Cardiopulmonary diagnostic testing and interventions Flashcards
why would a chest x-ray be ordered?
1) cardiomegaly
2) congestive heart failure
3) valve dysfunction
4) differential diagnosis pulmonary conditions
cardiomegaly
cardiothoracic ratio (maximum width of the heart/maximum internal diameter of the thoracic cage > 50% considered positive; some limitations
common types of chest radiography
- posterior.anterior view, anterior-posterior view, lateral view
- assess density of various structures, are findings normal?, and is there any consistency (right vs. left)
echocardiography
1) cardiac echo: non-invasive procedure using high frequency ultrasound waves to create images to assess the function of the heart
2) size of the ventricle, integrity and thickness of the ventricular walls and septum, valve integrity and health, volumes of ventricle, ejection fraction can be estimated
2D echocardiography
depicts anatomic relationships and movement of cardiac structures relative to one another; wall and valve motions; intracardiac masses; measures ventricular thickness, contractile function and ejection fraction
Doppler imaging
depicts blood flow direction and velocity; identifies regions of vascular turbulence (usually seen distal to a stenosis); color flow mapping show the location of stenotic and regurgitant valves and other blood flow issues in the heart and vena cavae and aorta
echocardiography
- uses pulse of reflected ultrasound to evaluate the functioning of the heart
- provides real-time images of beating heart
- information derived - size of ventricular cavity, thickness, and integrity of interatrial and intraventricular septa, functioning of valves, motion of individual segments of ventricular wall
- quantify volumes of left ventricle, estimate SV and ejection fraction
CT-Computed tomography
- CT uses a series of thin x-rays to generate cross sectional images of the heart, vasculature and pulmonary vasculature
- x-ray device rotates around patient and the generated beams are partially absorbed by body tissues. the remaining beams emerge and are captured as images
- often requires administration of an intravenous contrast agent to distinguish between blood and tissue
- CT used for great vessels, pericardium, myocardium, and coronary arteries
- CT used to diagnose aortic dissections and aneurysms myocardial abnormalities; intracadiac thrombus formation
- limitation: artifact from patient moving and breathing; radiation
spiral CT
- helps guard against this as it is quick enough to get images while the patient is holding breath; lower radiation; very useful for the detection of PE
EBCT
electron beam CT uses a direct electron beam to acquire images in milliseconds (during a single cardiac second)
CT uplmonary angiography (CT-PA)
- direct visualization of the pulmonary arteries and can detect a thrombus
- becoming more preferred diagnosis of pulmonary embolism (PE)
- benefits: rapid reporting, high sensitivity and specificity, widely available
0 3rd most common acute CVD is PE … estimated 200,000-300,000 annually in US
cardiac MRI (CMR)
- uses a powerful magnetic field to obtain images of internal structures; requires no ionizing radiation
- best at differentiating tissue types (especially soft tissue); often without the use of contrast dyes
- used to diagnose congenital anomalies, diseases of the aorta including dissection and aneurysm
- used to assess ventricular mass and volume, intravascular thrombus, cardiomyopathies, pericardial disease, and cardiac cancers
- captures images at discrete times in the cardiac cycle used for evaluating valvular and ventricular function
- better for patients with kidney dysfunction or allergy to contrast dye
coronary magnetic resonance angiography (coronary MRA)
non-invasive, contrast-free way to image the coronary arteries
contrast-enhanced MRI
contrast agent used post MI to differentiate between damaged but salvageable and infarcted (non-reversible) cardiac tissue
positron emission tomography
- nuclear technique that provides visualization and direct measurement of metabolic functioning
- gold standard for blood flow measurement
- costly
- advantage - can detect jeopardized by viable myocardium without exercise
nuclear imaging
- evaluate heart function using injected, radioactive tracers
- used to assess myocardial perfusion and how the blood is passing through the heart and vessels and to localize and quantify myocardial ischemia and infarction
duplex ultrasound
- records sound waves reflecting off objects, such as blood, to measure qualities of the flow
- determines whether plaque or other matter is blocking blood flow int he arteries
carotid duplex
- evaluation of the arteries in the neck
- most accurate test available to determine if a patient has carotid artery disease
- plaque buildup in the carotid artery can break up into small particles and result in CVA
ultrasound technology
- images and records appearance and the amount of arterial blockage
MRA
- high sensitivity and specificity for detecting PAD
- advantages include lack of radiation exposure and removal of background structures
- aids in visualizing the vessels
- may be used to get visual of abdominal aorta, post op complications to r/o occlusions, infections, hemorrhage
ABI
- ankle brachial index
- clinical test used to diagnose PAD
- measures and compares the blood pressure in the arms and legs of a person in order to identify any blood flow problems
- preferred initial screening test
- equipment: hand-held Doppler, ultrasound gel, and BP cuff
ABI procedure
- pt supine
- resting for 5-10 mins prior to testing
- obtain brachial pressure, place BP reading BUE’s, document highest systolic number
- obtain ankle pressure, place BP cuff and obtain pressure reading in both right/left side
stress test
- treadmill stress test or exercise stress test
- measures the heart under a standardized workload
