Cardiology – Diagnostic Testing

Question 1

When to do stress ECHO?

When is stress ECHO Limited?

Answer 1

#Baseline EKG is abnormal
#For information on a particular area of myocardium

#Baseline Wall Motion Abnormalities
#Single Vessel disease

Question 2

If stress ECHO imaging is suboptimal, can improve image quality with?

Answer 2

Microbubble transpulmonary contrast

Question 3

Nuclear SPECT Is recommended when?

Correctable limitation? (and how to correct?)

Answer 3

LBBB - Conduction delay in the septum may cause false-positive abnormality (vasodilator stress)

#Abnormal baseline EKG
#Particular area of my accordion needs to be evaluated
#Viability testing with thalium

Question 4

Basic Stress test recommended in patients who cannot exercise?

Contraindicated if? Test specific accommodation?

Answer 4

Dobutamine ECHO

#Severe baseline hypertension
#Unstable angina
#Arrhythmias

Hold beta blockers before test (if diagnosing CAD)

Question 5

Stress test recommended in patients with LBBB who cannot exercise?

Options for drug? Contraindicated if? Test specific accommodation?

Answer 5

Vasodilator nuclear perfusion

Adenosine, dipyridamole, regadenoson

#Bronchospastic airway disease
#Theophylline
#Sick sinus syndrome
#High degree AV block

Hold caffeine for 24 hours

Question 6

Stress test of choice soon after myocardial infarction?

Answer 6

Vasodilator stress test

Question 7

Stress test for patients who cannot exercise and have contraindications to vasodilators?

Contraindications? Test specific accommodation?

Answer 7

Dobutamine nuclear perfusion baseline

#Severe baseline hypertension
#Unstable angina
#Arrhythmias

Hold beta blockers before test

Question 8

Test the provides the best perfusion images larger patients? Additional benefits of the test (in terms of diagnosis and comparative usefulness)?

Answer 8

PET/CT

#Provides data on perfusion, function, and viability
#Lower radiation dose than conventional nuclear perfusion imaging
#Absolute myocardial blood flow can be measured

Question 9

Reasonable test in asymptomatic patients with intermediate risk for CAD?

Answer 9

Coronary artery calcium

Question 10

Noninvasive test that can identify anomalous coronary arteries? Use in which patients? Limitations?

Answer 10

Coronary CT angiography

Intermediate risk for CAD

#Does not provide detailed images of distal vessel anatomy
#limited by calcification

Question 11

Test that uses gadolinium enhanced images to identify viable/infarcted myocardium?

Contraindications?

Answer 11

Cardiac MRI

#Pacemaker, ICD
#Kidney failure
#non-sinus or tachycardia rhythm (for improved image quality)

Question 12

Duke treadmill score based on? Score provides information on?

Answer 12

Chest pain
Hemodynamic changes
ST segment depression
Exercise duration
Heart rate recovery (HR should drop over 12 BPM in first minute)

Five year mortality risk

Question 13

On exercise testing, adequate workload generally defined as? Patients should ideally exercise for how long?

Answer 13

#85% age-adjusted maximal heart rate
#Rate pressure product (HR x SBP) greater than 25,000

6-12 minutes

Question 14

Medications that may be held before and exercise stress test?

When to continue versus hold for an exercise stress test?

Answer 14

Nitrates, beta blockers

Define prognosis/determine ischemia on current regimen versus diagnose CAD

Question 15

Patients with these pathologies should not undergo exercise stress testing? (Instead should undergo?)

Answer 15

#Severe aortic stenosis
#Abdominal aortic aneurysm
#Severe hypertension
#Uncontrolled arrhythmias

Vasodilator stress test

Question 16

On stress Imaging, normal findings at rest but after stressor, notable LV dilation – interpretation?

Answer 16

Balanced ischemia or multi vessel CAD

Question 17

On stress testing, Wall motion abnormality at baseline. Improvement with low dose exercise/dobutamine but worsens at higher levels. Suggests?

Answer 17

Hibernating myocardium

Question 18

Preferred stress test for patients with Aortic stenosis and low ejection fraction?

