Cardiac investigations

Question 1

24/48 HOUR TAPE

i) name four indications
ii) what will the patients be asked to do?
iii) when do patients wear them?
iv) what is chronotropic incompetence? what is the most common cause
v) name two pros and three cons

Answer 1

i) investigations of palpitations, syncope, prescent of silent AF, patients who complain of daily symptoms, classify burden of disease
ii) ask patients to document events while they wear the monitor to see if symptoms match findings
iii) patients wears it constantly while doing normal daily activities

iv) heart rate doesnt reach maximal effort required for exercise
- get breathless on exertion
- most commonly reason is too much medication eg BB

v) pros - cheap, easy to fit
cons - if leads come off findings cant be analysed, some patients get rash from the stickers, patients carry around the recorder, arrhytmia has to occur during recording period
- typically three lead to no info regarding underlying structural or ischaemic abnorms

Question 2

HOLTER MONITOR/EVENT RECORDER

i) what length of time are they usually used for?
ii) what does it record? what does it not do?
iii) give an indication for this type of monitor
iv) name a con

Answer 2

i) used for around 7 days but can be for up to 2 weeks
ii) records irregular heart rhythms but doesnt record all data during the period that it is worn
iii) patients who complain of a symptom on a weekly basis
iv) con - have to keep it on for duration of recording - may impact on patient ADLs

Question 3

EXERCISE TESTING

i) name four indications
ii) what happens?
iii) name two pros and three cons

Answer 3

i) assess for ischaemic ECG change on exercise (only if coronary anatomy is known)
- assess CV risk - can use in valve disease if pt asymp
- assess chronotropic incompetence
- fitness to practice for some occupations

ii) patient asked to exercise usually on a treadmill at incremental levels
- have ECG and BP cont assessed
- patient needs to be motivated to reach max effort for useful results

iii) pros - dynamic test with ECG monitoring and urgent findings flagged on teh day
cons - patient needs to be mobile, some meds eg BB can give negative tesults
- not sensitive if coronary anatomy isnt known - espec in females therefore no longer part of guidance for detection of chest pain

Question 4

IMPLANTABLE LOOP RECORDER

i) name an indication
ii) how are they inserted?
iii) how long can they stay in situ for?
iv) what is the device connected to?
v) name two pros and two cons

Answer 4

i) infrequent episodes of symptoms assoc with tachy/bradyarrhytmias
ii) inserted as a day case > local anaes > insert above pec major > glue or suture closed
iii) can stay in for three years
iv) connected to a base station that can send data to the hospital

v) pros - long term monitoring and continuously records > alerts physiologist if concerning arrhyth are recieved
- cons - invasive, more expensive, small risk of infection, need second procedure to remove

Question 5

WHICH MONITOR TO PICK?

what should be picked for symptom frequency of:

i) daily
ii) every 2-3 days
iii) every week
iv) every month
v) less than once per month

Answer 5

i) 24hr holter, in hosp telemetric monitoring
ii) 49-72hr holter
iii) 7 day holter or ext loop recorder
iv) 14-30 day ext loop recorder
v) implantable loop recorder

Question 6

TILT TABLE TESTING

i) what is it predominantly used for? what else may it be used for?
ii) what happens?
iii) how long does the test last

Answer 6

i) used for diagnosis of syncope (50-90% patients will demonstrate positive response to tilt)
- patient who have had unexplained syncope
- can also be used to dx POTS (post orthostatic tachy syndrome)

ii) patient is tilted to an angle of 60 degrees for 45 mins and ECG/BP is monitored throughout
- massage carotid sinus to see if this starts the symptoms
- spray GTN to see if it starts symptoms

iii) lasts around 45 mins