PACES Cardiovascular Examination Guide | Station 3 Tips 2026

By Dr Zac Hana | 2026-05-20

Why the Cardiovascular Station Matters

Station 3 of PACES gives you 10 minutes to examine the cardiovascular system and present your findings. This station has a reputation for being one of the most challenging — not because the examination is complex, but because candidates often miss subtle signs or present their findings without conviction.

The good news: the same conditions appear repeatedly. If you can reliably identify valve replacements, murmurs, and signs of heart failure, you will pass this station.

The 3-Minute Cardiovascular Routine

You need to complete your examination in approximately 3 minutes, leaving time for presentation and examiner questions. Here is the routine that works:

Step 1: General Inspection (20 seconds)

From the end of the bed, observe:

  • Breathing — is the patient propped up (heart failure)?
  • Body habitus — Marfanoid features (mitral valve prolapse, aortic root dilatation)
  • Scars — midline sternotomy (valve replacement, CABG), lateral thoracotomy (mitral valvotomy)
  • Devices — pacemaker box, ICD, monitoring

    • Step 2: Hands (30 seconds)

  • Clubbing (endocarditis, congenital heart disease)
  • Splinter haemorrhages (endocarditis)
  • Osler nodes, Janeway lesions (endocarditis — rare but pathognomonic)
  • Peripheral cyanosis
  • Xanthomata (hyperlipidaemia)

    • Step 3: Pulse and Blood Pressure (30 seconds)

  • Rate and rhythm — regular, irregularly irregular (AF), collapsing
  • Character — slow-rising (aortic stenosis), collapsing (aortic regurgitation), bisferiens (mixed aortic valve disease)
  • Radio-radial delay — coarctation
  • Blood pressure — wide pulse pressure (aortic regurgitation), narrow (aortic stenosis)

    • Step 4: Face and Neck (30 seconds)

  • Malar flush (mitral stenosis)
  • Pallor (anaemia worsening murmurs)
  • Central cyanosis
  • JVP — height (right heart failure), waveform (giant V waves in tricuspid regurgitation, cannon A waves in complete heart block)
  • Carotid pulse character

    • Step 5: Precordium (90 seconds)

    Inspection:

  • Visible apex beat
  • Scars (sternotomy, thoracotomy, pacemaker)

    • Palpation:

  • Apex beat — position (displaced = LV dilatation), character (heaving = pressure overload, thrusting = volume overload)
  • Parasternal heave (RV hypertrophy — pulmonary hypertension, mitral stenosis)
  • Thrills — palpable murmurs (aortic area = AS, apex = MR)

    • Auscultation (the critical part):

    Listen in all four areas with the diaphragm, then the apex with the bell:

    AreaPositionWhat You're Listening For AorticRight 2nd intercostalEjection systolic murmur (AS) PulmonaryLeft 2nd intercostalPulmonary stenosis, flow murmurs TricuspidLeft lower sternal edgePansystolic (TR), diastolic (TS) MitralApexPansystolic (MR), mid-diastolic (MS) Apex with bellLeft lateral positionLow-pitched mid-diastolic rumble (MS)

    Dynamic manoeuvres:

  • Left lateral position with bell at apex — mitral stenosis
  • Sitting forward in expiration, diaphragm at left sternal edge — aortic regurgitation (early diastolic murmur)

    • Don't forget:

  • Lung bases (pulmonary oedema — bibasal crackles)
  • Peripheral oedema (ankle, sacral)
  • Hepatomegaly (right heart failure)

    • The Top 5 Cardiovascular Cases in PACES

    ConditionKey SignsWhat Confirms It Metallic valve replacementSternotomy scar, metallic click, possible murmurClick timing tells you which valve Aortic stenosisEjection systolic murmur radiating to carotids, slow-rising pulseNarrow pulse pressure, S4 Mitral regurgitationPansystolic murmur at apex radiating to axillaDisplaced apex, S3, AF Aortic regurgitationEarly diastolic murmur (sit forward), collapsing pulseWide pulse pressure, displaced apex Mitral stenosisLow-pitched mid-diastolic rumble (bell, left lateral), loud S1Malar flush, AF, tapping apex

    How to Present Cardiovascular Findings

    Use this structure:

    > "On examination of the cardiovascular system, this patient has [key positive findings]. The peripheral signs include [relevant peripherals]. On auscultation, I heard [describe murmur: timing, location, radiation, grade]. The important negatives are [no signs of failure/endocarditis]. My diagnosis is [condition], and I would like to [confirm with echocardiography/check bloods]."

    Example presentation:

    > "This gentleman has a midline sternotomy scar. His pulse is 78 and irregularly irregular, consistent with atrial fibrillation. The JVP is not elevated. The apex beat is undisplaced. On auscultation, there is a metallic click in the mitral area with a short systolic murmur. The lung bases are clear and there is no peripheral oedema. My diagnosis is a metallic mitral valve replacement, functioning well with no evidence of significant paravalvular leak or heart failure. I would like to confirm with a transthoracic echocardiogram and check his INR."

    Common Mistakes That Fail Candidates

  • Not sitting the patient forward — you will miss aortic regurgitation every time
  • Not rolling to the left — mitral stenosis is inaudible in the supine position
  • Forgetting to check lung bases and ankles — signs of heart failure change your management
  • Describing the murmur without committing to a diagnosis — examiners want you to interpret, not just describe
  • Missing the sternotomy scar — if there's a scar, the diagnosis is almost certainly a valve replacement

    • Practice Strategy

    The cardiovascular station requires hearing real murmurs — recordings and simulation cannot replicate the subtlety of a quiet aortic regurgitation or a mitral stenosis rumble.

    To prepare effectively:

  • Examine at least 10 patients with confirmed cardiac signs
  • Practise your routine until it takes exactly 3 minutes without rushing
  • Listen to the same murmur repeatedly until you can grade it confidently
  • Practise presenting with a timer — you should present in under 90 seconds

    • At our PACES courses at Guy's Hospital, you'll examine multiple cardiovascular patients with confirmed valve lesions, prosthetic valves, and heart failure — with immediate feedback from cardiology-trained faculty.

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    Continue your preparation: PACES Respiratory Examination Tips | How to Pass PACES First Time