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ALU 301 > Chapter 6- Underwriter's Guide to Cardiac Diagnostic Testing > Flashcards

Chapter 6- Underwriter's Guide to Cardiac Diagnostic Testing Flashcards

1
Q

What are important factors to be evaluated during cardiovascular testing?

A
  1. how well the heart is functioning. (LVF, EF)
  2. How much the heart muscle is damaged or at risk.
  3. is there risk of sudden death? (arrythmias)
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2
Q

What is the difference between infarct and ischemia?

A

Infarct: myocardium permanently scarred
ischemia: Myocardium not receiving adequate blood flow

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3
Q

What are the 3 factors used to determine which cardiovascular test would be most suitable to execute?

A
  1. accuracy of test
  2. cost of procedure
  3. risk to the patient.
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4
Q

Define sensitivity.

A

test that will give a positive results when a particular condition is present, even at early stages.

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5
Q

Give sensitivity example using EKG stress test

A

100 CAD pts did Xtest. 66% were +ve, 34% were negative. it is 66% senstitive and the 34% were false negatives.

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6
Q

What is specificity?

A

it is only positive for a condition or disease

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7
Q

Give a specificity example using EKG stress test

A

EKG stest, 100 patients without known CAD had ST changes. Diagnostic test found that CAD was causing ST abnormalities in 84 patients, while HTN and Rx was causing changes in other 16 patients.
This test would be 84% specific for CAD, the other 16 tests would be false positives.

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8
Q

what is conditional probability ?

A

a rational method to minimize the diagnostic uncertainty surrounding cardiac testing.
- mathematically expressed.

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9
Q

What 3 underwriting risk assessment results can be provided from Bayesian analysis using the stress test.

A
  1. offered rated policy based on the company’s rating schedule
  2. postpone pending further evaluation by the APS
  3. order additional testing for cause of abN
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10
Q

What is the most valuable element of a physical examination for CAD?

A

auscultation with the stethoscope.

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11
Q

How can one diagnose a murmur?

A

stethoscope,

intensity is related to severity of the valvular impairments.

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12
Q

Murmurs are graded according to their intensity. What are the 6 grades?

A
  1. barely audible with utmost concentration
  2. soft, but easily heard
  3. loud without thrill
  4. loud with a thrill
  5. loud, heard with barely any contact between stethoscope and chest wall
  6. loud, heard with stethoscope off the chest wall.
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13
Q

What are sounds from a stethoscope that can be related to cardiovascular disease.

A 
Click's 
Friction rub (superficial, high-pitched, or scratchy = pericarditis)
gallop rhythm (low pitched soft sounds)
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14
Q

What is Brain natriuretic hormone (BNH)?

A

metabolite of NT-proBNP - relatively new lab marker . Synthesized by cardiac ventricles in response to cardiac stress and failure

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15
Q

Define acute coronary syndrome

A

ranges from CP including unstable angina to MI.

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16
Q

What is Troponins

A

Troponin1 and troponinT form at the contractile apparatus of the heart and are present in trace quantities in the blood.
When there’s EKG changes the troponin are most sensitive and specific biomarkers for MI.

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17
Q

What are Creatinine Phosphokinase proteins?

A

CPK- proteins elevated at time of the acute MI presentation but can be normal on first testing.
Peaks 15-20 hours after the onset of sxs.
- can be elevated with other drugs

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18
Q

How is an MI diagnosed using CPK

A
  • Diagnosis of MI and is based on elevated CPK “isoenzymes” (MB and BB)
  • CPK-BB: is concentrated in the brain and lungs
  • CPK-MB: is found mostly in the heart
  • CPK-MM: Is found mostly in Skeletal muscle.

a percentage increase of CPK-MB is most commonly over 4% of the Total CPK measured and provides grater sensitivity for the use of this test in MI.

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19
Q

How is AST affected with CAD.

A

higher lab levels are related to the size of the infarct and the amount of time that has passed since the onset of the occlusion.
4-10x higher following MI and return to within normal levels 3-4 days later

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20
Q

How is LDH affected by an MI

A

rises 12 hours after the infarct and returns to normal after CPK and AST have normalized.

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21
Q

How are cardiac Xrays used for CAD diagnosis?

A

examination of post-anterior (PA) and lateral chest films.
Review heart size and shape and evaluation of lungs.
- newer tests now used.

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22
Q

What is an EKG?

A

recording (tracing) of the electrical impulses within the heart, which regulates the heart’s contractions.
- dx arrhythmia, ischemia and infarction, atrial/ventricular enlargement, conduction delays, and pericarditis.

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23
Q

Are ST-segment changes a better or worse prognosis than T-wave changes alone?

A

Worse

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24
Q

How is an EKG preformed?

A

pt is laying down, electrodes attached on the arms and left leg and the chest. They record 12 views of the hearts electrical activity.

