www.medinaz.com FIRST EDITION VISUAL MNEMONICS CARDIOLOGY A Mupe @ New drugs highlight MED Fa. Dr. Nazmul AlamCopyright © 2019 by Nazmul Alam. All rights reserved. No part of 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 of the publisher. TERMS OF USE This is a copyrighted work and Medinaz and its licensors reserve all rights in and to the work. Use of this work is subject to these terms. Except as permitted under the Copyright Act of 1976 and the right to store and retrieve one copy of the work, you may not decompile, disassemble, reverse engineer, reproduce, modify, create derivative works based upon, transmit, distribute, disseminate, sell, publish or sublicense the work or any part of it without Medinaz’s prior consent. You may use the work for your own noncommercial and personal use; any other use of the work is strictly prohibited. Your right to use the work may be terminated if you fail to comply with these terms. www.medinaz.comwha Visit for other books < o HIGH-YIELD og ANTIBIOTICS TRAD Data cA© INDEX MEDINAZ © Cardiac Anatomy & Embryology © Cardiac Physiology © Cardiac Pharmacology © Cardiac Pathology © Cardiac Medicine © Cardiac Surgery © Cardiac Drug of choice © Cardiac New drugs highlightCardiac Anatomy & Embryology @NEETPGSURGEONMEDINAZ Heart valves (right to left) “They Pay Me Alcohol” Tricuspid valve Pulmonary semilunar valve Mitral (bicuspid) valve Aortic semilunar valve Aorta development www.medinaz.com fo* on Aorta = Forth Branchial arch LALeft Coronary Artery branches www.medinaz.c 1A COLA” Ant. interventricular artery Circumflex artery Obtuse marginal artery Left diagonal artery Atrial, ant. & post. ventri Right Coronary Artery branches ‘www.medinaz.com Acute marginal artery Post. interventricular ar’ Acute marginal artery Rt. conus artery Nodal artery Atrial, ant. & post. interventricular arterMEDINAZ Cardiac PhysiologyMEDINAZ Cardiac tissue conduction velocity Purkinje System WEDCOME) Atrial “muscle Ventricular muscle Av node ¥ Slowest Auscultation of the heart (where to listen) www.medinaz.com “MAP Tricuspid area” Mitral area Aortic area Pulmonic areaMEDINAZ Heart Sounds Aortic “ All People Enjoy Pulmonic The Meal” Erb’s point Tricuspid Mitral or Apex Murmurs; systolic vs. diastolic PASS — Pulmonic & Aortic Stenosis = Systolic. PAID — Pulmonic & Aortic Insufficiency = DiastolicValve Movement Aortic valve ‘moves Vertically Mitral valve mov Side to Side naz_artonomy& MEDINAZ Cardiac PharmacologyTEDINAZ Drugs used for the t/t of eee in n Pregaancy Cases = (B- blocker Motrén = Methyldopa Care = Clonidine During = Dihydvopyridine Hypertensive = Hydralazine Pregnancy = Prazosin Drugs for Bradycardia and Hypotension i IDEA e I soprenatine DopamineAntiarrythmic class 1A www.medinaz.com TEDINAZ Quinidine Procainamide Disopyramide ims Diso’s Pyramid” Antiarrythmic Class 1B www.medinaz.com “Preferably I Buy Lido’s Mexican Toffee” Phenytoin Lidocaine Mexiletene Tocainide * shorten repolarizationMEDINAZ Antiarrythmic Class IC www.medinaz.com Moricizine “More Fries Please !! I Can eat” Flecainide Propefanone Antiarrhythmic drugs Class III www.medinaz.com Sotalol “So Am i Do” Amiodarone a DofelitideAntiarrhythmic drugs Class III www.medinaz.com MEDINAZ Sotalol Amiodarone Dofelitide Antiarrhythmics potassium channel blockers (class III) “AIDS” Amiodarone Ibutilide Dofetilide Sotalol.TEDINAZ Beta 2 Agonists Salmeterol Metaproterenol Aluterol Ritodrine Terbutaline naz_artonomy Cardioselective Beta-blockers Nebivolol “New Beta Blockers Acting Betaxolol Bisoprolol Acebutolol Esmolol Atenolol Metoprolol CeliprololTEDINAZ Dilated cardiomyopathy Caused by: Doxorubicin Daunorubicin Prevent