Visual Mnemonics Cardiology [1 ed.]

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FIRST EDITION

www.medinaz.com

VISUAL MNEMONICS

C A R D IO LO G Y

• 100+ Mnemonics $ Drug of choice £

MED

Mew drugs highlight

Dr. Nazmul Alam

Copyright © 2019 by Nazmul Alam. All rights reserved. No part o f this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission o f the publisher.

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R eferences and updates from Goodman Gilm an’s 13/o, Katzung & Trevor Irevor 13/e, Harrison's 19/e, CMDT 2018 & Standard journals

DR. NAZMUL ALAM

w w w .m edinaz.com

FIRST EDITION

VISUAL MMEMOHICS Microbiology

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DR. HIMEL MONDAL

FIRST EDITION

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INDEX

O Cardiac Anatomy & Embryology C Cardiac Physiology

O Cardiac

Pharmacology

C Cardiac Pathology

O Cardiac

Medicine

C Cardiac Surgery C Cardiac Drug of choice C Cardiac New drugs highlight

MEDINAZ

C a rd ia c A n a to m y & E m b ry o lo g y

@NEETPGSURGEON

MEDINAZ

A o rta d e v e lo p m e n t www.medinaz.com

© -I®

£orta = Forth Branchial arch _________________________________________________________ &.

M E D 1 MA Z

Left Coronary Artery branches www.medinaz.com MEDINAZ

;i a

co

Ant. in te rv e n tric u la r a rte ry Circumflex a rte ry Obtuse marginal a rte ry Left diagonal a rte ry A tria l, ant. &. post, v e n tric u la r

Right Coronary Artery branches www.m edinaz.com

£cute marginal artery Post, interventricular artery £cute marginal artery Rt. conus artery Modal artery Atrial, ant. 8c post, interventricular artery

________________________________ ©- age

MEDINAZ

Cardiac Physiology

Cardiac tissue conduction velocity

P u p k in je System

Atr>/dL vnuscLe ven-hmcuLar3 muscLe A Av 77ode

A u scu ltatio n o f th e h e a rt (where to listen)

www.medinaz.com

“M$P 1 ricuspid area” M itra l area A o rtic area Pulmonic area T ricu sp id area

Heart Sounds www.medinaz.com MEDINAZ

A o rtic “£ll People Enjoy

Pulmonic

The Meal”

E rb ’s point T ricu sp id M itra l or

■

E

D I

N A Z

Murmurs; systolic vs. diastolic www.medinaz.com

PASS —»Pulmonic & Aortic Stenosis = Systolic.

PAID —»Pulmonic & Aortic Insufficiency = Diastolic __________________________________________________________

MEDINAZ

Valve Movement / X o v ’fic vdl\/ = M e tKyLdopa = C L o n i dine

During » D!hydr>opy™dine HypeY’ t-eMsive = Hydr> ErnboLi

S —>S e p s is

Myxom s

Acute Ml treatment www.medinaz.com

Glycerol trin itra te Oxygen Aspirin Cyclomorph

_______________________ »- 'g*

“GOA Calling”

Aneurysm Types www.medinaz.com

“B$D Circulatory M£Ss” Aortic aneurysm Berry Arteriovenous fistula Dissecting Capillary micro aneurysm Mycotic Atherosclerotic Syphilitic ___________________________________________________ g). > .-

Anti-arrythmics for AV nodes www.medinaz.com MEDINAZ

Beta blockers Adenosine Digoxin Verapamil

u

B£D Ventricle

needs treatment

Aortic Dissection risk factors www.medinaz.com

Atherosclerosis, Ageing, Aortic aneurysm Blood pressure high, Baby (pregnancy) Connective tissue disorders (Marfan’s, Ehlers-danlos), Cystic medial necrosis ____________________

M K D I »

A X

A o rtic dissection Life threatening complications www.medinaz.com

MEDINAZ

“AORTIC” Aortic A ,dissection , A o rtic in s u ffic ie n c y O c clu s io n o f c o ro n a ry a r te r y R u p tu re am ponade Is c h e m ia o f v is c e ra CVA ________________________________________________ ft-J