Answer 18

Dobutamine stress test

Question 19

Patient with wall motion abnormality.

If Baseline perfusion defect but metabolically active cells on viability study, suggests?

If no perfusion defect and metabolically inactive cells on viability, suggestive of?

Answer 19

Hibernating myocardium

Stunned myocardium

Question 20

Technetium versus thalium as radiotracer?

Answer 20

Better in patients with breast attenuation (women)

Can assess viability (Potassium analog and can only be taken up by active myocytes) but more radioactivity

Question 21

PET vs SPECT?

Answer 21

#More diagnostic accuracy
#Also evaluates peak stress ejection fraction, myocardial blood flow, myocardial metabolism
#Coronary calcification

Question 22

Coronary artery calcium scoring?

Who gets it?

Answer 22

0 – no disease
1-99 – mild disease
100-399 – moderate disease
Over 400 – severe disease

Asymptomatic patients with intermediate Framingham risk score (10-20%)

Question 23

Pharmacologic stress agents are associated with which adverse developments?

Answer 23

#AV block
#Bronchospasm

Question 24

Gadolinium associated with what adverse sequela?

Answer 24

Nephrogenic fibrosing dermatopathy

Question 25

How to detect PFO or intracardiac shunt on cardiac imaging?

Answer 25

ECHO with IV agitated saline contrast (normally cleared in pulmonary vasculature, so should not be in left heart)

Question 26

When to get a TEE instead of TTE?

Answer 26

``` #Endocarditis #Prosthetic valve dysfunction #aortic disease #Left atrial thrombus ```

Question 27

Went to get three-dimensional ECHO?

Answer 27

``` #Mitral valve disease #ASD ```

Question 28

Purpose of radionuclide angiography (MUGA)?

Answer 28

Evaluation of LV systolic function (for serial LVEF measurements)

Question 29

Meijer indications for cardiac MRI?

Answer 29

``` #Congenital heart disease #Aortic disease #Myocardial diseases (infiltrative, myocarditis, hypertrophic cardiomyopathy) #Right ventricular cardiomyopathy #LV function ```

Question 30

Arrhythmia monitoring (after basic EKG) if patient presents with: 1. Daily arrhythmias 2. Arrhythmias provoked by exercise 3. Infrequent symptomatic arrhythmias that last over 1 minute 4. Infrequent, symptomatic, brief arrhythmias 5. Syncope 6. Very infrequent arrhythmias 7. Extremely rare arrhythmias

Answer 30

1. Holter monitor (ambulatory EKG) 2. Exercise EKG 3. Patient triggered event recorder 4. Loop recorder 5. Loop recorder 6. Implantable loop recorder and 7. Mobile cardiac outpatient telemetry

Question 31

Exercise ECG would need to be replaced/paired with additional imaging if patient has these EKG findings? Patients that undergo an exercise stress test will have more false positives / more difficult to interpret findings if the patient has these EKG findings?

Answer 31

``` #LVH #LBBB #paced rhythm #WPW #greater than 1 mm ST segment depression ``` ``` #Right bundle branch block #Bifascicular block #Digoxin ```

Question 32

Stress testing is appropriate in patients with what pretest likelihood of CAD?

Answer 32

10 to 90%

Question 33

Patient presents with intermediate pretest probability of CAD. Next test if: 1. EKG normal and able to exercise 2. EKG abnormal and able to exercise 3. EKG abnormal patient unable to exercise

Answer 33

1. Exercise treadmill stress test 2. Exercise nuclear stress test OR exercise ECHO 3. Pharmacologic stress test

Question 34

A markedly positive Exercise treadmill stress test is defined by:

Answer 34

``` #ST segment depression at low workload #ST elevations #hypotension ```

Question 35

A markedly positive Exercise nuclear stress test is defined by?

Answer 35

``` #Transient ischemic dilation #lung uptake of thallium #ischemia in over 2 vascular distributions #EF under 35 ```

Question 36

A markedly positive Exercise ECHO stress test is defined by?

Answer 36

``` #EF under 35 at rest #Ischemia over to vascular distributions #Drop in EF with stress ```