Pathological Conditions and Their Manifestations, Lecture notes of Medicine

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Cardiac Pathology: Chapter 1.2 Stable Angina, Vasospastic Angina, ACS Rupture at the Stables

1. "70"-shaped tongs : fixed coronary plaques causing >70% stenosis will present clinically ( stable angina )
2. Clutching chest over anvil : stable angina ( predictable episodes chest pain and pressure worse with exertion)
3. Plaques secured above stable : stable fixed atherosclerotic plaques cause stable angina (predictable symptoms)
4. Dark spot on inner horseshoe surface : stable angina involves transient subendocardial ischemia
5. Tired blacksmith with armor on left arm : typical symptoms of stable angina include chest pressure/pain which can radiate to left arm and chin, diaphoresis and dyspnea (elderly diabetic, female pts may have minimal atypical sx)
6. Relaxing on nitro crate : stable angina is relieved with rest or nitroglycerine (usually <30 min)
7. Sleeping stable boy : vasospastic (Prinzmetal) angina symptoms occur at rest, more commonly at night
8. Twisted red sleeve : vasospastic angina is caused by transient coronary vasospasm
9. Startled awake: the paroxysmal vasospasm seen in vasospastic angina is likely due to smooth muscle hyper-reactivity in the coronary artery wall
10. Plaque mounted above stable: paroxysmal vasospasm seen in vasospastic (prinzmetal) angina common occurs over a stable atherosclerotic coronary plaque (may occur in disease free vessels)
11. Relaxing on nitro box: nitroglycerin improves symptoms of vasospastic angina
12. "Calci-Yum" icecream: calcium channel blockers are the 1st-line therapy for long term management of vasospastic (prinzmetal) angina (vasodilated and ↓spasticity)
13. Smoker : cigarette smoking is a major risk factor for prinzmetal angina (encourage pts to quite)
14. Sumo stable manager with cocoa kid: sumatriptans and sympathomimetic agents (e.g. cocaine, amph) can precipitate vasospastic angina
15. Ruptured stable : plaque rupture
16. Thrombotic hay released toward home plate : atheromatous plaque rupture lead to exposure of thrombogenic substances (ie. Tissue factor, Collagen) → platelet and coagulation pathway activation → luminal thrombus formation
    17. Repairing ruptured fence: plaque rupture is quite common (repeated cycles of plaque disruption and repair are usually subclinical! )
    18. "ACS" horse rupture : acute coronary syndrome (ACS) includes unstable angina, NSTEMI, STEMI (destabilized coronary plaque → occlusive thrombus → cardiac ischemia or infarction)
    19. Disrupted plaque: ACS occurs due to acute plaque destabilization (rupture, erosion)
    20. Hay scattered from rupture: Plaque rupture/erosion exposes prothrombotic surface →occlusive luminal thrombus →cardiac ischemia or infarction (ACS)
    21. Flipping coin: we have no good way of predicting which plaques are vulnerable to rupture (NOT necessarily the largest or most occlusive)
    22. Partially filled lumen: UNSTABLE ANGINA is caused by a partially occlusive (or transient) thrombus
    23. Falling anvil : UNSTABLE ANGINA presents with unstable symptoms (new onset angina, angina with less exertion or at rest)
    24. Broken heart string : during NSTEMI, ischemia progresses to infarction and myocardial cell death
    25. Disrupted plaque: ACS (e.g. Unstable angina) occurs due to acute plaque destabilization (rupture, erosion)
    26. Falling StreeT sign : NST“ACS” horse rupture through gate : Acute Coronary Syndrome (ACS) includes unstable angina, NSTEMI, STEMI ( destabilized coronary plaque →occlusive thrombus → cardiac ischemia or infarction)
    27. ELEVATED StreeT sign : vasospastic angina presents with transient ST segment elevation in ECG leads that correspond to the region of ischemic myocardium
    28. Sweeping up thrombotic hay: Unstable ANGINA is caused by a transient (or only partially occlusive) thrombus
    29. Dark spot on inner horseshoe surface: NSTEMI involves subendocardial region of infarction/cell death ( ST depressions on ECG = subendocardial involvement)

