Investigations in Cardiac Disease Flashcards
Describe the imaging techniques used in cardiovascular disease, e.g. echocardiography
types -
Two-dimensional real time echocardiography: for wall motion abnormalities
M-mode echocardiography: measurement of size of heart chambers, EF and cardiac events accurate timing.
Doppler echocardiography: detects direction of blood flow, regurgitation
Appropriateness Criteria for Echocardiography
Appropriate indications include but are not limited to:
• Symptoms possibly related to cardiac etiology, such as dyspnea, shortness of breath, lightheadedness, syncope, cerebrovascular events
• Initial evaluation of left-sided ventricular function after acute myocardial infarction
• Evaluation of cardiac murmur in suspected valve disease
• Sustained ventricular tachycardia or supraventricular tachycardia
• Evaluation of suspected pulmonary artery hypertension
• Evaluation of acute chest pain with nondiagnostic laboratory markers and electrocardiogram
• Evaluation of known native or prosthetic valve disease in a patient with change of clinical status
two types of echocardiograms
- TEE
2. TTE
Indications for ambulatory ECG - class I
Class I (Recommended)
• Patients with unexplained syncope, near syncope, or episodic dizziness in whom the cause is not obvious
• Patients with unexplained recurrent palpitations
• To assess antiarrhythmic drug response in individuals with well-characterized arrhythmias
• To aid in the evaluation of pacemaker and ICD function and guide pharmacologic therapy in patients receiving frequent ICD therapy
Indications for ambulatory ECG - class IIA
Class IIa (Weight of Evidence/Opinion Is in Favor of Usefulness/Efficacy) • To detect proarrhythmic responses in patients receiving antiarrhythmic therapy • Patients with suspected variant angina
Indications for ambulatory ECG - class IIB
Class IIb (Usefulness/Efficacy Is Less Well Established by Evidence/Opinion)
• Patients with episodic shortness of breath, chest pain, or fatigue that is not otherwise explained
• Patients with symptoms such as syncope, near syncope, episodic dizziness, or palpitation in whom a probable cause other than an arrhythmia has been identified but in whom symptoms persist despite treatment
• To assess rate control during atrial fibrillation
• Evaluation of patients with chest pain who cannot exercise
• Preoperative evaluation for vascular surgery of patients who cannot exercise
• Patients with known coronary artery disease and atypical chest pain syndrome
• To assess risk in asymptomatic patients who have heart failure or idiopathic hypertrophic cardiomyopathy or in post–myocardial infarction patients with ejection fraction less than 40%
• Patients with neurologic events when transient atrial fibrillation or flutter is suspected
CIMT indications
CIMT = carotid intima media thickness
to determine risk of MI and stroke. predict CAD
Indications for Exercise Stress test
- To diagnose suspected obstructive CAD based on age, gender, and clinical presentation, including those with right bundle branch block and less than 1 mm of resting ST depression
- For risk stratification, functional class assessment, and prognosis in patients with suspected or known CAD based on age, gender, and clinical presentation
- To evaluate patients with known CAD who have noticed a significant change in their clinical status
- To evaluate patients with vasospastic angina
- To evaluate patients with low- or intermediate-risk unstable angina after they had been stabilized and who had been free of active ischemic symptoms or heart failure
- After MI for prognosis assessment, physical activity prescription, or evaluation of current medical treatment before discharge with a submaximal stress test 4 to 6 days after MI or after discharge with a symptoms limited EST at least 14 to 21 days after MI
- To detect myocardial ischemia in patients considered for revascularization
- After discharge for physical activity prescription and counseling after revascularization as part of a cardiac rehabilitation program
- In patients with selected valvular abnormalities to assess functional capacity and symptomatic responses in those with a history of equivocal symptoms
- To evaluate the proper settings in patients who have received rate-responsive pacemakers
- To investigate patients with known or suspected exercise-induced arrhythmias
Describe the imaging techniques used in cardiovascular disease, e.g. coronary angiography
Coronary angiography = gold standard for CAD diagnosis.
Coronary angiography benefits and disadvantages
+:
visualize arteries anatomically, combine diagnosis and treatment in one step.
-: invasive, cannot perform functional assessment, interobserver reliability, does not distinguish between vulnerable and stable plaque.
CT coronary indications
lesion assessment before coronary artery angioplasty
the evaluation of chest pain after coronary artery bypass surgery
the assessment of stent restenosis
the anatomical assessment of congenital anomalies in the origin and subsequent course of the main coronary arteries
Relative and absolute contraindications for a CT coronary angiography
ABSOLUTE
severe renal impairment because of the high risk of contrast-induced nephropathy (CIN) and some permanent decrement in kidney function.
Pregnancy is a contraindication due to radiation exposure.
RELATIVE
Known coronary artery disease: Most patients with known coronary artery disease and symptoms will be evaluated with catheter angiography rather than CT scanning. Patients with symptoms consistent with obstructive coronary artery disease, and who have associated abnormal ECG and/or elevated cardiac enzymes are considered high risk and are not suitable for cardiac CT.
Renal impairment: Contrast-induced nephropathy (CIN) is more frequent in patients with pre-existing kidney function reduction, cardiac failure and possibly also hypertension. Some diuretics also increase the likelihood of CIN.
Asthmatic patients: Patients with asthma might not be able to tolerate beta-blockers. The respiriatory effort involved in dyspnoeic patients could degrade image quality, making the study non-diagnostic.
Morbid obesity: Image quality will be impaired in very large patients. There are weight limits for CT scanner tables.
Contrast medium hypersensitivity/allergy: A history of a severe allergic reaction to contrast medium is a relative contraindication to CTCA. A history of minor hypersensitivy reactions might not necessarily be a contraindication.
Other relative contraindications include: the presence of arrhythmias, high coronary calcification scores (Calcium scores) and an inability of the patient to concentrate and follow instructions in the communicative language.
Which test is appropriate?
Calcium score :
Asymptomatic only
Screening
The most accurate risk screening test
vs CTCA : Equivocal symptoms Equivocal ECG changes Excellent test for selected patients Rule out significant coronary artery disease
coronary angiography vs CTCA
CA =invasive
CTCA = non-invasive
Appropriate Indications for Cardiac Magnetic Resonance
- Evaluation of chest pain syndrome in patients with intermediate pretest probability of CAD
- Evaluation of suspected coronary anomalies
- Evaluation of LV function after myocardial infarction or in patients with heart failure in patients with technically limited or indeterminate echocardiograms
- Evaluation of extent of myocardial necrosis and microvascular obstruction (“no reflow”)
- Evaluation of myocardial viability • Evaluation of myocarditis
- Evaluation of specific cardiomyopathies (e.g., infiltrative cardiomyopathies, HCM)
- Characterization of native and prosthetic cardiac valve dysfunction in patients with technically limited images from echocardiogram or TEE
- Evaluation of suspected constrictive pericarditis
- Evaluation of cardiac and pericardial masses
- Evaluation of pulmonary veins before pulmonary vein isolation for atrial fibrillation
- Assessment of congenital heart disease
- Evaluation for aortic dissection
