Cardiology

ECG first, then troponin, then the diagnosis follows

A memory aid for separating unstable angina, NSTEMI and STEMI.

Sit up, oxygen, nitrates, diuretics, and treat the cause

A mnemonic for the immediate treatment of acute pulmonary oedema.

Two of four features: pain, rub, ECG changes, effusion

A memory aid for the diagnosis of acute pericarditis.

Aortic pressure, systemic vascular resistance, ventricular radius and wall thickness

A memory aid for the factors setting ventricular afterload.

Aortic, Pulmonary, Tricuspid, Mitral

A mnemonic for the four cardiac auscultation areas in order.

Daytime average over at least 14 measurements, with lower thresholds

A memory aid for the use and thresholds of ambulatory blood pressure monitoring.

Match the monitoring duration to the frequency of the symptoms

A memory aid for choosing the right rhythm monitoring device.

Three features define typical angina

A memory aid for typical, atypical and non-anginal chest pain.

Adenosine for supraventricular tachycardia, amiodarone broadly, digoxin for rate control

A memory aid for choosing antiarrhythmic drugs by arrhythmia.

ACE inhibitors, calcium channel blockers, thiazides, then spironolactone or beta blockers

A memory aid for the main antihypertensive drug classes and their side effects.

Aspirin blocks thromboxane, clopidogrel blocks ADP, abciximab blocks GPIIb/IIIa

A memory aid for the antiplatelet classes and their targets.

Tearing pain to the back, with unequal pulses

A memory aid for the presentation and classification of aortic dissection.

A wide pulse pressure produces a long list of eponyms

A memory aid for the eponymous peripheral signs of aortic regurgitation.

SAD: Syncope, Angina, Dyspnoea

A mnemonic for the symptoms, signs and severity of aortic stenosis.

Fifth intercostal space in the mid-clavicular line

A memory aid for where the apex beat is normally felt.

Endothelial injury, lipid entry, foam cells, fatty streak, then fibrous plaque

A memory aid for the stages of atherosclerotic plaque formation.

Rate or rhythm, plus stroke prevention, considered separately

A memory aid for rate control, rhythm control and anticoagulation in AF.

Sinoatrial node 60 to 100, atrioventricular junction 40 to 60, ventricle 20 to 40

A memory aid for the intrinsic rates of the cardiac pacemakers.

Chronotropy, inotropy, dromotropy and lusitropy

A mnemonic for the four autonomic actions on cardiac function.

Carotid sinus and aortic arch stretch receptors adjust autonomic outflow within seconds

A memory aid for the short-term regulation of blood pressure.

Hypotension, raised jugular venous pressure, muffled heart sounds

A mnemonic for the three signs of cardiac tamponade.

Cardioselective agents spare beta-2 receptors; non-selective agents do not

A memory aid for the differences between beta blockers.

Cuff size, position, rate of deflation and repetition

A memory aid for measuring blood pressure accurately and its pitfalls.

Blood pressure

The pressure exerted by circulating blood on arterial walls.

Atropine first, then the risk factors for asystole

A memory aid for the management of bradycardia and when pacing is needed.

WiLLiaM MaRRoW: left gives W in V1 and M in V6; right gives M in V1 and W in V6

A mnemonic for distinguishing right from left bundle branch block.

WiLLiaM MaRRoW: W in V1 and M in V6 is left, M in V1 and W in V6 is right

A mnemonic for telling left from right bundle branch block.

All Points Reach Plateau, Restore

A mnemonic for the five phases of the ventricular cardiac action potential.

Two shockable, two non-shockable, and the four Hs and four Ts

A memory aid for shockable and non-shockable rhythms and the reversible causes.

Sympathetic from T1 to T5, parasympathetic from the vagus

A memory aid for the autonomic innervation of the heart.

Both positive is normal; leads pointing away from each other indicate deviation

A memory aid for working out the cardiac axis from leads I and aVF.

Troponin is the standard, rising at 3 to 6 hours and remaining raised for days

A memory aid for the timing of cardiac markers after infarction.

Right border is right atrium; left border is aortic knuckle, pulmonary trunk, left atrial appendage and left ventricle

A memory aid for which chambers form the cardiac silhouette on a chest radiograph.

Sinoatrial node, atrioventricular node, bundle of His, bundle branches, Purkinje fibres

A memory aid for the sequence of the cardiac conducting system.

