DIAGNOSTICS PROCEDURES OF

CARDIOVASCULAR SYSTEM

Presented by: Shaina Sharma

R.N, M.Sc N

•Chest radiograph

•Angiography

•Blood Tests 

•Cardiac enzymes

•Cardiac Catheterization

•Computed Tomography (CT scan) Electron Beam Computed Tomography (EBCT or Ultrafast® CT)Multi-Detector Computed Tomography (MDCT)

•Echocardiography

•Intravascular Ultrasound (IVUS)/Intravascular

•Stress Echocardiography

•Transesophageal Echocardiography (TEE)

•Electrocardiogram (ECG or EKG)

•Phonocardiogram

•vectorcardiogram

•Electrophysiology Studies (EPS)

•Exercise Stress Test

•Gated Blood Pool Scan (MUGA)

•Holter Monitoring

•Magnetic Resonance Angiography (MRA)

•Cardiac Magnetic Resonance Imaging (Cardiac MRI)

•Nuclear (Thallium) Stress Test

•Positron Emission Tomography (PET scan)

•Central venous pressure

•Pulmonary artery wedge pressure

•Intraarterial blood pressure

Chest X-RAY

•A radiology test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest.

•An X-ray film is positioned against the body opposite the camera, which sends out a very small dose of a radiation beam.

• As the radiation penetrates the body, it is absorbed in varying amounts by different body tissues depending on the tissue's composition of air, water, blood, bone, or muscle.

Patient is asked to wear X-ray gown, and extra metallic objects such as jewellery are removed from the chest and/or neck areas.

. Patients may be asked to take a deep breath and hold it during the chest X-ray in order to inflate the lungs to their maximum

The radiology technologist or technician is a trained, certified assistant to the radiologist who will help the patient during the X-ray and actually perform the X-ray testprocedure.

Procedure:-

POSITIONING A PATIENT FOR PA FRONTAL CHEST RADIOGRAPH. THE X-RAY TUBE IS BEHIND THE PATIENT AND THE X-RAY FILM IS CLOSE TO HIS ANTERIOR CHEST.

TYPICAL CARDIAC CARE UNIT (CCU) PATIENT POSITIONED FOR AN AP CHEST RADIOGRAPH. NOTE THAT, AS OFTEN OCCURS IN THE CCU, THE PATIENT’S CHEST IS NOT PERFECTLY PERPENDICULAR TO X-RAY TUBE. THIS CAUSES THE HEART TO APPEAR LARGE AND INDISTINCT. THIS IS CALLED A LORDOTIC POSITION.

an x-ray technique where dye is injected into the chambers of your heart or the arteries that lead to your heart (the coronary arteries).

Angiography

CORONARY ANGIOGRAM SHOWING BLOCKAGE IN CORONARY ARTERY

Informed consent is taken from the patient.

Assess for allergies to

seafood, iodine or

radiopque dyes.

Ask the patient to not to eat or drink anything

after midnight

before test. If patient is

having diabetes,

doctor should be consulted about the food and insulin intake.

Talk to doctor

about any medicines

that patient is taking,

because he or she may

want the patient to

stop taking them

before the test.

PREPROCEDURE

The patient is carried to the lab. Patient will lie on an examination table, which is usually near an x-ray camera. Small metal disks called electrodes will be placed on his chest. These electrodes have wires called leads, which hook up to an electrocardiogram machine. This machine will monitor heart rhythm during the test.

To prevent infection, patient will be cleansed around the area of leg where the catheter will be inserted.

A needle with a tube connected to it will be put in patient’s arm. This is called an intravenous line or IV. Patient will be given a mild sedative through the IV to relax throughout the test.

DURING PROCEDURE

•The patient will be given an anesthetic medicine with a needle to numb the area around where the catheter will be inserted. The patient may feel mild discomfort.

•Next, a small incision will be made in the skin. Once doctors see the artery into which the catheter will go, a special needle is used to poke into it. Then the catheter is put into the artery in leg.

•The catheter is gently threaded through the artery and into heart. If we want to measure blood pressure in the left ventricle (the heart's main pumping chamber), then position the catheter there and pump some dye into heart.

CONT…….

•If we want to see blood flow through coronary arteries, then position the catheter at the opening of each of the arteries and pump the dye into them. The dye will let us see whether the patient have blockages in a main artery or its branches. This information is recorded on a television monitor.

•then, the catheter and IV will be removed. Firm pressure will be applied to the site where the catheter was inserted to stop any bleeding. The patient will also be bandaged.

CONT……

Post procedure:-

•The patient will be moved to another room where patient will need to rest for a few hours. Patient may feel a little sleepy until the sedative has worn off. Tell the patient to lie still and not bend knee too much. Nurses will watch to see that heart rate and blood pressure are normal. After this time of rest, the patient will be able to go home.

•Angiography is a very safe test. The dye used for the test is harmless, and by drinking lots of liquids after the test, which can help rid body of the dye.

Blood Tests

CBC- one of the most common blood tests. It is usually done as part of a routine checkup and can help detect a number of blood disorders, such as anemia, infections, clotting problems, blood cancers, and immune system problems.

It also measures the hemoglobin (iron) levels in blood and hematocrit, which is how much space red blood cells take up in blood. An elevated hematocrit can result from vascular volume depletion. Decreases in hematocrit and hemoglobin indicates anemia.