Cardiac Pathology: Chapter 1.2 Continued

30. Completely filled lumen of lute : STEMI is caused by a fully occlusive (or prolonged) thrombus
31. Entire Thickness of horseshoe dark : STEMI angina involves transmural infarction/ cell death (ST elevation on ECG = transmural involvement)
32. T weather vane: hyperacute T waves within seconds corresponding to area of ischemia (STEMI progression of ECG changes 1of4)
33. Elevated ST: „tombstone” shaped ST elevation within minutes, corresponding to the area of infarction (STEMI progression of ECG changes 2of4)
34. „Q” lasso : after initial ST changes, negative Q waves develop corresponding to the area of necrosis (STEMI progression of ECG changes 3of4)
35. Inverted T shadow: after initial ST changes, T wave inversion (STEMI progression of ECG changes 4of4)
36. Pathologically old stable keepe r: pathologic Q waves persists (area of previous infarct)
37. Thatcher with bundle of stick(on the roof): new - onset of LBBB is also diagnostic of STEMI (LBB is supplied by LAD)
38. Falling StreeT sign: unstable angina will present with ST segment depressions in ECG leads that correspond to the region of ischemia
39. Dark spot on inner horseshoe surface: unstable angina involves sunendocardial ischemia ( ST depressions on ECG = subendocardial involvement)
40. Entire Thickness of horseshoe dark : vasospastic (prinzmetal) angina involves transient transmural ischemia (ST elevation on ECG = transmural involvement)
41. ELEVATED StreeT sign : vasospastic angina presents with transient ST segment elevation in ECG leads that correspond to the region of ischemic myocardium
    42. Grillmaster holding T-Bone steak: Death and rupture of cardiac myocytes in NSTEMI and STEMI leads to spillage of cellular enzymes, one of which is Troponin
    43. T-bone steak : Troponins are serum markers used to detect infarction (dx NSTEMI n STEMI) (Troponin I is more SPEC I F I C for cardiac muscle damage, troponin T is more SENSI T IVE)
    44. CkicKen bucked „now with More Biscuits!”: CK, isoform MB ( CKMB) is a cardiac - specific serum marker used to detect infarction (dx NSTEMI and STEMI)
    45. T-bone 24/7 : serum troponin levels peak ~24hr after MI and remain ↑ for ~7 days
    46. „ Good the next day”: serum CK-MB levels peak in ~24 hours and fall over the next ~24 hrs
    47. “try rehydrated ”: serum CKMB can be used to dx reinfarction (relatively short time course of ↑ and return to baseline

Cardiac Pathology: Chapter 1.3 Continued __

37. Half-moon shield : histopathology of MI 3 - 14 days (~½ month)
38. Cage transporter : between days 3-14, macrophages infiltrate the area of necrosis
39. Tunic rife with blue dots : numerous macrophages infiltrating on histology 3-14 days post MI
40. Granny with tissue : granulation tissue can be seen on histology 3- 14 days post MI (activated myofibroblasts and vascularity)
41. Granny in vascular dress : granulation tissue is accompanied by neovascularization 3-14 days post MI
42. Ruptured string holder : ischemia of the papillary muscle causes necrosis and rupture 3-14 days post-MI
43. Regurging jester with bicuspid hat : rupture of papillary muscle and chordae tendinae → mitral regurgitation 3-14 days post-MI
44. Murmur lines from bottle spray : mitral regurgitation presents with a holosystolic blowing murmur that radiates to the left axilla
45. Jester with wet suit : mitral regurgitation causes pulmonary edema and worsening dyspnea 3-14 days post-MI
46. Posterior descending jester hat : papillary muscle rupture can occur with occlusion of the posterior descending artery (branch of right coronary) which perfuses the posteromedial papillary muscle
47. Left anterior descending jester hat : interventricular septum rupture can occur with occlusion of the LAD (branch of left coronary) which perfuses the anterior 2/
48. Ruptured tambourine : ischemia of the interventricular septum causes necrosis and rupture 3-14 days post-MI
49. Jester spitting spray : interventricular septum rupture presents with a holosystolic murmur
50. Ruptured lute body : ischemia of the ventricle causes necrosis and rupture 3-14 days post-MI
51. Left side of jester hat : ventricular free wall rupture can occur with occlusion of the left coronary (or its branches) which perfuses the anterior ventricular wall and apex
    52. Guitar case full of water : ventricular free wall rupture leads to massive hemopericardium and tamponade
    53. Lightning heart sigil on cage : any form post-infarct muscle rupture (3-14 days post-MI) can cause hypotension and cardiogenic shock
    54. Cork bouncing off big scar knight : after 14 days post-MI, fibroblasts (activated by macrophages) deposit collagen and fibrotic tissue → scar formation → decreased risk for rupture
    55. Quivering heart held by scar knight : scar formation (after 14 days post-MI) can cause conduction abnormalities and fatal ventricular arrhythmias (sudden cardiac death)
    56. Failing heart balloon : myocardial scar formation can lead to heart failure weeks to months post-MI (decreased contractile function)
    57. Many moon lanterns : histopathology weeks to months post-MI
    58. Crossdresser with red lute case : autoimmune (late-onset) pericarditis (Dressler's syndrome) can occur weeks to months post- MI
    59. Shark tooth necklace : Dressler's syndrome presents with pleuritic chest pain (worse on inspiration and better with leaning forward)
    60. Friction mark ings : Dressler's syndrome presents with a pericardial friction rub on physical exam
    61. Flaming dress : Dressler's syndrome presents with a fever and leukocytosis weeks to months post-MI
    62. Antibody arrows shooting at crossdresser : Dressler's syndrome is an autoimmune pericarditis that results from the formation of IgG autoantibodies against myocardial antigens exposed during acute MI
    63. Peasant caving in t ent : a ventricular wall aneurysm can form weeks to months post-MI due to thinning of a transmural scar
    64. Failing heart bal loon : a ventricular wall aneurysm can cause systolic heart failure
    65. Bird nests on wall with embolizing droppings : ventricular wall aneurysm can cause blood stasis and mural thrombus formation → embolization→ ischemic stroke weeks to months post-MI

Cardiac Pathology: Chapter 2.1 CHF Pathophysiology “Congestive Love Failure”