CT for the arteries, MRI for the muscle

A memory aid for when to use cardiac CT and when to use cardiac MRI.

Atrial systole, isovolumetric contraction, ejection, isovolumetric relaxation, then filling

A memory aid for the seven phases of the cardiac cycle.

Four fibrous rings that anchor the valves, attach the myocardium and insulate atria from ventricles

A memory aid for the functions of the fibrous skeleton of the heart.

Branching striated fibres with central nuclei and intercalated discs

A memory aid for identifying cardiac muscle microscopically.

Cardiac muscle is a functional syncytium with a long refractory period and cannot tetanise

A memory aid for the differences between cardiac and skeletal muscle.

Preload, Rate, Stroke volume, Heart contractility

A mnemonic for the four main determinants of cardiac output.

Cardiac output equals heart rate multiplied by stroke volume

A memory aid for calculating cardiac output and its normal values.

Fick principle, indicator dilution, thermodilution, Doppler and pulse contour analysis

A memory aid for the methods of measuring cardiac output.

Cardiac afferents enter the cord at T1 to T4 and are misattributed to those dermatomes

A memory aid for why cardiac pain is felt in the chest, arm and jaw.

Absolute refractory period prevents tetany; the relative period allows vulnerable re-excitation

A memory aid for the absolute and relative refractory periods of cardiac muscle.

Equalisation of diastolic pressures with impaired filling and pulsus paradoxus

A memory aid for the haemodynamics of cardiac tamponade.

Pressure work is far more costly in oxygen than volume work

A memory aid for the components of cardiac work.

Dilated, hypertrophic and restrictive, each with a distinct physiology

A memory aid for the three types of cardiomyopathy.

Maximum cardiac width divided by maximum thoracic width, normally less than 0.5

A memory aid for measuring heart size on a chest radiograph.

Hands, pulse, face, neck, praecordium, then back and legs

A memory aid for the order of a cardiovascular examination.

Congestive failure, Hypertension, Age, Diabetes, Stroke, Vascular, Age, Sex

A mnemonic for assessing stroke risk in atrial fibrillation.

Chylomicrons carry dietary fat, VLDL endogenous fat, LDL delivers cholesterol, HDL returns it

A memory aid for the lipoprotein classes and their roles.

Acetyl-CoA to mevalonate via HMG-CoA reductase, the rate-limiting step

A memory aid for the cholesterol synthetic pathway and its regulation.

Purkinje fastest, atrioventricular node slowest

A mnemonic for the relative conduction speeds in the heart.

Kussmaul's sign and the y descent separate them

A memory aid for distinguishing constriction from tamponade.

Sympathetic drive and calcium raise it; hypoxia, acidosis and beta blockade lower it

A memory aid for what increases and decreases myocardial contractility.

Dominance is decided by whichever artery gives the posterior descending branch, the right in about 85 per cent

A memory aid for what determines coronary dominance and which artery supplies the conducting nodes.

Local metabolic factors dominate, especially adenosine and hypoxia

A memory aid for what controls coronary blood flow.

The left coronary artery fills in diastole, when the myocardium is relaxed

A memory aid for when the coronary arteries actually fill.

Great, middle and small cardiac veins, posterior vein of the left ventricle and the oblique vein of the left atrium

A memory aid for the veins draining into the coronary sinus.

Dilating already maximally dilated vessels diverts flow away from ischaemic territory

A memory aid for the mechanism of coronary steal.

The five Ts, numbered by the great vessel count

A mnemonic for the cyanotic congenital heart lesions.

Score first, then D-dimer or ultrasound accordingly

A memory aid for the Wells score and the diagnostic pathway for DVT.

Electrocardiogram

A recording of the heart’s electrical activity over time.

II, III and aVF inferior; V1 to V4 anterior; I, aVL, V5 and V6 lateral

A memory aid for which ECG leads look at which part of the heart.

Rate, rhythm, axis, intervals, then the waves in every lead

A memory aid for reading an ECG systematically.

P atrial depolarisation, QRS ventricular depolarisation, T ventricular repolarisation

A memory aid for what each ECG wave and interval represents.

Parasternal, apical and subcostal windows, transthoracic or transoesophageal

A memory aid for the standard echocardiographic views and what they answer.

