Invasive and Noninvasive Cardiology Diagnostic Methods PDF

DIAGNOSTIC METHODS IN CARDIOLOGY Bülent Mutlu, Prof. MD Marmara University Faculty of Medicine Department of Cardiology  OBJECTIVES Noninvasive and invasive diagnostic methods Principles of diagnostic methods Diagnostic importance How can we use in...

DIAGNOSTIC METHODS IN CARDIOLOGY Bülent Mutlu, Prof. MD Marmara University Faculty of Medicine Department of Cardiology  OBJECTIVES Noninvasive and invasive diagnostic methods Principles of diagnostic methods Diagnostic importance How can we use in clinical practice ? NONINVASIVE & INVASIVE  NONINVASIVE DIAGNOSTIC METHODS Electrocardiography CHEAP Easy Accessible Chest X-Ray Ambulatory methods Stress Testing Echocardiography Nuclear Imaging Cardiac CT & MRI EXPENSIVE Complex Limited ELECTROCARDIOGRAPHY  Electrocardiography (ECG) ECG is a graphic representation of the electrical activity of the heart The standard ECG provides 12 different vector views of the heart’s electrical activity as reflected by electrical potential differences between positive and negative electrodes placed on the limbs and chest wall. Six of these views are vertical (using frontal leads I, II, and III and limb leads aVR, aVL, and aVF), and 6 are horizontal (using precordial leads V1, V2, V3, V4, V5, and V6).  Electrocardiography (ECG) Contraction of any muscle is associated with electrical charges called depolarization These changes can be detected by electrodes attached to the surface of the body Each event has a different waveform The study of the waveform can give us better idea about patient’s cardiac pathophysiology  How can we use in clinical practice ? Relative size of the heart chambers Cardiac arrhythmias Myocardial ischemia and myocardial infarction Pericarditis The effect of electrolyte disturbances The effect of certain drugs toxicity acute inferoposterolateral myocardial infarction Posterior Leads V7-V9 were added  Type #3: Posterior ST Elevation MI Now, here is the same patient with a posterior ECG tracing. Leads V7-V9 were added. Leads V1 and V2 were moved a bit just to confuse us. There is not quite 1 mm ST elevation in these posterior leads, but you can see at least some slight elevation. VT Hyperkalemia CHEST X-RAY  Chest X-Ray (CXR) What is the most common reason fro chest XRAY order ? Chest X-Ray is an important part of the cardiology examination A chest x-ray aides in the differentiation between respiratory and cardiac causes of dyspnea Common findings are cardiomegaly, interstitial edema, pulmonary edema and pleural effusions Evidence of surgery (eg CABG, valve repair, ICD implantation) is also detected by CXR.  ELECTRICAL ALTERNANS JVD WATER BOTTLE  Common findings of chest x Ray are aortic disection , pulomnary edema , pneumothorax, penumonia In addition, congestive heart failure, pulmonary venous congestion ental Adema congestion and Adema calcification tetragon fallout can be detected AMBULATORY METHODS  Ambulatory Holter ECG monitoring Event recorder Ambulatory blood pressure monitoring  Ambulatory Holter ECG Monitoring Continuous electrocardiographic tape recorders represent the traditional Holter monitoring and What is holter montring uslaay used for typically record two or more electrocardiographic channels for 24 hours. Prolonged electrocardiographic recording is the Palpitations and Syncope: most useful non-invasive method to document Evaluates patients with symptoms such as palpitations, the frequency and complexity of an arrhythmia. dizziness, or syncope to see if these correlate with heart rhythm changes. The Holter monitoring is portable, enabling Assessing Treatment patients to participate in normal daily activities. Effectiveness: Helps to evaluate the effectiveness of medications for arrhythmias or It is useful for evaluating intermittent arrhythmias other heart conditions.  Event recorder Event recorders are used for up to 30 days and can detect infrequent rhythm abnormalities that 24-h Holter monitoring may miss. The recorder may operate continuously and also be activated by the patient when symptoms occur. A memory loop enables information to be stored for seconds or minutes before and after activation.  Indications for Ambulatory ECG Monitoring Assessment of symptoms possibly related to rhythm abnormality Arrhythmia detection to assess risk for future cardiac events in patients without symptoms Measurement of heart rate variability to assess risk for future cardiac events in patients without symptoms Assessment the effect of antiarrhythmic therapy Ambulatory Blood Pressure Monitoring This technique allows information to be obtained on 24-hour average blood pressure level, such as the day, the night, and the morning. This technique allows more accurate information about blood pressure than office The main blood pressure measurements. indication of ambulatory BP measurement is to This technique usually uses to eliminate white eleminate white coat effect coat effect on blood pressure at the outpatient clinics. Indications for Ambulatory Blood Pressure Monitoring To evaluate the effect of antihypertensive drugs. To detect white coat