1. Failing heart balloon: congestive heart failure
2. Systolic spray: systolic HF (ejection dysfunction)
3. Falling cake fraction: HF with reduced ejection fraction (systolic HF)
4. 40 shaped cake server: ejection fraction <40% (reduced ejection fraction)
5. Ultrasound horn: use cardiac ultrasound to measure ejection fraction
6. Weak arm lifting heart: reduced cardiac contractility → reduced ejection fraction (systolic HF)
7. High pressure balloon : ↑end diastolic PRESSURE (seen in systolic HF)
8. High volume balloon: ↑ end diastolic VOLUME (seen in systolic HF)
9. Diamond tiara: diastolic HF
10. Difficulty filling glasses: diastolic HF (filling dysfunction)
11. 55 cake topper: ejection fraction >55%(preserved ejection fraction)
12. Lifting cake fraction: HF with preserved ejection fraction (diastolic HF)
13. Fallen compliance papers: reduced ventricular compliance seen in diastolic HF
14. High pressure balloon: ↑ end diastolic PRESSURE with normal diastolic volumes(seen in diastolic HF) Dysfunctions that cause systHF
15. Clogged coronary crown: coronary artery disease (CAD) can cause cardiac ischemia →↓ contractility → systolic HF
16. Broken heart string: ACS (e.g. Acute myocardial infarction) can cause myocardial scarring → ↓ contractility→ systolic HF
17. Dilated heart sac: dilated CMP causes ↓ contractility→ systolic HF
18. Regurgitating drink: valvular insufficiency (e.g. Aortic or mitral regurg) can cause volume overload → systolic HF
19. Unbuttoned shirt: LtoR shunt (e.g. VSD) can cause volume overload → systolic HF Dysfunctions that cause diasHF
20. Stenotic aortic hat (she pulls down her hat=stenosis): AS can cause pressure overload →ventricular hypertrophy→ diastHF
21. High pressure steam: long standing HTN can cause pressure overload →LV hypertrophy→diastolicHF(most common cause)
    22. Big obstructed bagpipes: hypertrophic obstructive CMP causes ventricular hypertrophy →diasHF
    23. Heart in restricted net: restricted CMP causes a non-compliant ventricle→diasHF
    24. Clogged coronary crown: coronary artery disease (CAD) can cause cardiac ischemia→ noncompliant ventricle→diasHF
    25. Constricting bow(heart like gift): constrictive pericarditis causes a non-compliant ventricle→diasHF Histology systHF
    26. Pulling load(pulling by a jacket): systolic HF is associated with↑PRELOAD(volume-overload states)
    27. Long eccentric eel: eccentric hypertrophy (sarcomeres add in series) in response to volume-overload states→systolicHF
    28. Dilated cave: systolic HF is associated with ↑ chamber size (due to eccentric hypertrophy) Histology diasHF
    29. Pushing load: chronic HTN and valvular stenosis cause diastolic HF by ↑ afterload
    30. Concentric conch shell: concentric hypertrophy (sarcomeres add in parallel) in response to ↑ afterload (e.g. HTN stenotic valve) →diastHF
    31. Small shell opening: diastHF with concentric hypertrophy is associated with ↓chamber size and ↑wall thickness
    32. Bulging septum(heart tube): HOCM causes distHF with isolated septal hypertrophy
    33. Normal cardiac bow: restricted CMP and constrictive pericarditis cause diastHF with normal chamber size and wall thickness

Cardiac Pathology: Chapter 2.2 CHF - Clinical Manifestations “Under the CHF”

Left side HF - left side of sketch-

1. Wet life vest prince: left-side heart failure
2. Wet pulmonary vest: pulmonary edema: left-sided HF)
3. Pink sea foam in abalone shells: frothy pink transudate on the intra- alveolar surface (left-side HF)
4. Rusty macro-cages: hemosiderin-laden alveolar macrophages – HF cells (L side HF)
5. Restrictive corset: pulmonary edema reduces pulmonary compliance
6. Difficult breath: HF can cause dyspnea with exertion
7. „C” hook fishing line: pulmonary C fibers sense pulmonary edema →dyspnea
8. Reclining into water: orthopnea (left sided HF)
9. Gasping awake(guy in canal): paroxysmal nocturnal dyspnea (PND- left sided)
10. Bilateral slurping snorkels: bibasilar inspiratory crackles(left-sided HF)(sound like slurping soda)
11. Wheezy party blower: peribronchial edema causes wheezing (left sided HF)(known as like „cardiac asthma” )
12. Skull and X bones: chest xray(imaging for suspected left sided HF)
13. White branches over the top sails: cephalization of the pulmonary vessels on CXR (left sided HF)
14. infiltrating fog: pulmonary edema looks like fluffy bilateral („batwing” shape) opacities on CXR)(left sided HF)
15. Curly letter B: Kerley B lines (fluid accumulation between lobes) on CXR(left sided HF)
16. Shadow of captain on sail: air bronchogram(dark airway against opacified interstitium) on CXR (left sided HF)
    17. Big heart: cardiomegaly on CXR (HF)
    18. „slushi3”: s3 hear sound(more common in systolic HF) (comes after s1 and s2; early diastole) sound like „slushing in”, „slushing in”„slushing in”„slushing in”„slushing in”„slushing in”
    19. Stiff s4 chair: S4 heart sound (more common in diastolicHF)(comes before s1 and s2; late diastolic); sound like „a stiff wall”, „a stiff wall”, „a stiff wall”, „a stiff wall”, „a stiff wall”, „a stiff wall”
    20. Systolic spray murmur: left sided HF can present with a systolic murmur (mitral regurg)
    21. Regurgitating mitral hat jester: dilation of mitral annulus→ mitral regurg(left sided HF)
    22. Dilated balloon: dilated atrium(due to left-sided HF(when mitral valve is open up and blood going in wrong direction→chronic dilation of LA)
    23. Irregularly irregular signal: Afib(due to atrial dilation in HF)
    24. Left side HF can damage to endothelium lining of pulmonary vasculature
    25. Damaged NO exhaust: left-sided HF causes dmg to the pulmonary vascular endothelium → ↓NO→vasoconstriction
    26. Twisted arterial shirt: dmg to the pulmonary vascular endothelium →↓NA and ↑endothelins →vasoconstriction
    27. Smooth muscular shark tattoo: pulmonary vascular remodeling→collagen deposition (intimal hypertrophy) and smooth muscle cell proliferation(medial hypertrophy)
    28. Tense pulmonary tree: left-sided HF →pulmonary artery HTN→Right sided failure(most common cause)

