Cardiac Diagnostics Flashcards
what does GDMT stand for
guideline directed medical therapy
what does OMT stand for
optimal medical therapy
what does EF stand for
ejection fraction
what does HFrEF stand for
Heart failure with reduced left ventricular ejection fraction (EF < 0.4)
what does HFpEF stand for
heart failure with preserved left ventricular ejection fracture (> 0.5)
what does HFmEF stand for
heart failure with midrange ejection fraction (EF < 0.5 but > 0.4)
what does RVSP stand for
right ventricular systolic pressure
5 tests of perfusion
- treadmill (Bruce Protocol)
- treadmill (MPS)
- stress echo
- PET
- arteriogram
Describe components of a stress test
- Protocol: Bruce vs Lexiscan vs Dobutamine
- +/- imaging or Myoview
- gives information about perfusion, chroncotropic competence, METs, arrhythmia, exercise tolerance
- Instructions to pt: hold BB/CCB 48 hrs, no caffeine 24 hrs
pros of a stress test
4
- relatively inexpensive
- gain info about METs, ischemia, arrhythmia, exercise tolerance
- easy to get insurance approval
- different modailities
cons of a stress test
- affected by body habitus
- false +/-
- equal balanced ischemia
downsloping of what more than what is an indication for termination of a stress test?
- ST segment
- 2mm
Absolute contraindications for stress test
9
- active endocarditis
- acute aortic dissection
- acute myocarditis/pericarditis
- decomponsated heart failure
- inability to exercise
- MI within 2 d
- ongoing unstable angina
- uncontrolled arrhythmias with hemodynamic compromise
- sx severe aortic stenosis
Relative Contraindications for stress tests
- Acquired complete heart block (LBBB)
- hypertrophic obstructive cardiomyopathy w/ severe resting gradient
- known L main CAD
- recent stroke or transient ischemic attack
- resting systolic blood pressure > 200 or diastolic > 110
- tachyarrhythmia w/ uncontrolled ventricular rate
pros of a stress echo
4
- quick interpretation at bedwisde
- less expensive than MPS
- info about heart valves, estimate RVSP
- can look for ASD/VSDs (bubble study)
cons for stress echo
4
- limited by body habitus
- need good tech
- more challenging if they have underlying wall abnormalities (LBBB/RBBB)
- prefer patient to be in NSR/SB
normal sinus rhythm/sinus brady
6 tests for heart anatomy
- cardiac CTA
- heart catheterization
- cardiac MRI
- 2-d echo
- transesophageal echo (TEE)
- cardiac MRA
pros of cardiac CTA
2
- high specificity
- leads to diagnosis of +/- ASCVD thus prossible interventional strategies
cons of Cardiac CTA
8
- dye and radiation exp
- weight restrictions
- must be brady
- hold breath for 20s
- can be difficult to get approval by insurance
- “blooming artifact”
- limiting imaging if hx CABG
- know your facility/readers
heart cath overview
5
- right vs left
- flow wire (FFR)
- intravascular ultrasound (IVUS)
- w/ or w/out LV gram
- Dye exposure
pros of left heart cath
4
- 99.9% accurate
- can evaluate anatomy and perfusion
- quick turn around/immediate interpretation
- final stop: can determine +/- fix while there
cons of heart cath
- invasive procedure w/ associated risk
- $$$
- dye/rad exposure
how to order a heart cath
- “Right +/- Left heart cath w (w/out) LV gram; do not use access site blank”
- Hold DOAC tx 48 hours (if INR < 2.0 do not hold anti-platelets)
- hold nephrotoxic agents 48 hrs (ACE, ARB, ARNI, metformin, Loops)
when to order left heart cath (LHC)
5
- (-)STEMI/ACS
- (+) ischemia on stress test
- (+) >80% lesion on CTA
- pre-valve work-up
- high suspicion for blockage
where does right heart cath measure pressures in the heart?
6
- RA: right atrial pressure
- RV: right ventricular pressure
- PA: pulm artery pressure
- PCW: pulm capillary wedge
- LA: left atrial pressure
- LV: left ventricular pressure
what is an echocardiogram
ultrasound to evaluate the heart tissues (muscle/valve) and their movements
2 types of echo you could order?
- trans throacic (TTE)
- trans esophageal (TEE)
what does echo show?
- muscle abnormalities
- EJ
- chamber size
- valvular disease
- estimated RVSP
pros of echo
4
- non-invasive, lots of info
- low cost
- low risk
- no rad/dye exp
cons of echo
2
- limited by HR
- limited by body habitus
what info do you get from cardiac MRI?
- cardiovascular tissue/muscle defects
- muscle function
- tumors
how can you use cardiac MRI?
pre-procedural or pre-surgical mapping
pros of cardiac MRI
2
- very detailed anatomical model of heart/structures
- no rad
cons of cardiac MRI
3
- need experienced reader/equipment
- difficult to get approval from insurance
- contraindicated in pts with metal implants
what does MRA stand for
magnetic resonance angiography
pros of cardiac MRA
4
- very specific to recreate anatomy of an artery (aneurysm, narrowing, bleeding, plauqe, ect)
- used in a lot of stroke protocols
- no rad exposure
- non-iodine contrast dye (can order w/ or w/out)
cons of cardiac MRA
2
- no metal implants in pts
- need good reader/equipment
OVERALL
when to order:
1. stress test (treadmill)
2. stress echo
3. RHC
4. LHC
5. Cardiac CTA
6. MRA
7. MRI
- blockage/perfusion
- EF/valves
- valve work up
- blockage
- blockage/anatomy
- blockage/anatomy
- evaluate restrictive cardiomyopathy
5 tests for electrophysiology
- ECG
- telemetry
- ambulatory electronic monitoring (AEM)
- treadmill
- EP study
what can ecg show?
4
- arrhythmia
- structural changes to heart
- ischemia
- drug side effects
what is telemetry?
continuous tracing, usually 2-5 leads
what is telemetry primarily used for?
arrhythmia detection
overview of ambulatory event monitoring
- worn by pt for period of time (24hrs-2wks)
- can be continuous monitoring or triggered
treadmill testing w/ ecg overview
- tracing during test will show heart rate variability, exercise/rate induced changed
- pt terminated vs tech terminated
describe EP study
- advanced invasive testing of electrical system of the heart performed by EP
- can perform mapping, induce arrhythmias
- requires venous access
describe tilt table test
- monitors BP, HR, rhythm in various positions
- used in work up of syncope
- may use provocative measures
purpose of multigated acquisition (MUGA) & how to do it
- to evaluate cardiac muscle, EF
- IV injection of dye and placed under scanner
describe artery calcium score (CAC)
- give agaston score to quantify plaque burden
- anything > 0 is abnormal
- has benefit in decision making on rx for statin +/- ASA
describe arterial brachial index
looking for peripheral arterial disease
when would you use abdominal ultrasound
to evaluate the abdominal aorta to rule out an aneurysm
what does a cardiac doppler do?
ultrasound of cardiac arteries
how to measure EF
5 tests
- best test is echo
- MUGA
- MRI
- LV gram on cath
- spect imaging report
what to order if echo shows hypertorphy?
MRI to r/u infiltrative disease
what do you need to order to concretely r/o a blockage?
RHC
