Diagnostic Tools in Cardiovascular Examination 2009

7/28/2019 Diagnostic Tools in Cardiovascular Examination 2009

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DIAGNOSTIC

TOOLS INCARDIOVASCULAR

EXAMINATIONAbdullah Afif Siregar

dan

Zulfikri Mukhtar

Departemen Kardiologi dan Kedokteran Vaskuler

Fakultas Kedokteran USU MedanKuliah 2009


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Standard Kompetensi Dokter (konsil

Kedokteran Indonesia)

Level of expected ability :

Level 1 = mengetahui dan menjelaskan

Level 2 = pernah melihat atau pernahdidemonstrasikan

Level 3 = pernah melakukan atau pernah

menerapkan dibawah supervisiLevel 4 = mampu melakukan secara mandiri

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DIAGNOSTIC TOOLS IN CARDIOVASCULAR

EXAMINATION

1. History of Illness

2. Physical Examination3. EKG or Electrocardiogram

4. Chest x-ray

5. Echocardiogram & TEE or TransEsophageal Echo

6. Stress Test :1. Treadmill Ergocycle Stress Test

2. Isotope Stress Test

3. Chemical Stress Test

4. Echo Stress Test

7. Tilt Table Test

8. Holter Monitor

9. Cardiac Catheterization & Angiography

10. Etc

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1. History of Illness

1. Chief or predominat complaint :chest pain, shortness of

breath, dizziness, blackout spells, palpitations weakness, swelling

of the legs, etc

2. Other heart related complaint :shortness of breath,

sweating, dizziness, weakness, nausea, vomiting, etc.

3. Past history : questions about diseases such as diabetes, highblood pressure, elevated cholesterol levels, prior surgery, asthma,

stroke, cancer, allergies, etc. The presence of diabetes, high blood

pressure and high cholesterol is known to increase the risk of heart

disease. 4


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1. History of Illness (continued)

4. Family history : certain cardiac illnesses such as coronary

artery disease and high blood pressure may occur in more thanone member of a family.

5. Social history : Information about smoking, drinking andcaffeine can provoke irregular heartbeats.

6. Review of system : This is a "laundry list" of symptoms

related to various organs of the body

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2. Physical Examination :

1. Inspection : The physician inspects or looks at different parts ofthe patient's body.

2. Palpation or "hands-on" examination : Duringpalpation, the physician uses his or hands to examine the patient.The physician can feel the heart beat and diagnose enlargement.Loud heart murmurs may also be felt without the use of astethoscope. This is known as a "thrill."

Inspection

Palpation or

"hands-on"

examination

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2. Physical Examination (continued)

3. Percussion or "tapping" examination : Hollow andsolid areas generate different vibrations, the physician uses this

technique to measure the size of various organs (heart, liver, etc.).Percussion is also used to diagnose fluid in the abdominal andchest cavities

4. Auscultation or use of stethoscope : Duringauscultation, the physician listens to the patient's heart beat,lungs and blood vessels of the neck and groin. Certaincharacteristics of the murmur and other portions of theexamination help the physician diagnose specific forms of heartdiseases

Percussion or

"tapping"

examination

Auscultation or

use of

stethoscope

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3. ECG or EKG or Electrocardiogram :The EKG can provide important information about the

patient'sheart rhythm, aprevious heart attack (MCI),

increasedthickness of heart muscle, signs of decreased

oxygen delivery to the heart(Ischaemic), and problems

withdisturbance conduction of the electrical current from

one portion of the heart to another, electrolyte in the blood,effect some drugs to the heartetc

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Resting ECG (Electrocardiogram)

Hearts electrical activity is recorded

as wave line on paper

Detect abnormalities in the heart :

Arrhythmias (abnormal rhythm)

Myocardial ischaemieInfarct (acute or old)

Conduction disturbances (block)

Hypertrophy (atrial , ventricle)


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4. Chest x-ray

A Chest x-ray isvery valuable inanswering the following questions:

Is theheart enlarged or normal? Are theresigns of heart failure and fluid overload?

Does the patient havepneumonia or a collapsedlung?

Is there evidence ofemphysema? Is there atumor in the lungthat could represent

cancer?

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Chest X ray

Shadows lung and heart

Artery knob : Aorta (elongation, dilatation),

Po Artery (prominent).Vascular : Phletora (hypervascularization),

Oligemie (hypovascularization).

Venous congestion.

Heart : enlargement (cardiomegaly)- CT ratio > 50 %.


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Are there findings of ananeurysm

involving the aorta(the major bloodvessel that arises from the heart and

supplies oxygenated blood to the

body)?

Is therefluid in the sacthat surroundsthe lung?

Is therefree air under the diaphragm

(the partition that separates the chest

from the abdomen) to suggest a holein the bowel wall?