Hypercalcaemia shortens the QT interval; hypocalcaemia prolongs it

A memory aid for the cardiac effects of calcium disturbance.

Hyperkalaemia gives tall T waves and a wide QRS; hypokalaemia gives flat T waves and U waves

A memory aid for the cardiac effects of hyperkalaemia and hypokalaemia.

Three bipolar limb leads forming a triangle around the heart

A memory aid for the arrangement of the limb leads.

Stroke volume divided by end-diastolic volume, normally over 50 per cent

A memory aid for calculating and interpreting ejection fraction.

Graded exercise with continuous ECG, looking for ischaemic change

A memory aid for the use, endpoints and limits of exercise ECG testing.

Very high cholesterol, tendon xanthomata and a family history of early death

A memory aid for recognising familial hypercholesterolaemia.

The more the ventricle fills, the harder it contracts, within limits

A memory aid for the relationship between ventricular filling and stroke volume.

First degree long PR, second degree some dropped beats, third degree complete dissociation

A memory aid for the degrees of atrioventricular block.

Sympathetic activation, renin-angiotensin activation, and ventricular remodelling

A memory aid for the compensatory mechanisms in heart failure and why they fail.

ACE inhibitor, beta blocker, mineralocorticoid antagonist and SGLT2 inhibitor

A memory aid for the drugs that improve survival in heart failure.

S1 atrioventricular valves close, S2 semilunar valves close, S3 rapid filling, S4 atrial contraction

A memory aid for what produces each of the four heart sounds.

Tricuspid has anterior, posterior and septal cusps; mitral has anterior and posterior

A memory aid for the names of the cusps of each heart valve.

Anaemia, pregnancy, thyrotoxicosis, sepsis, beriberi, Paget disease and arteriovenous fistula

A mnemonic for the causes of a high output circulation.

Heart rate

The number of heart beats per minute.

Raised cardiac output early, raised systemic vascular resistance later

A memory aid for the mechanisms underlying essential hypertension.

End organ damage, not the number, defines the emergency

A memory aid for distinguishing hypertensive emergency from urgency.

Vegetations on damaged valves, with embolic and immune complications

A memory aid for the organisms, valves and complications of endocarditis.

Perfusion falls, then metabolism, then diastolic and systolic function, then ECG changes, then pain

A memory aid for the sequence of events after coronary occlusion.

Jugular venous pressure

A clinical sign used to estimate right atrial pressure.

a, c and v waves with x and y descents

A memory aid for the waves and descents of the jugular venous pulse.

Phase 1 gives systolic pressure and phase 5 gives diastolic

A memory aid for the five phases of the Korotkoff sounds.

Wall stress equals pressure times radius divided by twice the wall thickness

A memory aid for how chamber size and wall thickness affect wall stress.

Left anterior descending and circumflex arteries

A memory aid for the branches of the left coronary artery and the territory they supply.

Left failure causes pulmonary congestion; right failure causes systemic congestion

A memory aid for distinguishing left from right heart failure.

Diastolic pressure plus one third of the pulse pressure

A memory aid for calculating mean arterial pressure.

Myocardial infarction

Myocardial injury caused by ischaemia, commonly known as a heart attack.

A mid-diastolic murmur with an opening snap, almost always rheumatic

A memory aid for the signs and complications of mitral stenosis.

SCRIPT: Site, Character, Radiation, Intensity, Pitch, Timing

A mnemonic for describing a heart murmur completely.

Systolic murmurs come from stenotic outflow or leaking inflow valves, and diastolic murmurs the reverse

A mnemonic for the causes of systolic and diastolic murmurs.

Coagulative necrosis, then neutrophils, macrophages, granulation tissue and scar

A memory aid for the histological evolution of a myocardial infarct.

Heart rate, contractility and wall stress

A memory aid for the determinants of myocardial oxygen consumption.

Stunning follows restored flow; hibernation persists with reduced flow

A memory aid for distinguishing stunned from hibernating myocardium.

Width tells you where it starts, regularity tells you which one

A memory aid for classifying a tachycardia by QRS width and regularity.

Released by stretched myocardium; they oppose the renin-angiotensin system

A memory aid for the actions of atrial and brain natriuretic peptide.

Four classes, graded by the activity that causes symptoms

A memory aid for grading the functional severity of heart failure.