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25
Q

The views recorded in an EKG are called leads and are recorded in what sequence?

A
  1. limb leads: 1, 2, 3, AVR, AVL, AVF

2. Chest leads: V1, V2, V3, V4, V5, V6

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26
Q

EKG abnormalities are categorized into the following areas.

A
  1. hear rate
  2. heart rhythm/arrhythmia
  3. Axis or position of the heart
  4. cardiac hypertrophy
  5. Myocardial infarction and/or ischemia
27
Q

What are the sensitivity and specificity of the resting electrocardiogram for the dx of CAD?

A

52%, and 85% respectively.

  • used as a red flag indicator
28
Q

What is a Holter Monitor test?

“ambulatory electrocardiogram monitoring”

A

Records EKG patterns of an ambulatory pt over a 24-hour period.
*diary included.
used for: arrhythmia, heart blocks, and possible drug tx.

29
Q

What is an echocardiogram?

A

test that uses ultrasonic, high frequency impulses, to visualize the structure.
- can be done at bed side, not expensive,

30
Q

What are the sections included in an echocardiogram report?

A
  1. M mode exam- images allowing accurate measures of EJ, Chamber size, Aortic dimensions, wall thickness
  2. 2D: analyzing wall motion, qualitative summary of abnormalities
  3. Doppler Flow: procedure focuses on flow in and around the CV, showing degree of stenosis and/or regurgitation present.
31
Q

What is a transesophageal echocardiography (TEE)?

A

test that indicated for specialized evaluation of congenital cardiac abnormalities or when the results of a thoracic echocardiogram have been suboptimal. A miniaturized, high frequency ultrasound-transducer is mounted on an endoscope and record ultrasound images.

32
Q

What cardiac abnormalities are better suited to TEE imaging?

A

those involving atrial abnormalities:

  1. atrial/ventricular septal defects
  2. complex valvular heart disease and endocarditis.
  3. atrial enlargement with suspected atrial blood clots
  4. intracardiac tumours.
33
Q

What is a Stress Test?

A

exercise program performed while the individual is on a motor-driven treadmill or while pedalling an ergometer (bicycle).

  • includes EKG record, optional: nuclear or echocardiographic imaging study.
  • 30 mins.
34
Q

What is monitored during a Stress test?

A

EKG, HR, BP.
Clients walk at progressive speeds and elevations. abnormalities include: EKG changes, fatigue, weakness, abN BP changes or intolerable sxs.
- EKG during recovery is also monitored for changes.

35
Q

What are common reasons for stopping a stress test?

A
  1. Reached Max possible performance-
  2. emergency of signs and sxs of a disease process.
  3. achievement of a predetermined end point.
36
Q

What should an UW review when going over a stress test?

A
  1. type of exercise protocol used
  2. stage and time exercise was concluded
  3. max HR and BP
  4. reason for termination
  5. Max ST-segment depression and slope of ST-segment depression
  6. workload measurement at the stage where ST-Segment depression became 1.0mm horizontally depressed.
  7. length of time ST changes persist into the recovery phase.
  8. presence of arrhythmias
37
Q

What are examples of abnormal responses to a stress test that are indicative of heart disease.

A
  1. reduced exercise capacity
  2. changes in BP,
  3. certain changes in HR, and arrhythmia
  4. unusual sxs like Pain, SOB, dizziness, confusion.
38
Q

What are the diagnostic findings most commonly related to CAD?

A

ST-Segment depression

including if at rest and fall by 1.0mm or more in horizontal or down-sloping directions.

39
Q

When are ST-Segment changes related to CAD?

A
  1. ST- segment depression at peak exercise is >1-1.5mm
  2. ST-segment change occurs early in the test
  3. ST-segment change occurs in multiple, rather than in single, EKG leads
  4. ST-depression persists longer than one min into the recovery phase of the test.
40
Q

In the absence of CAD, what other factors that can cause ST-segment depressions?

A

Ventricular hypertrophy
valvular disease
blood abnormalities
medication

41
Q

What is a Myocardial Perfusion Study?

A

use of thallium 201 or technetium 99m radioactive materials (via IV) and using single photon emission computed tomography (SPECT) imaging, for multiple image views which a computer then created 3-D image.

42
Q

what would you see during a radionuclide imaging during a stress test?

A

the isotopes concentrate in areas of the heart muscle receiving good blood flow, leaving holes or defects in areas where blood flow is reduced.

43
Q

What version of a radionuclide imaging can be done if the pt is unable to exercise?

A

imaging done using vasodilators (dipyridamole or adenosine)

44
Q

Apart from MI and ischemic severity measurement, what is another role for the radionuclide imaging?

A

assessment of ventricular function.

45
Q

What is a Gated or Multi-gated equilibrium agio-cardiography (MUGA scan)

A

looks at the radionuclide circulating within the heart, producing multiple imagine within a single cardiac cycle.
EF can be measured during rest AND exercise.
- also can assess effects of bypass surgery and coronary stenting.

