Colleen Walsh-Irwin, RN, MS, CCRN, ANP 9/5/2018

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1 Colleen Walsh-Irwin, DNP, RN, ANP-BC, AACC, FAANP Department of Veterans Affairs At the end of this presentation, participants will be able to: 1- Describe when to order a regular stress test vs. a nuclear stress test. 2- Understand when an echocardiogram is more useful to evaluate an ejection fraction than a MUGA. 3- Discuss the risks/benefits of cardiac catheterization and when to refer a patient. 72 yo male PMH HTN, DM, +smoker, +FH C/o vague chest pain BP 140/84 P 72 PE- WNL Meds- amlodipine, metformin, lisinopril EKG-NSR with abnormal ST segments Cardiac Diagnostic Testing 1

2 Regular Stress Testing Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging Stress Echo To rule out CAD S/P MI Evaluate exercise capacity Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling co-morbidity. Exercise stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling co-morbidity 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease Cardiac Diagnostic Testing 2

3 ECG abnormalities that reduce test accuracy ST segment abnormalities LV hypertrophy LBBB Ventricular-paced rhythm 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease Exercise preferred Pharmacologic- Dobutamine Dipyridamole Regadenoson Adenosine Indications Same as exercise/ pharmacologic Rest and stress images Exercise or pharmacologic Cardiac Diagnostic Testing 3

4 Indications Higher sensitivity and specificity than treadmill alone Pharmacologic testing Thallium or Technetium Isotope injected intravenously Cardiac magnetic resonance Cardiac Computed Tomography Positron Emission Tomography Cardiac Diagnostic Testing 4

Bruce Ramp Protocol Peak BP 210/96 Peak HR 133 7 METS 90% MPHR DP 27,980 2mm horizontal ST

5 Bruce Ramp Protocol Peak BP 210/96 Peak HR METS 90% MPHR DP 27,980 2mm horizontal ST segment changes V3 2mm downsloping leads I, II, V6 4mm downsloping V4, V5 Cardiac Diagnostic Testing 5

6 Cardiac catheterization revealed 3V CAD Normal EF S/P CABG X 3V 50 yo male PMH HTN, +FH BP controlled on Amlodipine Seen in ER for 1 complaint of CP after running marathon Normal EKG R/O MI Cardiac Diagnostic Testing 6

Started on ASA 81mg Stress Test- Bruce Ramp Protocol 12 minutes Peak HR 150 Peak BP 180/88 MPHR 88% DP- 27,000 13 METS Reason for

7 Started on ASA 81mg Stress Test- Bruce Ramp Protocol 12 minutes Peak HR 150 Peak BP 180/88 MPHR 88% DP- 27, METS Reason for termination- leg fatigue 1mm horizontal ST segment depression leads AVF, V5, V6 High exercise tolerance Denies chest pain Cardiac Diagnostic Testing 7

8 68 yo male PMH HTN, Afib seen in ETA for c/o SOB and LE edema Medications: Digoxin, Diltiazem Pt non-compliant BP 176/100 P 118 Lungs with rales 1/3 up b/l S1 S2 irregular II/VI SEM 2+ pitting edema of LE Chem 7, CBC WNL EKG - Afib 118 LVH Chest x-ray- enlarged heart Cardiac Diagnostic Testing 8

9 EKG Echocardiogram vs. MUGA Stress Test- R/O CAD Indications Can help to diagnose Infarct Ischemia Left Ventricular Hypertrophy Arrhythmias & Heart Blocks Electrolyte Abnormalities Drug Overdose Indications Assessment of LV function Evaluation of valvular function Assessment of ischemia/ infarct Diagnose cardiomyopathy Cardiac Diagnostic Testing 9

10 Diagnose Pericardial Disease Evaluation of tumors, thrombi, and vegetations Evaluation of structural heart disease Injection of radioactive substance Evaluates LVEF Can also measure RVEF Echocardiogram Results EF 35% Global hypokinesis Dilated LA Mild MR Cardiac Diagnostic Testing 10

