — Lifestyle: Smoking cessation, Mediterranean diet, exercise 30–60 min/day, weight
loss, BP <130/80, LDL <70 mg/dL (very high risk).
2. Step 2 — Medical therapy (ALL stable CAD patients): (a) Antiplatelet: Aspirin 81 mg/day OR
clopidogrel if aspirin intolerant. (b) Statin: High-intensity (atorvastatin 40–80 mg or rosuvastatin
20–40 mg). (c) Beta-blocker: First-line anti-anginal if tolerated. (d) ACE inhibitor/ARB: If DM,
CKD, EF <40%, or HTN.
3. Step 3 — Add anti-anginal if symptoms persist: Long-acting nitrates (isosorbide
mononitrate), calcium channel blockers (amlodipine), ranolazine.
4. Step 4 — Revascularization: PCI for 1–2 vessel disease. CABG preferred for LM disease, 3-
vessel disease with DM, or 3-vessel disease with reduced EF (per SYNTAX trial).
,USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 3
Common Pitfalls
• Pitfall: Ordering stress test without first checking resting ECG — ST changes at rest (LBBB,
WPW, digoxin effect) make exercise ECG uninterpretable; go straight to imaging modality.
• Pitfall: Choosing PCI over CABG in a diabetic with 3-vessel disease — FREEDOM trial showed
CABG superiority in this group.
• Pitfall: Stopping aspirin before elective surgery in a stent patient within 6 months — risk of stent
thrombosis outweighs bleeding risk.
, USMLE Step 2 CK — High-Yield Cardiology Review 2026 Page 4
1.2 Acute Coronary Syndromes (ACS)
ACS Spectrum — Quick Differentiator
Feature Unstable Angina (UA) NSTEMI STEMI
Troponin Normal Elevated Elevated
ECG ST depression / T- ST depression / T- ST elevation ≥1mm in
wave changes OR wave changes ≥2 contiguous leads
normal OR new LBBB
Mechanism Plaque rupture + partial Partial occlusion with Complete occlusion;
occlusion; no necrosis myocardial necrosis transmural infarction
Reperfusion goal Medical management ± Invasive within 2h Primary PCI within 90
early invasive (high-risk) or 24-72h min (door-to-balloon)
(intermediate)
STEMI Management Algorithm
5. Immediate (within minutes): MONA-B — Morphine (if pain unrelieved), Oxygen (if SpO2
<90%), Nitroglycerin (SL ×3, then IV if persistent pain; CONTRAINDICATED if inferior MI with
RV involvement, hypotension, or recent PDE5 inhibitor use), Aspirin 325 mg chew, Beta-blocker
(oral if hemodynamically stable).
6. Anticoagulation: Unfractionated heparin (UFH) bolus + infusion for PCI route; bivalirudin
alternative.
7. P2Y12 inhibitor loading: Ticagrelor 180 mg OR prasugrel 60 mg (preferred over clopidogrel for
PCI); clopidogrel 600 mg if others unavailable or if fibrinolysis used.
8. Reperfusion: Primary PCI <90 min from first medical contact (FMC) if capable cath lab
available. Fibrinolysis (tPA/TNK) if PCI cannot be performed within 120 min of FMC — must
give within 12h of symptom onset.
9. Fibrinolysis contraindications (absolute): Prior hemorrhagic stroke, ischemic stroke <3
months, intracranial neoplasm, active internal bleeding, suspected aortic dissection, significant
closed-head trauma <3 months.
NSTEMI/UA Management Algorithm
10. HEART score / TIMI score: Risk-stratify immediately. High-risk features: dynamic ST changes,
elevated troponin, hemodynamic instability, recurrent ischemia, signs of HF.
11. High-risk → Early invasive strategy: Cath within 2 hours (very high risk: ongoing ischemia,
hemodynamic instability) OR within 24 hours (high-risk).
12. Intermediate-risk → Ischemia-guided: Cath within 72 hours OR noninvasive stress testing if
stabilized.
13. Medical management (same as STEMI minus emergent reperfusion): Dual antiplatelet
(aspirin + P2Y12), anticoagulation (UFH, LMWH, or bivalirudin), high-intensity statin, beta-
blocker, ACEi.