46
Q

Is the stress nuclear test more sensitive and specific than the EKG stress testing in terms of detecting coronary ischemia?

A

yes,

  • helps estimate prognosis following acute MI, since it sees the extent of scarring.
  • helps with those with bundle branch blocks.
47
Q

What is Echocardiographic stress test.

A

shows the heart doing weak contractions as a result of ischemia, via localized wall motion abnormalities.
Exercise is preformed or stimulated via pharmacologic agents. and 2-D echo provides video of ventricle wall motion at rest and with exercise.

48
Q

During an ECHO-Xtest ventricular wall motion is analyzed, both at rest and during exercise, and can be classified into one which 5 categories?

A
  1. normal
  2. hyperkinetic (> normal)
  3. Hypo-kinetic (reduced motion)
  4. akinetic (no wall motion)
  5. dyskinetic (movement in wrong direction).
49
Q

What ECHO-Xtest change suggests ischemia?

A

Localized hypokinesis.

50
Q

What ECHOXtest change suggests permanent Myocadial changes?

A

akinesis or dyskinesis

51
Q

What is Positron emission Tomography (PET)?

A

accurate method test for identifying how much the heart has been damaed by infarction and how much is still viable.

  • use in clinical medicine is increasing
  • radionuclide tracer is injected and a scan used to detec radioactive decay.
  • $$$$
52
Q

How is a CAT (computed Tomography) used in cardiac diagnosis?

A

computer-assisted imaging methods that accurately pictures many xrays together.

53
Q

New CT rapid systems- (64frames/second) result in two new importing testing modalities which are more accurate than the typical CT. What are they?

A
  1. coronary calcium scan

2. CT angiogram

54
Q

How does conventional wisdom describe a predictable patterns for heart disease?

A
  1. atherosclerotic plaque starts to accumulate in the coronary artery
  2. the artery narrows
  3. individuals begin to have a chest pains or other symptoms of heart disease
  4. Their stress test show blockages
  5. eventually, they have heart attacks.
55
Q

How does the ultrafast CT detect CAD?

A

they detected atherosclerotic calcium deposition before the buildup of arterial plaque has advanced enough to disrupt blood flow.
flecks of calcium appear as bright white flakes on the dark grey x-ray films.

56
Q

What is a CT angiogram

A

next steps in the evolution of CAT scan imaging in CAD.

- can detect small, non0obstructive atherosclerotic plaques as well as flow- limitting larger stenotic coronary lesions.

57
Q

how is the MRI used for CAD diagnosis

A

Magnetic resonance imaging produces cardiac cross-sectional images by placing pt in a strong magnetic field and bombarding them with radio waves.

  • used for aortic aneurysms, lesions in aorta, other large arteries, congenital heart abnormalities, chest tumours, pericardial diseases and evidence of an old MI.
  • cant be used with pacemakers, metallic objects/prosthetics
58
Q

What is Cardiac Catheterization and coronary angiography

A

gold standard test.
3 parts
1. coronary arteriography
2. intracardiac pressure measurements
3. left ventriculogram
- Xray table and EKG, and pt turned side to side, to review hearts changes to position. catheter is then inserted
- used with invasive studies have not been able to provide a diagnosis or when revascularization is contemplated.

59
Q

Lt main coronary obstruction is an indication for immediate revascularization, otherwise CAD extent will be report based on what 3 categories?

A
  1. number of coronary vessels involved
  2. location of blockages: proximal (close to origin of artery), mid-coronary, or distal
  3. extent of obstruction: non-significant (<50%) or significant (>50%)
60
Q

Ejection fraction, is best indicator of Left ventricular function. It is categorized into 4 categories.

A
  1. normal value: >50%
  2. Mild impairment: 45-50%
  3. moderate impairment: 40-45%
  4. severe impairment: <40%
61
Q

Wall motion described by catheterization reports will be similar to echocardiograms, and categorized into one of what 5 groups?

A
  1. normal
  2. hypokenetic (inward motion during systole)
  3. akinetic (absence of inward motion during systole)
  4. duskinetic- abnormal outward motion during sytol
  5. aneurysmal- presence of an aneurysm of the ventricular wall
62
Q

What is Lt ventricular end diastrolic pressure measurements

A

measurement of the pressure within the Lt ventricle at the end of the diastolic phase when the heart is completely filled with blood.
normal: 4-12 mmHg,

63
Q

Why is an Electrophysiology procedure (EP) or HIS bundle procedure?

A

invasive test that is used in the diagnosis and treatment of ventricular arrhythmias.

  • measure conduction system of the heart through solid electrode catheters.
  • dx hearts conduction system and see how well arrhythmia tx is working.
  • used to distinguish between atrial and ventricular rhythms.
  • tx for abN test results: pacemakers AICD implants,

ALU 301 (14 decks)

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