Cardiology Testing. Sandra Keavey, DHSc, DFAAPA, PAC

Transcription

1 Cardiology Testing Sandra Keavey, DHSc, DFAAPA, PAC

2 Before We Start CPR Call 911 Let s go a few weeks back in time.

3 History Let s get the history.

4 History Tell me about your chest pain.

5 History An elephant is standing on my chest.

6 History An elephant is standing on my chest. I feel tired and short of breath.

7 History An elephant is standing on my chest. I feel tired and short of breath. The pain is going down my arm.

8 The Story Chest pain Don t expect the Hollywood Heart Attack. Therefore eliciting the history is YOUR responsibility. Patients may downplay their symptoms but they were worried enough to be seen.

9 Ask about. What does it feel like? Had similar pain before? Where is the pain? If recurrent, same location? When did it start? Intermittent? How does it get better or worse? Rest vs activity? Associated symptoms- weakness, nausea, diaphoresis, dyspnea, lightheadedness.

10 Pain.. please Sharp Dull Squeezing Crushing Pressure Sore Irritation Tingle Cramp Ache Discomfort Different

11 More Pain.. In describing pain ask about heaviness, pressure, squeezing, aching Discomfort in the chest, back, neck, shoulders, or arms, wrists, elbows, between the shoulder blades Aching in the jaw, throat, or even gums or earlobes Fatigue, shortness of breath, loss of drive or lack of energy

12 Pretty good story even with no cardiac history or co-morbid conditions. When you hear chest pain it is angina or a heart attack until you convince yourself it s not. History is paramount in creating a list of differential diagnoses that will guide testing and management. It will allow you to have information to convince a patient to have testing they may not want or that testing they do want is not indicated. Be sure you document the interview.

13 What Constitutes a Good Story? When did it start? Minutes or hours What were you doing? Activity What happened when you sat down or stopped? Stopped, eased up Where is the pain? Precordium Where does it go? Shoulders, neck, back What symptoms are associated with it? Nausea, weakness, diaphoresis, dyspnea, not right Is this pain similar to what you have had before? Yes History of CAD, Angina, DM? Yes

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15 A Bad Story? When did it start? Days or weeks, constantly there. What were you doing? It hurts all the time, doesn t change with activity. What happened when you sat down or stopped? Still hurt. Where is the pain? All over. How long does it last? Seconds or days Where does it go? All over. What symptoms are associated with it? ROS

16 Pretty good story even with no cardiac history or co-morbid conditions. The presumptive differential of coronary artery disease is included after the patient's medical history is carefully reviewed, a physical exam is performed, and the patient's symptoms are evaluated. Due to the potential morbidity and mortality associated with CAD/AMI if it is being considered it must be worked up. Tests used to confirm a diagnose coronary artery disease include: electrocardiogram stress tests cardiac catheterization imaging tests such as a chest x ray, echocardiography, or computed tomography (CT) blood tests to measure blood cholesterol, triglycerides, and other substances- not to be discussed today.

17 Pretty good story even with no cardiac history or co-morbid conditions. The presumptive differential of coronary artery disease is included after the patient's medical history is carefully reviewed, a physical exam is performed, and the patient's symptoms are evaluated. Due to the potential morbidity and mortality associated with CAD/AMI if it is being considered it must be worked up. Tests used to confirm a diagnose coronary artery disease include: electrocardiogram stress tests And liability cardiac catheterization imaging tests such as a chest x ray, echocardiography, or computed tomography (CT) blood tests to measure blood cholesterol, triglycerides, and other substances

18 More History Dyspnea on exertion frequently precedes other symptoms of cardiac ischemia or heart failure. Arrhythmia Duration: sudden short episodes (minutes) suggest paroxysmal tachycardia; longer duration (hours to days) with irregularities suggests atrial dysrhythmia. Lightheadedness or chest pain while sitting elevates the likelihood of pathology For MI s chest pain with associated with radiation, worse with exertion, relieved by rest, nausea, diaphoresis, dyspnea, feeling faint or syncope increase the likelihood of pathology Is this pain similar to when you had your prior heart attack?

