Diagnostic Studies (Lecture 2) Flashcards
With transthoracic (echo) imaging, the patient is positioned to bring the cardiac structures close to the chest wall, usually in a ______ position,
left lateral decubitus
Indications for a ECHO?
Valvular lesions
Ventricular assessment (assess V width and EF)
CAD (every patient with heart attack gets an ECHO)
Cardiomyopathy
Pericardial (but what’s the gold standard)
Implantable monitor Cardiac stress testing (w/ IV meds) Cardiac cath EPS Echo
Invasive studies
How soon shuold a CXR be obtained in patients with suspected cardic issues?
30 mins
In addition to enlargement/cardiomegaly, you can see wht on a CXR?
Ventricular aneuryms (“7 days after an MI”)
also, calcifications, cardiac malconfigurations
CXR in pt w/ COPD might show what?
Flattened diaphragm
Where do you hear aortic regurgitation? What would you see on CXR?
Erb’s point
LV dilation
Dilated aortic
WHere do you hear mitral stenosis? What accompanying sound would you hear?
Apex (5th MCL)
You’d hear an opening snap
Mitral regurgitation is accompanied by?
Pansystolic murmur accompanied by “blowing”
CT use in cardiology is limited. BUt it’s the gold standard for?
chronic obstructive pericarditis
It can also be used to assess great vessel problems in STABLE patients
If creatinine is lower than ___ we shouldn’t do a contrast CT
1
MRI using ____ can help differentiate between impaired (reversible) and infarcted (irreversible) myocardium
gadolinium
EF=(EDV−ESV) / ____
EDV
This can be estimated with a TTE
With stenotic and regurgitant valves, blood flow velocities may be as high as 5 to 6 m/second, requiring the use of the _____.
continuous-wave Doppler mode
_____ uses the Doppler principle to record the velocity of motion of the myocardial wall. _____ recordings of the myocardium adjacent to the mitral annulus are used to evaluate diastolic ventricular function.
Tissue Doppler
A standard echocardiographic study includes pulsed Doppler measurement of antegrade flow velocities (transmitral and transaortic) and evaluation for _____ by continuous-wave and color Doppler modalities
valve regurgitation
With a standard TTE, you probably won’t be able to visualize which ventricle very well?
LV
For definitive/exact EF, use _____; otherwise, TTE can be used for an estimate.
cardiac cath
Transesophageal echocardiography is much more sensitive than transthoracic echocardiography for detection of left atrial thrombus, _____, and prosthetic mitral valve regurgitation/prosthetic valve dysfxn
valvular vegetations
(also highly specific for aortic dissection, endocarditis,
Normal EF is anything > than?
55%
For eval of the aorta or LAA, we’ll probably use?
TEE
_____ is the clinical standard for evaluation of valvular stenosis. Cardiac catheterization is reserved for cases in which _____ is nondiagnostic, clinical data are discrepant with echocardiographic findings, or the coronary anatomy needs to be asses
Echocardiography
Even when transesophageal imaging might be helpful, most clinicians begin with a transthoracic examination; exceptions are for the patient with a possible acute ____, in whom transesophageal echocardiography should be performed as quickly as possible, and in the evaluation of possible _____
aortic dissection
left atrial thrombosis before cardioversion
The recommended scope of practice for point-of-care ultrasound studies includes diagnosis of pericardial effusion and evaluation of global left ventricular systolic function. In contrast, diagnosis of aortic dissection requires transesophageal echocardiographic or computed tomographic or magnetic resonance imaging. Diagnosis of aortic valve stenosis requires continuous-wave Doppler recording of the transvalvular velocity by an experienced sonographer. Acute anterior myocardial infarction results in hypokinesis or akinesis of the anterior wall, which can be visualized by _____, but evaluation of regional myocardial dysfunction is challenging and requires additional training and experience. Papillary muscle rupture might be diagnosed on transthoracic imaging, but transesophageal imaging often is required. Papillary muscle rupture is likely to be missed with current point-of-care ultrasound systems or by less experienced clinicians.
echocardiography
CT is used to diagnose ___ and ____. It can identify abnormal pericardial fluid, thickening, and calcification. Myocardial abnormalities, such as regional hypertrophy or ventricular aneurysms, and intracardiac thrombus formation can be distinctly visualized by CT
aortic dissections and aneurysms
Normal QTc range for men?
Women?
Men = 390-450 msec women = 390-460 msec
HR for newborn?
At what age does a child’s normal HR become the same as an adults?
110-150
Age 6
Details/side effects of amiodarone?
(it’s a C3 K+ channel blocker)
300 mg, then 150
CI in hyperthyroidism/iodine allergy, 3rd HB,
Pulmonary function tests/CXR required to assess fibrosis…
May turn them blue
Liver toxicity
Lots of drug interactions
Lidocaine, what about it?
Fast Na Channel blocker
Terminate Vtach w/ pulse (alternate if pulseless if no amiodarone)
Least toxic Na channel blocker (only IV/IM)
CI in 3rd HB
Procainamide?
Ventricular/SVTs
HOTN if given too quickly (which is why PO is MC)
QT PROLONGATION
Lupus-like effects
_____ is useful for narrow-complex tachycardias both diagnostically and therapeutically. For example, if the tachycardia continues with flutter waves or P waves during atrioventricular (AV) block, then a diagnosis of atrial flutter or atrial tachycardia is established. Likewise, the termination of the tachycardia with a P wave that is not conducted to the ventricle is much more likely to be an AV or AV nodal re-entrant tachycardia.