hypertension To detect masked hypertension To detect nocturnal hypertension (Dipper or non-dipper status) To detect baroreceptor impairment STRESS TESTING  Stress Testing The heart is monitored by ECG and ischemic areas can be identified with the help of several stress methods. Heart rate is increased to 85% of age- predicted maximum level (target heart rate) or until symptoms develop, whichever occurs first. What is strees testing usually used fro ? Stress testing is commonly used for : *Diagnosing coronary artery disease (CAD) *Classifying risk in patients with known CAD *Monitoring patients with known CAD  In patients with CAD, a blood supply that is adequate at rest may be inadequate when cardiac demands are increased by exercise or other forms of stress. Stress testing detects pathophysiologic abnormalities of blood flow. It can define the functional significance of abnormalities in coronary artery anatomy It can lead to life threaten events including malign arrhythmias and myocardial infarction  Stress Test Methodologies Exercise stress testing Pharmacologic stress testing What are the indicators for pharmologic stress Pharmacologic stress testing is usually testing Exercise is preferred to drugs for increasing cardiac demand because used when patients cannot walk on a it more closely replicates ischemia- treadmill long enough to reach their target inducing stressors. heart rate because of musculoskeletal disorders, obesity, peripheral arterial Usually, a patient walks on a disease, or other disorders. conventional treadmill until the Drugs used include IV dipyridamole, target heart rate is reached or adenosine, and dobutamine. symptoms occur.  How can we use in clinical practice ? When do we use stress testing ? Evaluation of chest pain Evaluation of myocardial ishemia It can determine risk of future cardiac events Determining Severity of heart valve disease exercise tolerance before surgery is not massive and it’s low cost because he falls Determination of exercise related arrhythmias positive very often specifically in woman Evaluation of functional capacity Basal ECG Exercise ECG ECHOCARDIOGRAPHY  Echocardiography Echocardiography uses ultrasound waves to produce an image of the heart, heart valves, and the great vessels. It helps to assess heart wall thickness (eg, in hypertrophy or atrophy) and motion and provides information about myocardial ischemia and infarction. It can use to assess systolic function as well as diastolic filling patterns of the left ventricle It can also use to assess the structure and function of the heart valves; detect valvular vegetations and intracardiac thrombus. There are two major echocardiographic techniques; Transthoracic and Transesophageal echo  Transthoracic echocardiography Transthoracic echocardiography (TTE) is the most common echocardiography technique. In TTE, a transducer is placed along the left or right sternal border, at the cardiac apex, at the suprasternal notch, or over the subxiphoid What do we get information region to demonstrate the different cardiac on TTE? structures. Anatomical and functional assessment of cardiac chambers, valves, myocardium, pericardium, and the aorta are important aspects of the echocardiographic examination. How can we use in clinical practice ? Chamber size and shape Blood flow velocities Systolic and diastolic function Cardiac contractility Wall motion abnormalities and ejection fraction Valve function Presence of chamber thrombus Transesophageal echocardiography In transesophageal echocardiography (TEE), a transducer on the tip of an endoscope allows visualization of the heart via the esophagus. TEE is used to assess cardiac disorders when transthoracic study is technically difficult, as in obese patients and in patients with COPD.  Transesophageal echocardiography It reveals better images of small abnormal structures (eg, endocarditic Unlike Transthoracic vegetations or patent foramen ovale) and echocardiogramohy it is invasive posterior cardiac structures (eg, left atrium, left atrial appendage, interatrial Which structures are imaged with TOE ? septum, pulmonary vein anatomy) because they are closer to the esophagus than to the anterior chest wall. TEE can also produce images of the ascending aorta, structures < 3 mm (eg, thrombi, vegetations), and prosthetic valves. How can we use in clinical practice ? Assessment of complications of MI Detection of aortic dissection We can detact aortic Diagnosis of infective endocarditis and dissection + infective its complications in native and endocar+ embolic source via TOE prosthetic valves Determination of embolic source Demonstration of cardiac tumors Evaluation of congenital heart disease Assessment of critically ill patients Guiding for cardiovascular surgery and percutaneous cardiac interventions. Echocardiographic Methodologies Contrast echocardiography Spectral Doppler echocardiography Tissue Doppler imaging Color Doppler echocardiography Three-dimensional echocardiography  Stress echocardiography SE is an alternative to radionuclide imaging to identify myocardial ischemia during and after exercise or pharmacologic stress testing. Stress echocardiography shows regional wall motion abnormalities. Computer programs can provide side-by-side assessment of ventricular contraction during systole and diastole at rest and under stress. Exercise and pharmacologic protocols are the same as those used in radionuclide stress testing.  