PACES cardiovascular station: routine, common cases and viva questions
The PACES cardiovascular encounter: an efficient 6-minute routine, the common cases (valve disease, prosthetic and dual valves, VSD, pulmonary stenosis, HOCM and more), signs of severity and likely viva questions.
The short answer
- The cardiovascular encounter is the first half of Station 3: up to 6 minutes to examine, then at least 4 minutes of questions. Skills A, B, D, E and G are marked.
- The common cases are aortic stenosis and regurgitation, mixed aortic valve disease, mitral regurgitation and stenosis, mitral valve prolapse, prosthetic valves (including dual valve replacements), VSD, pulmonary stenosis and HOCM. Dextrocardia and heart transplant also appear.
- Present the lesion, then its severity, likely cause and complications. Time every murmur against the carotid pulse, and use the manoeuvres that bring out diastolic murmurs.
A 6-minute routine
- Introduce, consent and position the patient at 45° with the chest exposed appropriately.
- General inspection: breathlessness, audible prosthetic clicks, and scars. A sternotomy without a leg scar suggests valve surgery; a sternotomy with a saphenous vein harvest scar suggests CABG, possibly with a valve as well. Look for a pacemaker or ICD, and a left thoracotomy scar (previous mitral valvotomy).
- Hands: clubbing, splinter haemorrhages and other stigmata of endocarditis.
- Pulse: rate, rhythm and character (slow-rising, collapsing or jerky). Ask about shoulder pain before checking for a collapsing pulse, and ask for the blood pressure.
- Face and neck: pallor, malar flush, the JVP and its waveform, and the carotid pulse.
- Precordium: apex beat position and character (heaving, thrusting, tapping or double), heaves and thrills. If the apex isn't on the left, check the right side for dextrocardia.
- Auscultation: all four areas, timing against the carotid. Then left lateral position with the bell at the apex in expiration (mitral stenosis), and sitting forward in expiration at the left sternal edge (aortic regurgitation). Check radiation to the axilla and carotids, and whether right-sided murmurs get louder on inspiration.
- Finish: lung bases, sacral and ankle oedema, and peripheral pulses if relevant.
Common cases
| Lesion | Key signs | Signs of severity | Causes to mention |
|---|---|---|---|
| Aortic stenosis | Slow-rising, low-volume pulse; heaving, usually undisplaced apex; harsh ejection systolic murmur loudest at the right upper sternal edge, radiating to the carotids | Narrow pulse pressure, late-peaking murmur, soft or absent A2 (sometimes paradoxical splitting), thrill, S4, heart failure. Loudness is not a guide | Degenerative calcification, bicuspid valve (younger patients), rheumatic disease |
| Aortic regurgitation | Collapsing pulse, wide pulse pressure, displaced hyperdynamic apex, early diastolic murmur at the left sternal edge (sitting forward, expiration), often an ejection systolic flow murmur | Very wide pulse pressure, long diastolic murmur, soft A2, Austin Flint murmur, markedly displaced apex, heart failure | Bicuspid valve, aortic root dilatation (hypertension, Marfan syndrome), endocarditis, rheumatic disease, aortitis |
| Mixed aortic valve disease | Both an ejection systolic and an early diastolic murmur | Decide the predominant lesion: slow-rising pulse, narrow pulse pressure and heaving apex favour AS; collapsing pulse, wide pulse pressure and displaced apex favour AR | Bicuspid valve, rheumatic disease, degenerative disease, previous endocarditis |
| Mitral regurgitation | Often atrial fibrillation; displaced hyperdynamic apex; pansystolic murmur at the apex radiating to the axilla; soft S1 | Third heart sound or apical mid-diastolic flow murmur, displaced apex, AF, pulmonary hypertension, heart failure | Prolapse or flail leaflet, degenerative, ischaemic or functional (dilated ventricle), rheumatic, endocarditis |
| Mitral stenosis | Malar flush, AF, tapping undisplaced apex, loud S1, opening snap, low-pitched mid-diastolic murmur at the apex (bell, left lateral, expiration) | Long murmur, opening snap close to A2, pulmonary hypertension (parasternal heave, loud P2), functional TR | Rheumatic heart disease; look for a valvotomy scar |
| Mitral valve prolapse | Mid-systolic click followed by a late systolic murmur | Progression to significant mitral regurgitation | Associations include Marfan and Ehlers–Danlos syndromes and polycystic kidney disease |
| Mechanical aortic valve | Sternotomy, crisp metallic click with S2, ejection systolic flow murmur | Muffled click, new early diastolic murmur (leak), fever or emboli (endocarditis), anaemia (haemolysis) | Previous valve replacement; look for anticoagulant bruising |