19 Important History Do you have a history of heart disease? Ever had a heart attack? Are you diabetic? Have you ever been worked up for chest pain? Have you had a stress test? A cardiac catheterization? How long ago? Results? Have you ever had stents placed? Bypass surgery? Are you on blood thinners? ASA? Clopidigrel (Plavix) (or equivalent)? Warfarin?

20 Important History Do you have a history of heart disease? Ever had a heart attack? Are you diabetic? Have you ever been worked up request. for chest pain? Have you had a stress test? A cardiac catheterization? How long ago? Results? Have you ever had stents placed? Bypass surgery? The more concerned you are about cardiac ischemia the more detail you must You would think they would tell you this. And they will, if you ask. Are you on blood thinners? ASA? Plavix (or equivalent)? Warfarin?

21 A Heart Story As experienced by the staff of Heart Hospital

22 Cast Intern Fellow NP Resident PA Attending Chester Payne

23 A Heart Story The patient has a good chest pain story.

24 A Heart Story The patient has a good chest pain story. What are your initial orders?

25 A Heart Story Vital signs, ASA, IV, Monitoring, Labs

26 A Heart Story Good management orders.

27 A Heart Story How do we evaluate his chest pain?

28 A Heart Story What is the gold standard for evaluation of cardiac disease?

29 A Heart Story Cardiac catheterization

30 A Heart Story A little premature at this point. What shall we start with?

31 A Heart Story EKG?

32 Electrocardiogram (ECG) Order routinely in new patients when there is a history of Hypertension CAD Arrhythmia Diabetes Endocrine disorders Over 50 to establish baseline

33 Electrocardiogram (ECG) Order acutely when patient has. Chest pain Elevated BP Arrhythmia Dyspneic Diaphoretic Syncopal or near Weakness or? of stroke

34 A Heart Story EKG shows NSR, no ST elevation or depression, no T- wave inversion, normal intervals, no Q waves.

35 A Heart Story What does that mean?

36 A Heart Story No acute cardiac ischemia or arrhythmia

37 A Heart Story Okay group, what should we order to evaluate his chest pain?

38 A Heart Story Stress test

39 When To Do Stress Testing If there are symptoms..because Stress tests have a high degree of accuracy, but These tests are not risk free These tests are not inexpensive $$$$$ So when?? If you have chest pain, shortness of breath, an irregular heartbeat or palpitations, or other symptoms of heart disease. A case can also be made for people with diabetes or other risk factors who are just starting to exercise.

40 Stress Test Types Treadmill test Exercise test Non-imaging test Pharmacological SPECT (imaging)

41 When to order what type of stress test? Exercise Tracers with imaging Dobutamine stress? vs Non-exercise Pharmacological Caveat Exercise testing is superior unless patient unable to use a treadmill. And the patient must be able to reach 85% maximum heart rate.

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43 Increased stress is not resulting in dilatation, i.e. ischemia occurs.

44 Ischemia is everywhere. Blood flow through exercising skeletal muscles can be 15 to 20 times greater than through resting muscles. The increased blood flow is the product of local, nervous, and hormonal regulatory mechanisms. When skeletal muscle is resting, only 20% to 25% of the capillaries are open, whereas during exercise 100% of the capillaries are open. Think of peripheral vascular disease, intermittent claudication, ischemic bowel.

45 Amazing! The average heart (weighs 10 ounces) beats 72 times per minute >100,000 times a day 38 million times a year by 70 a staggering 2.5 billion beats. Approximately 4-5% of the blood output of the heart goes to the coronary arteries 2.4 ounces/heartbeat 1.3 gallons/minute 1,900 gallons/day 700,000 gallons/year 48 million gallons by 70.