Are there changes ofbronchitis or

emphysema.

4. Chest x-ray (continued)

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Echocardiogram (ultrasound)(transthoracal , transesophageal)

2 Dimension

3 Dimension

M mode Colour Doppler

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EchocardiogramEvaluate :

Chamber dimension Wall or septal thickness

Wall motion

Valves (stenosis , regurgitation)

Defect or shunt


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5. Echocardiogram

Echocardiogram :

Trans Thoracal Echocardiogram (TTE)

Trans Esophageal Echocardiogram (TEE)

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5. Echocardiogram (continued)

Echocardiogram is a test in which ultrasound is used toexamine the heart.

M-mode echo that allows accurate measurement of the

heart chambers 2-D Echo evaluates the size, thickness and movement

of heart structures (chambers, valves, etc.).

Doppler examination, the ultrasound beams will

evaluate the flow of blood as it makes it way thoughand out of the heart.

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2 D-TTE

M - Mode


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Doppler flow

Color Doppler


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What information does Echocardiography

and Doppler provide? Size of the chambers : the dimension or volume of the cavity and the

thickness of the walls.

Pumping function : . This measure is known as an ejection fraction or

EF

Valve Function : identifies the structure, thickness and movement ofeach heart valve.

Volume status : The inferior vena cava is distended or increased in size

in patients with heart failure and reduced in caliber when the blood

volume is reduced. Other Uses : diagnosis of effusi pericard, congenital heart diseases,

blood clots or tumors within the heart, active infection of the heart

valves, abnormal elevation of pressure within the lungs, etc.

Echocardiogram (continued)

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TEE or Trans Esophageal Echo

2 D-TEE

the echo transducer is placed in the esophagus and

the esophagus location sits behind the heart21


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How is a a TEE performed?

The patient is made to lie on the left side.

A sedative is given through an intravenous (IV) line to help inrelaxation

The throat is sprayed with an anesthetic to "numb" it.

The patient begins to swallow the tube and the procedurebegins

By rotating and moving the tip of the transducer, the physiciancan examine the heart from several different angles.

The heart rate, blood pressure and breathing are monitoredduring the procedure.

Oxygen is given as a preventive measure and suction is used, asneeded.

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How is a a TEE performed?(continued)

After the procedure, driving is not allowed for 12 hours(because of the use of sedatives).

Eating and drinking should be avoided for at least twohours because the throat will still be numb and the food ordrink could be aspirated into the lungs.

Hot food and drinks should not be used for about 24 hours.

The throat may be sore and throat lozenges can be usedafter two hours of the procedure.

The complication is unusual to experience bleeding,persistent pain or fever.

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Preparing patient for the TEE procedure :

Do not eat or drink for six hours. This will minimize the risk

of vomiting and aspirating during the procedure.

Medications prescribed by your doctor may be taken with

sips of water, if you are not instructed to hold them.

Arrange for a drive home if the procedure is performed onan outpatient basis.

Be sure to notify the doctor or nurse if you have any

allergies, or if you have any difficulty in swallowing orproblems with your mouth, esophagus or stomach.

Dentures should be removed.

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The actual procedure usually lasts 10 to 30 minutes. The

remainder of the time is spent in preparation and observation.

TEE is a relatively common procedure and considered to be fairlysafe. Breathing problems, abnormal or slow heart rhythm,

reaction to the sedative and minor bleeding

The physician can usually provide the results immediately after

the procedure.

TEE is extremely useful in detecting blood clots, masses and

tumors that are located inside the heart.

TEE can also gauge the severity of certain valve problems andhelp detect infection of heart valves, certain congenital heart

diseases and dissection of the aorta

The procedure may detect the clot inside the left atrium.

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6. Stress Test

1. Treadmill Stress Test Ergocycle Stress Test

2. Isotope Stress Test

3. Chemical Stress Test4. Echo Stress Test

How does a Regular Stress Test Work? Patients with coronary arteryblockages may have minimal symptoms and an unremarkable or unchangedEKG while at rest.

The symptoms and signs of heart disease may become unmasked by exposing theheart to the stress of exercise. During exercise, healthy coronary arteries dilate 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 it's area ofdistribution. This reduced flow causes the involved muscle to "starve" during exercise. The

"starvation" may produce symptoms (like chest discomfort or inappropriateshortness of breath), and the EKG may produce characteristic abnormalities.

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Treadmill (exercise)

testExercise or physical stress increase heart rate andblood pressure : observe

Electrical abnormalities (arrhythmia)

Symptom angina or dyspnoe

ECG changes such as ST segment depression orelevation


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6. Stress Test


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A regular stress test is considered in the following

circumstances:

Patients with symptoms or signs that are suggestive ofcoronary artery diseases (CAD).