• Mean corpuscular volume, which is a measure of the average size of red blood cells. Specific blood tests can be performed to see if there is a problem with heart or blood vessels

• Blood coagulation factors: an increase in coagulation factors can occur during and after MI which places the client at greater risk for thrombophlebitis and extension of clots in coronary arteries.

• Serum lipids: the lipid profile measures serum cholesterol, triglycerides and lipoprotein levels. It is also used to assess the risk of developing coronary artery disease. The desirable range for serum cholesterol is less than 200mg/dl, with LDL cholesterol less than 130mg/dl and HDL cholesterol at 30-70mg/dl.

ELECTROLYTES

SODIUM

The serum sodium level decreases with the use of diuretics.

The serum sodium level decreases in heart failure, indicating water excess.

Calcium

Hypocalcemia can cause ventricular dysrhytnmias,

prolonged ST and QT interval and cardiac arrest.

Hypercalecemia can cause a shortened ST interval, atrioventricular block,

tachycardia or bradycardia, digitalis hypersensitivity and

cardiac arrest.

Phosphorus phosphorus levels should

be interpreted with calcium levels because the kidneys

retain or excrete one electrolyte in an inverse relationship to the other.

Magnesium:A low magnesium level can cause

ventricular tachycardia and fibrillation.

A high magnesium level can cause muscle weakness,

hypotension, bradycardia and a prolonged PR interval and wide

QRS complex.

Blood glucose: an acute cardiac episode can elevate

the blood glucose.

Blood urea nitrogen: it is elevated in heart disorders that

adversely affect renal circulation

( heart failure and cardiogenic shock)

Arterial blood gas studies: measure how well the blood is being oxygenated

in the lungs.

Blood cultures: used to determine if there are

microorganisms (like the bacteria that causes

endocarditis) in the body’s system. After the blood is

drawn, it is placed on a culture, which helps the

bacteria grow. The bacteria is then analyzed to determine

what type it is and what medicines can be used to kill

it.

CARDIAC ENZYMES

•CK-MB( creatine kinase, myocardial muscles)Certain enzymes will be present if the heart muscle (myocardium) has been damaged by a heart attack, because damaged heart cells release these enzymes into the blood. The most common cardiac enzyme that is released is creatine kinase.

• An elevation occurs within 4-6 hours and peaks 18-24 hours following an acute ischemic attack. Normal value is 0-5% of total; total CK is 26-174 units/L.

Lactate dehydrogenase (LDH), elevations in LDH occur 24 hours following MI and peak in 48-72 hours. When serum concentration of LDH1 is higher than LDH2 the pattern is indicated as “flipped”, signifying myocardial necrosis. Normal value in

conventional units is 140 to 280 international units.

Myoglobin is an oxygen binding protein found in cardiac and skeletal muscle.

Level rises within 1 hour after cell death, peaks in 4-6hours and returns to normal

within 24-36 hours.

Troponin I has a high affinity for myocardial injury, it rises within 3 hours and persists upto 7 days. Normal values

are low, with troponin T normally ranging from 0-0.2ng/ml and troponin I being less

than 0.6ng/ml.

Cardiac Catheterization Method used to perform many tests and procedures available for diagnosing and treating coronary artery disease. Cardiac catheterization is used with other tests such as angiography, arteriography, and electrophysiology studies (EPS).

• First of all informed consent is taken and patient is assessed for allergies to seafood, iodine or radiaopaque dyes.

• Patients are usually told not to eat or drink anything after midnight the night before the test to prevent vomiting and aspiration during the procedure.

• If the patient is taking some medicines to stop taking them before the test. This is especially important if patient is taking blood-thinning medicines or anti-platelet medicines. patient will most likely have blood tests, an electrocardiogram, and a chest x-ray taken before the procedure.

• If the patient is having diabetes, physician is consulted about food and insulin intake, because not eating can affect blood sugar levels.

• Document the client’s height and weight because these data will be needed to determine the amount of dye administered.

INTERVENTIONS (PREPROCEDURE)

•Document baseline vital signs and note the quality and presence of peripheral pulses for postprocedure comparison.•Inform the client that a local anesthetic will be administered before catheter insertion.

• Inform the client that he/she may feel fatigued because of the need to lie still on a hard table for upto 2 hours.

• Inform the client that he may have a fluttering feeling as the catheter passes through the heart, a flushed warm feeling when dye is injected, a desire to cough and palpitations caused by heart irritability.

• Prepare the insertion site by shaving and cleaning with an antiseptic solution if prescribed.

• Administer preprocedure medications if prescribed.

• Insert the IV line if prescribed.

POST PROCEDURE

The patient will be moved to another room where he will need to rest for a few hours. He may feel a little sleepy until the sedative has worn off. Ask the patient to lie still and not bend knee too much.

Monitor vital signs and cardiac rhythm for dysrhythmias at least every 30 minutes for 2 hours initially.

Assess for chest pain and if dysrhythmias or chest pain occurs notify the physician.

Monitor peripheral pulses and the colour , warmth and sensation of the extremity distal to insertion site atleast every 30 minutes for 2 hours initially.

•Notify the physician if the client complains of numbness and tingling, if extremity becomes cool, pale, cyanotic or if loss of the peripheral pulses occurs.

•Monitor the pressure dressing for bleeding or hematoma formation.

