Slide set 4 Flashcards
Invasive Dx testing
Echo (TEE) Cardiac stress testing (IV medications) Cardiac catheterization Electrophysiologic studies Implantable monitor
What views to obtain on CXR
PA and lateral
What can you visualize on CXR (7)
Cardiac silhouette Cardiac configuration Calcifications Artificial Devices G
What view is best to view Cardiomegaly
PA view (AP distorts heart)
CT can eval
Great vessels Pericardium Myocardium Coronary arteries
CT primary indications are
Great vessel issues (AA or disection) Pericardial ABNLs (Pericarditis)
TOC for pericardial diseases
EBCT
EBCT and MSCT abbreviation is
Electron beam CT Multislice CT
Is CT coronary angiography invasive?
No (EBCT/MSCT)
What kind of score can we obtain from CT and for what purpose?
Agatstan score for Coronary artery calcification risk factor
What are the limitations of CT
Contrast dye Rad exposure Artifact from pt motion
Cardiac cath is great for
Identifying problem AND fixing it (therapeutic)
MRI of the heart is also known as
Cardiovascular magnetic resonance
CMR advantages
No radiation, Evals almost everything cardiac
CMR disadvantages
Expensive
CMR can eval
Function Perfusion Viability Tissue characterization
CMRA is an abbreviation for
Cardiovascular magnetic resonance angiography
CMRA advantages are
Noninvasive Contrast free High Sensitivity for CAD or congenital ABNLs of the coronary arteries
Gandolinium contrast in an MRI is used for
Distinguish between impaired and infarcted (irrev) tissue
Echocardiogram primarily focuses on
Suspected murmurs Cardiac function assessment Other suspected structural heart DZ
Echo U/S modes
M-mode, 2-D, 3-D, Doppler
Echo M-mode is useful for
measuring wall thickness or chamber diameters
Echo 2D-mode is useful for
Defines cardiac structures relative to another
Echo Doppler-mode is useful for
eval blood flow, velocity, turbulence
What are the two types of echocardiogram
TTE - Trans-Thoracic Echo TEE - Trans-Esophageal Echo
TTE echo transducer is placed where
On the chest
TTE echo is CI in
Heavy people
TTE echo is useful for
EF calculation Ventricle Dilation Left Atrium size Paradoxical septal motion
TEE Echo transducer is placed where
In the esophagus via endoscopy and posterior to the heart
TEE Echo can help rule out what
Aortic Dissection Endocarditis Prosthetic valve dysfx Left atrium thrombus prior to cardiversion
TEE Bubble study concept
Sterile saline with bubbles are injected- Bubbles should be seen on R-side but no L-side to to lungs filtering them out.
TEE bubble study is useful for ID of
VSD/ASD
Types of nuclear cardiology tests
MUGA and PET
MUGA stands for
Multi-unit gated acquisition
PET scan stands for
Positron Emission Tomography
MUGA is useful for
Assessment of Left-Ventricular function
PET scan is useful for
Assessment of myocardial perfusion
Another name for MUGA
RVG or Radionuclide ventriulography
Concept of MUGA
Radiolabels RBCs w/ technetium 99m to determine Left and Right Ventricle EF’s
MUGA (RVG) advantages are
Highly accurate providing RV/LV info at the same time Not limited by body habitus Done in 30m
MUGA (RVG) disadvantages are
Radiation exposure Not for pts with arrythmias No info on valvular structures
PET scan is the fallback for what
Stress test for patients who have L-BBB, ventricular pacing, or A-fib
PET scan is essentially
A CT with nuclear sugar solution (dead cells don’t uptake sugar)
PET scan is not counterindicated but what
Vasodilaters like dobutamine
Holter monitor is
Ambulatory EKG monitoring for 1-2D
Holter monitor is useful for
Suspected frequent recurrent arrythmias
Continuous EKG monitoring is also known as
Telemetry
Event monitor (Loop monitor) is used for
Extended EKG monitoring (3D-3Wks) and records per pt as symptoms occur
Event monitoring is indicated for
Infrequent arrythmia-type symptoms
An implanted event monitor (loop recorder) is reserved for
Infrequent but concerning symptoms of a pathologic arrythmia (Unexplained syncope)
Types of cardiac stress tests
Treadmill EKG Treadmill stress imaging (Echo/Nuclear) Pharmocologic stress test
The HR goal of a stress test is
85% of their max HR
IF they have an ST seg elevation during the stress test what happens?
Go straight to the cath lab
Primary goal of a stress test is to
Determine likelihood of underlying CAD
What is most important when determing probablity during stress test?