A o r tic re g u rg itatio n c a u s e s www.medinaz.com

“C R E A M ” Congenital Rheumatic damage Endocarditis A o rtic dissection A o rtic root dilation M a rfa n ’s _______________________________________ 9 -««S

M E D I »

A Z

Aortic regurgitation causes www.medinaz.com

MORRIS Marfans Ankylosing spondylitis Rheumatic fever Rheumatoid arthritis Infective endocarditis Syphilis _________________ e

Aortic stenosis characteristics www.medinaz.com

Syncope Angina Dyspnoea _________________©- was

M E

D I

M A Z

55

Atherosclerosis risk factors www.medinaz.com

BP high : hypertension £ge : Middle aged, elderly Diabetes mellitus Sex - male Elevated cholesterol Tobacco

I---------------- -B/\D SET o f life ”

Beck’s triad (Cardiac tamponade) www.medinaz.com

Distant heart sound Distended jugular veins Decreased arterial pressure

Breast cancer risk assessment www.medinaz.com MEDINAZ

History (family, previous episode) Abortion / Aqe. (old) Late menopause

“History 410NE”

Obesity Nulliparity Early menarche

M ost com m on 1° ca rd ia c tumor in Adults - Myxoma Most common 1° cardiac tumor in Children - Rhabdomyoma

( i t * /\ t—*

i

www.medinaz.com

Myxoma Adults Rhabdomyoma Children

■

S D I ■ A X

Dilated cardiomyopathy Etiologies www.medinaz.com

MEDINAZ

Alcohol abuse (chronic) B eriberi (wet) Coxsackie

B

viral m yocarditis

Cocaine use (chronic) Chagas disease Doxorubicin to x icity a. U&S

“ ABCCD”

Heart Failure Causes H ypertension Em bolism A nem ia R heum atic heart d ise a se T h y ro to x ico sis M yocard ia l infarction Arrhythm ia Diet and lifestyle Infection E n d o ca rd itis

0,^

"heart MA DIE"

Bacterial Endocarditis www.medinaz.com MEDINAZ

Fever Roth spots

Janeway

Nail-bed hemorrhage

Osier nodes

Bacterial Endocarditis www.medinaz.com

Fever Roth spots

“FROM JANE”

Osier nodes Murmur Fever

Janeway lesions

Roth spots

Anem ia Nail-bed hemorrhage Janeway

Emboli

lesions

Osier nodes E

D

I

N A X

Kaw asaki Disease I www.medinaz.com MEDINAZ

B /L nonexudative Fever fo r

conjunctivitis

5 days Mucositis

Cervical lymph

Strawberry tongue

node > 1.5cm

Red lip

Coronary a rte ry

Rash

aneurysm

Swelling &./or erythema

Usually child < 5 years

of palms/soles

naz_artonomy

K a w a s a k i D is e a s e

www.medinaz.com

Apply “Warm CREAM” in Kawasaki disease

Warm = Fever >5 days C = Conjunctivitis (non-exudate) R = Rash E = Edema / Erythema of hands &. feet A = Adenopathy cervical M = Mucositis, strawberry tongue

K A W A S A K I D IS E A S E MEDINAZ S a u sag e fingers C on ju nctival redness

Rash

“SCREAM Fever”

Extrem ity involvem ent A denopathy

A

M u co sa l erythem a FEVER

\

V

o -^ i

Ml Complications Arrhythmias Congestive heart failure Pericarditis Shock cariogenic Thromboembolism Rupture Aneurysm cardiac Post myocardial infarction syndrome w w w .m edinaz.com

naz_artonomy

“All Cardiac Patients Suffer TR AP”

Patau Syndrome MEDINAZ

((

CRAM P

C le ft lip /p a la te R e n a l A b n o r m a lit ie s c A r d ia c d e fe c t s M e n ta l R e ta rd a tio n , M ic r o c e p h a ly P o ly d a c t y ly

PATAU Syndrom e www.medinaz.com

Microcephaly Mental retardation Sv

cleft lip / palate c

^

malformed ears Cardiac defects

Renal problems

polydactujly or extra fingers Undescended or abnormal testes

Rocker bottom foot

jj

t

^

MEDINAZ

It

13 letters = Trisomy 13

PATAU S yndrom e www.medinaz.com

Microcephaly Mental retardation cleft lip / palate2 i< J

^ -

'