Adenosine
MUGA (aka RVG) is a nuclear imaging study that cna be used for ?
Why do this over an Echo?
What are its pitfalls?
1 board question = not very accurate for patients w/ arrhythmias (e.g., pt with AFib) (maybe use a PET scan instead)
LV fx (do this over an echo if you have a “fluffy” patient)
NO INFO ON VALVULAR STRUCTURES
PET scan is a nuclear imaging study that can be used for ?
myocardial perfusion
Usually first non-invasive assessment For frequent, recurrent arrhythmias?
Holter monitor (will last for 24-48 hrs)
outpatient procedure
Usually reserved for pts w/ infrequent arrhythmia-type sxs OR patients w/ non-diagnostic holter monitor eval?
Event monitor (3 days - 3 weeks)
Recent STEMI < 2 days High risk ACS (perform coronary angiogram) Decompensated HF Active Endocarditis Severe Aortic stenosis Symptomatic HOCM Acute myocarditits Physical disability
CI to ALL stress testing
Bayes theorem?
Post test prob = pre test prob x likelihood ratio
If they have a high probability of CAD (>85%) would you do a cardiac stress test?
(High probability is men>40, women>60 with typical angina OR patients with a buncha risk factors; smokin, DM, etc.)
No, typically reserve stress tests for those at intermediate to low risk
TEST QUESTION:
Baseline EKG abnormalities that preclude ECG based testing (i.e., stress test)?
LBBB
Any ST depression > 1mm
LVH or digoxin w/ any ST depression
WPW
RAD/extreme RAD causes?
Left posterior fascicular block Lateral myocardial infarction Right ventricular hypertrophy Acute lung disease (e.g. Pulmonary Embolus) Chronic lung disease (e.g. COPD) Ventricular ectopy Hyperkalaemia Sodium-channel blocker toxicity WPW syndrome Normal in children or thin adults with a horizontally positioned heart
Maximum heart rate?
220-age
A stress test continues until any of the following occurs?
Angina
Signs of myocardial ischemia on EKG
Target HR is achieved (85%)
Patients become too fatigued
coronary revascularization is pursued if (1) the patient’s symptoms of angina do not respond adequately to antianginal drug therapy, (2) unacceptable side effects of medications occur, or (3) the patient is found to have high-risk coronary disease for which revasculariza- tion is known to improve survival (as described in the next section). The two techniques used to accomplish mechanical revascularization are ______ and _____
percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery.
How could you localize areas of ischemia on a treadmill test?
ECHO
EKG
Radionucleotide study (technetium/PET scan)
TEST question…
Markedly positive findings on a stress test include:
- Ischemic findings w/in 3 minutes of exercise OR persist 5 minutes AFTER stopping
- ST depression greater than 2 mm
- Systolic pressure decreases
- High grade ventricular arrhythmias develop
AND?
Pt unable to exercise for at least 2 min b/c of cardiopulmonary limitations
“Regular” positive test findings (i.e., not necessarily “marked”) on cardiac stress test include (2)?
Chest pain
ST segment changes
For a stress echocardiogram, a heart rate can be artificially stimulated by continuous intravenous infusion of ____
dobutamine
With a nuclear stress myocardial perfusion study, patients who are unable to exercise, ____, ___, and ___ may be used as to induce a “chemical stress test”
dobutamine, adenosine, or dipyridamole
____ and ____ induce relative coronary artery dilation that approximates the effects of exercise WITHOUT inducing an increased HR
ADENOSINE and DIPYRIDAMOLE
“For old people, unable to exercise, this is great for a stress test…”
Gold standard for invasive cardiac measurements?
Cardiac catheterization
Left cardiac cath normally accessed through?
Femoral, but brachial and axillary are possible too.
Use fluoroscopy
Cardiac caths are risky.. typically reserved for?
STEMIs
NSTEMIs that aren’t responsive (typcially 24-48 hours after lack of responsive)
Indications for left cardiac cath?
Acute ST elevation Unstable angina or NSTEMI Post infarction angina Refractory stable angina Previous cardiac arrest Assess LV function Evaluate proximal aortic dz Assess hemodynamics in pericardial constriction
Weird name for the balloon-tipped catheter used in right catheterization
Swan-Ganz catheter
An elevated wedge pressure (meaning high atrial pressure) would probably be accompanied by?
A reduced wedge pressure would imply?
Elevated = volume overload = wet = S3
Reduced = volume depletion = dry = treat w/ fluids
INdications for right heart cath?
Assess filling pressures/CO in HF
Assess volume status/vascular resistance
Creatinine level greater than 1?
DON’T GIVE CONTRAST
from a Chem 7
For electrophysiology studies, Primary diagnostic indications include?
supraventricular tachycardia
ventricular tachycardia
sudden cardiac death
(WPW, Brugada, AF refractory to treatment)
Right ventricular systolic pressure is increased by ____ or pulmonary hypertension. Right ventricular diastolic pressure increases when the right ventricle is subjected to pressure or volume overload and may be a sign of right heart failure
pulmonic valve stenosis
Elevation of the mean PCW is seen in left-sided heart failure and in
mitral stenosis or regurgitation