Nitric oxide donation causes venodilatation, reducing preload and wall stress

A memory aid for how nitrates relieve angina.

Phase 4 funny current, phase 0 calcium influx, phase 3 potassium efflux

A memory aid for the three phases of the sinoatrial node action potential.

Transverse sinus behind the great arteries; oblique sinus behind the left atrium

A memory aid for the two pericardial sinuses and their surgical relevance.

Enter at Larrey's point, left of the xiphoid, aiming for the left shoulder at 30 degrees

A memory aid for the subxiphoid approach to the pericardium.

Fibrous pericardium, parietal serous layer, pericardial cavity, visceral serous layer

A memory aid for the layers of the pericardium from outside in.

Janeway lesions, Osler nodes, Roth spots, splinter haemorrhages and clubbing

A mnemonic for the peripheral stigmata of endocarditis.

Venous return, venous tone, blood volume, atrial contraction, heart rate and compliance

A memory aid for the factors setting ventricular preload.

Filling, isovolumetric contraction, ejection, isovolumetric relaxation, traced anticlockwise

A memory aid for the four sides of the ventricular pressure-volume loop.

Hypertension with hypokalaemia, high aldosterone and suppressed renin

A memory aid for the features and investigation of Conn syndrome.

Raised hydrostatic pressure or increased permeability floods the interstitium then alveoli

A memory aid for the mechanisms of pulmonary oedema.

Slow rising in aortic stenosis, collapsing in aortic regurgitation

A memory aid for the abnormal arterial pulse waveforms.

Stroke volume divided by arterial compliance

A memory aid for the determinants of pulse pressure.

Low potassium, magnesium and calcium, plus many drugs, prolong the QT interval

A memory aid for the causes of QT prolongation.

Two pathways, unidirectional block and slow conduction

A memory aid for the three conditions needed for a re-entrant arrhythmia.

Renin, angiotensinogen, angiotensin I, ACE, angiotensin II, aldosterone

A memory aid for the steps of the renin-angiotensin-aldosterone cascade.

JONES for the major criteria, FEAR for the minor

A mnemonic for the Jones criteria for acute rheumatic fever.

Systolic blood pressure

The arterial pressure during ventricular contraction.

Renal, endocrine, vascular and drug causes

A memory aid for the causes of hypertension other than essential.

The four drugs, plus rehabilitation and risk factor control

A mnemonic for the drugs and measures given after an infarct.

Heart rate rises on inspiration and falls on expiration through varying vagal tone

A memory aid for the mechanism of respiratory sinus arrhythmia.

Left ventricular hypertrophy criteria, and the causes of small complexes

A memory aid for high and low voltage on the ECG.

Normal splitting widens on inspiration; wide, fixed and reversed splitting are abnormal

A memory aid for the patterns of S2 splitting and their causes.

Elevation suggests transmural injury; depression suggests subendocardial ischaemia

A memory aid for the significance of ST segment shift.

Statins inhibit HMG-CoA reductase; ezetimibe blocks absorption; PCSK9 inhibitors preserve LDL receptors

A memory aid for the lipid-lowering drug classes.

Vagal manoeuvres, then adenosine, then rate control

A memory aid for the stepwise treatment of a regular narrow complex tachycardia.

About one-third systole and two-thirds diastole at rest

A memory aid for how the cardiac cycle divides between systole and diastole.

PROVe: Pulmonary stenosis, Right ventricular hypertrophy, Overriding aorta, VSD

A mnemonic for the four features of tetralogy of Fallot.

A marker of myocardial injury, not of myocardial infarction

A memory aid for interpreting a raised troponin.

Intrinsic sinoatrial rate is about 100; resting vagal tone brings it down to about 70

A memory aid for the dominance of parasympathetic tone in the resting heart.

Pressure rise, reduced venous return, release, then overshoot

A memory aid for the four phases of the Valsalva manoeuvre.

Stenosis creates a pressure load; regurgitation creates a volume load

A memory aid for the loading conditions produced by each valve lesion.

Sodium blockers, Beta blockers, Potassium blockers, Calcium blockers

A mnemonic for the classes of antiarrhythmic drug.

Rapid filling, diastasis and atrial systole

A memory aid for the three phases of diastolic filling.

Elastic arteries store energy in systole and release it in diastole

A memory aid for the role of aortic elasticity.