46 A Heart Story What type of testing should we do?

47 There s an app for that! Although this chart from a paper published in 2010 and focuses on women the critical analysis is the same. Kohli P, and Gulati M Circulation. 2010;122:

48 A Heart Story Cardiac catheterization

49 A Heart Story Not yet. What test should we order?

50 A Heart Story Treadmill with myocardial imaging.

51 Exercise Stress Test w/ Myocardial Imaging So let s put our patient on the treadmill and see how he does. We will see how he exercises Take some before and after cardiac images Compare the results

52 Bruce Protocol Stage Minutes % Grade MPH Mets Maximum Heart Rate (MHR) is typically calculated with the formula 220-age or 220-age X85%. The test is resulted in the time patient is actively walking on the treadmill in minutes.

53 MET Significance MET (metabolic equivalent) is a term used to represent the intensity of exercise. One MET equals the uptake of 3.5 ml of oxygen per kilogram of body weight per minute 1 2 is the basal rate ( while sleeping) walk 2 mph on level surface 4 4 mph on level surface or what it takes to perform the activities of daily living. Poor prognosis if <65 Limit immediate post MI 10 As good a prognosis with medical therapy as CABG 13 Excellent prognosis, regardless of other exercise responses 16 Aerobic master athlete 20 Ultra aerobic athlete

54 MET Activity Level Light (<3 ) Moderate (3-6) Heavy (>6) Sleeping (1.0) Walking briskly 6mph (10) Walking slowly (2.0) Cleaning heavy ( ) Shoveling (7.0 8) Sitting (1-1.5) Working on computer (1.5) Windows, vacuuming, mopping Carrying heavy loads (7.5) Standing Mowing lawn-walk power mower (5.5) Bicycling 16 mph (10.0) Cooking, washing dishes (2.5) mph) (6.0) Basketball game = 8.0 Fishing-sitting (2.0) Badminton recreational (4.5) Soccer casual (7.0) Playing most instruments ( ) Tennis doubles (5.0) Tennis singles (8.0)

55 Modified Bruce Protocol Starts at a lower workload than the standard test and is typically used for elderly or sedentary patients. It is also used prior to discharging a NSTEMI patient. The first two stages of the Modified Bruce Test are performed at a 1.7 mph and 0% grade and 1.7 mph and 5% grade The third stage corresponds to the first stage of the Standard Bruce Test protocol.

56 Absolute Contraindications Acute myocardial infarction within 48 hours Unstable angina not yet stabilized with medical therapy Uncontrolled cardiac arrhythmia, which may have significant hemodynamic responses (e.g. ventricular tachycardia) Severe symptomatic aortic stenosis, aortic dissection, pulmonary embolism, and pericarditis Multivessel coronary artery diseases that have a high risk of producing an acute myocardial infarction Decompensated or inadequately controlled congestive heart failure Uncontrolled hypertension (blood pressure>200/110mm Hg) Severe pulmonary hypertension Acute aortic dissection Acutely ill for any reason Severe asthma or COPD Physically unable to safely complete treadmill test

57 Relative Contraindications Known left main coronary artery stenosis Moderate aortic stenosis Hypertrophic obstructive cardiomyopathy Other forms of outflow tract obstruction Significant tachyarrhythmias or bradyarrhythmias High-degree atrioventricular block Electrolyte abnormalities Mental or physical impairment leading to inability to exercise adequately.

58 Reliability of an Exercise Stress Test? If a patient is able to achieve the target heart rate, a regular treadmill stress test is capable of diagnosing important disease in approximately 67% or 2/3 of patients with coronary artery disease. The accuracy is lower (about 50%) when patients have narrowing in a single coronary artery or higher (greater than 80%) when all three major arteries are involved. Approximately 10% of patients may have a "false-positive" test (when the result is falsely abnormal in a patient without coronary artery disease). Exercise stress testing has a lower diagnostic value in patients who cannot achieve an adequate heart rate and blood pressure response.

59 Diagnostic Value of Various Stress Testing Modalities in Women Stress Testing Modality Sensitivity Specificity NPV PPV Exercise ECG Exercise Echocardiography Exercise SPECT Pharmacological echocardiography Pharmacological SPECT Values are percentages. PPV indicates positive predictive value.

