Non-invasive Cardiac Diagnostics

Question 1

What is Echocardiography? Useful for? not helpful for?

Answer 1

– Cardiac ultrasound procedures that generate images of the heart and related structures • Useful for assessment of LV function and valvular heart disease • Not helpful for imaging of coronary arteries • Provides excellent spatial resolution • Superior to M-mode in evaluating LV function, LV aneurysms, and intracavitary thrombus

Question 2

Explain M-mode echocardiography?

Answer 2

 M-Mode Echocardiogram • Original ultrasound technique • Sound waves are transmitted along a single line (“ice pick” view) • Provides excellent temporal resolution • Performed together with 2-D Echo in current clinical practice

Question 3

Explain doppler echocardiography?

Answer 3

• Doppler Echocardiography – Cardiac ultrasound procedure that allows measurement of flow across valvular structures • Useful for assessment of valvular stenosis or regurgitation • May help identify intracardiac shunts

Question 4

Explain contrast echocardiography?

Answer 4

• Contrast Echocardiography – A 2-D echo study which also includes the injection of intravascular bubbles • May help identify intracardiac shunts • Not as commonly employed since the advent of Doppler echocardiography

Question 5

explain Transesophageal echocardiography? good sensitivity for? Helpful for? Risks?

Answer 5

• Improved sensitivity for left atrial appendage thrombus • Helpful to detect atrial septal defect and patent foramen ovale with addition of 2-D, color flow and saline contrast • Ascending aorta, arch and descending aorta evaluation without expense, radiation or contrast exposure of other modalities • Risks of conscious sedation and esophageal rupture are small but need to be factored into decision

Question 6

Explain stress testing? types?

Answer 6

• Stress Testing – Provides diagnostic and prognostic information in patients with suspected or known CAD • Exercise testing (treadmill) • Pharmacological (e.g. dobutamine) • ST segment depression suggests myocardial ischemia

Question 7

explain stress nuclear imaging?

Answer 7

• Stress Nuclear Imaging – Isotopes (e.g., thallium) injected at peak exercise reveal myocardial blood flow that is compared to resting scan

Question 8

Explain a stress echocardiogram?

Answer 8

• Stress Echocardiogram – LV function assessed at rest and exercise to reveal stress-induced deterioration of regional LV function

Question 9

What is a MUGA scan?

Answer 9

• Multiple gated acquisition averages hundreds of heartbeats to evaluate left ventricular function and wall motion • Much more accurate than gated wall motion of nuclear stress test which utilizes only a few heartbeats and is susceptible to arrhythmias or motion artifact • Nuclear exposure less than total dose of nuclear stress perfusion testing

Question 10

What is a Holter monitor?

Answer 10

• Holtor Monitor – 24 hour recording device of 2 or 3 ECG leads to help diagnose rhythm disturbances

Question 11

What is an event recorder?

Answer 11

• Event Recorder – Portable device that can worn up to one month that can be triggered to record rhythm during symptoms

Question 12

Which test is most appropriate?

• R. T. is a 35 year old female who presents to your office with complaints of left sided chest pain for the last three weeks • + Smoker • + Family history • EKG looks like this:

1. Echocardiography 2. Exercise nuclear perfusion imaging 3. Exercise Stress EKG 4. Cardiac CTA

Answer 12

3. Exercise Stress EKG

Question 13

• J.J. is a 54 year old male, a new patient to your practice, who complains of shortness of breath with exertion for the past 6 months. • + Hypertension • + Hyperlipidemia • Physical exam: murmur that the patient states had not been mentioned to him —last doctor visit 1979

Which test is most appropriate?
A. Echocardiography B. MUGA scan C. Exercise nuclear perfusion imaging D. Cardiac CTA E. Cardiac MRI

Answer 13

A). Echocardiography (with doppler)

Question 14

• L.F. is a 52 year old male who presents to hospital with left middle cerebral artery stroke symptoms and this EKG rhythm strip:

What is the cardiac rhythm? A. Normal Sinus Rhythm B. Atrial Fibrillation C. Sinus rhythm with PAC’s D. Sinus rhythm with blocked PAC’s

Which test is most appropriate?
A. Echocardiogram B. Stress Echocardiogram C. Transesophageal echocardiogram D. Cardiac CTA E. MUGA Scan

