Slide set 4 Flashcards by E *

Invasive Dx testing

Echo (TEE) Cardiac stress testing (IV medications) Cardiac catheterization Electrophysiologic studies Implantable monitor

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What views to obtain on CXR

PA and lateral

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What can you visualize on CXR (7)

Cardiac silhouette Cardiac configuration Calcifications Artificial Devices G

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What view is best to view Cardiomegaly

PA view (AP distorts heart)

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CT can eval

Great vessels Pericardium Myocardium Coronary arteries

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CT primary indications are

Great vessel issues (AA or disection) Pericardial ABNLs (Pericarditis)

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TOC for pericardial diseases

EBCT

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EBCT and MSCT abbreviation is

Electron beam CT Multislice CT

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Is CT coronary angiography invasive?

No (EBCT/MSCT)

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What kind of score can we obtain from CT and for what purpose?

Agatstan score for Coronary artery calcification risk factor

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What are the limitations of CT

Contrast dye Rad exposure Artifact from pt motion

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Cardiac cath is great for

Identifying problem AND fixing it (therapeutic)

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MRI of the heart is also known as

Cardiovascular magnetic resonance

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CMR advantages

No radiation, Evals almost everything cardiac

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CMR disadvantages

Expensive

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CMR can eval

Function Perfusion Viability Tissue characterization

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CMRA is an abbreviation for

Cardiovascular magnetic resonance angiography

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CMRA advantages are

Noninvasive Contrast free High Sensitivity for CAD or congenital ABNLs of the coronary arteries

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Gandolinium contrast in an MRI is used for

Distinguish between impaired and infarcted (irrev) tissue

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Echocardiogram primarily focuses on

Suspected murmurs Cardiac function assessment Other suspected structural heart DZ

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Echo U/S modes

M-mode, 2-D, 3-D, Doppler

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Echo M-mode is useful for

measuring wall thickness or chamber diameters

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Echo 2D-mode is useful for

Defines cardiac structures relative to another

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Echo Doppler-mode is useful for

eval blood flow, velocity, turbulence

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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