60 Diagnostic Value of Various Stress Testing Modalities in Women Stress Testing Modality Sensitivity Specificity NPV PPV Exercise ECG Exercise Echocardiography Exercise SPECT Pharmacological echocardiography Pharmacological SPECT Values are percentages. PPV indicates positive predictive value. If an exercise SPECT or exercise echo is negative, you don t have it.

61 Hah!

62 Radionuclide Imaging Also known as a nuclear, thallium, Cardiololite or dual isotope stress test, depending upon the method used. During exercise, healthy coronary arteries dilate (develop a more open channel) more than an artery that has a blockage. This unequal dilation causes more blood to be delivered to heart muscle supplied by the normal artery. In contrast, narrowed arteries end up supplying reduced flow to its area of distribution. This reduced flow causes the involved muscle to "starve" during exercise. The "starvation" may produce symptoms (like chest discomfort or inappropriate shortness of breath), and EKG abnormalities. When a "perfusion tracer" (a nuclear isotope that travels to heart muscle with blood flow) is injected intravenously, it is extracted by the heart muscle in proportion to the flow of blood.

63 How is a Nuclear Stress Test Done? The patient is brought to the patient is placed under a scanning camera. Two sets of isotope images are obtained. One at rest, and one following exercise. The scanning camera rotates around the patient's chest, stopping to take individual pictures. The patient needs to lay flat and still during the scanning period which takes approximately 11 to 20 minutes, depending upon the type of scanning camera. Patients with severe claustrophobia should receive a mild tranquilizer before the test to minimize discomfort.

64 OR---- Inject the tracer Take a picture (baseline image) Stress the patient (physically or chemically) Inject more tracer Take 2nd picture (test image) Compare the images

65 How Are Nuclear Stress Images Read? The pictures or images are fed into a computer, which reconstructs them as "slices" of a three dimensional heart. Areas that fall out side the expected normal range is presented as a blacked out area. Area of hypoperfusion

66 How Are Nuclear Stress Images Read? The pictures or images are fed into a computer, which reconstructs them as "slices" of a three dimensional heart. Areas that fall out side the expected normal range is presented as a blacked out area. Area of hypoperfusion

67 How Are Nuclear Stress Images Read? The pictures or images are fed into a computer, which reconstructs them as "slices" of a three dimensional heart. Areas that fall out side the expected normal range is presented as a blacked out area. Area of hypoperfusion And here

68 How Are Nuclear Stress Images Read? The pictures or images are fed into a computer, which reconstructs them as "slices" of a three dimensional heart. Areas that fall out side the expected normal range is presented as a blacked out area. Area of hypoperfusion And here Here

69 Pharmacological Stress Test A chemical stress test combines an intravenous medication with an imaging technique (isotope imaging or echocardiography) to evaluate the LV. Stress causes normal coronary arteries to dilate, while the blood flow in a blocked coronary artery is reduced. In these cases, the medication serves as a substitute for exercise by dilating the coronary vessels. Patients frequently feel flushed or fluttery or short of breath with this medication. This reduced blood flow may decrease the movement of the affected wall (as seen in a stress echo), or have reduced isotope uptake in a nuclear scan.

70 Stress Test Report DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy. DESCRIPTION OF PROCEDURE: The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain. IMPRESSION: 1. Average exercise capacity. 2. Somewhat blunted heart rate response secondary to beta-blocker use. 3. Normal blood pressure response. 4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test. 5. Sestamibi imaging results will be reported separately

71 Stress Test Report DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy. DESCRIPTION OF PROCEDURE: The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain. IMPRESSION: 1. Average exercise capacity. 2. Somewhat blunted heart rate response secondary to beta-blocker use. 3. Normal blood pressure response. 4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test. 5. Sestamibi imaging results will be reported separately This information can be helpful in evaluating study.