■—

\s 's

v N

malformed ears

Cardiac defects

j

y

vi

polydactyly or extra fingers Rocker bottom foot

P e rica rd itis C www.medinaz.com auses Collagen vascular disease Aortic dissection Ra d i a t i o n Drugs Infections Acute renal failure Cardiac (MI) Rheumatic fever In j u r y Neoplasms Dressier syndrome

“ C A R D IA C RIN D ”

MEDINAZ

Right-to-Left shunts: eaR Ly cyan o sis Left-to-Right shunts: “Late R ” cyanosis. www.medinaz.com

Raised JV P differential www.medinaz.com Pericardial effusion Quantity of fluid raised (fluid over load) Right heart failure Superior vena caval obstruction Tricuspid stenosis Tricuspid regurgitation Tamponade (cardiac

“ PQRST”

M E D I N A Z

Restrictive Cardiomyopathy (Causes) www.medinaz.com MEDINAZ

Hemochromatosis Lo ftie r syndrome Amyloidosis

“Heart 14 SER”

S arcoidosis Endocardial fib ro e la sto sis post Radiation _____________________________ ©-^3

R e s t r ic t iv e / in f ilt r a t iv e c a r d io m y o p a t h y www.medinaz.com

Postradiation fibrosis Loftier endocarditis Endocardial fibroelastosis Amyloidosis Sarcoidosis Hemochromatosis ____________________________Q-

■

K O I ■ A ft

Puppy LEASH

Rheumatic Fever (Major criteria)

www.medinaz.com

MEDINAZ

J o i n t ( m ig r a t o r y p o ly a r t h r it is )

Carditis N o d u le s in s k in ( s u b c u t a n e o u s )

Erythema marginatum Sydenham chorea

Rheumatic Fever: Minor criteria www.medinaz.com

CRP Arthralgia Fever Elevated ESR Prolonged PR interval Anamnesis Rheumatism Leukocytosis ----------------------------------SjfflS

“ CAFE PAL”

RIGHT-TO-LEFT SHUNTS www.medinaz.com MEDINAZ

U Truncus arteriosus (1 vessel)

5 T ’s

5?

Transposition (2 switched vessels) Tricuspid atresia (3 = Tri) Tetralogy of Fallot (4 = Tetra) T£P\/R (5 letters in the name)

E

D

I

N

A

Z

Right to Left Shunt

4'r

Tetralogy of fallot Tricuspid atresia Truncus arteriosus Transposition of great vessels

MEDINAZ

Angina precipitating factors E 's

V L xertion r d tin g

E-motional, distress Extreme

temperature

Im m ediate trea tm e n t of M yocardial Infarctio n

O x y < f"

Nitrocjlyce r>in e Qfo

"¥^AcetylSdlicyl''C add $ q

Secondary Hypertension Causes www.medinaz.com

“Pathological A o r t a Causes Secondary H ypertension”

Pheochromocytoma A ortic coarctation Cushing syndrome Stenosis of renal arteries Hyperaldosteronism (Conn syndrome) (8-na

naz_artonomy

S y n c o p e c a u s e s (CVS) www.medinaz.com

Heart attack Embolism (PE) Aortic obstruction (IHSS, AS or myxoma) Rhythm disturbance, ventricular Tachycardia

u H

■ K Q I M A X

E

A

R

T

Syncope causes (Vascular) www.medinaz.com MEDINAZ Vasovagal Ectopic (reminds one of hypovolemia) Situational Subclavian steal ENT (glossopharyngeal neuralgia) Low systemic vascular resistance (Addison's, diabetic vascular neuropathy) Sensitive carotid sinus

______________________________ £>-aa

“VESSELS”

Vasculitis Causing Granuloma This Way Comes Granulom^ Takayasu arteritis Wegener’s granulomatosis Churg Strauss Syndrome Giant cell arteritis