Bayes Theorem - Pre-test probability (Clinical picture)
CI to all stress test modalities
Recent STEMI <2Ds High Risk for acute coronary syndrome Active heart failure Severe Aortic stenosis Symptomatic HOCM
Stress testing works best for who
Intermediate pre-test probability
High probability of CAD
> 85% Angina in older patients with multiple risk factors (DM, Tob, Hyperlipidemia)
Intermediate probability of CAD
15-85% and younger <40/<60F with angina/risk factors present/not present
Low probability of CAD
<15% young patients with possible angina
EKG ABNLs that will make stress test EKG hard
L-BBB Paced rhythm, any ST depression >1mm, LVH,
CI for exercise stress test (3)
Pre-existing ST-T wave changes Pacemakers ST depression already
Most common treadmill stress protocol is
Bruce protocol
When do you stop Standard exercise stress test
Angina EKG signs of myocardial ischemia Max HR achieved (85% MHR) Pt fatigued
ABNL stress testing is defined by
Clinical parameters (index) Electrical paramaters (ST seg depress >1mm)
Markedly positive POS stress test means
Ischemic EKG seen w/in 3m or persist 5m after exercise stopped ST depression >2mm SBP drops during exercise High grade Ventricular arrythmias occur Pt
What score is used for prognosis using a treadmill stress test
Duke prognostic score
What three variables go into a Duke prognostic score
Exercise time Max ST segment deviation Exercise Angina
What is Duke prognostic score risk values
Low risk - (>5) Mod risk - (-11 to +4) High risk - (
Besides Duke prognostic score what other findings suggest poor prognosis
Early ST depression or severe angina <6m ST depression >2mm in >5 leads ST segment rise w/out prior Q waves Sustained BP decrease >10mmHg HR <12bpm w/in 1m (strong indicator) Arrythmias - Persist VT or Complex PV
ST seg depression is
Ischemia
ST seg elevation
Infarcation
What can happen to V-tach during Stress test
Can degrade into V-fib
If a pt has angina during stress test it means
Pt’s CO cant keep up with demand
What is a POS on a Stress echocardiogram
Wall-motion ABNLs
What stress studies can estimate Efs
Stress echocardiogram and Stress Nuclear perfusion study
For pts who cannot exercise pts can take what
A positive inotrope like dobutamine
Nuclear stress myocardial perfusion study uses what material
Usually Thallium
The purpose of a nuclear perfusion study is to
Using pre and post exercise images to determine areas of ischemia
In a nuclear perfusion stress test when a pt cant exercise you can use
Dobutamine (POS inotrope) Adenosine and Dipyridamole (Coronary artery dilation)
Which is preferred Chemical or Exercise stress test?
Exercise stress test
What is a cardiac cath?
Fluid filled catheters are introduced into circulation followed by a dye injection
Cardiac cath is the gold standard for what
Invasive cardiac measurments
If we want to assess RA/RV/pulm pressures with cardiac cath use what blood vessels
Brachial, femoral, or jugular VEIN
If we want to assess Aorta/LV pressures with cardiac cath use what blood vessels
Brachial, femoral ARTERY
What side cath can indirectly measure CO
Right side cath
What side cath can directly measure CO and EF
Left side cath
Is flouroscopic guidance used for L-Heart cath?
Yes, It can be
Where does L-side cath enter
(MC) femoral, brachial, or acillary artery
Which type of Cardiac cath is most common?
Left heart cath
Left heart cath therapeutic indications
Treat CAD Treat cardiogenic shock Valvular stenosis Intracardiac shunt closures
How to TXT CAD with Left heart cath
Ballon angioplasty & stent placement
How to TXT Cardiogenic shock with Left heart cath
Intra-aortic balloon pump placement
How to TXT valvular stenosis with Left heart cath
Balloon valvuloplasty
Left heart cath diagnostic indications
Defining coronary anatomy Assess LV fx Eval proximal aortic DZ Assess hemodynamics with pericardial constriction
Where does R-side cath enter
Subclavian, internal jugular, brachial, or femoral vein
What type of cath is used for R-heart cath
Swan-Ganz catheter
Is flouroscopic guidance used for R-Heart cath?
Not required
What concepts should be used when performing a R-Heart cath
Pressure waveforms and pulmonary capillary wedge pressure
What pressure approximates LA pressure
pulmonary capillary wedge pressure
Elevated wedge pressure implies
Volume overload (wet)
Decreased wedge pressure implies
Volume depletion (dry)
Who is R-Heart cath primarily used for
Crticially-ill pts with complex hemodynamic issues
R-heart cath indications?
Assess HF filling pressures and CO Assess volume status/PVR in septic pts Eval intra-cardiac shunts Eval pericardial disease Peri-operative monitoring for HF
Uncommon Complications related to cardiac cath
AMI Stroke Bleeding
Common Complications related to cardiac cath
Allergic reactions to dye Dye induced renal failure
Electrophysiology study is
Invasive cath procedure using multiple electrodes to directly record/pace heart
Electrophysiology diagnostic indication is
detailed analysis of difficult to manage arrythmias
Electrophysiology therapeutic indication is
Asess pharm/impant efficacy Ablation of arrythmia unresponsive to Rx