with: Dexrazoxane Carditis (myocarditis) Contraindicated Increased calcium In Weak HEART” WPW syndrome Hypokalemia & Hypomagi Elderly AV block (partial) Renal failure ‘Thyroid (hyper or hypo)TEDINAZ Hyperglycemia causing Drugs www.medinaz.com Tacrolimus Protease inhibitors “The People Need Niacin Hard Candies” HCT2Z Corticosteroids Hypertension in pregnancy Tit “He Likes Hydralazine My Neonate” Labetalol Methyldopa Nifedipine.MEDINAZ Management of PSVT (Paroxysmal SupraVentricular Tachycardia) Adenosine > Beta (B) blocker > Calcium channel blocker (verapamil) > Digoxin DRUGS CAUSING TORSADES DE POINTES eR Cisapride ey Haloparidol Erythromycin {re Amiodarone, Arsenium| ProcainamideTEDINAZ BETA BLOCKER MEMBERS The ——_» Timolol N ———_, Nadolol = ———. Esmolol P ——__, Pindolol A —_____» Atenolol L ———> Labetalol Prime ——} Propanolol Minister —, Metoprolol Amiodarone Procainamide Arsenium Cisapride Haloperidol ErythromycinMEDINAZ vat Go Ge Adverse Effects of Beta Blockers Bronchoconstriction Bradycardia Arrhythmias Lethargy Disturbance in glucose metabolism Fatigue Insomnia Sexual dysfunction Hypotension Immediate treatment of a4 M => Morphine Q-%" N -> Nifroglyeerine a A = Acebylsalicylic acid @ @TEDINAZ Ventricular Trachycardia treatment L= Lidocaine A= Amiodarone M- Mexiltene/Magresium B = Beta- blocker Supraventricular Tachycardia T/t www.medinaz.com Adenosine Beta blocker Calcium channel blocker Digoxin Excitation (vagal stimulMEDINAZ Cardiac PathologyTEDINAZ Coronary artery disease risk factors Fatty (HyperLipidemia) Smoking Qbesity Family history Type 1 «2 diabetes Hypertension Age Eating too much Fatty sort | Male HAM can cause Cononany arteny disease Causes of new onset Atrial Fibrillation P—Pumonany | l — Ischemic R> Rheumatic A> Atrial MyxomaAcute MI treatment www.medinaz.com Glycerol trinitrate Oxygen Aspirin Cyclomorph “GOA Calling” @. v Aneurysm Types wwiw.medinaz.com “BAD Circulatory MASs” Aortic aneurysm Berry - Arteriovenous fistula Dissecting Capillary micro aneurysm Mycotic Atherosclerotic Syphilitic LATEDINAZ Anti-arrythmics for AV nodes Beta blockers Adenosine Digoxin Verapamil u sine | ane “BAD Ventricle” needs treatment LA * Aortic Dissection risk factors “AB.C” Aortic dissection Atherosclerosis, Ageing, Aortic aneurysm Blood pressure high, Baby (pregnancy) Connective tissue disorders (Marfan’s, Ehlers-danlos), Cystic medial necrosisMEDINAZ Aortic dissection Life threatening complications “AORTIC” Aortic dissection Aortic insufficiency Occlusion of coronary artery Rupture Tamponade Ischemia of viscera CVA Aortic regurgitation causes www.medinaz.com Congenital Rheumatic damage Endocarditis Aortic dissection Aortic root dilation Marfan’sMEDINAZ Aortic regurgitation causes www.medinaz.com ARRIS” Marfans Ankylosing spondylitis Rheumatic fever Rheumatoid arthritis Infective endocarditis Aortic stenosis characteristics www.medinaz.com Syncope “SAD” Angina Dyspnoea ysp' a aa? cMEDINAZ Atherosclerosis risk factors www.medinaz.com BP high : hypertension Age : Middle aged, elderly Diabetes mellitus Sex - male Elevated cholesterol Tobacco “BAD SET of life” Beck’s triad (Cardiac tamponade) www.medinaz.com Distant heart sound Distended jugular veins Decreased arterial pressureMEDINAZ Breast cancer risk assessment www.medinaz.com History (family, previous episode) Abortion / Age (old) Late menopause Obesity “History ALONE” Nulliparity Early menarche Most common 1° cardiac tumor in Adults - Myxoma Most common 1° cardiac tumor in Children - Rhabdomyoma ___—"MARCh ay Myxoma Adults Rhabdomyoma ChildrenMEDINAZ Dilated cardiomyopathy Etiologies www.medifaz.com Alcohol abuse (chronic) Beriberi (wet) Coxsackie B viral myocarditis Cocaine use (chronic Chagas disease Doxorubicin toxici “ABCCD” LA Heart Failure Causes Hypertension Embolism Anemia Rheumatic heart disease Thyrotoxicosis Myocardial infarction Arrhythmia Diet and lifestyle Infection EndocarditisMEDINAZ Bacterial Endocarditis www.medinaz.com Janeway lesions Nail-bed hemorrhage 4 N\ : Osler nodes Bacterial Endocarditis www.medinaz.com Fever ee ” Roth spots FROM JANE Osler nodes Murmur Janeway lesions Roth spots g Anemia Nail-bed hemorrhage Emboli Janeway \\ lesions LK, Osler nodesMEDINAZ Kawasaki Disease www.medinaz.com B/L nonexudative Fever for conjunctivitis 5 days Cervical lym) Mucositis auberry tongue Kawasaki Disease 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 naz_artonomyMEDINAZ KAWASAKI DISEASE Sausage fingers Conjunctival redness Rash «sg Extremity involvement Adenopathy Mucosal erythem: FEVER MI Complications “All Cardiac Patients Suffer TRAP” Arrhythmias Congestive heart failure Pericarditis Shock cariogenic Thromboembolism Rupture Aneurysm cardiac Post myocardial infarction syndrome on www.medinaz.com naz_artonomyMEDINAZ Patau Syndrome “Cc Cleft lip/palate Renal Abnormalities cArdiac defects Mental Retardation, Microcephaly Polydactyly ATAU Syndrome www.medinaz.com Microcephaly rt etardation Undescended 0} abnormal testeTEDINAZ qi? letters = Trisomy 13 oo Syndrome Microcephaly wmnedinaz.com Pericarditis Causes “CARDIAC Collagen vascular disease Aortic dissection Radiation Drugs Infections Acute renal fail Cardiac (MI) Rheumatic fever Injury Neoplasms Dressler syndromeMEDINAZ Right-to-Left shunts: eaRLy cyanosis Left-to-Right shunts: “LateR” cyanosis. waw.medinaz.com Raised JVP 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”MEDINAZ Restrictive Cardiomyopathy (Causes) Hemochromatosis Loffler syndrome Amyloidosis “Heart LASER” Sarcoidosis & = Endocardial fibroel is] a post Radiation — ( ) Restrictive/infiltrative cardiomyopathy wwwemedinaz.com Postradiation fibrosis Loffler endocarditis Endocardial fibroelastosis Amyloidosis Sarcoidosis Hemochromatosis “Puppy LEASH”MEDINAZ Rheumatic Fever (Major criteria) Joint (migratory polyarthritis) ey Carditis Nodules in skin (subcutaneous) = Erythema marginatum LA Rheumatic Fever: Minor criteria CRP Arthralgia row “CAFE PAL” Elevated ESR Prolonged PR interval Anamnesis Rheumatism: LeukocytosisRIGHT-TO-LEFT SHUNTS www.medinaz.com ITruncus arteriosus (1 vessel) n (2. switched vessels) ‘etralogy of Fallot (4 = ‘APVR (5 letters in the n: Right pe. Left Shunt ‘etralogy of fallot cuspid atresia Truncus arteriosus nsposition of great vessels:MEDINAZ = ee Angina precipitating factors Exertion Eating Emotional distress Extreme temperature Immediate treatment of Myocardial — M => Morphine > Nitrogtyce rine OY rn = Acelylsalicylic acid @ @MEDINAZ Secondary Hypertension Causes www.medinaz.com “Pathological Aorta Causes: Secondary Hypertension” Pheochromocytoma Aortic coarctation Cushing syndrome Stenosis of renal arteries Hyperaldosteronism (Conn syn naz_artonomy Syncope causes (CVS) wwamedinaz.com Heart attack Embolism (PE) Aortic obstruction (IHSS, AS or myxoma) Rhythm disturbance, ventricul: Tachycardia “HEART”TEDINAZ Syncope causes (Vascular) wimedinaz.ce Vasovagal Ectopic (reminds one of hypovolemia) Situational Subclavian steal ENT (glossopharyngeal neuralgia) Low systemic vascular resistance (Addison's, diabetic vascular neuropathy) Sensitive carotid sinus “VESSELS” SS Vasculitis Causing Granuloma “This Way Comes Granuloma”, Takayasu arteri is Wegener's granulomatosis Churg Strauss Syndrome, Giant cell arteritisMEDINAZ Tetralogy of Fallot www.medinaz.com ‘Overriding aorta