CRC 431 Special procedures Bill Pruitt, MBA, CPFT, RRT, AE-C Cardiorespiratory Care University of South Alabama

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1 CRC 431 Special procedures Bill Pruitt, MBA, CPFT, RRT, AE-C Cardiorespiratory Care University of South Alabama

2 Cardiac diseases are complex in nature New and advanced diagnostic tests and tools are constantly being developed and introduced Tests are both invasive and non-invasive Comprehensive in nature This simplifies the diagnosis of cardiac diseases

3 Non-invasive Invasive or interventional

4 Ultrasound Echocardiography Carotid and extremity vascular testing CAT scans Electrocardiography (EKG) Holter and event (loop) monitoring Exercise Stress tests MRI VO2 max study

5 Right heart catheterization Left heart catheterization Percutaneous transluminal coronary angioplasty (PTCA) Blood tests Electrophysiology studies

6 Echocardiography uses sound wave to produce images of the heart and to evaluated blood flow 2-D image: (2 dimensional), transthoracic (TTE), gives heart size, structure and function Doppler evaluates the direction and speed of blood flow. Added to 2-D to enhance images of flow Doppler and color flow evaluates chamber leaks and heart valves for leaks uses shades of blue (going away from the transducer) red (towards the transducer) to look for valve

7 COPD may interfere with obtaining quality images due to airtrapping which dampens the ultrasound wave Newer machines may generate 3-D images

8 Produces still images and dynamic real time images linked to EKG, add sound with doppler. The probe is placed transthoracic, angled up/down or rolled to change the picture as a scan is done.

9 Probe is swallowed patient is sedated, given analgesics Uses an endoscope to put the echo probe inside the esophagus to look at the heart Gives clearer images COPD is not a problem Especially good for viewing the aorta and atria (clots?) and to evaluate prosthetic heart valves

10 Carotid vascular testing Looks for atherosclerotic plaque in carotid arteries The amount of plaque correlates with risk for stroke Determines which patients should have an endarterctomy Upper and Lower Extremity Venous duplex may add doppler and color flow Images the inside of veins looking for a clot in the arms or legs (DVT) Assess risk for PTE

11

12 Slices through the heart and great vessels Shows normal or abnormal anatomy, fluids, trauma, cancer, etc.

13 Limb leads and V leads (10 leads provide 12 electrical patterns) Rate and rhythm Current or past heart attack Signal averaged EKG magnifies the waveforms P-wave QRS

14 Treadmill or stationary bicycle used to increase exercise level Constantly records EKG and blood pressure, SpO2 Increases speed and elevates the treadmill at designated times (or increases the load on the bicycle) Treadmill changes defined by Bruce protocol

15 Stress shows how the heart and blood pressure responds to exercise Target for exercise = 80 to 85% of maximum predicted HR (MHR) Formula: MHR = age May reveal ischemic changes on EKG, bring out c/o angina Ischemia : > 1 mm depression or downsloping in the S-T segment Evaluate c/o angina, SOB, lightheadedness

16 Dipyridimol (Persantine) or adenosine given to patient at rest These drugs cause coronary vasodilation Radioactively tagged particles (RTPs) are injected during the vasodilation A special camera scans the heart to see hot or cold spots which indicate good or bad blood flow respectively *Invasive

17 Alternative: dobutamine (positive inotrope) given to increase myocardial oxygen demand (simulates exercise) Then RTPs are injected and the heart is scanned Hot spots = good flow, healthy tissue Cold spots = poor flow, ischemic of infarcted tissue *Invasive

18 Battery-operated recording over 1 to 5 days to analyze EKG (continuous). Patient keeps a log of activity and symptoms Evaluate abnormal rhythm, ischemia pacemaker function, effectiveness of medications (especially anti-arrhythmics)

19 Small recorder that is worn for months Records during an event Wrist-watch sized or smaller (may be implanted) Results can be accessed remotely by telephone

20 No radiation exposure Greater contrast and detail than CAT scans May generate 2-D or 3-D images No known biological risk Safer than x-ray, no contrast needed May reveal many issues coronary artery blockages or weakened heart muscle, valve disease, peripheral arterial disease, congenital defects