Stress echocardiography Stress echocardiography is valuable in evaluating the hemodynamic severity of aortic valve stenosis When do we use stress echocardiography? in patients with significant symptoms but whose resting transvalvular pressure gradient is not Patient comes with suspicion markedly high. of artistic stenosis but resting transocular pressure Stress echocardiography and radionuclide stress remains constant to confirm your suspension which one testing detect ischemia equally well. The choice of the test below should be between tests is often based on availability, the used provider’s experience, and cost. Stress echo assesses patients with suspected or known myocardial ischemia This test is valuable in assessment of viable/ischemic myocardium in known CVD  E.A. 64 years Female 10 year – Hypertension – DM (with oral antidiabetic) – Glaucoma 1,5 month ago CVA with left hemiparesis 1 weak ago sudden diplopia with headache CT angiography and MRI verify ischemic CVA PT send to Cardiology outpatient clinic for Evaluation of CVA Comprehensive clinical examination Hemogram normal BP: 145/95 HR: 82/dk BGlu :141 mg/dl Pretibial odema +1 HbA1C 6.9 NtProBNP 1300 pg/mL  Systolic ejection murmur ,Heard best in HsTroponin 41 ng/mL aortic area and radiates to the neck TC 250, LDL 155, HDL 42, TG 265 mg/dl (DD!..)  Which one below is used for AVA Percise measurement of transvavular gradient? 2-D and Doppler Echocardiography Thickened valve cusps with restricted motion used to provide information about direction, speed and Concentric left ventricular hypertrophy characteristics of blood flow Ejection fraction ( Teicholtz ) by M-mode and 2-D Precise measurement of the transvalvular gradient Aortic valve area (AVA) by Doppler TOE Biküspit MANAGEMENT  If the patient is asymptomatic no therapy is required Risc factor treatment HT DM DL  32 years old male Asymptomatic No medical history No family history of cardiovascular disease BP 145/45/0 mmHg HR 82/m/r  High pitched early decresendo diastolic murmur heard best along the left sternal border 3D ECHO NUCLEAR IMAGING Myocardial Perfusion Scintigraphy MPS is a noninvasive nuclear medicine scan that examines myocardial perfusion both at rest and under stress using a small amount of a radioactive substance Stress scanning may be conducted after exercise or using medication (adenosine, dipyridamole, dobutamine) to increase the blood flow to the heart. The study identifies severity of coronary artery disease as well as providing information regarding management such as the need for angiography or coronary artery revascularization. How can we use in clinical practice ? Evaluate patients with chest pain of uncertain origin Determine the functional significance of coronary artery stenosis seen on angiography Determine the functional significance of collateral vessels seen on angiography Evaluate the success of reperfusion interventions (eg, coronary artery bypass grafting [CABG], percutaneous intervention, thrombolysis) Estimate prognosis after myocardial infarction Positron Emission Tomography Positron emission tomography (PET) is a technique that measures physiological function by looking at blood flow, metabolism, neurotransmitters, and radiolabelled drugs PET provides absolute measurement of myocardial blood flow and has enabled the demonstration of coronary microvascular dysfunction In clinical practice, we mostly use this technique to evaluate the viability of the myocardium CARDIAC CT & MRI Cardiac Computerised Tomography Cardiac CT uses CT technology to provide detailed images of the heart This may include identification of anatomical abnormalities such as aneurysms or valve dysfunction Cardiac CT also provides information about patency of grafts following CABG CT angiography uses the addition of a contrast dye to prove more detailed information about CAD Calcium scoring may be undertaken with CT to investigate the presence, location and extent of calcific plaque in the coronary artery  Spiral CT may be used to evaluate pericarditis, congenital cardiac disorders, great vessels, cardiac tumors, and pulmonary embolism. Multidetector CT (MDCT) is currently used for patients with indeterminate stress imaging test results as a noninvasive alternative to coronary angiography. Cardiac Magnetic Resonance Imaging Cardiac MRI uses high intensity magnetic fields to produce 3D images with high resolution. The image provides accurate information about cardiac volumes, muscle mass, contractility, tissue scarring and ejection fraction. The image can identify regional wall motion abnormalities, valve disease, myocardial fibrosis, several cardiomyopathies, myocarditis and cardiac sarcoidosis.  