Cardiovascular Investigations

Question 1

Hypertension:

Answer 1

• Ambulatory blood pressure monitoring (ABPM)
• Home blood pressure monitoring (when ABPM not appropriate)
• Assess those risk factors. E.g do a fasting glucose for diabetes mellitus to quantify the overall risk

To access end organ damage:

• ECG (LVH in the heart)
• Echocardiogram (LVH in the heart)
• Blood tests
• Urinalysis (urine)
• Proteinuria (urine)
• Renal ultrasound (kidney - renal artery stenosis )
• Renal function (kidney - U+E)

Screen for treatable causes: 
Renal artery stenosis/FMD
Cushings disease
Conn’s Syndrome (decreased potassium concentration)
Sleep apnoea

Question 2

Atherosclerosis:

Answer 2

Blood test (for hyperlipidaemia)

Question 3

Stable Angina:

Answer 3

• ECG (mostly normal but can show pathological Q waves - evidence of past MI, inverted T waves or ST depression)
• Echocardiogram

Blood test to include:

• Full blood count
• Fasting lipid profile (elevated LDL associated with increased risk)
• Fasting glucose (elevated in diabetes)
• U + E
• Thyroid function test
• Chest x-ray (can show pulmonary oedema)
• Exercise tolerance test
• Myocardial perfusion imaging (to look at blood supply to the heart and the pumping action of the heart)
• CT coronary angiogram

Question 4

STEMI/NSTEMI/Unstable Angina (ACS):

Answer 4

• ECG (shows ST elevation and pathological Q waves in STEMI. Shows no ST elevation and no pathological Q waves in NSTEMI and unstable angina)
• Cardiac biomarkers - troponin I and T (look for elevated troponin. Elevated cTn suggests high risk of adverse effects)
• Echocardiogram
• Bloods to include FBC and U+E
• Coronary angiogram
• Chest x-ray (look for cardiomegaly, pulmonary oedema)

Question 5

Mitral Stenosis:

Answer 5

• ECG (can show AF, p-mitrale >0.12 s, RVH)
• Chest x-ray (shows left atrial enlargement, pulmonary oedema and mitral valve calcification)
• Echocardiography (this is diagnostic, thickening and scarring of the leaflets)
• Cardiac cathatarisation (to confirm diagnosis - inject radiopaque contrast medium to image the coronary arteries)
• Cardiac MRI

Question 6

Mitral Regurgitation:

Answer 6

• ECG (can show AF, p-mitrale >0.12 s, RVH)
• Chest x-ray (shows left atrial enlargement, pulmonary oedema, mitral valve calcification as well as CARDIOMEGALY)
• Echocardiogram (this is diagnostic, shows LV dimensions and can show aetiology of MR)
• Cardiac catheterisation (to confirm diagnosis and exclude other valve diseases)
• Cardiac MRI

Question 7

Aortic Stenosis:

Answer 7

• ECG (shows evidence of LVH of left ventricular strain)
• Chest x-ray (calcification of aortic valve, cardiac enlargement)
• Echocardiogram (this is diagnostic
• Cardiac catheterisation (confirms diagnosis, also assesses the valve gradient)
• Cardiac MRI

Question 8

Aortic Regurgitation:

Answer 8

• ECG (shows evidence of LVH)
• Chest x-ray (shows cardiomegaly, pulmonary oedema and DILATED ASCENDING AORTA)
• Echocardiogram (this is diagnostic)
• Cardiac catheterisation (to confirm diagnosis and assess severity of the lesion as well as anatomy of the AORTIC ROOT)
• Cardiac MRI

Question 9

Heart Failure:

Answer 9

• Blood tests to include: FBC and serum U+E
• 12 lead ECG ting (can indicate the cause)
• B-natruietic peptide
• Chest x-ray (in LVH, Alveolar oedema, Kerley B lines, Cardiomegaly, Dilated prominent upper lobe vessels, pleural Effusion) - ABCDE
• To look for cardiac dysfunction ( do an ECHOCARDIOGRAM, radionucleotide scan, left ventriculogram and cardiac MRI)
• Echocardiography (simpson’s rule)
• Radionucleotide angiography (Simpson’s Rule)
• MRI

