Cardiology board certification in the USA and Canada: ABIM and Royal College exams
North America has two routes to cardiology certification: the American Board of Internal Medicine (ABIM) Cardiovascular Disease Certification Examination in the United States, and the Royal College of Physicians and Surgeons of Canada (RCPSC) Examination in Cardiology (Adult) in Canada.
They test the same specialty, but they are built very differently. The ABIM exam is a written examination spanning one and a half days, including a distinctive half-day of electrocardiogram and imaging interpretation. The Royal College examination pairs a written component with an applied (oral) component in which examiners question you directly.
This guide covers both. It reflects information published by ABIM and the Royal College; confirm current dates, fees and requirements with the boards themselves before you register.
At a glance
| ABIM (United States) | Royal College (Canada) | |
|---|---|---|
| Credential | Board certification in Cardiovascular Disease | Certification in Cardiology (Adult) |
| Prerequisite | ABIM certification in internal medicine | Royal College Internal Medicine certification |
| Fellowship | 36 months, of which 24 clinical | Subspecialty training in Adult Cardiology |
| Written component | 240 multiple-choice questions | Written examination |
| Second component | ECG and imaging cases (~72) | Applied examination (stations, examiner-led) |
| Total length | One and a half days | Written plus applied |
| Question style | Single best answer, clinical stem | MCQ plus examiner discussion |
The ABIM Cardiovascular Disease exam (United States)
Eligibility
ABIM sets clear prerequisites. To sit the Cardiovascular Disease certification examination you must:
- Be previously certified in internal medicine by ABIM
- Complete 36 months of fellowship training, of which 24 months must be clinical
- Train in a programme accredited by ACGME, the Royal College of Physicians and Surgeons of Canada, or the Collège des médecins du Québec
- Have completed that training, including vacation time, by October 31st of the year of the examination
- Hold a valid, unrestricted and unchallenged licence to practise medicine
You also need satisfactory ratings from your programme director across the six ACGME/ABMS competencies and on overall clinical competence in your final training year.
Procedural competence
Beyond knowledge, ABIM requires demonstrated competence in a defined list of procedures:
- Advanced cardiac life support with cardioversion
- Electrocardiography, including ambulatory monitoring and exercise testing
- Echocardiography
- Arterial catheter insertion
- Right-heart catheterisation with temporary pacemaker insertion and management
- Left-heart catheterisation and diagnostic coronary angiography
Format: a day of questions, then a day of images
This is the part that distinguishes the ABIM cardiology exam from most other board examinations, and the part candidates most often under-prepare for.
Day one — multiple choice. 240 questions delivered in four two-hour sessions, with a maximum of 60 questions per session, taking approximately ten hours in total. Questions are single-best-answer and the overwhelming majority use a clinical stem: a patient scenario that tests decision-making rather than recall.
A separate day — electrocardiograms and imaging studies. Approximately 72 cases across two sessions, taking around five hours:
- Electrocardiograms — up to two hours, maximum 35 cases
- Imaging studies — up to two hours and fifteen minutes, maximum 37 cases
Each case gives a brief patient description and one or more images.
The published weighting within that component is:
| Component | Share |
|---|---|
| Electrocardiograms | 48% |
| Echocardiograms | 37% |
| Coronary angiograms | 15% |
Nearly half of the image component is ECG interpretation. If your revision has concentrated on management algorithms, that is a large and very trainable gap.
Questions across the exam may require interpretation of intracardiac electrograms, haemodynamic recordings, chest radiographs, photomicrographs, ventriculograms, myocardial perfusion images, CT, MRI and intravascular ultrasound.
For the full blueprint — the medical content categories and their exact percentage weightings — use ABIM's published Cardiovascular Disease certification blueprint, which is the authoritative source and is updated periodically.
After certification: maintenance
Certification is not permanent. ABIM offers two routes to maintain it:
- The traditional 10-year MOC examination — 220 single-best-answer questions, of which roughly 50 are new and unscored. Candidates have access to an external resource (UpToDate®) for the entire exam.
- The Longitudinal Knowledge Assessment (LKA®) — a five-year cycle in which you answer questions on an ongoing basis and receive feedback as you go.
The MOC blueprint is deliberately weighted differently from the certification blueprint: it places less emphasis on rare conditions and more on situations where intervention changes outcomes, and for conditions usually managed by other specialists it focuses on recognition rather than management.
The Royal College examination in Cardiology (Adult) — Canada
The Royal College examination has two components: a written examination and an applied examination.
The written component assesses the knowledge and application of knowledge needed to function unsupervised as a competent cardiologist. Most questions concentrate on the Medical Expert role, but the examination also assesses the other intrinsic CanMEDS roles — Communicator, Professional, Health Advocate, Leader, Collaborator and Scholar. That is a real difference from the ABIM exam, which does not examine those domains as named roles.