Answer 14

B. Atrial Fibrillation

C. Transesophageal echocardiogram

Question 15

• D.F. is a 63 year old female who complains of back pain with climbing stairs • Diabetic for 10 years Type II • Hypertriglyceridemia • Father MI at 58 • EKG looks like this:

Which test is most appropriate?
A. Echocardiogram B. Stress nuclear perfusion imaging C. Cardiac CTA D. MUGA scan E. Cardiac MRI

Answer 15

B. Stress Nuclear perfusion imaging

Question 16

• F.R. is 53 year old female history of breast cancer with anthracycline chemotherapy with increased shortness of breath • BP 90/50 Pulse 110 regular • S3 gallop • 1+ edema pretibial

Which test is most appropriate?
A. Stress Echocardiogram B. MUGA scan C. Cardiac CTA D. Nuclear stress perfusion imaging E. Transesophageal Echocardiogram

Answer 16

B. MUGA scan

Question 17

• B.Z. is a 48 year old male with chest pain for 6 months. • 5’10” 235# • Hyperlipidemia • Smoker • Appropriately ordered stress test from PCP shows no EKG changes but small reversible defect in the inferior wall

Which test is most appropriate?
A. Echocardiogram B. Stress Echocardiogram C. Cardiac CTA D. Transesophageal echocardiogram E. Cardiac MRI

Answer 17

Cardiac CTA

Question 18

• A.C. is a 38 year old female with shortness of breath for 2 months • Married 3 months ago for first time • Mother MI at 56 • Regular stress test done in PCP office shows 1mm ST depression isolated to recovery without symptomatic CP or DIB

Which test is most appropriate?
A. Echocardiogram B. Nuclear stress perfusion imaging C. Stress echocardiogram D. Cardiac CTA

Answer 18

Stress echo

Question 19

What is echocardiography good for?

Answer 19

• Evaluate left and right ventricular function
• Determine chamber dimensions
• Measure wall thickness
• Valvular asessment for stenosis and regurgitation
• Assess pericardial structure and R/O effusion
• No radiation or procedural risk
• Relatively low cost for amount of information provided

Question 20

Uses for Transesophageal Echocardiography?

Answer 20

• Improved sensitivity for left atrial appendage thrombus
• Atrial septal defect and patent foramen ovale evaluation with 2D, color flow and saline contrast
• Ascending, arch and descending aorta evaluation without expense, radiation or contrast exposure of other modalities
• Risks of conscious sedation and esophageal rupture are small but need to be factored into decision

Question 21

Stess echocardiography is good for?

Answer 21

• Sensitivity and specificity shown to be about equal to that of nuclear perfusion imaging in qualified echo lab
• Still allows for information on exercise tolerance if walking test
• With use of echo contrast (not iodinated) allows evaluation of larger patients who may otherwise have false positive nuclear perfusion imaging
• No radiation involved with the test so ideal for women of child bearing age

Question 22

Exercise stress testing uses?

Answer 22

• Low cost and wide availability
• Exercise capabilities evaluated
• Specificity and sensitivity in the 70% range so good initial test for low pre-test probability patients
• No radiation exposure involved

Question 23

Nuclear imaging uses?

Answer 23

• Allows noninvasive imaging of patients with abnormal baseline EKG ex. LBBB, WPW, Digoxin use
• Increased sensitivity and specificity approximately 90%
• Increased cost compared to plain exercise stress electrocardiography
• Radiation exposure with cardiolyte (technicium 99) depending on dose and technique 5-8 mSv

Question 24

Cardiac CTA uses?

Answer 24

• Allows evaluation of coronary arteries directly without invasive catheterization
• Negative predictive value greater than 95%
• Positive predictive value with 64 slice scanner and qualified reader around 80% and increasing with higher slice scanners
• Limited by calcified arteries, motion and arrhythmias
• Radiation exposure no longer highest of noninvasive imaging 3-9 mSv
• Iodinated contrast exposure

Question 25

Cardiac MRI uses?

Answer 25

• Useful for tumors/masses that are intracardiac
• Myocardial viability studies are improved dramatically
• Still not able to do coronary imaging on mass scale
• No radiation exposure
• Gadolinium can be nephrotoxic
• Cost can be prohibitive