| Mechanical mitral valve | Sternotomy, metallic click with S1, often AF | New pansystolic murmur (paravalvular leak), heart failure, endocarditis | Previous valve replacement |
| Dual mechanical valves | Clicks with both S1 and S2 | Any new murmur or loss of a click | Aortic plus mitral replacement |
| VSD | Harsh pansystolic murmur loudest at the left lower sternal edge, often with a thrill | Loud P2 with a quieter murmur (rising pulmonary pressure); cyanosis and clubbing in Eisenmenger syndrome | Congenital, or after myocardial infarction |
| Pulmonary stenosis | Ejection systolic murmur at the left upper sternal edge, louder on inspiration, no carotid radiation, thrill | Soft P2 with wide splitting of S2 | Congenital; Noonan syndrome, tetralogy of Fallot |
| HOCM | Jerky pulse, double apical impulse, ejection systolic murmur at the left sternal edge that gets louder on standing or Valsalva and softer on squatting | Syncope, heart failure; look for an ICD | Usually inherited: ask about family history and sudden death |
| Tricuspid regurgitation | Large v waves in the JVP, pansystolic murmur at the lower left sternal edge louder on inspiration, pulsatile liver, oedema | Ascites, marked oedema | Pulmonary hypertension (often from left-sided disease), endocarditis, pacing leads |
Also on the list
- Dextrocardia: apex beat and heart sounds on the right. Think of Kartagener syndrome (with bronchiectasis and sinusitis).
- Heart transplant: sternotomy, resting sinus tachycardia from cardiac denervation, and signs of immunosuppression (Cushingoid features, tremor, gum hypertrophy).
- Pulmonary regurgitation: early diastolic murmur at the left upper sternal edge that gets louder on inspiration, usually secondary to pulmonary hypertension.
Likely viva topics
- Investigations: ECG, chest X-ray, transthoracic echocardiography (transoesophageal if endocarditis or prosthetic dysfunction is suspected), and blood cultures if endocarditis is possible.
- Severe aortic stenosis on echo: peak velocity ≥4.0 m/s, mean gradient ≥40 mmHg, valve area ≤1.0 cm². Intervention is mainly for symptomatic severe stenosis, or severe stenosis with LVEF below 50%. Surgical AVR or TAVI is a heart team decision.
- Mechanical valves: lifelong warfarin (DOACs are contraindicated). Typical INR targets are 2.5 for a mechanical aortic valve (3.0 with extra risk factors) and 3.0 for a mechanical mitral valve.
- Mitral stenosis: intervention is considered when the valve area is ≤1.5 cm²; percutaneous commissurotomy if the anatomy is suitable.
- Atrial fibrillation: rate versus rhythm control, and stroke risk with CHA₂DS₂-VASc.
- Endocarditis prophylaxis: in the UK, antibiotic prophylaxis is not routinely recommended for dental procedures (NICE).
Common pitfalls
- Not timing a murmur against the carotid pulse.
- Forgetting the manoeuvres, and missing mitral stenosis or aortic regurgitation as a result.
- Missing a sternotomy, a leg scar or prosthetic clicks during inspection.
- Judging aortic stenosis severity by how loud the murmur is.
- Reporting a murmur you weren't sure you heard.
Sources
Frequently asked questions
What are the common cases in the PACES cardiology station?
Aortic stenosis, aortic regurgitation, mixed aortic valve disease, mitral regurgitation, mitral stenosis, mitral valve prolapse, prosthetic valves (including dual valve replacements), ventricular septal defect, pulmonary stenosis, HOCM and tricuspid regurgitation. Dextrocardia and heart transplant also appear.
How long do you get for the PACES cardiovascular examination?
Up to 6 minutes to examine, with a warning at 5 minutes, followed by at least 4 minutes of questions from the examiners.
How do you assess the severity of aortic stenosis clinically?
Signs of severe aortic stenosis include a slow-rising pulse, narrow pulse pressure, a late-peaking murmur, a soft or absent A2, a thrill, a fourth heart sound and signs of heart failure. The loudness of the murmur is not a reliable guide.
How do you tell a mechanical aortic valve from a mitral valve?
A mechanical aortic valve gives a crisp metallic click with the second heart sound, usually with an ejection systolic flow murmur. A mechanical mitral valve gives a click with the first heart sound. Clicks with both suggest dual valve replacement.
What does a sternotomy scar mean in PACES?
A sternotomy without a leg scar suggests valve surgery. With a saphenous vein harvest scar, think of CABG, possibly combined with a valve replacement. Listen for prosthetic clicks to decide.
Written by The Ace PACES team. Exam facts are taken from the Federation of the Royal Colleges of Physicians’ published PACES guidance, linked in the sources above. This guide supports exam preparation and is not a clinical guideline.
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