Standard MRI is useful for evaluating areas around the heart, particularly the mediastinum and great vessels Sequential MRI after injecting a contrast agent produces higher resolution of myocardial perfusion patterns. MRI is generally considered the most reliable measure of ventricular volumes as well as ejection fraction. Magnetic resonance angiography (MRA) is used to assess blood volumes of interest. MRA can be used to detect aneurysms, stenosis, or occlusions in the carotid, coronary, renal, or peripheral arteries.  Stress MRI A stress myocardial MRI is a MRI scan that uses an intravenous infusion of a drug (adenosine, dipyridamole or dobutamine) to increase the work load of the heart. A gadolinium dye or contrast agent is injected and provides images as it passes through the myocardium. The stress MRI identifies myocardial scarring or defects and myocardial perfusion and is valuable in assessment of ischemic myocardium for possible revascularization or treatment.  INVASIVE DIAGNOSTIC METHODS Which one of beloa is an Cardiac catheterization invasive diagnositic method Coronary angiography Electrophysiology studies Cardiac biopsy CARDIAC CATHETERIZATION  Cardiac Catheterization Cardiac catheterization is the passage of a catheter through peripheral arteries or veins into cardiac chambers, the pulmonary artery, and coronary arteries. Cardiac catheterization can be used to do various tests, including; angiography, intravascular ultrasonography, measurement of cardiac output (CO), detection of cardiac shunts, and endomyocardial biopsy These tests define coronary artery anatomy, cardiac anatomy, cardiac function, and pulmonary arterial hemodynamics to establish diagnoses. Cardiac catheterization is also the basis for several therapeutic interventions.  Left heart catheterization Left heart catheterization is commonly used to assess cardiac anatomy. Left heart catheterization is also used to assess aortic blood pressure, systemic vascular resistance, aortic valve function, mitral valve function, left ventricular pressure and function. The procedure is done via femoral, subclavian, radial, or brachial artery puncture, with a catheter passed into the coronary artery ostia or across the aortic valve into the LV.  Right heart catheterization Right heart catheterization is most commonly used to assess right atrial (RA) pressure, right ventricular (RV) pressure, pulmonary artery pressure, pulmonary artery occlusion pressure. PAOP demonstrates left atrial and left ventricular end-diastolic pressure. In seriously ill patients, PAOP helps assess volume status and, can help guide therapy. Right heart catheterization is also useful for assessing intracardiac shunts. Right heart pressure measurements may help in the diagnosis of cardiomyopathy, constrictive pericarditis, and cardiac tamponade. CORONARY ANGIOGRAPHY  Coronary Angiography Coronary angiography is a procedure that can be used in both the diagnosis and the treatment of coronary artery disease. Coronary angiography is an invasive procedure which involves a catheter placed into an artery under local anesthetic injection. The tube is then passed along the blood vessels and guided to the heart under X-ray imaging. Coronary angiography via left heart catheterization is used to evaluate coronary artery anatomy in various clinical situations, as in patients with suspected coronary atherosclerotic or congenital disease, valvular disorders before valvular replacement, or unexplained heart failure.  Angiography Pulmonary angiography via right heart catheterization can be used to diagnose pulmonary embolism. Aortic angiography via left heart catheterization is used to assess aortic regurgitation, coarctation, patent ductus arteriosus, and dissection. Ventriculography is used to visualize ventricular wall motion and ventricular outflow tracts. It is also used to estimate severity of mitral valve regurgitation.  Coronary artery flow measurements Coronary angiography shows the presence and degree of stenosis but not the functional significance of the lesion Extremely thin guidewires are available with pressure sensors. Data from these sensors can be used to estimate coronary artery blood flow, which is expressed as fractional flow reserve (FFR). FFR measurements are useful with intermediate lesions (40 to 70% stenosis) and with multiple lesions to identify those are clinically significant or not. ELECTROPHYSİOLOGIC STUDİES  Electrophysiologic studies In electrophysiologic studies, recording and stimulating electrodes are inserted into all 4 cardiac chambers via right- or left-sided cardiac catheterization. Electrophysiologic studies are indicated primarily for evaluation and treatment of arrhythmias that are serious, sustained, and difficult to capture. These studies may be used to make a primary diagnosis, to evaluate the efficacy of antiarrhythmic drugs, or to map arrhythmia foci before radiofrequency ablation therapy. CARDIAC BIOPSY  Endomyocardial biopsy Endomyocardial biopsy helps to assess transplant rejection and myocardial disorders due to infection or infiltrative diseases. The biopsy catheter (bioptome) can be passed into either ventricle, usually the right. The main complication of endomyocardial biopsy, cardiac perforation, occurs in 0.3 to 0.5% of patients;