72 Stress Test Report How well the patient was able to complete the test. DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy. DESCRIPTION OF PROCEDURE: The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain. IMPRESSION: 1. Average exercise capacity. 2. Somewhat blunted heart rate response secondary to beta-blocker use. 3. Normal blood pressure response. 4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test. 5. Sestamibi imaging results will be reported separately

73 Stress Test Report DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy. Baseline EKG. Good information to have. DESCRIPTION OF PROCEDURE: The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain. IMPRESSION: 1. Average exercise capacity. 2. Somewhat blunted heart rate response secondary to beta-blocker use. 3. Normal blood pressure response. 4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test. 5. Sestamibi imaging results will be reported separately

74 Stress Test Report DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy. DESCRIPTION OF PROCEDURE: The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain. IMPRESSION: 1. Average exercise capacity. 2. Somewhat blunted heart rate response secondary to beta-blocker use. 3. Normal blood pressure response. 4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test. 5. Sestamibi imaging results will be reported separately Did the patient stop prematurely?

75 Stress Test Report DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy. This is certainly an encouraging report DESCRIPTION OF PROCEDURE: The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart but rate the of 142, real which answer is 81% is of his age-predicted maximum heart rate. Resting heart rate in was the 80 images. with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142. Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain. IMPRESSION: 1. Average exercise capacity. 2. Somewhat blunted heart rate response secondary to beta-blocker use. 3. Normal blood pressure response. 4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test. 5. Sestamibi imaging results will be reported separately

76 . Normal Nuclear Imaging Results MYOCARDIAL PERFUSION IMAGING: 1. The overall quality of the scan was good. This is a good result. 2. There was no diagnostic abnormality on rest and stress myocardial perfusion imaging. 3. The left ventricular cavity appeared normal in size. 4. Gated SPECT images revealed no wall motion abnormalities. 5. Overall left ventricular systolic function was normal with calculated left ventricular ejection fraction of 60% at rest.

77 . Normal Nuclear Imaging Results MYOCARDIAL PERFUSION IMAGING: Supported by good LV function. 1. The overall quality of the scan was good. 2. There was no diagnostic abnormality on rest and stress myocardial perfusion imaging. 3. The left ventricular cavity appeared normal in size. This is a good result. 4. Gated SPECT images revealed no wall motion abnormalities. 5. Overall left ventricular systolic function was normal with calculated left ventricular ejection fraction of 60% at rest.

78 . Abnormal Nuclear Imaging Results MYOCARDIAL PERFUSION IMAGING: Fixed perfusion defect means old. 1. The overall quality of the scan was good. 2. There was a fixed perfusion defect in the apex and a reversible perfusion defect in the anterior left on stress myocardial perfusion imaging. 3. The left ventricular cavity appeared normal in size. 4. Gated SPECT images revealed mild septal hypokinesis and mild-moderate apical hypokinesis. Overall left ventricular systolic function was low with calculated ejection fraction of 40% at rest.

79 . Abnormal Nuclear Imaging Results MYOCARDIAL PERFUSION IMAGING: Reversible means a lesion that is likely causing the symptoms. 1. The overall quality of the scan was good. 2. There was a fixed perfusion defect in the apex and a reversible perfusion defect in the anterior left on stress myocardial perfusion imaging. 3. The left ventricular cavity appeared normal in size. 4. Gated SPECT images revealed mild septal hypokinesis and mild-moderate apical hypokinesis. Overall left ventricular systolic function was low with calculated ejection fraction of 40% at rest.

80 . Abnormal Nuclear Imaging Results MYOCARDIAL PERFUSION IMAGING: Hypokinesis is loss of contractility. If permanent it is from an old infarct. 1. The overall quality of the scan was good. 2. There was a fixed perfusion defect in the apex and a reversible perfusion defect in the anterior left on stress myocardial perfusion imaging. 3. The left ventricular cavity appeared normal in size. 4. Gated SPECT images revealed mild septal hypokinesis and mild-moderate apical hypokinesis. Overall left ventricular systolic function was low with calculated ejection fraction of 40% at rest.