Question 10

Atrial Fibrillation:

Answer 10

• Blood tests to include: FBC and serum U+E
• 12 lead ECG (absent P waves, irregularly, irregular QRS complexes
• Thyroid function tests
• Echocardiogram

Question 11

Acute limb ischaemia:

Answer 11

• Pulse examination
• Ankle brachial pulse index
• CT angiography
• Doppler ultrasound

Question 12

Chronic limb ischaemia:

Answer 12

• Ankle brachial pulse index (ABPI < 0.9)
• CT angiogram
• Doppler ultrasound

Question 13

Abdominal Aortic Aneurysm:

Answer 13

• Full blood count
• X-ray of the abdomen (may be done for other reasons and show an aneurysm unexpectedly)

- Abdominal ultrasound: Normal aorta = Dischage, 
Small AAA (3-4.4cm) = Annual ultrasound scan 
Medium AAA (4.5-5.5cm) = 3 monthly ultrasound scans
Large AAA (> 5.5cm) = Surgery 

• CT/MRI

Question 14

Thoracic Aneurysm:

Answer 14

XXX

Question 15

Infective Endocarditis:

Answer 15

• FBC
• CRP
• ESR!!!!!!!!
• U+E
• Urinalysis
• ECG
• Chest x-ray
• TTE (trans thoracic echocardiogram)
• 3 blood cultures from 3 different sites, > 6 hours apart
  (to be done before antibiotic treatment)

(Use the modified Duke criteria. Definite: 2 major, 1 major + 3 minor or 5 minor. Possible: 1 major or 3 minor)

Question 16

Aortic Dissection:

Answer 16

• FBC
• ECG
• Chest x-ray (widened mediastinum)
• Echocardiogram (confirms diagnosis)
• CT scan (confirms diagnosis)
• Renal function tests

Question 17

Restrictive Cardiomyopathy:

Answer 17

• Repeated ECG noting LBBB if present and other conduction defects
• Chest-ray
• N termial pro Brain Natriuetic Peptide
• Basic bloods: FBC, U+E, be on the look out for sarcoid and haemachromatosis
• Auto antibodies for sclerotic CT diseases
• Amyloid needs non cardiac biopsy to help establish the diagnosis
• Fabry; low plasma alpha galactosidase A activity
• Echo
• CMRI, probably best imaging modality
• Biopsy more helpful but still has high false negative rate

Question 18

Dilated Cardiomyopathy:

Answer 18

• Repeated ECG noting LBBB if present
• Chest x-ray
• N termial pro Brain Natriuetic Peptide
• Basic bloods FBC, U+E
• Echo
• CMRI, probably best imaging modality
• Coronary angiogram
• Sometimes biopsy depending on time course of cardiomyopathy

Question 19

Hypertrophic Cardiomyopathy:

Answer 19

• ECG, often abnormal but a few are normal where phenotype is poorly expressed in genotype +ve individuals
• Echocardiogram
• Cardiac MRI
• Risk stratification for SCD, may need ICD
  Holters repeatedly, ETT, FH ?

Question 20

Myocarditis:

Answer 20

ECG usually abnormal
 Biomarkers often elevated but not falling in a pattern consistent with MI
 Echo, can get RWMA
 CMRI can see oedema in certain images
 Endomyocardial biopsy 
 Viral DNA PCR
 Auto antibodies
 Step antibodies
 Lyme B burgdorferi
 HIV

Question 21

Pericarditis:

Answer 21

• ECG (ST elevation and PR segment depression)
• Serum troponin
• Blood culture
• CRP
• FBC
• Chest x-ray (cardiomegaly may indicate a pericardial effusion)
• Echocardiogram