■

s

o

i

m

a

x

t

Tetralogy of www.medinaz.com Fallot

^

MEDINAZ

Overriding aorta

Narrowing o f pulmonary value

d efect

Marrow to lungs

Right ventricular hypertrophy

Tetralogy of www.medinaz.com Fallot Pulmonary infundibular stenosis (most im p o rta n t determ inant fo r prognosis) Right v e n tric u la r h y p e rtro p h y (RVH) — boot-shaped h e a rt on CXR O verriding a o rta

“PROVe”

VSD O verriding a o rta

Narrowing of pulmonary valve

Narrow openings to lungs

Right ventriculai hypertrophy ■

E

O

1 M A

Z

defect

h MEDINAZ

Cardiac Medicine

A cute Myocardial Infarction www.medinaz.com

M a jo r c o m p lic a t io n s Aneurysm LV dysfunction Arrhythmias

ALARMS

Rupture Mitral regurgitation Septal defect

Angina Precipitating Factors

www.medinazscom

4 E’s Exertion Eating Emotional distress Extreme temperature

M B D I M A Z

&

A o rtic In su fficien cy C a u s e s www.medinaz.com MEDINAZ

Rheumatic heart disease Aneurysm (aortic) Dissection (aortic) Congenital a ortic value disease Hypertension

“ R A D CHEMISTS”

Endocarditis M arfan’s &. other collagen vascular diseases Iatrogenic (e.g. LHC) Systemic disease (SLE, Ankylosing spondylitis) Trauma to chest Sedation (before paralysis)

o

i

a

a

z

CHF: ca u se s of www.medinaz.com

F o rg o t m edication A r r h y th m ia / Anaem ia Is c h e m ia / In fa r c t io n / In fe c tio n L ife s ty le : ta k e n to o much s a lt U p re g u la tio n o f CO: pre gn a n cy, h y p e rth y ro id is m Renal fa ilu re Embolism: pulm onary

FAILURE

CXR findings in Aortic Dissection www.medinaz.com

“WEEDS are Bad Widened mediastinum

for heart”

Effusion (plural) Effusion (pericardial) Dilated aortic arch Separation of intimal calcification Blurring of aortic contour

Diastolic Heart failure causes www.medinaz.com

A o rtic stenosis Pericard ial disease

Age

“ A PAIR o f H eart

Ischemic heart disease R estrictive cardiomyopathy Hypertension

M E D I ■ A Z

ECG: left vs. right bundle block www.medinaz.com MEDINAZ W pattern in V1-V2 and M pattern in V3-V6 is Left bundle block. M pattern in V1-V2 and W in V3-V6 is Right bundle block.

“WilliaM MaRRoW”

H eart blocks www.medinaz.com

If the R is fa r from P, then you have a F irs t Degree. Longer, longer, longer, d ro p! Then you have a Wenkebach. if some P's don't get through, then you have M o b itz II. If P's and Q’s don't agree, then you have a T h ird Degree. ____________________________________________________________ ft

JVP wave form www.medinaz.com

MEDINAZ

A tr ia l c o n tra c tio n S y s to le (v e n tric u la r c o n tra c tio n ) K lo sure (closure) o f tric u s p s , so

U

ASK ME

a tr ia l fillin g M axim al a tr ia l fillin g E m ptying o f a triu m _____________________________ tQ-Ng

M E

D

t

K A Z

LV Aneurysm Clinical Presentation

www.medinaz.com

“ Enlarged Ventricular --------------- C A R - ----VT Embolism &. Thrombus CHF Angina Rupture

Ml: therapeutic treatment www.medinaz.com MEDINAZ

Oxygen Beta blocker

“0 BATM AN ”

ASA Throm bolytics (e.g. heparin) Morphine A c e prn

N itroglycerin

M e

D I K A X

R is k f a c t o r s fo r A c u t e A o r t ic S y n d r o m e www.medinaz.com

“ BACKACH ES” Bicuspid aortic value Atherosclerosis Connective tissue disorder Known aneurysm Arteritis Cocaine and Crack Hypertension Expecting (pregnancy) Surgery (cardiac) ri&

M E D

1

M A X

Pulmonary Hypertension causes www.medinaz.com

t ^ MEDINAZ

Embolism Congenital Heart Disease Left heart disease Inherited (e.g. BMPR2, ALK1) Pulmonary disease (COPD, OSA)