Cardiac Pathology: Chapter 2.2 CHF - Clinical Manifestations “Under the CHF”

Right side HF

29. Cork on the bottle: cor pulmonale (right-sided HF due to pulmonary HTN)
30. Embolic sea - cucumbers : chronic pulmonary emboli→cor pulmonale(right-sided HF)
31. Embolic saddle: a saddle pulmonary embolism→ right heart strain and failure
32. Little mermaid pushing her father=pushing load: RV works against an ↑ afterload (cor pulmonale)
33. When RV fails →pressure ↑ and stretch open fibrous ring attached to tricuspid valve→tricuspid regurgitation
34. Regurgitating on three peaks: dilation of tricuspid annulus→tricuspid regurg (right-sided HF)
35. Systolic spray murmur: right-sided HF can present with systolic murmur (tricuspid regurg)
36. More pressure in RA→backup to venous system
37. Distended blue jug: jugular vein distention (JVD) seen in right-sided HF
38. Liver knocking over distended jugular hepato- jugular reflux(right- sided HF)(pressure to RUQ)
39. Kaussmal sign(when you breath in lung sucks in blood into pulmonary vasculature, all this blood is coming from right side of heart, so the JV empty as well. This is normally seen as ↓Jugular vein distention during inspiration
    40. Cookie smell from distended jug: Kussmaul sign (JVD ↑ during inspiration) seen in right-sided HF
    41. Swollen sweat pants(mermaid's): peripheral edema of lower extremities (right-sided HF)
    42. Wet pleural shirt: pleural effusion (right-sided HF)
    43. Wet heart case: pericardial effusion (right-sided HF)
    44. Course III: zone3 (centrilobular) necrosis due to hepatic venous congestion (right-sided HF)
    45. Nutmeg sprinkled liver: centrilobular necrosis apprears as „nutmeg liver” on gross pathology
    46. Painful liver spot: hepatic congestion causes painful hepatomegaly (right-sided HF)
    47. High pressure porthole: portal HTN seen in right-sided HF If portal pressure ↑→fluid leaks out into peritoneal cavity
    48. swollen inner tube: ascites due to portal HTN (right-sided HF)