Narrowing of th sR eitar pulmonary valve| Septal defect Narrow opening hypertrophy Tetralogy of Fa ot www.medi Pulmonary infundibular stenosis (most important determinant for prognosis) Right ventricular hypertrophy (RVH) — boot-shaped heart on CXR Overriding aorta vspTurner Syndrome www.medinaz.com development leformityMEDINAZ Cardiac MedicineMEDINAZ Acute Myocardial Infarction Major complications synwemediings.cor Aneurysm LV dysfunction é ss Arrhythmias ALARMS Rupture Mitral regurgitation Septal defect Exertion Eating Emotional distress Extreme temperatureAortic Insufficiency Causes ‘www.medinaz.com Rheumatic heart disease Aneurysm (aortic) Dissection (aortic) Congenital aortic valve disease fypertension “RAD CHEMISTS” Endocarditis Marfan's & other collagen vascular diseases Iatrogenic (e.g. LHC) Systemic disease (SLE, Ankylosit spondylitis) ‘Trauma to chest Sedation (before paralysis) CHF: causes of exacerbation www.medinaz.com Forgot medication Arrhythmia/ Anaemia “FAILURE” Ischemia/ Infarction/ Infection Lifestyle: taken too much sal Upregulation of CO: pregnanet hyperthyroidism Renal failure Embolism: pulmonaryCXR findings in Aortic Dissection www.medinaz.com “WEEDS are Bad Widened mediastinum Effusion (plural) Effusion (pericardial) Dilated aortic arch Separation of intimal calcificatti Blurring of aortic contour Diastolic Heart failure causes www.medinaz.com Aortic stenosis Pericardial disease Age “A PAIR of Heart” Ischemic heart disease Restrictive cardiomyopatht HypertensionECG: left vs. right bundle block www.medinaz.com 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” Heart blocks ‘www.medinaz.com If the R is far from P, then you have a First Degree. Longer, longer, longer, drop! Then you have a Wenkebach. if some P's don't get through, then you have Mobitz Il If P's and Q's don't agree, then you have a Third Degree. easJVP wave form w.medinaz.cony Atrial contraction om Systole (ventricular contraction) | ¢ ” Klosure (closure) of tricusps, so ASK ME atrial filling Maximal atrial filling Emptying of atrium LV Aneurysm Clinical Presentation “Enlarged Ventricular ”MEDINAZ MI: therapeutic treatment Oxygen Beta blocker ASA Thrombolytics (e.g. heparin) “O BATMAN” Morphine Ace prn Nitroglycerin Risk factors for Acute Aortic Syndrome “BACKACHES” Bicuspid aortic valve Atherosclerosis Connective tissue disorder Known aneurysm Arteritis Cocaine and Crack Hypertension Expecting (pregnancy) Surgery (cardiac)MEDINAZ Pulmonary Hypertension causes Embolism Congenital Heart Disease Left heart disease Inherited (e.g. BMPR2, ALK1) Pulmonary disease (COPD, OSA) Toxin or drug-induced “ECLIPTIC” Iatrogenic or multifactorial Connective tissue disorder ST elevation in ECG’S causes www.medinaz.com “ELEVATION” 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 LATreating Congestive Heart Failure www.medinaz.com UNLOAD FAST” Upright position Nitrates (low dose) Lasix Oxygen Aminophylline Digoxin Fluids (decrease) Afterload (decrease) Sodium restriction Test (DIG level, ABGs, Potassium leva Ventricular Arrhythmia causes www.medinaz.com Drug (cocaine, meth) Idiopathic Long QT syndrome Electrolyte abnormalities (k,Mg) Coronary Ischemia (active) Overexertion Surgery (esp cardiac) Myopathy (Cardiomyopathy) Infarct (sear) Congenital (brugada, ARVO) Myocarditis Medications (pro-arrhythmic) Alcohol to excess “COSMIC DILEMMA”MEDINAZ Cardiac SurgeryCauses of Postop Electromechanical Dissociation ‘www.medinaz.com Hypothermia Electrolytes Acidosis “HEARTBEAT” Reduced oxygenation Tamponade Blood volume decreased Embolism (pulmonary) Anaphylaxis Tension PTX Causes of Tachycardia after Surgery www.medinaz.com