“ECLIPTIC”

Toxin or drug-induced Iatrogenic or multifactorial Connective tissue disorder ______________________________ Ol

S T elevation in E C G ’S c a u s e s www.medinaz.com

“ELEV A TIO N ” Electrolytes LBBB (left bundle branch block) Early repolarisation Ventricular hypertrophy Aneurysm Treatment — pericardiocentesis Injury (acute myocardial infarction, contusion) Osborne waves (in hypothermia) Non-occlusive vasospasm &

Treating Congestive Heart Failure www.medinaz.com t ^ MEDINAZ U pright position

"U n l o a d

fast

N itra te s (low dose) Lasix Oxygen Aminophylline Digoxin

Fluids (decrease) A fte rlo a d (decrease) Sodium re s tric tio n Test (DIG level, ABGs, Potassium

Ventricular Arrhythmia causes www.medinaz.com

Coronary Ischemia (activ/e) Overexertion Surgery (esp cardiac)

Drugs (cocaine, meth) Idiopathic Long QT syndrome Electrolyte abnormalities (k.Mg)

Myopathy (Cardiomyopathy) Infarct (scar) Congenital (brugada, ARVD)

Myocarditis Medications (pro-arrhythmic) Alcohol to excess

“COSMIC DILEMMA”

MEDINAZ

Cardiac Surgery

C a u s e s o f P o sto p E le c t r o m e c h a n ic a l D is s o c ia tio n

www.medinaz.com MEDINAZ

Hypothermia Electrolytes Acidosis

U

H E A R T B E A T

Reduced oxygenation Tamponade Blood volume decreased Embolism (pulmonary) Anaphylaxis Tension PTX 0 "as

O

I

M A Z

C a u s e s o f T a c h y c a r d ia a f t e r S u r g e r y www.medinaz.com

Cardiogenic shock Oxygenation poor Malignant hyperthermia Bleeding Anemia Temperature elevated Inotropes Volume deficit Emotion and pair^

C D I N A Z

u

COMBATIVE”

C o m p licatio n s a fte r A o rtic valv e re p la c e m e n t www.medinaz.com MEDINAZ Thromboembolism AV block M ism atch (PPM)

“TAMPONADE”

P e riv a lv a r leak O b s tru c tio n o f c o ro n a ry a r te r y N eurologic d e fic its Abscess D ysfu n ctio n o f value le a fle ts E n d o c a rd itis Q-Nr*

M E D I N A Z

C o r o n a r y a r t e r y b y p a s s g raft: in d ic a t io n s www.medinaz.com

Depressed ventricular function Unstable angina Stenosis of the left main stem Triple vessel disease

M E D I N A Z

i“ DUST”

Indications for Operating on a Type B Dissection www.medinaz.com MEDINAZ

T E V A R expertise

“TEA R ’EM”

Effusion-left pleural Aneurysmal dilation Refractory pain Extension Proximally Malperfusion syndrome ____________________________>;■MS

“DASHBOARD” for LVAD Referral www.medinaz.com

D stage heart failure Anemia (Hct 1.8) Diuretic resistance (e.g. lasix >1 2 0 mg/d)

HoortMalo IILVAS System Controllor D I

M A Z

Major complications of Heart surgery www.medinaz.com MEDINAZ S troke Kidney fa ilu re Infection Rhythm disturbances

“SKIRMISH”

M yocardial ischemia o r In fa rc tio n Inflam m atory s ta te (SIRS) Shock Haemorrhage o r tamponade

M E

D I

K A Z

M a jo r C o m p lic a t io n s a ft e r H e a r t S u rg e ry www.medinaz.com

H a e m o rrh a g e M yo card ial isch e m ia or in frac tio n Rhythm d istu rb an ces In fec tio n In fla m m a to ry s ta te S tro ke, Shock K idney fa ilu re _____________________ ©- IjM ll

“High Myocardia R IS K ”

Optimizing RV Function www.medinaz.com MEDINAZ

“C H AM P IO N S” CO2 (blow off) Heme (optimize Hgb) Acid-base (correct acidosis) MCS (if all else fails) Paralyse (after sedation) Inotropes (esp milrinone) Oxygenate Nitric oxide Sedation (before paralysis)