•Apply sandbag or compression device to the insertion site to provide additional pressure if required

•Monitor for bleeding and if bleeding occurs apply pressure immediately and notify the physician.

•Monitor for hematoma and if hematoma develops notify the physician.

•Keep the extremity extended for 4-6 hours as prescribed, keeping the leg straight to prevent arterial occlusion.

•Maintain strict bed rest for 6 to 12 hours as prescribed however the client may turn from side to side; do not elevate the head of the bed more than 15 degrees.

•If the antecubital vessel was used, immobilize the arm with an armboard.

•Encourage fluid intake, if not contraindicated to promote renal excretion of the dye.

•Monitor for nausea, vomiting, rash or other signs of hypersensitivity to the dye.

Computed Tomography (CT) Scan

An x-ray technique that uses a computer to create cross-sectional (or slice-like) pictures of the heart.

How does it work?

The CT scanner is a large X-ray machine that has a short, open-ended tube in the middle (like a very short tunnel). The patient lies on a scanning table, which slides through the middle of the CT scanner. The CT scanner takes many x-ray pictures of thin slices of heart. A computer then puts these images together to make one detailed picture. In some cases, a contrast dye is injected into the bloodstream to help physician get a clearer picture.

Interventions

•If a contrast dye is not going to be used during CT scan, ask the patient not to eat for about 2 hours before the test. If a contrast dye is going to be used, ask patient not to eat for about 4 hours before the test. The contrast dye may cause hot flushing in some patients.

•Patient will be asked to undress and put on a hospital gown. Then, patient is asked to lie down on a table, which will be slowly moved through the hollow center of the CT scanner. The patient is asked to lie still and to hold breath briefly as each picture is taken.

•After the test, patient may go about normal activities. Some people find that they have a bad reaction to the contrast dye, but this is rare. If this happens, patient will be treated at the hospital after test.

•CT scanning is a safe test. Although exposure to radiation is small, pregnant female should not have a CT scan.

A CT scan does not get a moving picture of the heart. Instead, CT scans are used to see if part of the heart has calcified. This patient has had a heart attack that scarred the heart's main pumping chamber (the left ventricle). The red arrows point to the scarred part of the heart that has since formed a thick, calcified wall at the tip of the left ventricle

A CT scan gets a number of images that can be looked at one by one. New computer technology now lets technicians stack the images on top of each other to get a 3-D image that can be rotated and viewed from any angle. The red arrows in the images above point to a large aneurysm of the abdominal aorta seen from the front (left picture) and the side (right picture).

Electron Beam Computed Tomography (EBCT or Ultrafast® CT)

Faster type of CT scanning, which takes an x-ray of the heart in about one-tenth of a second. Ordinary CT scanning can take anywhere from 1 to 10 seconds. EBCT takes pictures so quickly that it can avoid blurred pictures caused by the beating of the heart, a problem with a regular CT scan

Multi-Detector Computed Tomography (MDCT)

Used routinely to measure the amount of calcium in the coronary arteries—similar to EBCT—but are also now able to take images of the coronary arteries that are nearly comparable to those taken during a cardiac catheterization.

The two MDCT views above show that the left coronary artery (red arrows) and its side branches are normal.

This 3D MDCT view is looking down on top of the left ventricle. It shows a normal coronary artery (black arrow) and side branches.

EchocardiographyUses sound waves to produce an image of the heart and to see how it is functioning. Depending on the type of echocardiography test used, size, shape, and movement of heart muscle can be known. This test can also show how the heart valves are working and how blood is flowing through heart. Echocardiography can also give information about arteries.

•One-dimensional or M-mode echocardiography is one beam of ultrasound directed toward the heart. Doctors most often use M-mode echocardiography to see just the left side (or main pumping chamber) of heart.  •Two-dimensional echocardiography produces a broader moving picture of heart. Two-dimensional echocardiography is one of the most important diagnostic tools.  •Doppler echocardiography measures blood flowing through the arteries and shows the pattern of flow through the heart.

How does it work?

1. • No special preparation is needed before an echocardiogram.

2

• During the test, patient lies on an examination table. A technician will place small metal disks called electrodes on chest. These electrodes have wires called leads, which hook up to an electrocardiogram machine. This machine will monitor heart rhythm during the test.

3 •Next, the technician will put a thick gel on patient’s chest. The gel may feel cold, but it does not harm skin. Then, the technician will use the transducer to send and receive the sound waves.

INTERVENTIONS

4.•The transducer will be placed directly on the left side of chest, above heart. The technician will press firmly as he or she moves the transducer across chest. Patient may be asked to breathe in or out or to briefly hold breath during the test. But, for most of the test, patient will lie still.

5.• An echocardiogram may

take up to 45 minutes to perform. Patient should not have any pain or discomfort during the test

•A combination of echocardiography and cardiac catheterization. Uses sound waves to produce an image of the coronary arteries and to see their condition. The sound waves travel through a tube called a catheter. The catheter is threaded through an artery and into heart. This test lets us to look inside blood vessels. •It is usually done at the same time that a percutaneous coronary intervention, such as angioplasty, is being performed.

Intravascular Ultrasound

The transducer is attached to the end of a catheter, which is threaded through an artery and into heart. The sound waves bounce off of the walls of the artery and return to the transducer as echoes. The echoes are converted into images on a television monitor to produce a picture of coronary arteries and other vessels in body.