21 Linked with exercise or pharmacologic stress test to produces images of the heart at work and at rest using radioactively tagged particles Shows perfusion (hot or cold areas) Treadmill or bicycle for exercise or use drugs Technetium-99m (specifically Tc-sestamibi ), or thallium-201 is injected at maximum exercise then image is taken immediately with gamma camera. Cold spots = poor perfusion *Invasive

22 Later the At rest injection of the same radioactivley tagged particles is performed Results are compared to previous injection (arteries dilated by exercise or drugs) Cold spot remains = absence of blood flow, infarction, scar Cold spot resolves = ischemia Assess effectiveness of CABG or PTCA stenting *Invasive

23 Evaluate if exercise limitations are due to heart or pulmonary limitations Evaluates aerobic exercise and anaerobic threshold Measures oxygen consumption (VO 2 ) and carbon dioxide production F I O 2 - F E O 2 = O 2 consumption F E CO 2 - F I CO 2 = CO 2 production Uses a graded exercise protocol to increase the workload (Bruce for treadmill) Krebs cycle Set limits for exercise programs

24 Cardiac catheterization Diagnostic Right heart catheterization (PA Catheter) Subclavian or internal jugular veins through the right heart and into the pulmonary artery Check pressures, cardiac output, SvO2 Uses balloon to float the catheter, may use fluoroscopy 4 distinctive pressure waveforms distinguish the progress through the heart PA or Swan-Ganz catheter connected to a pressurized, heparinized system

25 Note the pressures and waveforms

26 Cardiac cath: Left heart catherterization Access the aorta through the femoral artery (groin) or radial artery (wrist) under moderate sedation Shoot dye and record flow through the coronary arteries by using fluoroscopy Check pressures and output (assess valve stenosis, stroke volume, C.O.) and left venticulogram Issues with dye and kidney function Check local SaO2/PaO2 levels to evaluate shunts (Ventricular septal defects or VSD)

27

28 Therapeutic or interventional catheterization (correct the coronary artery blockages) Follows diagnostic catheterization Balloon angioplasty (PTCA) Laser, rotoblator Placement of drug-eluting stents If too many blockages or too severely blocked (can t access for PTCA) patient is transferred to OR and a CABG is performed

29

30 Blood fat profile Cardiac enzymes Blood Natriuretic Peptide (BNP) C-reactive protein (CRP) Prothrombin Time (PT) Partial Thromboplastin Time (PTT) International Normalized Ratio (INR)

31 LDL (bad) Optimal < 100 mg/dl Above optimal mg/dl Borderline high mg/dl High mg/dl Very >190 mg/dl HDL (good) Low risk < 40 mg/dl men, <50 mg/dl women Average risk mg/dl men, mg/dl women

32 Triglycerides Desirable < 150 mg/dl Borderline high High Very high > 500 Cholesterol Desirable < 200 mg/dl Borderline high mg/dl High > 240 mg/dl

33 2 most often used cardiac enzymes Creatine kinase-mb [called CK-MB] Elevated when there is myocardial damage Elevates in 4-6 hrs and peaks hrs following an acute ischemic attack Troponin Rises within 3 hrs and persists up to 7 days Normal values are low any increase can indicate myocardial cell damage

34 B-type Natriuretic Peptide (BNP) Important in the labwork for CHF Rises with heart failure, gives a rating for severity C-reactive protein (CRP) Inflammatory marker Helps assess risk of having a heart attack or stroke High levels indicate there is inflammation (but not heart specific)??

35 Prothrombin Time (PT) Used to monitor bleeding times and effect of warfarin (Coumadin) Normal seconds (with no anticoagulants) Partial Thromboplastin Time (PTT) Used to monitor bleeding times and the effect of heparin Normal seconds (no anticoagulants) International Normalized Ratio (INR) 2.0 and 3.0 for patients with atrial fibrillation, or between 3.0 and 4.0 with patients with a mechanical heart valve. Above 4 = too high, below 2 = too low

36 Cardiac mapping of the electrical impulses Uses an electrode catheter to stimulate various areas of the heart looking for abnormal pathways (trying to generate arrhythmias and find the origin) Assess need for an implantable device (pacemaker, pacer/defibrillator) Provides access for ablation and assess the success

37 Performed after EP studies map out the paths or the cells causing arrhythmias Pathways or cells are destroyed which stops the transmission of abherrant signals Heat (radiofrequency ablation) Extreme cold (cryoablation) Lasers (Paths or cells may also be destroyed or removed during open heart surgery)

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