R easo n s fo r U rg e n t CABG (Coronary A rtery Bypass Graft)

VSD

“ V A PO R IS E ”

Anatomy (e.g. Tight IM) Papillary muscle rupture Ongoing angina Rupture of LV free wall IABP dependence Shock Evolving MI 19-

M E D I N A Z

www.medinaz.com

S ites to search bleeding during R eexploratio n www.medinaz.com MEDINAZ

Epicardial wire sites Meek region

“ENIGMATIC”

IMA bed Grafts Marrow Anastomoses Tube entry sites Incisions (heart) Cannulation sites

Surgical indications for Endocarditis www.medinaz.com

Prosthetic Heart failure Abscess Sepsis, uncontrolled Embolisation Size of vegetation

“ PH4SE”

Cardiovascular system MEDINAZ Angina acute a tta c k — Sublingual n itro g ly c e rin e Long term p ro ph yla xis in stable angina — B eta blockers A o rtic dissection — Labetalol A rte ria l fib rilla tio n and flu tte r — Acute a tta c k — IV Ibutilide Rhythm c o n tro l — Amiodarone Rate co n tro l — Beta blockers A nticoagulation in A tria l fib rilla tio n — D abigartan, Apixaban Acute CHF f i r s t drug o f choice — Furosemide Acute CHF In o tro p e o f choice — Dobutamine Chronic CHF — ACE in h ib ito rs / ARBs H ype rtrig lycerid e m ia — Fibrates Chylomicronemia syndrome — Fibrates Type III hyperlipoproteinem ia — Fibrates H ypercholesterolem ia — S ta tin s H ypertension f ir s t line drugs — ACE in h ib ito rs , ARB, CCB R e sista n t hypertension — A ldosterone a n ta g on ists H ypertension in elderly — CCB H ypertension in young p a tie n ts - ACE in h ib ito rs / ARBs PSVT — IV Adenosine PSVT p ro ph yla xis — Verapamil o r beta blockers A na ph yla ctic shock — Epinephrine Cardiogenic shock — N orepinephrine o r Dopamine S e p tic shock — Norepinephrine V a so dia latory shock — N orepinephrine SVT tre a tm e n t &. p ro ph yla xis — Verapamil SVT associated CHF — Digoxin Torsades de pontes — Magnesium sulphate V e n tric u la r e x tra s y s to le (sym ptom atic) — beta blockers V e n tric u la r fib rilla tio n — Amiodarone V e n tric u la r tra c h y c a rd ia in MI and d ig ita lis to x ic ity — Lidocaine WPUJ syndrome — IV procainam ide

« t ^ MEDINAZ

New Drugs

New cardiovascular drugs Ivabridine MOA - Inhibits current in SA node that decrease it's automaticity and myocardial oxygen consumption USE - Decrease in oxygen demand is beneficial for

Angina CHF Cangrelor MOA - P2Y12 platelet receptor inhibitor that blocks ADP - induced platelet activation and aggregation USE - Antiaggregant Vorapaxar MOA - Protease Activating Receptor -1 (PAR -1) antagonist, which inhibits thrombin

induced and thrombin receptor agonist peptide (TRAP) - induced platelet aggregation USE - Antiaggregant Riocieuat MOA - Soluble guanylate cyclase stimulator, which increase cGMP and cause vasodialation USE - Pulmonary artery hypertension Mipomersen sodium MOA - Inhibits ApoB - 100 protein and decrease LDL production USE - Homozygous familial hypercholesterolemia Macitentan MOA - Endothelial receptor agonist USE - Pulmonary artery hypertension Lomitapide MOA - Microsomal triglyceride transport protein (MTP) inhibitor

USE - Homozygous familial hypercholesterolemia Icosapent MOA - Decrease VLDL synthesis and secretion USE - Hypertriglyceridemia Sacubitril MOA - Inhibits Neutral endopeptidase USE - Chronic CHF along with ARBs Omapatrilat MOA - Vasopeptidase inhibitor USE-Chronic CHF Evolocumab MOA -A n ti PCSK-9 Ab USE - Hyperlipidemia