Cardiology Diagnostic Evaulation Flashcards
what is a CCTA?
what is the procedure
CCTA: Cardiac CT anigography (with contrast)
- using at EKG: the contrast dye is timed so that it is entering the cornary vessels and entering the left ventricle at the proper point (administered into venous)
- CT imaging with the contrast shows the perfusion of the vessels – no cath used – just inserted dye to look at the left heart
- reported as a CAD-RAD score of % stenosis
procedure
- beta blockade, nitroglycerin (vasodilator) & IV contrast administered to the pt.
- “gate” the CT image so that you are seeing it during diastole with the EKG as a guide
when is CCTA used (2 indications)
Indications:
Stable Angina: those with an intermediate pre-test probability can get a CCTA to…
- detect an obstruction with CAD highly sensitive as the an noninvasive test, variable specifictiy get some false positives but its good at getting for those who have >50%
- detects cornary plauqe without an obstruction see the % of the vessel that is narrowed risk is based on degree of plaque not degree of obstruction
Acute Cornary Syndrome: NOT often used in this context: those with a low pre-test probability
- usually instead these people (becuase low probability of having a CVD) we observe, trend cardiac enzymes & serial EKG (and if there is something – to the cath lab for catheter)
- if these is absence of CVD on the CCTA = very low risk of an event happening in 2 years
for those with HIGH test probability –> we are skipping a CCTA because then need immediate left heart catheterization as they most likely have obstruction or blockage & need to be stented/ballooned
CCTA Contraindications
these are all relative contraincidations
- allergy to iodine
- renal insufficiency
- irregularities or tacharrythmias (because we cant block with EKG)
- inability of pt. to lie flat and hold their breath 5-10 seconds
what is a CAC Score? what does it indicated
- can get a CAC score (cornary artery calcium score) to see how calcified the vessel is
- CAC is done withOUT contrast— you cannot see the calcium with the contrast
- amount of calcium is related to the amount of burden
what is a Left Heart Catheterization?
possible sights of entrance
how is it monitored (what imagining)
Left Heart Cath–> a diagnostic procedure conducted in which a catheter is threaded through the arteries to get to the left heart (from the aorta) and into the cornary vessels through to ostia in the aorta
- follows the Seldinger Technique
- uses contrast and real time CT imaging as you thread the wire to the cornary vessels
Entranct Points
- Femoral Artery
- Radial Artery
- Brachial Artery
what is a Left Heart Catheterization?
possible sights of entrance
how is it monitored (what imagining)
Left Heart Cath–> a diagnostic procedure conducted in which a catheter is threaded through the arteries to get to the left heart (from the aorta) and into the cornary vessels through to ostia in the aorta
- follows the Seldinger Technique
- uses contrast and real time X ray imaging (fluroscopy) as you thread the wire to the cornary vessels
Entranct Points
- Femoral Artery
- Radial Artery
- Brachial Artery
what is a percutaneous conarary intervention (PCI)
3 types of PCI
a therapeutic process done through the process of a left heart cath. procedure (need the left heart cath. to do the procedure)
- the PCI is the process of ballooning, opening the vessel and possibel stenting of the vessel to ensure it stays open
- done with continuous monitoring of the placement through xray technology
Types of PCI
- ballooning: rarely done alone used to deploy the stent & squish the plaque to the sides (blow it up and place the stent) – if there contraindication to placing a stent (inability to have long-term platlet therapy or problem with leaving a stent) –> then would just balloon
- Stenting: balloon and then place meshwire stent to ensure vessel stays open ( predilate the vessel then place stent) must put pt. on antiplatlet therapy for 30 days.
- Thrombectomy: the process of physicailly removing the clot(can be done with a variety of different tools)
Indications for a Left Heart Cath & PCI (acute cornary syndromes)
- elective
- urgent
- emergency
- salavage
Emergency: MUST INTERVENE – STEMI this is the “door to balloon time” we think about
Urgent: must intervene while they’re in the hospital – within the next few hours — NSTEMI, unstable angia (if pre-test prob. indicates) need to get done while theyre here but not in the next minutes
Elective: will help them, do within the next days/weeks — Stable angina
Salvage: unknown time in Vfib/VTach cath to help salavage what remains of the heart function (while your doing compressions or ECMO)
non acute cornary syndrome indications for a left herat cath.
- evaluate cornary artery bypass graft (prior to)
- assessment of vavlular disease (atrial/mitral = left heart) (tricuspid & pulm. = right heart)
- percutaneous interventions of valves & closure of congenitial defects (ASD,VSD,PDA)
- cardiac arrythmias (ablations of the foci)
contracindications for a left heart cath.
all relative– if they need it, theyll get it
- severe peripheral vascular disease (all collateral, tortous veins, with now clear path)
- severe HTN
- unable to lie flat as pt.