How does it work

IVUS image of inside a coronary artery. IC=IVUS catheter, L=lumen, P=plaque

INTERVENTIONS

Ask the patient - Do not eat or drink anything after midnight, the night before test. Doctor is consulted about any medicines that patient is taking, because some medicines are to be stopped taking them before the test. Patient will most likely have blood tests, an electrocardiogram, and a chest x-ray taken before the procedure.

Once patient is in the catheterization laboratory (also called the cath lab), television monitors, heart monitors, and blood pressure machines are there to monitoring. Patient will lie on an examination table, which is usually near an x-ray camera.

Electrodes will be placed on patient’s chest. These electrodes have wires called leads, which hook up to an electrocardiogram machine. This machine will monitor heart rhythm during the test.

To prevent infection, patient will be shaved and cleansed around the area of groin or arm where the catheter will be inserted.

A needle with a tube connected to it will be put in arm. This is called an intravenous line or IV. Patient will get a mild sedative through the IV to relax throughout the test. Patient will be given an anesthetic medicine with a needle to numb the area around where the catheter will be inserted. Patient may feel mild discomfort

Next, a small incision will be made in the skin. Once vein or artery into which the catheter will go is seen, a special needle is used to poke into it. then put the catheter into the artery or vein in groin or arm. Patient should not feel pain during this part of the test.

The catheter is gently threaded through the artery and into heart. On the end of the catheter is the transducer, which takes pictures of heart. Doctors can move the catheter to get pictures of the inside of heart from different angles.

After having enough pictures, the catheter and IV line will be removed. Patient will also be disconnected from the electrocardiogram machine. Firm pressure will be applied to the site where the catheter was inserted to stop any bleeding. Patient will also be bandaged.

Patient will be moved to another room where he will need to rest for 5 or 6 hours. Patient may feel a little sleepy until the sedative has worn off. Patient will be told to lie still. If the catheter was inserted in groin, try not to bend knee. If the catheter was inserted in arm, try not to bend elbow. Nurse will watch you to see that heart rate and blood pressure are normal. After this time of rest, patient can go home.

Uses sound waves to produce an image of the heart and to see how it is functioning. Stress echocardiography (or stress echo) lets to see the wall motion of the heart's pumping chambers before and after exercise. The test can show if certain areas of the heart muscle are not getting enough oxygen-rich blood.

Stress Echocardiography

After heart has reached a certain rate during exercise on a treadmill or stationary bike, patient is asked to lie down on an examination table. Next, the technician will put a thick gel on chest. The gel may feel cold, but it does not harm skin.

Then the technician will use the transducer to send and receive the sound waves.

The transducer will be placed directly on chest, above heart. The technician will press firmly as he or she moves the transducer across chest. Patient is asked to breathe in or out or to hold breath briefly during the test. For most of the test, patient will lie still.

Most stress echo tests take about 45 minutes, but a dobutamine stress echo takes longer.

INTERVENTIONS

TEE uses sound waves to produce an image of the heart and to see how it is functioning. But unlike standard echocardiography, the sound waves travel through a tube-like device put in the mouth and passed down the throat into the esophagus.

Shows the detailed size, shape, and movement of heart muscle, and the condition of aorta, which is the main blood vessel supplying blood to body. It can also show how the heart valves are working and how blood is flowing through heart. TEE also gives doctors information about arteries. Doctors use this test when they cannot get a clear picture of heart using standard echocardiography.

Transesophageal Echocardiography

How does it work?

TEE uses high-frequency sound waves (also called ultrasound) that can provide a moving picture of heart. The test is like standard echocardiography except that the pictures of the heart come from inside the esophagus rather than through the chest wall. The sound waves are sent through the body with a device called a transducer, which is attached to a tube and put down esophagus. The sound waves bounce off of the heart and return to the transducer as echoes. The echoes are converted into images on a television monitor to produce a picture of heart and aorta.

Patient need to stop eating for at least 4 hours before the test. Consult the doctor about any medicines that patient is taking, because some medicines need to stopped before the test.

The test will begin with the technician spraying throat with an anesthetic, which will make it feel numb. Then, patient will lie down on the examination table. Small metal disks called electrodes will be placed on chest. These electrodes have wires called leads, which hook up to an electrocardiogram machine. This machine will monitor heart rhythm during the test.

Then, a small flexible tube called a probe will be put down throat. The technician will ask patient to swallow, and the probe will be gently moved down throat. This is often the most uncomfortable part of the test. Once the probe is in place, patient should not feel any pain.

On the end of the probe is the transducer, which takes pictures of heart. The technician can also move the probe to get pictures of heart from different angles.

After the technician has enough pictures, the probe and IV line will be removed. Patient will also be disconnected from the electrocardiogram machine. Patient may feel a little sleepy until the sedative has worn off, and you will be watched to see that your heart rate and blood pressure are normal.

If the patient is having a sore throat or trouble swallowing after the procedure. These side effects usually go away after a day or so.

An electrocardiogram (ECG or EKG) test.

(ECG or EKG) is a routine test that is used to look at the electrical activity of the heartbeat. An electrocardiogram tells a lot about heart and how it is working. This test can help us learn more about heart rhythm, the size and function of the chambers of heart, and heart muscle. A healthy person's electrocardiogram has a certain pattern. When there are changes in that pattern, then there is a problem with heart. For example, during a heart attack, the EKG machine records the changing pattern of the heart's electrical activity.