- can be done as a routine exam or if signs and symptoms suspicious for ischemia are present or to determine a safe level of exercise or check the heart after any kind of procedure
- patient is hooked up to an EKG and walks or runs on the treadmill following a standardized protocol
- VO2 max is also taken at the same time - milliliters of O2 consumed in 1 minute per kilogram body weight`
pharmacological stress testing
- used when a patient is unable to perform upright exercise on a treadmill or cycle
- injection of a pharmacological agent to induce physiological stress
- adenosine or dipyridamole-walk protocol
- combined low-level treadmill exercise during adenosine infusion
arteriography
- contrast angiography
- picture of blood vessels is produced to identify blood flow dynamics, normal vs. abnormal vascular anatomy
- side effects usually occur from reaction to dye or puncture site problems
- sensitivity reaction
- hemorrhage/hematoma
- thrombosis
contrast echocradiography
- use of intravenously injected contrast agent with echocardiogram
- assesses myocardial perfusion and ventricular chambers
- used with TEE or epicardial echocardiography to assess distribution or cardioplegia and degree of valvular regurgitation
trans-esophageal echocardiography (TEE)
- improved view of the mediastinum
- given sedation, catheter travels into esophagus
- trying to rule out bacterial endocarditis, aortic dissection, valve regurgitation, left atrial thrombus, septal defect
3D echocardiography
- uses 3D echo are of particular benefit to show valvular defects, intracardiac masses, and congenital malformation
- transducer mounted on a catheter to provide images
- solves the problems of image quality issues with non-invasive echocardiography has with artifacts of pulmonary issues, obesity, chest wall abnormalities
IVUS - intravascular ultrasound
- tiny ultrasound probe on the end of a catheter is inserted into artery to visualize the interior walls of the artery
- real-time visualization using echocardiography
- assists with planning procedures: sizing stents, visualizing complex lesions and complex or tortuous arteries
cardiac catheterization
- invasive procedure: intravascular catheter percutaneously inserted and maneuvered to the heart to visualize chambers, valves, coronary vessels, cardiac pressures, volumes to evaluate cardiac function
- both diagnostic and therapeutic
- uses fluoroscopy (moving x-ray)
- R-side catheterization: evaluate right ehart pressures
- L-side catheterization: usually inserted through common femoral A or radial artery to evaluate aorta, L side of heart
- indications: aortic dissection, atypical angina, cardiomyopathy, congenital disease, CAD, s/p MI, valve disease
indications for cardiac catheterization
- cardiac arrest or ventricular fibrillation
- MI in progress or inevitable
- pulmonary edema
- intolerance of or noncompliance with medical therapy for angina
- job description mandate
- significant decrease in exercise duration
- progressive decline in systolic BP to <100 mmHg during exercise
- evidence of symptomatic hypoperfusion during exercise
- left ventricular ejection fraction (<35%)
- ventricular tachycardia with exercise
cardiac catheterization
- procedure to examine how well heart is working and to check for blockages of the coronary vessels
- pressure and blood flow can be measured in the heart, identify disease of heart muscle, valves, or coronary arteries
- contrast dye injected and visible on x-ray (fluorscopy) to look at flow through cardiac arteries, done in a spcial room in radiology (cath lab)
- blockages can be treating once diagnosis is confirmed (PCI/PTCA)
cardiac catheterization - angioplasty
- can place stents - scaffolding to support arterial wall
- balloon angiography - inflate a tiny balloon to push the thrombus/lesion/plaque against the arterial wall, aka PCI percutaneous coronary intervention
Roto bladder - Roto Rooter for artery, literally grinds up calcified blockages - atherectomy - small vacuum like device can remove part or all of blockage
angioplasty and stenting - treatment
PTCA percutaneous transluminal coronary angioplasty
- balloon and stent inserted into diseased artery
- balloon inflated with stent expanded
- balloon deflated and withdrawn leaving stent behind
- often done at the same times as the evaluative catheterization
laser
- transmyocardial laser revascularization, used for patients who need revascularization but are not candidates for CABG
- use a laser to create a tiny tunnel directly through the myocardial wall to re-prefuse the left ventricle
groin or wrist puncture site
- needs pressure 20-30 minutes immediately after sheath is pulled out
- must keep groin straight x 4 hours
- not needed of access is through radial artery
- PT does not usually get involved for just cardiac catheterization but often get involved with patients who have additional needs post-cath
- patients often goes home or stays max 1 day in hospital post-procedure
transcatheter aortic valve replacement (TAVR)
- minimally invasive surgical procedure repairing valve that is damaged
- intermediate or high-risk patient for standard valve replacement with aortic stenosis can be considered for this option
- procedure - enter through femoral artery or small chest incision through a transapical approach
left ventricular assist device (LVAD)
- pump used for patients who are end-stage heart failure
- surgically implant battery-operated mechanical pump to pump blood to the body
- “bridge to transplant” - considered a life saving therapy, now often permanent
- measure BP with a Doppler over radial or brachial artery
endarterectomy
- carotid endarterectomy is a surgical procedure to open or clear the carotid artery (goal is reducing stroke risk)
- indicted when moderate blockage (50-79%) and experiencing symptoms of TIA stroke
- indicated when severe blockage (>80%) even without symptoms
- under local or general anesthesia
- risk: stroke (2-7%), MI, nerve damage
- carotid artery can be cleared endovascularly by a cardiologist with advanced training
