Cardiovascular Diagnostics: Vascular Assessment & Other CV studies

Question 1

what is required for pre-catherterization?

Answer 1

• patient NPO > 6 hours
• IV conscious sedation
• if suspected CAD: pretreat with aspirin 325mg
• if likely to require percutaneous coronary intervention (stent placement) pretreat with clopidogrel 600mg loading dose
• Goal INR < 2.0 to limit access-site bleeding complication
• no antibiotic prophylaxis

hold warfarin starting 48 hrs prior to catheterizaiton

Question 2

How do you care for someone with stents?

Answer 2

Statin Therapy

• High intensity statin therapy (atorvastatin 80mg or Rosuvastatin 20mg)
• for BMS and DES: 12 months of dual antiplatelet therapy: clopidogrel (P2Y12 inhibitor) + aspirin 325mg, then risk of bleeding is low continue another 18-24 months (DAPT score)
  -minimum for BMS- 1 month of dual therapy
  -minimum for DES- 6-12 months of dual therapy

secondary prevention strategies: (lipids, HTN, T2DM, obesity, smoking, physical inactivity

Question 3

In a PCI vs. CABG what is CABG better for?

Answer 3

• Left main disease
• 3 vessel disease in patient with reduced LVEF or treated diabetes
• long lesions (> 35mm)/ diffuse disease

Question 4

what are indications for right heart cath?

Answer 4

• unexplained dyspnea
• valvular heart disease
• pericardial disease
• right and/or left ventricular dysfunction
• congenital heart disease
• suspected intracardiac shunt

Question 5

Indications for cardiac cath?

Answer 5

• evaluate the extent and severity of cardiac disease in symptomatic patients (stable angina)
• to exclude severe disease in symptomatic patients with equivocal findings on non-invasive studies
• to determine if medical, surgical or catheter-based interventions are warrented
• to plan for up coming surgical procedures
• to intervene on known ischemia heart disease (i.e, STEMI/NSTEMI)

Question 6

what are contraindications to cardiac catheterization?

Answer 6

• No absolute contraindications if the intent is a life-saving intervention
• relative contraindications: (often revolve around things we may give during the procedure- heparin, contrast)

Question 7

what type of stents are available?

Answer 7

BMS

• Compressed over deflated angioplasty balloon
• balloon inflation enlarges stent to approx. “normal” vessel lumen
• balloon deflated and removed

DES (Drug-eluting stents (DES)

• antiproliferative agent attached to stent
• drug elutes from stent over 1-3 month period
• reduce clinical restenosis by 50%
• much higher rate of restenosis

Question 8

• Visualize abnormalities of ascending aorta
• aneurysmal dilation & involvement of the great vessels
• aortic dissection
• used to assess: Patency of saphenous vein grafts, shunts involving the aorta (i.e, PDA)
• severity of aortic regurgitation

Answer 8

Aortagraphy

Question 9

• minimally invasive, and when combined with perfusion imaging, can provide an assessment of the coronary arteries and the cardiac myocardium in one setting
• useful when probability of severe CAD is low to rule out ACS/CAD in setting of chest pain
• high sensitivity= high negative predictive value (NPV) among low to intermediate- risk patients with chest pain

Answer 9

Coronary CT angiogram (CTA)

Question 10

• No ionizing radiation
• high resolution dynamic (moving) images of myocardium
• can image aorta, pericardial, valvular disease, congenital heart disease, ischemic heart disease
• late gadolinium enhacement can be used to help assess-myocardial viability
• breath holds, or respiratory gating is often needed

Answer 10

Cardiac MRI

Question 11

contraindications to cardiac MRI

Answer 11

metallic implants of many types

• cochlear implant
• ICD (relative, we have a protocol)
• insulin pump
• metal or bullet
• drug infusion port
• neural stimulator
• CNS clips

Question 12

Continuous ambulatory ECG monitoring- 24 or 48hrs. Useful in the diagnosis of:

• Daily symptoms (dizziness, syncope, near syncope, palpitations)
• arrhythmias
• antiarrhythmic drug therapy
• severity/frequency of ischemic episodes
• detect silent preoperative and perioperative ischemia (reveals transient ST-T wave abnormalities of which 70-80% are not accomplished by symptoms)

Answer 12

Holter Monitoring

Question 13

• 30 days
• evaluate syncope, dizziness, palpitations that occur less frequently (once a month or once a week.) Also used in patients with cryptogenic stroke
• triggered (auto, self activated)
• fewer leads to evaluate

Answer 13

event monitoring

Question 14

• 2 weeks
• similar to a holter
• disposable
• wireless
• one lead recording

Answer 14

Zio patch

Question 15

• tests the electrical conduction system of the heart to assess electrical activity and conduction pathways
• used to investigate the cause, location of origin and ideally treath various arrythmias
• catheters (single or multiple) situated within the heart through vein or artery and manipulated to map out electrical conduction pathways
• may administer pro-arrhythmic drugs to induce arrhythmia
• if abnormal electrical activity identified, may ablate the cells of origin

Answer 15

Electrophysiology Study

Question 16

indications for electrophysiology study?

Answer 16

• AVRT associated with WPW syndrome
• AVNRT
• atrial tachycardia (focal atrial tachycardia)
• atrial flutter
• atral fibrillation
• frequent ventricular ectopy
• ventricular tachycardia