Patients with significant risk factors for CAD. To evaluate exercise tolerance when patients have

unexplained fatigue and shortness of breath. To evaluate blood pressure response to exercise in

patients with borderline hypertension. To look for exercise-induced serious irregular heart

beats.

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i f h l S TTreadmill Stress Test


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Preparing for the Regular Stress Test:

The following recommendations are for all types of cardiac stresstests:

Do not eat or drink for three hours prior to the procedure. Thisreduces the likelihood of nausea that may accompany strenuousexercise after a heavy meal. Diabetics, particularly those who useinsulin, will need special instructions from the physician's office.

Specific heart medicines may need to be stopped one or two days

prior to the test. Such instructions are generally provided when thetest is scheduled. Wear comfortable clothing and shoes that are suitable for exercise. An explanation of the test is provided and the patient is asked to

sign a consent form.

How long does the entire test take? A patient should allowapproximately one hour for the entire test, including thepreparation.

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Treadmill Stress Test


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How safe is a Regular Treadmill Stress Test? Therisk of the stress portion of the test is very small

What is the reliability of a Regular Stress Test ? Theaccuracy is lower (about 50%) when patients have narrowing in asingle 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 coronaryartery disease).

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Stress Test Intro

Patients with coronary artery blockages may have minimalsymptoms and an unremarkable or unchanged EKG while atrest.

The heart may be stressed by having a patient exercise on a

treadmill or a stationary bicycle. If the patient is unable toexercise secondary to physical limitations such as severe arthritis,artificial limbs, generalized weakness, paralysis, unsteady gait,etc., the physician may choose a pharmacological or chemical

form of test. In the latter case, a medication is given intravenously to perform

a nearly comparable degree of cardiac stress.

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Stress Test Intro


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A drop in blood pressure during exercise may indicate heart

disease. Exercise may provoke arrhythmias or irregular heart rhythm

which may not be seen at rest and may or may not point to

heart disease.

The EKG is constantly monitored during exercise and

recorded on paper at intervals and compared to the EKG

obtained at rest. Changes in the ST segment and T waves

may indicate heart disease.

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Stress Test Intro


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PREPARATION:1. Do not eat three hours before the test.

2. Diabetics patient will need special instructions about the use and doseof insulin.

3. Wear comfortable clothes and walking shoes or sneakers that would

be suitable for exercise.

4. The RESTING EKG and serves as a baseline.

5. The physician will pay particular attention to changes in the pattern ofthe EKG (ST segments and T waves, heart rate, and the presence of an

abnormal heart rhythm).

6. The patient target heart rate (based upon age) must be achieves a. It

may be stopped early if the patient develops significant symptoms

(chest pain, shortness of breath, weakness, leg fatigue, dizziness,serious irregular heart rhythm or marked elevation of blood pressure).39


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Heart Scan and Cardiac nuclear

Heart scan : calcium score (atherosclerosis)

Cardiac nuclear : evaluate viability heart muscle(Thallium 201 test , Positron emission tomography(PET))


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How is an Isotope or Nuclear Stress Test performed?

The test is actually divided into three parts: A treadmillstress test, imaging at rest, and imaging after exercise.

The preparation for the test and the treadmill procedure issimilar to that described under the Regular TreadmillStress Test section.

In patients who are unable to complete a high level ofexercise because of physical limitations, stress to theheart is provided by pharmaceutical or chemicalstimulation.

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Approximately one to 1 1/2 minutes prior to termination of exercise,

the perfusion tracer or isotope is injected into the intravenous "plug"

that had been placed in the forearm or hand. This is followed by a

"flush" injection of saline to make sure that all of the tracer is

pushed into the blood circulation.

After a brief waiting phase (that allows the tracer to be taken up by

the heart muscle) the patient is placed under a scanning camera.

Two sets of isotope images are obtained. One at rest, and one

following exercise

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

The pictures or images are fed into a computer, which reconstructsthem as "slices" of a three dimensional heart. These slices are

presented in three views (vertical long axis or VLA, horizontal long

axis or HLA and short axis or SA).

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Normal

Ischemia

Heart attack

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If nothing happens, the table is returned to the flat position and an intravenous infusion of isoproternol (Trade name = Isuprel) is started.This medicine increases the HR and BP. This effect is similar to that produced by our own natural adrenaline release. As you may have gathered,the test is now simulating what happens when the sympathetic nervous system is stimulated and the "accelerator" is pressed. The tilt table is thenraised back up to 80 degrees and the IV medication continued.