- renal insufficiency
- acute CVA
- active bleeding/coagulopathy
- allergey to iodine contrast
- untreated sepsis/infection
Coronary angiography
placement of a catheter, wire and if necessary stent and balloon into the cornary vessels (entrance through the arteries and in)
- a therapeudic procedure done
- real time monitored through x-ray technology
looking at..
RCA: to the acute marginal & atrial branches & to the right posterior and right posterior atrioventrc.
LCA (left main): to LAD & Circumflex (LAD –> gives off diagonal) (circumflex –> gives off obtuse)
what can be measured through left heart cath. (think hemodynamics)
- aortic pressure
- LV pressure
- LA pressure
- valve pressure & gradients of pressure
what can be detected through a left heart ventriculography
example of a morphologic change you may find on ventriculgraphy
ventrilces, graphy — imagind done as the catether is placed in the let heart and dye is intorduced to see differences in contrast of strcutres
detected
- a measurement of the ejection fraction (% of blood leaving the LV)
- detect morphologic abnormalities
Type of abnormality: Takotsubo Cardiopmyopathy
- see the shaped of the pot as the ventricle –> narrow at top then bowl like and wide toward the inferior
- this is a stress cardiomyopathy (seen when the heart is under stress– pumping)
PCI Long-Term Outcomes
1-year mort. : 3.6% (complications like bleeding and revascualarization decrease this)
5-year mort: 37% : majority of these due to comorbid events
PCI Complications
(7)
- dissection or intraluminal hematoma
- distal embolization & reperfusion injury – once you allow blood flow to restore –> there is a large flood of blood and inflammatory markers which can damage the wall (myocardial and endothelial edema and vasospasms possible)
- cornary artery perforation: serious need immediate surgery
- side branch occlusion (the stent covers the side branch)
- in-stent REstenosis (covers the stent and creates plaque)
- sornary artery aneuryum (wall dialtes)
- access site bleeding & hematoma (at femoral, brachial, etc.)
PCI: long-term medication therapy (post-MI)
- ** single/dual action antiplatlet therapy** (asprin, clopidogrel, prasegreul, ticagrelor)
- beta blocker - decrease the O2 demand of the heart
- statin
- ACE/ARBs & aldosterone antagonists (HF pts.)
- angina – nitrates
CABG - procedure
CABG: Cornary Artery Bypass Graft —> such a large block that you need to bypass that area and perfuse the rest of the heart
- uses the internal mammary artery (LIMA) and have that perfuse
- harvest part of the great saphenous vein & place it to replace the bad artery
- can be single, double triple or quadruple
survival post-op heavily depends on the comorbidities and secondary prevention techniques
CABG Complications
- the general surgical complications
- bleeding
- stroke, neuropathy, cognitive dysfunction (because that alreation of blood flow)
- infection (in mediastinum)
- leg wound complications
- kidney injury
CABG long-term medication management
- single or dual antiplatelet therapy: asprign, clopridagrel, prasegreul, ticagrelor
- beta blocker
- statin
- ACE/ARB & aldosterone antago if HF
- angina –> nitrates
What is the tilt table test
- how does it work
- medications given for provocation ( if needed)
Tilt Table test
- pt. strapped to the table
- moves pt. from supine to upright in < 10 seconds
- monitor BP, EKG (EEG too sometimes)
Provication
- nitroglycerin – venodilator = drop the preload & provoke syncope becuase of drop in pressure
- isoroterenol – nonselective Beta agonists prevokes the syncope
Indications for a Tilt Table Test
- orthostatic hypotension
- recurrent syncope
- unexplained palpaltations
- POTS (postural orthostatic tachycardia syndrome) those who have extreme tachy when they change positions
what are the results of a tilt-table test
- explain SNS and HR relation & CO
- 3 factors of SV
we know that increase autonomic response will impact the HR
the tilt table test –> attempts to understand the cardiac output & how the body compensates
factors which impact the stroke volume
preload: end diastolic volume
inotropy: strength of squeeze
afterload: wall tensions opposing force of ejection
what do you see on the graphing of BP & HR with….
- initial orthostatic hypotensions (elderly)
- non-neurological orthostatic hypotension (hypovolemia)
- neurogenic orthostatis hypotension (brain issue)
- POTS
- initial orthrostatic hypotension: see a drop in BP counteracted with an increased in HR gradually- then back to baseline
- non-neuro: think low volume levels: low preload to start with but the proper compensation for a drop in the pressures was met with an increased in HR — just low levels of fluid
- neuro: the BP plumets— and the HR does NOT change — because there is a neurologic issue & there is no compensation
- POTS: HR Skyrockets when the BP dropes & remains high!!! doesnt come back down in expected short timeframe
Complications & Limitations of the Tilt Table Test
- no gold standard– calculating accuracy in measurements is difficult
- high rate of false negatives
- drug provocation (nitroglycerin or isoterenol) helps but can increase false positives
- **the potential to throw people into asystole!!!