How does it work?

For heart to beat, an electrical impulse is sent from the sinoatrial (SA) node, which is located in heart. The SA node helps heart keep a steady pace. An electrocardiogram can trace the path of electrical energy that is sent from the SA node and through heart. This helps us to know whether patient have a problem that might cause heart to beat irregularly.Small metal disks called electrodes are placed on skin. The electrodes are used to pick up the electrical impulses of the heart. The impulses are recorded, giving doctors a record of heart's electrical activity.

Electrocardiogram basics

•An electrocardiogram reflects the electrical activity of cardiac cells and records electrical activity at the speed of 25mm/sec.

•An electrocardiogram strip consists of horizontal squares representing seconds and vertical squares representing voltage.

•Each small square represents 0.04 second.•Each large square represents 0.20 second.

•The P-wave represents atrial depolarization.

•The PR interval represents the time it takes an impluse to travel from the atria through the AV node, bundle of his and bundle branches to the purkinje fibres.

•Normal PR interval duration ranges from 0.12 to .20 second.

•The PR interval is measured from the beginning of the P wave to end of the PR segment.

•The QRS complex represents ventricular depolarization.

•Normal QRS complex duration ranges from 0.04 to 0.1 second.

•The Q wave appears as the first negative deflection in the QRS complex and reflects initial ventricular septal depolarization

•The R wave is the first positive deflection in the QRS complex.

•The S wave appears as the second negative deflection in the QRS complex.

•The J point marks the end of the QRS complex and beginning of the ST segment.

•The QRS duration is measured from the end of the PR segment to the J point.

•The ST segment represents part of the ventricular repolarization.

•The T wave represents ventricular repolarization and ventricular diastole.

•The U wave may follow the T wave.

•A prominent U wave may indicate an electrolyte abnormality such as hypokalemia.

•The QT interval represents ventricular refractory time or the total time required for ventricular depolarization and repolarization.

•The QT interval is measured from the beginning of the QRS complex to the end of the T wave.

•The QT interval normally lasts 0.32 to 0.4 second but varies with the client’s heart rate, age and sex.

No special preparation is needed before an electrocardiogram.

During the test, patient will lie on an examination table. A technician will clean the areas on body where the electrodes will be placed, usually chest, back, wrists, and ankles. The electrodes have wires called leads, which hook up to the electrocardiogram machine.

Once the electrodes are in place, patient will be asked to lie down. The technician will enter some information into the electrocardiogram machine and then tell patient to lie still for about a minute while the machine takes its readings. The test is completely safe and painless.

INTERVENTIONS

Phonocardiography

The graphic recording of heart sounds and murmurs. The trem also includes pulse tracing ( carotid, apex and venous pulse).

It involves picking up, through highly sensitive microphone, sonic vibrations from the heart which are then converted into electrical energy and fed into a galvanometer, where they are recorded on paper.

•The procedure is most useful when there is evidence of heart murmurs or unusual heart sounds, such as gallops, that are difficult to discern by the human ear. Most recordings are made through an externally applied microphone but intracardiac recordings, made through a phonocatheter, are possible.

•Phonocardiography is a promising non-invasive diagnostic tool for the assessment of aortic stenosis (AS), and time-frequency representation is a potential tool to extract information from the phonocardiogram (PCG) signal.

VECTORCARDIOGRAPHY

Vectorcardiography is a method of recording the magnitude and direction of the electrical forces that are generated by the heart by means of a continuous series of vectors that form curving lines around a central point.

Vectorcardiography was developed by E. Frank in the early 30's. Since the human body is a three dimesional structure, the basic idea is to construct 3 orthogonal leads containing all the electric information. The three leads are represented by right-left axis (X), head-to-feet axis (Y) and front-back (anteroposterior) axis (Z).

Electrophysiology studies, or EPS, use cardiac catheterization techniques to study patients who have irregular heartbeats (called arrhythmias). EPS shows how the heart reacts to controlled electrical signals. These signals can help doctors find out where in the heart the arrhythmia starts and what medicines will work to stop it. EPS can also helps know what other catheter techniques could be used to stop the arrhythmia.

ELECTROPHYSIOLOGY STUDIES

How does it work?

EPS uses electrical signals to find out what kind of arrhythmia patient have and what can be done to prevent or control it. Doctors will perform a cardiac catheterization procedure in which a long, thin tube (called a catheter) will be put into an artery in leg and threaded into heart. This catheter can be used to send the electrical signals into heart.

Stimulating the heart will cause an arrhythmia, so record where in the heart it started. In some cases, patient might be given a medicine to cause an arrhythmia. Certain medicines can also be given through the catheter to see which ones will stop the arrhythmia.

Do not eat or drink anything after midnight the night before test

Electrodes will be placed on chest. These electrodes have wires called leads, which hook up to an electrocardiogram machine. This machine will monitor heart rhythm during the test.

To prevent infection, patient will be shaved and cleansed around the area of leg where the catheter will be inserted.

INTERVENTIONS

patient will be given a mild sedative through the IV to relax throughout the test.

Patient will be given an anesthetic medicine with a needle to numb the area around where the catheter will be inserted. Patient may feel mild discomfort. Next, a small incision will be made in the skin. Once the artery into which the catheter will go is seen, a special needle is used to poke into it. Then the catheter is inserted into the artery in leg.