Cardiac Pathology: Chapter 3.2 Hypertrophic Cardiomyopathy

1. Big obstructed heart bag : hypertrophic cardiomyopathy (HOCM)
2. Wide septal stripe on heart bag : the interventricular septum shows the most significant amount of myocardial hypertrophy in HOCM
3. Obstructive knot : the massive IVS in HOCM can obstruct blood flow out of the left ventricle
4. Difficulty filling glasses : massive septal hypertrophy in HOCM causes diastolic dysfunction (small chamber size)
5. Failing heart balloon : HOCM can cause diastolic heart failure
6. Domino sporran : HOCM is caused by an autosomal dominant mutation of sarcomere proteins
7. b-myosin rope on pipes : HOCM is commonly caused by a gain of function mutation in sarcomere proteins (e.g. b-myosin heavy chain, myosin binding protein C, troponin T) → increased myofilament activity and hypertrophy
8. Disorganized plaid pattern : the gain of function mutations in sarcomere proteins cause disorganized myofibrillar proliferations
9. Dead musician with quivering heart : aberrant myofibers cause aberrant conduction pathways → fatal arrhythmias (e.g. VT, VF) and SCD
10. Athletic sweatband : HOCM usually manifests before puberty and is most common cause of sudden death in young athletes
11. Obstructive knot below valve : the obstruction to blood flow from the LV in HOCM occurs below the aortic valve in the LVOT
12. Bicuspid jester hat blown forward : systolic anterior motion of the mitral valve (and its contact with the hypertrophied interventricular septum) causes LVOT obstruction in HOCM
13. Spilling on bicuspid hat : contact of the anterior leaflet of the mitral valve and the interventricular septum causes the mitral valve to remain open during systole → mitral regurgitation
14. Murmur from obstructed pipe : HOCM can present with a harsh, crescendo-decrescendo systolic murmur best heard at the left sternal border (caused by LVOT obstruction)
15. Standing and straining bagpiper : valsalva and standing DECREASE preload → higher degree of LVOT obstruction → INCREASED murmur intensity
16. Squatting leg raise : leg raise (when supine) and squatting INCREASE preload and ventricular size → smaller degree of LVOT obstruction → DECREASED murmur intensity
17. Pulling load : maneuvers that INCREASE preload (e.g. squatting, leg raise) DECREASE murmur intensity
18. Grappling and squatting : squatting and handgrip maneuvers increase SBP and afterload → slow movement of blood through LVOT → DECREASED murmur intensity
    19. Pushing load : maneuvers that increase afterload (e.g. squatting, handgrip) DECREASE the murmur intensity
    20. Stiff S4 chair : HOCM can present with an S4 heart sound (blood hitting the stiff noncompliant ventricle)
    21. Sinking in quicksand (sink hole) : HOCM can cause syncope from non-lethal arrhythmia or temporarily decreased CO
    22. Angina anvil : HOCM can cause angina (hypertrophic tissue impedes subendocardial blood flow)
    23. Muted bugle : HOCM can be treated with b-blockers (decrease inotropy and chronotropy)
    24. Floppy bass strings : b-blockers treat HOCM by decreasing cardiac contractility (decreased inotropy) → slow blood flow across LVOT obstruction - also, it just decreases myocardial oxygen demand
    25. Non-dairy Calci-Yum ice cream : non-dihydropyridine calcium channel blockers treat HOCM by decreasing cardiac contractility (decreased inotropy) → slow blood flow across LVOT obstruction
    26. Pulling load : b-blockers and non-dihydropyridines Ca Blockers treat HOCM by decreasing HR → increased time in diastole and left ventricular PRELOAD → decreased LVOT obstruction
    27. Avoid sinkhole : several medications are C/I in HOCM (e.g. drugs that decrease preload such as diuretics, nitrates, or dihydropyridines; and drugs that increase contractility such as digitalis or milrinone) → increase obstruction
    28. Dairy Calci-Yum ice cream : avoid dihydropyridine in HOCM (vasodilation decreases afterload → increased velocity of blood in LVOT → increased obstruction) → increased pressure gradient
    29. Dilated arterial sleeves : avoid vasodilators in HOCM (vasodilation decreases afterload → increased velocity of blood in LVOT → increased obstruction) → increased pressure gradient
    30. Sinking nitro box : avoid nitrates in HOCM (venodilation decreases preload and left ventricular size → increased LVOT obstruction)
    31. Falling aces : avoid ACE inhibitors in HOCM decreases preload and afterload (AGII) → increased LVOT obstruction) → less aldosterone also decreases preload
    32. Wet crotch : avoid diuretics in HOCM (decreases preload and left ventricular size → increased LVOT obstruction)
    33. Toppling free drinks : Friedreich’ ( AR trinucleotide repeat disorder that causes ataxia and cardiomyopathy) is associated with HOCM (the most common cause of death from Friedreich’s ataxia)

Cardiac Pathology: Chapter 3.3 MyoCarditis Late night at The Flaming Heart

1. The Flaming Heart: myocarditis (inflammatory dmg to myocardium caused by infection, toxin exposure, or hypersensitivity reaction)
2. Cockatoo : infection with Coxsackie B (enterovirus can cause myocarditis)
3. Scattered blue bird seed : viral myocarditis show an inflammatory infiltrate in the myocardium on histology
4. Spilled Ab toothpicks : viral damage to myocytes causes the release of cross-reactive Ag→ Ab target heart tissue (viral myocarditis involve direct viral injury to myocytes as well as further inflammation caused by own Ab response)
5. Dilated heart sack : myocarditis can lead to dilated CMP
6. Failing heart balloon : myocarditis can lead to systolic HF
7. Blowing nose : viral myocarditis may be preceded by flu-like symptoms(~1 week prior)
8. The Flaming Heart : myocarditis (inflammatory dmg to myocardium caused by infection, toxin exposure, or hypersensitivity reaction) +Nonviral causes
9. Che's gAs : Chagas disease (infection with the protozoan Trypanosoma cruzi) may include myocardial involvement→ myocarditis and dilated CMP
10. Protozoal bar nuts : T.cruzi infection of myocardium shows dense collection of protozoa on histology
11. Bacterial beer tap handle : bacterial infection (e.g. Borrelia, Rickettsia, Mycoplasma) can cause myocarditis
12. „ Robin of Ixodes ”: Lyme diseases (infection with the bacterium Borrelia burgdorferi) can include myocarditis
13. Heart shield : myocardial involvement in Lyme disease can manifest as heart block
14. Fungus beer tap handle : fungal infection(e.g. Candida, Mucor, Aspergillus) can cause myocarditis
15. Immunocompromised cane : fungal myocarditis is more common in immunocompromised
16. Toxin beer tap handle : toxins exposure (alcohol, carbon monoxide, cocaine, diuretics, abx) can cause myocarditis
17. Chips and dip : Corynebacterium.diphtheriae toxin can cause myocarditis
18. Box of rubies : anthracyclines (e.g. Doxorubicin/daunorubicin) can cause free radical damage and myocarditis Autoimmunity
19. Helper with squires(bottle): certain drugs can elicit a delay type IV hypersensitivity reaction (helper T cell mediated) → hypersensitivity myocarditis
20. Mortar and pestles : drugs that cause hypersensitivity myocarditis include sufla drugs, furosemide, HCTZ, ampicillin, azithromycin and zidovudine
21. B lue & pink shot glasses: hypersensitivity myocarditis manifests histological with lymphocytic and eosinophilic interstitial inflammatory infiltrates
22. AB darts : autoimmune disease (e.g. SLE, scleroderma, and RA) can cause myocarditis
23. Rhubarb pie : Acute Rheumatic Fever is associated with myocarditis (~2-4 weeks after Strep pyogenes pharyngitis via molecular mimicry) Clinical Signs
24. Hot dyspneic dark thrower : myocarditis often presents with constitutional symptoms such as fever, malaise, and dyspnea
25. Dark in chest : myocarditis can produce a precordial chest pain that can mimic MI
26. Bucket of Chicken and T Bone : inflammation and myocardial damage from myocarditis can cause release of troponins and CK MB
27. Passed out with vibrating heart : abnormal cardiac conduction from inflammation in myocarditis can lead to fatal arrhythmia and sudden cardiac death