A stop clock in the room is used to keep track of time. If an abnormal result is not seen, the table is lowered and then raised back up afterincreasing the dose of the IV medicine. In patients with NMS, the increase in HR and BP is usually sufficient to cause "panic in the back seat

driver" (parasympathetic nervous system). When this happens, the HR, BP or both drop suddenly and dramatically as theparasympathetic system "slams the brake pedal.". The patient gets dizzy and passes out. Thus, TTT succeeds in simulating a real life situation andestablishes the cause of recurrent black out spells. With the above changes, the test is considered positive. The IV medicine is immediatelystopped and the patient returned to the flat or supine position. Within a few seconds, the patient regains consciousness and both the HR and BPreturn to normal. The patient is observed for 10 to 20 minutes and then disconnected from the equipment.

How to prepare for the Tilt test? Check with your physician to see if any of your medications need to be held. You should not eat or drinkafter midnight to reduce the risk of nausea and vomiting during the test. Try and wear a blouse or shirt to expedite preparation for the test.How long does the Tilt test take? The test generally takes a total of 1 1/2 hours. This includes preparation, the actual test and the recoveryphase. Please make sure that somebody can drive you home after the test.How safe is a Tilt test? The test is fairly safe, although it can be dramatic for the patient if the test is positive and causes a black out spell. Not a

very pleasant circumstance! However, the patient needs to recognize that this denotes a positive response and opens the door to the addition ofextremely effective medications that may dramatically reduce or totally eliminate the patient's recurrent black out spells. In rare cases, the test mayproduce persistent abnormal heart rhythm and patients with coronary artery disease may occasionally experience lingering chest discomfort.Experienced staff and equipment are on hand to handle these potential complications.

What information is provided by the Tilt test? The tilt test helps to confirm the diagnosis of NMS. This is extremely important because thereis effective treatment for the condition which can either totally eradicate or dramatically reduce the frequency and intensity of symptoms(dizziness and black out spells). Recent research studies have also shown a correlation between chronic fatigue syndrome (CFS) and NMS.

Treatment aimed at NMS has been shown to be beneficial in many patients with CFS (if they have a positive tilt test). The use of beta-blockers ismost commonly employed in the treatment of NMS. The beta-blockers acts as a "governor" on a carburetor. The motor does not "rev up" asmuch (HR and BP does not increase drastically) and the back seat driver (parasympathetic system) remains calm and does not slam on the brakes.Other drugs that have shown benefit include aminophylline, disopyramide and certain anti-depressants serotonin-uptake inhibitors).How quickly will I get the results of the Tilt Test? The tilt test results are generally provided to you as soon as it is completed. Changes inyour medications, if indicated by the results of the test, may be discussed at the same time or during a subsequent office visit.

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How is the Test Performed? The chest is cleansed with an alcohol solution toensure good attachment of the sticky EKG electrodes. Men with hairy chest mayrequire small areas to be shaved. The EKG electrodes (circular white patches on theleft) are applied to the chest. Thin wires are then used to connect the electrodes to asmall tape recorder. The tape recorder is secured to the patient's belt or it can be slungover the shoulder and neck with the use of a disposable pouch. The recorder is wornfor 24 hours and the patient is encouraged to continue his or her daily activities. To

avoid getting the setup wet and damaging the recorder, the patient will not be able toshower for the duration of the test. A diary or log is provided so that the patient canrecord activity (walking the dog, upset at neighbor, etc.) and symptoms (skippedheartbeats, chest discomfort, dizziness, etc.) together with the time. The Holtermonitor has an internal clock which stamp the time on the EKG strips. These can beused to correlate the heart rhythm with symptoms or complaints. After 24 hours, theHolter monitor needs to be returned to the laboratory. This can be removed by the

staff. However, if you live out of town or need to take a shower before leaving thehouse, the monitor can be disconnected from the electrodes and sent back to thelaboratory, together with the completed diary.

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ar ac


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ar acCatheterization

Right heart catheterization:Femoral vein

vena cava inferior

right atrium a nd ventricle

pulmonal artery

PCW (pulmonary capillary wedge)


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Cardiac

CatheterizationLeft heart catheterization :

Femoral artery

Aorta

coronary artery or Left ventricle


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If catheters are introduced through the femoral (pronounced fem-rull) orgroin artery, the procedure is known as "left heart" catheterization, becausethe catheter goes from the femoral artery to the aorta, coronary arteries, andthe Left Ventricle (LV). This accounts for the majority of procedures. Leftheart cath can also be performed by using the artery in the arm.

If a catheter is also placed in the right femoral vein to measure pressures

within the right side of the heart, the procedure is called "right heart"catheterization. This is used in patients with congenital heart disease, diseasesof the heart valve, or certain conditions involving the pericardium(pronounced perry-card-e-yum), or sac, of the heart. This may also be used incertain diseases of the heart muscle, heart failure, shock, or whenmeasurements of heart output or lung pressures are needed. Right and leftheart catheterization is a combination of both.

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Diagnostic Tools in Cardiovascular Examination 2009