81 . Abnormal Nuclear Imaging Results MYOCARDIAL PERFUSION IMAGING: Hypokinesis can be a result of stunned myocardium in an acute event and be reversible. 1. The overall quality of the scan was good. 2. There was a fixed perfusion defect in the apex and a reversible perfusion defect in the anterior left on stress myocardial perfusion imaging. 3. The left ventricular cavity appeared normal in size. 4. Gated SPECT images revealed mild septal hypokinesis and mild-moderate apical hypokinesis. Overall left ventricular systolic function was low with calculated ejection fraction of 40% at rest.

82 MUGA Scans Using this scan the gamma camera acquires a series of pictures of the heart in synchrony with the patients ECG signals. The pictures record the heart's motion and determine if all of its segments are contracting properly. MUGA scanning may take 2 to 3 hours to obtain all the needed views and can be done both before and after you exercise. Multigated acquisition (MUGA) scans are used routinely before and after receiving a heart transplant to assess how well the heart is working. MUGA is also used to monitor the ejection fraction in people receiving chemotherapy, especially those receiving doxorubicin (Adriamycin). However a MUGA does not provide information about the heart valves or the thickness of the ventricle.

83 A Heart Story Cardiology Fellow, please present the case for Dr. Z.

84 A Heart Story 48 yom with known CAD, DM uncontrolled presents with substernal chest pain that is non-radiating. EKG, labs WNL but myocardial perfusion scan shows perfusion defects.

85 A Heart Story Excellent summary. So Dr. Z what do you want to do?

86 A Heart Story Cardiac catheterization.

87 Cardiac Catheterization Cardiac catheterization or coronary angiography are invasive, diagnostic procedures that are performed to obtain information about the heart or its blood vessels. These procedures involve directing a catheter or catheters into the right and/or heart chambers and into the origin of the coronary arteries. During cardiac catheterization the pressure and blood flow in the cardiac chambers are measured. Blood in these different chambers can also be collected to look for shunts or abnormal connections between chambers. During coronary angiography contrast material is directly injected into the coronary arteries and the subsequent image recorded on x ray.

88 Cardiac Catheterization Indications Cardiac catheterization is performed: To determine whether the coronary arteries are obstructed or narrowed. To determine the severity of the coronary stenosis, the number of coronary arteries involved and their location. To evaluate the severity of valve dysfunction. Determine the need for cardiac surgery. To evaluate congenital cardiac abnormalities.

89 Cardiac Cath Lab Fluoroscopy is used to visualize the vessels when the dye is injected. These images are saved for review following the procedure. If blockages are found angioplasty can be done immediately.

90 Coronary Angiography

91 Depending on the severity of the lesions, their locations the decision is made whether or not to try angioplasty with balloon or stent placement or schedule the patient for bypass graft surgery. Angioplasty

92 CABG Coronary Artery Bypass Grafting Whose coronary artery disease cannot be adequately treated by cardiac medications Cannot be treated with angioplasty Who suffer from intractable or unstable angina

93 Other individuals who may benefit from CABG after a heart attack include those who are suffering from cardiogenic shock or who remain unstable after PTCA. While bypass surgery can limit damage in people with an acute heart attack, it does not cure the underlying coronary artery disease. Many still require medications after CABG. Lifestyle modification and cardiac rehabilitation is recommended.

94 Bypass surgery is performed in people With an evolving heart attack when pain and ECG findings are unstable Who failed angioplasty (They still have persisting pain or continue to be unstable after angioplasty) Who are undergoing repair of mechanical complications such as a tear in the wall dividing the ventricles (ventricular septal defect) or heart valve insufficiency ("leaky" heart valves)

95 CABG Coronary Artery Bypass Grafting These individuals usually have significant obstruction of the three main coronary arteries significant obstruction of the left main artery depressed pumping action or blockage of the left anterior descending artery

96

97 Alternative Techniques In off-pump coronary artery bypass or OPCAB, bypass grafting is performed without the use of the heart-lung machine. Surgery is performed while the heart is still beating, although the heart rate is slowed and the heart partially held in place using surgical instruments. Another alternative is the use of smaller incisions that avoids splitting the breastbone. This is referred to as Minimally Invasive Direct Coronary Artery Bypass or MIDCAB.