The applied component is examiner-led. Stations may present written clinical vignettes, with or without images, followed by questions from the examiner covering diagnostic interventions, therapy, and the natural course of disease. Stations may also require interpretation of videos, diagnostic imaging studies, laboratory investigations and other test results.
Performance is scored with a global rating scale (GRS) suited to each station, focused on your ability to "systematically work through a case, with a focused, rational and efficient approach." The emphasis on approach, not just the final answer, is worth internalising: an examiner can see your reasoning, and a correct answer reached chaotically scores differently from one reached methodically.
Content is based on a blueprint reflecting the Competencies in the Subspecialty of Cardiology (Adult).
For the current number of stations, question counts and session timings, consult the Royal College's own examination format page for Cardiology (Adult), which publishes the specifications for each examination year.
How the two compare
Breadth is similar; the assessment method is not. Both examinations cover the whole of adult cardiology. But ABIM tests entirely in writing, over a long and demanding one and a half days, with a large dedicated block of image interpretation. The Royal College splits assessment between written questions and a live applied component where you explain your reasoning to an examiner.
Preparation should differ accordingly. For ABIM, sustained accuracy over many hours and fluency at ECG and imaging interpretation are decisive. For the Royal College, you additionally need to be able to articulate a structured approach out loud, under questioning.
What they share is the style of the underlying question: a clinical scenario with a single best answer, testing judgement rather than recall. That is the format worth practising in either case.
Preparing for either examination
- Start from the blueprint. ABIM publishes content categories with percentage weightings; the Royal College publishes competencies. Both tell you where the marks are. Revising without them means allocating your time by instinct.
- Train ECG interpretation deliberately. For ABIM this is 48% of an entire half-day component. For the Royal College it appears throughout the applied stations.
- Build imaging fluency. Echocardiograms are 37% of the ABIM image component and coronary angiograms 15%.
- Practise long. Ten hours of multiple-choice in a day is an endurance problem as much as a knowledge one. Sitting full-length blocks in advance is the only way to find out how your accuracy holds up in hour eight.
- Rehearse reasoning aloud if you are sitting the Royal College applied component. Structure is being scored, not only the conclusion.
- Review your errors properly. In a well-built exam the distractors are the common misconceptions — understanding why you were drawn to one teaches more than re-reading the correct answer.
Practise with our question banks
Our interactive exam bank holds 1,666 questions across 25 banks in the single-best-answer, clinical-stem format both examinations use. Each question gives instant feedback, and progress saves so you can work in short sessions.
Particularly relevant:
- General Cardiology Quiz 1 — the first of nine mixed banks drawn from the MedMCQA, MedQA (USMLE) and AMQA open question banks, closest in style to US board questions
- Management of Heart Failure — 230 questions
- Management of Acute Coronary Syndromes — 171 questions
- Management of Valvular Heart Disease — 161 questions
- ECG Test — Acute Coronary Syndromes and the other ECG banks, for the image component
For the underlying content, our knowledge base covers adult cardiology in full, and the clinical calculators cover the risk scores — GRACE, TIMI, CHA₂DS₂-VASc, HAS-BLED and others — that board questions routinely turn on.
Frequently asked questions
Do I need internal medicine certification first?
For ABIM, yes — you must be previously certified in internal medicine by ABIM before certifying in cardiovascular disease.
How long is the ABIM cardiology exam?
One and a half days: approximately ten hours of multiple-choice questions across four two-hour sessions, plus roughly five hours of ECG and imaging cases on a separate day.
How many questions are on the ABIM cardiology certification exam?
240 multiple-choice questions, plus approximately 72 ECG and imaging cases.
What proportion of the ABIM image component is ECG?
48%, with echocardiograms at 37% and coronary angiograms at 15%.
Does ABIM certification expire?
It must be maintained, either through the traditional 10-year MOC examination (220 questions, with UpToDate access during the exam) or the five-year Longitudinal Knowledge Assessment.
Is the Canadian exam oral?
Partly. It has a written component and an applied component; the applied component is examiner-led, with stations built around clinical vignettes and image interpretation, scored using a global rating scale.
Can I use my Canadian fellowship to sit the ABIM exam?
ABIM accepts training accredited by the Royal College of Physicians and Surgeons of Canada and the Collège des médecins du Québec alongside ACGME-accredited programmes. Confirm your specific circumstances with ABIM.
Official sources
- ABIM Cardiovascular Disease exam information
- ABIM Cardiovascular Disease exam content and format
- ABIM exam blueprints
- Royal College — examination format, Cardiology (Adult)
- Royal College — Subspecialty Training Requirements in Adult Cardiology
Requirements and formats are revised periodically. Treat this page as orientation and the boards as the authority.
Training in Europe instead? See our guide to the European Exam in Core Cardiology (EECC).