Cardiac Pathology: Chapter 4.1 Acute Rheumatic Fever Mitral Stenosis (Rheumatic Heart Disease)

1. Bicuspid chef hat : ARF primarily affects mitral valve
2. Rhubarb pie : rheumatic fever (ARF- acute multisystem inflammatory disease that can follow a group A Strep infection)
3. Striped pie chef : Strep pyogenes (group A Strep)
4. Scrumptious Stenosis - Acute Rheumatic Fever Mitral Stenosis (Rheumatic Heart Disease)
5. Red neck kerchief : streptococcal pharyngitis can lead to rheumatic fever (NOT skin or other GAS infection)
6. World map : ARF is prevalent in underdeveloped countries
7. Kids : ARF most often affects children between 5- 15 years old
8. Later in the month ( chef marking calendar ): ARF usually develop ~2- 3 weeks after strep pharyngitis
9. Antibody tongs : cardiac damage in ARF is caused by a type II hypersensitivity reaction (Ab mediated)
10. Kid mimicking chef : Ab in ARF are formed by molecular mimicry
11. JONES cupcakes : JONES criteria for dx ARF Joints (Migratory polyarthritis) O (myocarditis) Nodules (sub-q) Erythema marginatum, Sydenham chorea
12. “J” with frosting on elbows : ARF commonly presents with migratory polyarthritis (usually large joints such as the elbow, knees, and ankles)
13. “O” heart : ARF can cause pancarditis affecting pericardium, myocardium and endocardium(valves)
14. “N” with nodular candies : ARF can present with subcutaneous nodules (form mostly on extensor surface of forearm & may show central fibrinoid necrosis)
15. “E” : AFR present with a rash that consists of hove like C-shaped area of erythema
16. “S” falling : “Sydenham chorea”→ ARF present with rapid involuntary movements affecting all muscle throughout the body (may show up 1- 8 months after infection)
17. Pan of heart cookies : ARF can cause pancarditis affecting pericardium, myocardium and endocardium(valves)
18. Red heart case : ARF can cause pericarditis
19. Heart on fire : ARF can cause myocarditis (most common cause of death)
20. Failing heart balloon : ARF induced myocarditis can cause acute heart failure (pulmonary and peripheral edema in a young person)
    21. Multi-cupcake cage : granulomas composed of macrophage, multinucleated giant cells, lymphocytes and plasma cells can be found in any layer of heart in ARF
    22. “hand off” Aschoff bodies (characteristic granulomas histological finding in ARF)
    23. Caterpillar cupcakes : Anitschkow bodies („caterpillar”) cells(activated macrophages with slender, ribbon like nuclei) maybe be seen in granulomas of ARF
    24. Flame in heart : ARF can cause endocarditis - specifically a valvulitis-
    25. Frosting on bicuspid hat : ARF can cause fibrinoid necrosis and sterile verrucous vegetation on the line of valve leaflet closure (mitral most common)
    26. Regurgitation bicuspid hat chef : valve damage in ARF can cause Mitral regurgitation
    27. Murmur lines from regur : ARF can present with a new-onset harsh holosystolic murmur over the apex that radiated to left axilla (mitral regur)
    28. Regurgitation aortic princess hat : valve damage in ARF can cause aortic regurgitation(mitral more common)(diastolic= diamond)
    29. Lysed jelly donuts and eaten helix donut : Antistreptolysin-O and anti-DNase B titers can be used to dx previous strep infection in ARF (cultures may be negative by the time pts present)
    30. Purple pencil : penicillin tx ARF (sometimes given for years depending on severity of carditis)

Cardiac Pathology: Chapter 4.1 Acute Rheumatic Fever Mitral Stenosis (Rheumatic Heart Disease)