The catheter is gently threaded through the artery and into heart. Once the catheter is in place, doctors will give heart

small electrical impulses to make it beat at different speeds. patient will be able to feel his heartbeat changing speeds, and this may cause some mild discomfort. After the information is gathered, the catheter and IV will be removed. Firm pressure will be applied to the site where the catheter was inserted to

stop any bleeding. Patient will also be bandaged.

Patient will be moved to another room where he will need to rest for a few hours. Patient may feel a little sleepy until the sedative has worn off. Ask the patient to lie still and not bend knee too much. Nurses will watch you to see that heart rate and blood pressure are normal. After this time of rest, patient will be able to go home

A common test that is used to diagnose coronary artery disease. The test helps to see how the heart performs during exercise. It may also be called exercise tolerance tests, stress tests, exercise EKGs, or treadmill tests.An exercise stress test may also use echocardiography (called a stress echocardiogram) or radioisotope dyes that are injected into the bloodstream (called nuclear stress tests).

EXERCISE STRESS TEST

Its a test using radioisotope dye that shows how blood pools in heart during rest, exercise, or both. The test can tell how well the heart is pumping blood and if it is working harder to make up for one or more blocked arteries. This test is also very useful for finding "ejection fraction," which is the percentage of blood that is pumped out of heart's lower chambers with each heartbeat. This test is also called multi-unit gated analysis or MUGA.

GATED POOL BLOOD SCAN

How does it work?

Gated blood pool scanning makes use of a radioactive substance that is injected into bloodstream. The radioactive substance "tags" or "labels" the red blood cells in blood. This substance is safe and will not harm blood or organs. A gamma-ray camera is used to take pictures of heart as the "tagged" red blood cells circulate.

No special preparation is needed before patient have a resting gated blood pool scan.

Ask the patient not to eat or drink anything (Patient may only have water) after midnight the night before the test

The electrodes have wires called leads, which are attached to a nuclear imaging computer. Then the technician will give 2 injections to the patient: the first injection prepares the red blood cells, and the second is used to "label" the red blood cells. The technician will ask the patient to lie down on a small examination table, which has a special camera around it. Next, the technician will take a number of pictures of heart with the gamma-ray camera.

INTERVENTIONS

If doctor orders an exercise gated blood pool test, patient will be moved to a different examination table. When patient lie down, there will be pedals at the end of the bed. Patient is asked to put his feet in the pedals and, while still lying down, begin to pedal as if riding a bicycle. Using the gamma-ray camera, the technician will take a number of pictures of heart.

After the test, patient may feel tired, but patient will be allowed to resume his normal activities as soon as patient is done with the test. The harmless radioactive substance will leave the body within 2 or 3 days. Women who are pregnant or breastfeeding should not have a gated blood pool scan.

Holter monitoring

Gives a constant reading of heart rate and rhythm over a 24-hour period (or longer). The Holter monitor can record heart rate and rhythm when patient feels chest pain or symptoms of an irregular heartbeat (called arrhythmia).

How does it work?

The Holter monitor is a recording device. The monitor has a strap that patient wear over shoulder or around his waist. The Holter monitor is battery-powered and holds a regular-sized cassette tape, much like one patient would use in an audio tape player. The monitor has 5 to 7 wires called leads. The leads attach to metal disks called electrodes, which patient wear on his chest. These electrodes are very sensitive, and they can pick up the electrical impulses of the heart. The impulses are recorded by the Holter monitor and give a 24-hour record of patient’s heart's electrical activity.

Holter monitoring is a painless test. patient needs to go into doctor's office to

be fitted for the monitor. It is a good idea to bathe before

pateint go to the doctor's office, because once patient

is fitted with the Holter monitor, he cannot get it wet

in the shower or bathtub.

A nurse will clean the areas with alcohol and then place the electrodes on patient’s chest. For men, the nurse may have to shave some small areas of chest. The

electrodes stick to the skin with a gel. Sometimes, an

electrode and lead wire will be taped to chest to prevent

from moving around.

Patient will wearHolter monitor for at least 12 to 24 hours. While

patient is wearing the monitor, he will be asked to keep a log of his

daily activities: what he did and at what time. This will help the to

figure out what patient was doing during the times that there were

abnormal readings.

After 24 hours patient goes back to doctor's office to have the

electrodes removed. This may cause some discomfort, similar to having a

bandage pulled off.

MRI is a scan that lets us see inside the body without having to perform surgery. The test is painless, and uses no radiation. Cardiac MRI is a test that gives a detailed picture of the heart, including the chambers and valves, without patients having to undergo cardiac catheterization.

CARDIAC RESONANCE IMAGING

How does it work?

The MRI machine looks like a long, narrow tube. When patient is placed inside of the tube, he is surrounded by a magnetic field. The human body is made up of different elements, most of which are also magnetic. The magnetic field surrounding body reacts with the magnetic elements within body to transmit a faint radio signal.

This cardiac MRI picture shows the 4 chambers of the heart using what is called a "bright blood" technique. Blood within the heart shows up as white, and the heart muscle shows up as dark gray. The 4 chambers of the heart are the left ventricle (LV), the right ventricle (RV), the left atrium (LA), and the right atrium (RA).

No special preparation is needed before an MRI.