Cardiogenic shock Oxygenation poor Malignant hyperthermia Bleeding Anemia “COMBATIVE” Temperature elevated Inotropes Volume deficit Emotion and pailComplications after Aortic valve replacemen Thromboembolism AV block Mismatch (PPM) Perivalvar leak “TAMPONADE” Obstruction of coronary artery Neurologic deficits Abscess Dysfunction of valve leaflets Endocarditis Depressed ventricular function Unstable angina ‘Stenosis of the left main stem Triple vessel diseaseMEDINAZ ations for Operating on a Type B Dissection TEVAR expertise Effusion-Left pleural “TEAR’EM” Aneurysmal dilation Refractory pain Extension Proximally Malperfusion syndrome stage heart failure Anemia (Hot <35%) Sodium <136 mmol/L “DASHBOARD” Hospitalisation for HF within past 6 months BiV non responder One-block or less DOE oom ii ACEI/ARB/Beta blocker intolerance "=H // Renal dysfunction (BUN >40, Cr > 1.8) Diuretic resistance (e.g. lasix > 120 mg/d)MEDINAZ Major complications of Heart surgery www.medin: Stroke Kidney failure Infection Rhythm disturbances “SKIRMISH” Myocardial ischemia or Infarction _ Inflammatory state (SIRS) Gia Shock Haemorrhage or tamponade Major Complications after Heart Surgery www.medinaz.com Haemorrhage Myocardial ischemia or infraction Rhythm disturbances Infection Inflammatory state (SIRS) Stroke, Shock Kidney failureOptimizing RV Function www.medinaz.com TEDINAZ “CHAMPIONS” C02 (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) Reasons for Urgent CABG (Coronary Artery Bypass Graft) ad “VAPORISE” Anatomy (e.g. Tight LM) Papillary muscle rupture Ongoing angina Rupture of LV free wall IABP dependence Shock Evolving MITEDINAZ Sites to search bleeding during Reexploration Epicardial wire sites wz 5 Neck region ENIGMATIC IMA bed Grafts * Marrow Anastomoses Tube entry sites Incisions (heart) i Cannulation sites _ i. Surgical indications for Endocarditis Prosthetic Heart failure Abscess Sepsis, uncontrolled Embolisation Size of vegetation w.medinaz.com “PHASE”MEDINAZ Drug of choicex; Cardiovascular system MEDINAZ Angina acute attack — Sublingual nitroglycerine Long term prophylaxis in stable angina — Beta blockers Aortic dissection — Labetalol Arterial fibrillation and flutter — Acute attack — IV Ibutilide Rhythm control — Amiodarone Rate control — Beta blockers Anticoagulation in Atrial fibrillation — Dabigartan, Apixaban Acute CHF first drug of choice — Furosemide Acute CHF Inotrope of choice — Dobutamine Chronic CHF — ACE inhibitors / ARBs Hypertriglyceridemia — Fibrates Chylomicronemia syndrome — Fibrates Type Ill hyperlipoproteinemia — Fibrates Hypercholesterolemia — Statins Hypertension first line drugs — ACE inhibitors, ARB, CCB Resistant hypertension — Aldosterone antagonists Hypertension in elderly — CCB Hypertension in young patients - ACE inhibitors / ARBs PSVT — IV Adenosine PSVT prophylaxis — Verapamil or beta blockers Anaphylactic shock — Epinephrine Cardiogenic shock — Norepinephrine or Dopamine Septic shock — Norepinephrine Vasodialatory shock — Norepinephrine SVT treatment & prophylaxis — Verapamil SVT associated CHF — Digoxin Torsades de pontes — Magnesium sulphate Ventricular extrasystole (symptomatic) — beta blockers Ventricular fibrillation — Amiodarone Ventricular trachycardia in MI and digitalis toxicity — Lidocaine WPW syndrome — IV procainaiNew DrugsNew cardiovascular drugs Wvabridine MOA ~ Inhibits current in SA node that decrease it’s automaticity and myocardial oxygen consumption USE - Decrease in oxygen demand is beneficial for Angina CHE ngrelor 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 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 — Anti PCSK-9 Ab USE - Hyperlipidemia