31. Recurring bacterial lanterns : subsequently GAS infection cause repeat episodes of ARF and worsening symptoms →chronic rheumatic heart dis
32. Chronic grandfather clock : pts may present years later with rheumatic heart disease. Due to chronic damage and repair → chronic rheumatic heart disease
33. Chef wringing bicuspid hat : years of inflammation and scarring of the mitral leaflets in chronic RHD can lead to mitral stenosis
34. Stenotic princess (behind chef) chronic RHD may also present with aortic stenosis (mitral more common)
35. Bulging heart balloon : mitral (or aortic) stenosis can cause left atrial (LA) dilation (LA has to pump blood through tiny stenotic opening→ pressure↑ →LA dilation)
36. Irregularly irregular signal : LA enlargement can lead to atrial fib
37. Mural cupcakes : LA enlargement and A fib can cause blood stasis and mural thrombus formation
38. Chocolate spots on head : mural thrombi in LA enlargement can embolize→ischemic stroke
39. Recurrent reigns on horse : compression of left recurrent laryngeal nerve by a dilated LA can cause chronic cough or hoarseness
40. Gulping(horse): compression of esophagus by a dilated LA can lead to dysphagia and regurgitation of food
    41. Sweaty shirt(stenotic chef) Mitral Stenosis→ ↑LA pressure →symptoms of left heart failure (e.g pulmonary edema)
    42. Diamonds and rumbling stomach : Mitral stenosis presents with a mid-diastolic rumbling murmur
    43. “Snap! ” mid-diastolic murmur of Mitral Stenosis is preceded by an opening snap (head over apex of left sternal border) --snap is heard during diastole, which means it comes right after s2, when lots of pressure ↑behind stenotic valve it opens sooner in diastole the closer snap is to s2 the more severe stenosis
    44. 2 scared sisters : the closer the opening snap is to s2 heart sound, the greater severity of Mitral Stenosis
    45. Granny with calcifications around the mouth : MS can be also caused by annular calcifications(degenerative calcium deposition in fibrous ring of the mitral valve in older people) though uncommon

Cardiac Pathology: Chapter 4.3 Aortic Stenosis Aortic Regurgitation

Aortic Stenosis (AS)

1. Squeezing aortic princess hat : aortic valve stenosis
2. Milk on lips : calcific degeneration of aortic valve leaflets is mcc of AS in US
3. Black aortic hat tip : calcific degeneration of aortic valve is associated with endothelial and fibroblast cell death
4. Clogged arterial candle : risk factors for calcific degeneration of aortic valve include risk factors for atherosclerosis (eg HTN, hyperlipidemia, DM, inflammation)
5. Crusty tip on candle : calcific degeneration of aortic valve shows up as fine, gritty white clumps on histology
6. Bicuspid horse mouth next to milk : bicuspid aortic valves is at risk of early dystrophic calcification
7. Concentric conch : chronically increased afterload in AS leads to concentric hypertrophy of Left ventricle
8. Failing heart balloon : aortic stenosis can cause diastolic HF
9. Dilated left wing : AS causes chronically elevated pressure in the left ventricle and atrium →LA dilation and hypertrophy
10. Irregularly irregular signals : AS can cause aFib (due to LA dilation) Clinical manifestation of AS
11. Mouse huffing and puffing : AS can present with HF symptoms (dyspnea on exertion)
12. Dim heart light : AS can cause „fixed CO” (unable to ↑ with stress)
13. Angina anvil : AS can cause angina (due to a fixed CO and ↑O demand from cardiac hypertrophy)
14. Sinking quicksand : AS can cause syncope (due to fixed CO that cannot ↑ during standing or exercise → ↓brain perfusion)
15. Murmur from systolic spray : AS can present with harsh, crescendo- decrescendo holosystolic murmur
16. Pair of vibrating pipes : murmur of AS is best heard at right sternal border and radiates to carotid arteries
17. Stiff S4 chair : concentric hypertrophy in AS lead to LV wall stiffnes→S4 sound
18. “ Parvus and Tardus” : severe AS present with a weak slow-rising pulse („pulsus parvus et tardus”)
19. Late bloomer : more sever AS present with a late peak in the crescendo
20. Crossed out second sister : severe AS present with diminished S heart sound (s1=mitral valve closure, s2=aortic closure)
    21. Squatting Cinderella : maneuvers that ↑ preload (straight leg raise, squatting) ↑ murmur of AS (due to ↑ SV across valve)
    22. Straining to grip tail : maneuvers that ↓preload (standing Valsalva) or ↑afterload (handgrip) reduce the murmur of AS (due to reduced SV across the valve)
    23. Lysed tomatoes jet stream through a AS valve can cause hemolytic anemia (schistocytes on blood smear) Aortic Regurgitation (AR)
    24. Regurgitating aortic princess hat : AR
    25. Rhubarb pie in the center : valvulitis in ARF can cause AR (mcc in developing world) chronic rheumatic heart dis can cause AS
    26. Regurgitating milk : dystrophic calcification can also cause AR (mcc in developing. World)
    27. Bulging aortic hat base : aortic root dilation can cause AR
    28. Bark on aortic tree : aortitis in tertiary syphilis („tree-barking”) can cause AR (due to aortic root dilation)
    29. Inflamed tree base : large vessel vasculitides (eg Takayasu arteritis, giant cell arteritis (can cause AR (due to aortic root dilation)
    30. Bamboo spine : Ankylosing Spondylitis can cause AR (due to sclerosis of aortic root)
    31. Martian : collagen vascular dis (eg. Marfan, Ehlers-Danlos) can cause AR (due to aortic root dilation)
    32. Flame in heart : infective endocarditis can cause AR (due to valve damage)
    33. Eccentric myocardial ribbon : AR can cause chronically ↑ EDV and pressure→ LV eccentric hypertrophy
    34. Ejecting heart : eccentric hypertrophy of the LV allows for ↑ SV to maintain CO
    35. Bulging up and down : ↑SV in AR causes ↑SBP and ↓DBP→ widened pulse pressure (e.g. 160/60)
    36. Hammering water : AR causes rapid filling and collapse of blood vessels (corrigan or “water hammer” pulse)
    37. Bobbing doll head : AR can cause characteristic head bob with each pulsation (de Musset sign)
    38. Jumping on nail bed : ↑ pulse pressure in AR can cause pulsation in the lips or nailbeds (Quincke pulse)
    39. Murmur and diamonds : murmur of AR is described as blowing, decrescendo diastolic murmur (best appreciated at left sternal border in 3 or 4 intercostal space)
    40. Sloshing Slushi3 : dilation of LV with AR can cause S3 heart sound