The MRI machine will surround the patient during the test, and some people may feel closed in or claustrophobic. patient will have to lie still, and he may be asked to hold his breath briefly while the technician takes pictures of his heart.

An MRI is a completely painless test, and because the MRI machine uses magnetism, patient is not exposed to any radiation. MRI cannot be done if patient have a pacemaker.

INTERVENTIONS

MAGNETIC RESONANCE ANGIOGRAPHY (MRA)

When an MRI machine is used to study the blood vessels leading to the brain, heart, kidneys, and legs, it is called magnetic resonance angiography (MRA). MRA uses the same technology as MRI, but technicians use special settings on the machine to detect and diagnose blood vessel diseases. MRA can usually gives very clear images of the blood vessels without exposing the patient to radiation. In some cases, a harmless dye may be used to make the images even clearer. The MRA dye highlights the blood vessels, making them stand out from the tissues around them.

Cardiac MRI is an excellent way to show the shape and function of the heart and aorta (the main blood supplier to the body). This picture shows the aorta (arrowhead), the aortic valve, and the heart. This patient has an aneurysm of the aorta (double arrowheads) and a leaky aortic valve. The leaky (or regurgitant) aortic valve is causing blood to leak back into the left ventricle (the black area shown by the arrow).

Used to see the heart while resting and shortly after exercise. The test can give information about the size of the heart's chambers, how well the heart is pumping blood, and whether the heart has any damaged or dead muscle. Nuclear stress tests can also give information about arteries and whether they might be narrowed or blocked because of coronary artery disease.

NUCLEAR (THALLIUM) STRESS TEST

Images taken at rest (left) and during exercise (right) from a nuclear stress test. The dark area shows a location where blood flow is abnormal.

The results of the nuclear stress test can show if the heart is not working properly while resting, exercising, or both. If the test shows that blood flow is normal while resting but not normal while exercising, then it is evident that blood flow to heart is not adequate during times of stress. The heart normally pumps more blood during times of physical exertion.

If the test results are not normal during both parts of the test (rest and exercise), part of heart is permanently deprived of blood or is scarred. If radioactive substance in one part of heart is not seen, it probably means that section of heart muscle has died, either because of a previous heart attack or because the coronary arteries supplying blood to that area of the heart are blocked.

HOW DOES IT WORKS….?????

Just like the exercise stress test, patient will have small metal disks called electrodes placed on chest and back. The electrodes are attached to wires called leads, which are attached to an electrocardiogram machine. then patient walks walk on a treadmill.

After getting the information which is required from the exercise part of the test, patient is asked to step off of the treadmill and go into another room. patient will be given an injection of a radioactive substance, and he will be asked to lie on an examination table, which has a gamma-ray camera above it. The camera is used to take pictures of heart. The camera can pick up traces of the radioactive substance in body and then send a picture to a television monitor.

INTERVENTIONS

After this part of the test is over, patient can leave the testing area for 3 or 4 hours. Patient is asked not to exercise or drink or eat anything with caffeine, such as coffee, tea, sodas, or chocolate. When patient returns, another injection of the radioactive substance is given . patient will be asked to lie down on the examination table, and the gamma-ray camera will take pictures of heart while patient is resting. This will give your an idea of how heart works during both exercise and rest.

After the test is over, patient may eat, drink, and go back to his normal activities right away.

Positron emission tomography (PET) is a scan that uses information about the energy of certain elements in body to show whether parts of the heart muscle are alive and working. A PET scan can also show if heart is getting enough blood to keep the muscle healthy. A PET scan is very accurate because it actually shows heart at work.

POSITRON EMISSION TOMOGRAPHY

How does it work?

PET scanning uses a radioactive substance, which is injected into bloodstream. This radioactive substance goes to areas inside body, where tissue either is damaged or not working properly. These areas usually have increased or decreased "metabolic" activity. The PET scan machine then has hundreds of radiation detectors that can find this radioactive substance in body. The PET scanner measures this radioactivity throughout body and uses computers to create pictures of heart or other body tissues.

No special preparation is needed before a PET scan. If patient have diabetes, blood sugar levels will be monitored during the test, because the test results are not always accurate in patients with diabetes.

The PET scanner is a large machine that has a short, open-ended tube in the middle (like a very short tunnel). The patient lies on a scanning table, which slides through the middle of the PET scanner.

INTERVENTIONS

Patient will be asked to remove all clothes above waist. A technician will put a ring of detectors around chest. patient will then lie down

on a table, which will be moved inside of the PET scan machine. Doctors will take a picture of heart before the radioactive substance

is injected into bloodstream. This takes about 15 to 30 minutes. patient will need to keep his arms above his head during this part of the test. Next, a radioactive substance will be injected with a needle. patient will need to wait about 45 minutes for the substance to move through his bloodstream and into heart. Patient will be asked to hold

his arms above his head as doctor takes another picture of heart.

Central venous pressure (CVP)

Describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system.It is a good approximation of right atrial pressure, which is a major determinant of right ventricular end diastolic volume.Normal CVP can be measured from two points of reference:•Sternum: 0–5 cm H2O•Midaxillary line: 5–10 cm H2O

Normal values are 2–6 mmHg

Nursing Alert: Don’t rely on CVP alone, use them in conjunction with other assessment data. Report abnormal findings to the doctor.