98 If you didn t enter it in the chart it didn t happen. If it can t be read, it didn t happen

99 And the rest of the story.. Get off me!! I fainted because I just won the lottery!!

100 Arrhythmias Mr. Dude the palpitations you describe have not been seen on telemetry. Arrhythmias can be difficult to evaluate when they are episodic.

101 Arrhythmias Mr. Dude the palpitations you describe have not been seen on telemetry. What can we do? I can t stay in the hospital forever. Arrhythmias can be difficult to evaluate when they are episodic

102 Arrhythmias Mr. Dude the palpitations you describe have not been seen on telemetry. What can we do? I can t stay in the hospital forever. Let s order an event monitor. Arrhythmias can be difficult to evaluate when they are episodic

103 Holter Monitor A continuous tape recording of a patient's EKG. Since it can be worn during the patient's regular daily activities, it helps the physician correlate symptoms of dizziness, palpitations (a sensation of fast or irregular heart rhythm) or black outs. It is much more likely to detect an abnormal heart rhythm when compared to the EKG which lasts less than a minute. It can also help evaluate the patient's EKG during episodes of chest pain, during which time there may be telltale changes to suggest ischemia Commonly worn for 24 hours there are versions that can be worn 3-4 weeks (called event monitors).

104 Holter Monitor

105 Implantable Cardiac Monitors In cases where the patient is profoundly (such as syncope)but infrequently symptomatic an implantable monitor can be inserted under the skin. Called loop recorders

106 Ms. Smithers have you even been told you have a heart murmur?

107 Echocardiogram Ms. Smithers have you even been told you have a heart murmur? No.

108 I will order an echocardiogram.

109 Echocardiography What is an Echocardiogram: An echocardiogram is a test in which ultrasound is used to examine the heart. In addition to providing singledimension images, known as M-mode echo that allows accurate measurement of the heart chambers, the echocardiogram also offers far more sophisticated and advanced imaging. This is known as two- dimensional (2-D) Echo and is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle

110 Echocardiogram Evaluates- Heart size Heart function or ejection fraction Presence of cardiac malformations Presence of ventricular aneurysms Presence of scars Valve morphology Presence of masses in the heart or on the valves Presence of pericardial fluid

111 Left Ventricular Function Hyperdynamic Normal Mild LV dysfunction Moderate LV dysfunction EF (%) > Chest wall R L

112 Echocardiography. Color-Flow Echocardiogram: This is the part of the Doppler echocardiogram where we can determine the direction of blood flow according to the color on the screen Blood going away from the transducer looks blue, while blood coming towards the echocardiogram transducer looks red. In addition, there may be a mosaic of colors if there is turbulent flow as may be seen across a narrow blood vessel or heart valve. This is also helpful in detecting a leaky valve or a hole in the heart. This is a very sensitive instrument that may pick up a very mild degree of leakage in normal heart valves. This is what we call physiologic regurgitation (leakage). Virtually all normal human beings have physiologic regurgitation in one or more heart valves. The quality of the study is somewhat operator dependent.

113 Transesophageal Echocardiogram A TEE is extremely useful in detecting blood clots, masses and tumors that are located inside the heart. It can also gauge the severity of certain valve problems and help detect infection of heart valves, certain congenital heart diseases (like a hole between the upper chambers of the heart, known as an ASD or atrial septal defect) and a tear (dissection) of the aorta (major artery of the body). TEE is also very useful in evaluating for clots inside the left atrium.

114 Resources Articles on Chest Pain History jama.jamanetwork.com/article.aspx?articleid= American College of Cardiology American Heart Association Up to Date

115 Questions?