Cardiac Pathology: Chapter 5.1 L to R Shunt

1. Read comics left to right : left-to-right shunts (e.g. VSD, ASD, PDA)
2. 75% to 80% markdown : left-to-right shunts increase the O2 saturation in the right chambers of the heart
3. Rumbling diamond cave : ASD can present with a diastolic rumble (increased flow across the tricuspid valve)
4. Transforming Dr. Eisenmenger : Eisenmenger syndrome (left-to-right shunts reverse into right-to-left shunts due to formation of pulmonary artery hypertension
5. Tense arterial strings on chest : left-to-right shunts can cause pulmonary artery hypertension (PAH) → Eisenmenger syndrome
6. Late blue transformation : left-to-right shunt reversal leads to late onset cyanosis
7. Torn open chest V : ventricular septal defect (VSD - a left-to-right shunt)
8. Systolic spray from little V-man : a small VSD presents with a systolic ejection murmur
9. Hologram comic : a small VSD presents with a holosystolic murmur
10. Protected baby : a small VSD is usually asymptomatic
11. Falling feeding baby : a large VSD can cause failure to thrive and diaphoresis with feeding
12. Failing heart balloon : a large VSD can cause heart failure
13. "Please use second ostium" : the ostium secundum forms in the septum primum
14. Second set of septal doors : the septum secundum grows to cover the septum primum (and ostium secundum)
15. Holding open septal doors : incomplete formation of the septum secundum leaves an opening that communicates with the ostium secundum → atrial septal defect (ASD)
16. "Incomplete fusion" : incomplete fusion of the septum primum with the septum secundum leaves a patent foramen ovale (PFO)
17. Shooting through the septal doors from right to left : reversal of flow through an ASD or PFO allows a "paradoxical embolism" to reach the systemic circulation
18. Paradoxical dart hitting head : reversal of flow through an ASD or PFO can cause cryptogenic stroke (due to paradoxical embolism)
19. Straining to hold septal doors open : valsalva can reverse flow through an ASD or PFO (right to left shunt)
20. Shooting through the septal doors from right to left : reversal of flow through an ASD or PFO allows a "paradoxical embolism" to reach the systemic circulation
21. Systolic spray : ASD can present with a systolic murmur
22. Split sisters : ASD can present with a wide fixed splitting of the S heart sound
    23. Bubbles floating through septal doors : ASD has a positive bubble study on cardiac echo
    24. Open air ductus : patent ductus arteriosus (PDA - a left-to-right shunt)
    25. Ruby robot opening air ductus : congenital rubella infection can present with a PDA
    26. Pro slugger bat opening air ductus : prostaglandin E2 (produced by the placenta) keeps the ductus arteriosus open
    27. Fire extinguisher fending off baseball bat kid : indomethacin (an NSAID) closes a PDA (blocks prostaglandin production)
    28. Murmur from air conditioner machine : PDA can present with a continuous "machine-like" murmur (present during systole and diastole)
    29. Red body, blue legs : an untreated PDA (leading to Eisenmenger's) can cause cyanosis in lower extremities
    30. Colorful arch : coarctation of the aorta
    31. Dent near the air duct : coarctation of the aorta causes a narrowing of the descending aorta near the insertion of the ductus arteriosus
    32. Turning X shaped pinwheel : coarctation of the aorta can occur with Turner syndrome (monosomy X)
    33. Bicuspid horse mout h : coarctation of the aorta can be associated with a bicuspid aortic valve
    34. Pink body, blue legs : severe coarctation of the aorta can cause cyanosis in lower extremities (presents in infancy)
    35. Failing heart balloon : severe coarctation of the aorta can cause heart failure and shock (after closure of PDA)
    36. High pressure steam : coarctation of the aorta can cause hypertension
    37. Split pi pe : coarctation of the aorta can cause aortic dissection
    38. Red paint st roke : coarctation of the aorta can cause hemorrhagic stroke (due to ruptured berry aneurysm)
    39. High pressure in upper half of pi pe : coarctation of the aorta can cause a blood pressure discrepancy between the upper and lower extremities (or rarely between arms)
    40. Delayed events : coarctation of the aorta can cause delayed lower extremity pulses ("brachial-femoral delay")
    41. Paint clods on l egs : coarctation of the aorta can cause lower extremity claudication
    42. Notched rungs : coarctation of the aorta can cause inferior "rib notching" on CXR (due to collateral circulation in the intercostal arteries)
    43. Flame in heart lantern : left-to-right shunts (e.g. VSD, PDA, coarctation) can cause endocarditis
    44. Destroying endocarditis monster : ASD is unlikely to cause endocarditis (low pressure differential between the atria causes less hemodynamic injury)