Equipment: Venous pressure tray, cutdown tray, infusion solution and infusion set, 3-way- or 4-way stopcock (a pressure transducer may be used), IV pole attached to bed, arms board, adhesive tape, ECG monitor, carpenter’s level (for establishing zero point)

CONT……...

ACTIONS:

1.Assemble equipment according to manufacturer’s directions.

2.Explain that the procedure is similar to an IV and that the patient may move in bed as desired after passage of the CVP catheter.

3.Place the patient in a position of comfort. This is the baseline used for subsequent readings.

4.Attached manometer to the IV pole. The zero point of the manometer should be on a level with the patient’s right atrium.

5. Mark the midaxillary line on the patient with an indelible pencil.

6.The CVP catheter is connected to a 3-way stopcock that communicates to an open IV and to a manometer.

7.Start the IV flow and fill the manometer 10 cm above anticipated reading (or until the level of 20cm, HOH is reached). Turn the stopcock and fill the rubbing with fluid.

8.The CVP site is surgically cleansed. The physician, introduces the CVP catheter percutaneously or by direct venous cutdown and threaded through an antecubital, subclavian, or internal or external jugular vein into the superior vena cava just before it enters the right atrium.

9.When the catheter enters the thorax an inspiratory fall and expiratory rise in venous pressure are observed.

10.The patient may be monitored by ECG during catheter insertion.

11.The catheter may be sutured and taped in place. A sterile dressing is applied.

12.The infusion is adjusted to flow into the patient’s vein by a slow continuous drip.

TO MEASURE CVP

1.Place the patient in the identified position and confirm zero point. Intravascular pressures are measured to the atmospheric pressure at the middle of the right atrium; this is the zero point or external reference point.

2.Position the zero point of the manometer at the level of the right atrium.

3.Turn the stopcock so that the IV solution flows into the manometer filling to about the 20-25cm level. Then turn the stopcock so that the solution in manometer flows into the patient.

4.Observe the fall in the height of the column of fluid in the manometer. Record the level at which the solution stabilizes or stops moving downward. This is the central venous pressure. Record CVP and the position of the patient.

5.The CVP my range from 5-12cm. HOH.

6. Assess patient’s clinical condition. Frequent changes in measurements (interpreted within the context of the clinical situation) will serve as a guide to detect whether the heart can handle its fluid load and whether hypovolemia or hypervolemia is present.

7.Turn the stopcock again to allow IV solution to flow from solution bottle into the patient’s veins.

Pulmonary capillary wedge pressure

PCWP (also called the pulmonary wedge pressure or PWP, or pulmonary artery occlusion pressure or PAOP), is the pressure measured in by wedging a pulmonary catheter with a deflated balloon into a small pulmonary arterial branch.Physiologically, distinctions can be drawn among pulmonary venous pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and left atrial pressure, but not all of these can be measured in a clinical context.

How is it measured?

The PCWP is measured by inserting a balloon-tipped, multi-lumen catheter (Swan-Ganz catheter) into a peripheral vein, then advancing the catheter into the right atrium, right ventricle, pulmonary artery, and then into a branch of the pulmonary artery. Just behind the tip of the catheter is a small balloon that can be inflated with air (~1 cc). The catheter has one opening (port) at the tip (distal to the balloon) and a second port several centimeters proximal to the balloon. These ports are connected to pressure transducers

When properly positioned in a branch of the pulmonary artery, the distal port measures pulmonary artery pressure (~ 25/10 mmHg) and the proximal port measures right atrial pressure (~ 0-3 mmHg). The balloon is then inflated, which occludes the branch of the pulmonary artery. When this occurs, the pressure in the distal port rapidly falls, and after several seconds, reaches a stable lower value that is very similar to left atrial pressure (LAP, normally about 8-10 mmHg). The balloon is then deflated.

Why is it measured?

It is important to measure PCWP to diagnose the severity of left ventricular failure and to quantify the degree of mitral valve stenosis. Both of these conditions elevate LAP and therefore PCWP. These pressures are normally 8-10 mmHg. Aortic valve stenosis and regurgitation, and mitral regurgitation also elevate LAP. When these pressures are above 20 mmHg, pulmonary edema is likely to be present, which is a life-threatening condition.

Intra-arterial blood pressure

It is a technique in which an intra-arterial catheter (A-line: a very small plastic tube called catheter) is placed in one of blood vessels (an artery) by highly trained personnel. This is usually done during or before certain types of surgery or in the Intensive Care Unit.

Reasons for Placing A-Line

To watch blood pressure very closelyTo draw frequent blood samples for lab tests To test for the oxygen saturation in the blood (check how much oxygen is in your blood)

Method of Placement of A-Line

This is usually placed on the inner side of the wrist. It could also be placed in the artery on the inner side of the elbow, the groin or the foot.

The equipment used to place an A-line

The area is decided mainly upon how well your pulse is felt. That area of the skin cleaned well with a disinfecting solution and alcohol.

Preparation and cleaning of skin

Then, the pulse is felt. With a small needle the skin is numbed with local anesthesia. Then, using a needle with a plastic catheter the skin is entered.

Entering the skin

Once inside the artery, the plastic catheter is advanced further in and the needle is removed.

Removal of needle

The catheter is then connected to some tubing.

Covering area with a bandage

View of an anesthesia monitor (red line is the one measured from the A-line. It measures the blood pressure every beat of the heart)