11 Pt admitted to tele Diuretics ACEI Beta- blockers D/C Diltiazem Anticoagulation 67 yo female PMH CAD S/P DES to RCA, DM, HTN C/o increased DOE BP 108/60 P 56 Echo reveals EF 30-40% (Previously 55%) Angiographic examination of the coronary arteries Estimation of systolic and diastolic function Overall mortality risk is 0.14% Cardiac Diagnostic Testing 11

Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to

Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for

12 Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk. Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk. Patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk. Patent DES to RCA New LAD lesion S/P DES to LAD Echo 3 months later reveals EF 50% Cardiac Diagnostic Testing 12

13 75 yo male PMH COPD, HTN, anxiety C/o palpitations Episodes occur ~ 1x/week Last up to an hour Indications Evaluate for arrhythmia Evaluate treatment Evaluate pacemaker therapy Holter Monitoring Event Monitoring Loop Recorders Mobile Cardiac Telemetry (MCT) Internal Loop Recorder Cardiac Diagnostic Testing 13

14 Event Monitoring Normal results Refer for anti-anxiety treatment Diagnosis of Aortic Dissection, Aneurysm and Rupture Prior to cardioversion in patients who have suspected thrombus or are not candidates for anticoagulation Evaluation of conditions not adequately assessed on TTE Ischemia Viability Sarcoid Cardiac Diagnostic Testing 14

15 High resolution three dimensional images Diagnosis of diseases of the aorta and pericardium Evaluation of congenital defects and masses Potential applications include: Evaluation of coronary anatomy and ventricular function Assessment of viability Evaluation of valve regurgitation Contraindications: Claustrophobia Non- MRI compatible devices Coronary anomalies Congenital heart disease Right ventricular dysfunction Left ventricular dysfunction Prosthetic heart valves Anatomic mapping Pre-op cardiac surgery Cardiac Diagnostic Testing 15

16 Evaluate coronary anatomy For CT angiography, patient requirements may include the ability to: Hold still and follow breathing instructions. Tolerate beta blockers. Tolerate sublingual nitroglycerin. Lift both arms above the shoulders. Cardiac Diagnostic Testing 16

17 Placement of electrode catheters Records intracardiac electrical signals Program electrical stimulation Evaluates atrial and ventricular arrhythmias Ablation of atrial arrhythmias Indications Ventricular Tacchycardia Long QT syndrome AVNRT (AV nodal re-entrant tacchycardia) Wolf-Parkinson-White Syndrome 70 yo male PMH HTN C/o SOB with minimal exertion C/o chest tightness assoc with SOB Notes weight gain of 10 lbs over last week Cardiac Diagnostic Testing 17

18 VS BP 148/78 P 90 Mild JVD Lungs CTA S1 S2 nl -M/R/G 1+ pitting edema b/l LE Cardiac enzymes negative Regadenoson MPI Normal perfusion EF 62% Normal gated analysis Echocardiogram LVH, normal LVEF HR & BP control Beta- blockers Diuretics Cardiac Diagnostic Testing 18

19 74 yo female PMH HTN c/o SOB Medications: HCTZ, Lisinopril Former smoker, + FH PE significant for SEM EKG Echocardiogram Assess LV function Assess for valvular disease Severe aortic stenosis Normal mitral, tricuspid and pulmonic valved areas Normal left ventricular function Valve replacement Cardiac Diagnostic Testing 19

20 Taylor AJ, Cequeira M, Hodgson JM, Mark D, Min J, O Gara P,Rubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiographyand Interventions, and the Society for Cardiovascular Magnetic Resonance. J AmColl Cardiol 2010 Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas P,Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB III, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012;126:e354 e471. Heller GV, Beanlands R, Merlino, DA, Travin, MI, Calnon DA, Dorbala, S, Hendel RC, Mann A, Bateman TM, Van Tosh A, ASNC Model Coverage Policy: Cardiac positron emission tomographic imaging. J Nucl Cardiol 2013;20: Cardiac Diagnostic Testing 20

Colleen Walsh-Irwin, RN, MS, CCRN, ANP 8/28/2017

Colleen Walsh-Irwin, RN, MS, CCRN, ANP 8/28/2017 Colleen Walsh-Irwin, DNP, RN, ANP-BC, AACC Veterans Affairs Medical Center Northport, New York At the end of this presentation, participants will be able to: 1- Describe when to order a regular stress