What is a Cardiac Stress Test
Indications for the Test
How is it run (order of events)
cardiac stress test: a test conducted to increased the work load of the heart in order to understand the ability of the heart to perfuse itself!
- a diagnostic and prognostic tool
Indications for when to get a CST
1. Cornary artery disease (risk stratification tool & dx.)
2. Noncoranary disease (valve dysfunction, arrythmias)
How its Done
- diagnosic eval. with EKG
- run on the treadmill to stress you
- repeat the EKG after (and on) to see how your heart can perfuse its own vessels
Sources of Stress
- who should exercsie
- what types oh pharmacology can stress
- if they can exercise make them exercise
- caclculate predicted HR: 220-age
- those who can get to 85% of this can and should exercise to get best reading - pharmacologic drugs
- Vasodilators: adenosine, dipyridamole, regadenson
- these work by causing relaxation of the vascular smooth muscle and cornary artery vasodilation
- avoid in those with COPD & asthma – bronchoconstrictor
- avoid in those with bradycardia and hypotension & heart blocks
- Inotropes: doutamine
- beta 1 & 2 agonist: increase O2 demand of the heart
- avoid in those with ventricular arrythmias
Types of Diagnostic Modalitlies for Cardiac Stress Testing: how to monitor
Pros & Cons to each
EKG: not crazy sensitive, easy to get, not good to localize the ischemia
Echo: a bit expensive, better sensitivity, see the RV pushing on the LV (abnormal)
Nuclear Spect: expensive, good sensitivity, but you have radiation to see when there ischemia isnot colored
PET CT/MRI: most sensitive but most expensive, but not avalible often
get a CCT or Stress test for pts. with caridac issues but low-prob. of CVD — then if you see something can send to cath. lab
what is MUGA
when is it used (Indications)
Multi-gated Cardiac Blood Pool Imaging
- an RBS is labeled with a radioactive isope tracer
- the heart is imaged with gamma ray camera
- then cahnges in the radiotracer densitiy on screen = show chagnes in LV volume
high sensitivty of noting LV ejection fraction
Indications
- LVEF assessment if other modes of estimated teh EF have failed
- will be used serially to assess toxicity of chemo drugs in pts. on these meds
Limitations of MUGA
- need reliable IV access ( for injecting the radiotracer)
- have to be okay with getting increased levels of radiation
- need to be gated with EKG –pt. must have a regular rhythm
- anatomical abnormalities may make this difficult (pulm htn, severe COPD, congetial dz.)
TTE: Transthoracic echocardiogram
- what is it
- who does it & who interprets it
- when do we do it
- a formal assessment & comprehensive evaluation of the heart and its structure, function, hemodynamic ability
- preformed by a sonographer & read by cardiologist
when?
- virtually with ANY indication of the heart
- SOB, chest pain, pulm, HTN, etc., cong. defect
TEE: Transesophageal Echocardiogram
- when is this preformed
- indications
- an echo preformed that goes into the esophagus & views the heart much closer picture
When
-** rule OUT endocarditis
- evaluate the presence of a clot in a fib
- congential eval.
- surgical planning
- complex patho.**
*this is good because you can see the atria, a TTE cannot see the atria because theyre so superfisical
Difference between a TTE & A FoCUS/POCUS
- FoCUs & POCUS: aim to answer yes or no questions— this is a FUNCTIONAL ASSESSMENT OF THE HEART (and done and read by a provider)
TTE: done by trained professionals, looks at strucutre, function and hemodynamics (blood flow)
Difference between a TTE & A FoCUS/POCUS
- FoCUs & POCUS: aim to answer yes or no questions— this is a FUNCTIONAL ASSESSMENT OF THE HEART (and done and read by a provider)
TTE: done by trained professionals, looks at strucutre, function and hemodynamics (blood flow)
when would you do a FOCUS/POCUS
- evaulate LV and RV structure & function
- suspected HF
- suspected PE
- suspected pericardial effusion & tamponade
- volume status
- hypotension/shock
- cardiac arrest
- guidance for pacing in emergecny
- valve issues
views for a POCUS/FOCUS
parasternal long: gives you “hot dog” cut of the heart
- see ventricles and parts of the atria
parasternal short: gives you “hamburger” cut of the heart
- ability to “sweep” look at the low parts of ventricles, middle & higher
- see **papillary level, mitral level & aortic level*8
four chamber view: transducer at PMI
subcostals long axis: anotehr long view
IVC view: flipped trasnducer to see long axis of the IVC
