Dr. Gurumoorthi
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Prof. V. K. Bhatia

To assess electric and structural function Assessment of cardiac risk is an important factor for treatment decision making in patients with coronary artery disease Guidelines for preoperative investigation before cardiac surgery suggest the mandatory performance of full blood count, renal profile, ECG, chest radiograph, and consideration of a clotting profile. Cardiac surgery patients will also need many more specialized investigations.

Include simple non-invasive and more complicated invasive tests of cardiac function Non-invasive o Chest x-ray o ECG o Echocardiography o Exercise test Invasive o Cardiac catheterization o Thallium scanning Tests currently used for evaluation of patients with CAD include stress electrocardiography (ECG), stress or pharmacologic echocardiography, stress or pharmacologic myocardial perfusion imaging (MPI), electron beam computed tomography (EBCT), and positron emission tomography (PET)

Complete detailed clinical examination is the main part of test.

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Routine chest x-ray PA view is recommended in all cardiac surgery procedures. It is mainly indicated in the presence of cardio respiratory symptoms or signs Key clinical finding is heart size and pulmonary vascular flow. Important signs associated with increased cardiac morbidity are: o Cardiomegaly …. > 50% of width of thorax in absence of valvular and congenital disease is indicative of ventricular dysfunction.

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Pulmonary edema – increased pulmonary vascular marking indicates left ventricular dysfunction. Change in the cardiac outline characteristic of specific diseases.

ECG Key clinical finding includes rate, rhythm, axis, ischemia, infarction and hypertrophy. Usually 12 lead ECG is used. For preoperative assessment ECG should be taken 24-48 hours before surgery to rule out silent ischemic changes and it also provide a base line for comparison in operating room before induction as well as post operatively. Resting ECG is normal in 25-50% of patients with ischemic heart disease • • • Characteristic features of ischemia or previous infarction may be present Exercise ECG provides a good indication of the degree of cardiac reserve 24-hour monitoring is useful in the detection and assessment of arrhythmias [Ambulatory ECG monitoring (HOLTER]  Used to detect ECG changes during daily normal activity. ECHOCARDIOGRAPHY

Key clinical findings are segmental wall motion, ejection fraction, valvular function and congenital anatomic defects. Can be performed percutaneously or transoesophageal Two-dimensional echocardiography allows assessment of Muscle mass Ventricular function / ejection fraction End-diastolic and end-systolic volumes Valvular function Segmental defects Doppler ultrasound allows assessment of valvular flow and pressure gradients
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 Valvular heart disease- useful in identifying type, location, severity, physiological significance of valvular lesion, motility and thickening of stenotic valve.  Very sensitive detector of small pericardial effusion even less than 100 ml.

 Left ventricular ejection can be assessed by echo which gives a valuable information regarding myocardial function and cardiac reserve to anesthetists. Very useful in case of critical aortic stenosis, severe left ventricular failure or allergy to radiographic contrast material where cardiac catherisation is not possible.  Can find out outflow obstruction in case of hypertrophic sub aortic stenosis.  In case of ischemic heart disease it can give information regarding lack of contraction, myocardial thinning, dilatation, post infarction ventricular septal defect, left ventricular thrombus and aneurysm. EXERCISE TOLERANCE TEST • • For patient having pre existing and suspected CAD patients. Multiple protocols exist for exercise tolerance tests. One common protocol is to have the patient start walking on a treadmill and then to increase the treadmill speed and gradient until the patient experiences symptoms or ECG changes, heart rate, or blood pressure reaches preset limits, or the patient reaches a predetermined metabolic workload.[ Modified Bruce Protocol is a common regimen] • Expressed in metabolic equivalent and MET level of 5 corresponds to the ability to perform daily activity.

Test outcomes and interpretation
Exercise tolerance test is strongly positive and strongly suggest of left main or three vessel coronary artery disease when (1) systolic blood pressure falls 10 mm hg or more, (2) more than five leads show positive ST segment changes and (3) ischemic changes occur within 3 minutes and take longer than 9 minutes to resolve.

Electrocardiographic responses • ST-segment depression: Standard criterion for this response is horizontal or down-sloping ST-segment depression of 0.1 mV or more for 80 milliseconds. The probability and severity of coronary artery disease is related directly to the amount of depression and to the down-slope of the ST segment • • ST-segment elevation: In patients with no Q waves on the resting ECG, severe transmural ischemia is signified, and the site of ischemia is pinpointed Normal ECG during an exercise tolerance test should not necessarily be interpreted as a negative stress test. Other outcomes, including pain, workload, and vital sign abnormalities, are important clinical indicators as well. • No role in patients with resting ECG abnormalities (left bundle-branch block, paced rhythm, preexcitation syndromes, or ST depressions at rest), inability to exercise, angina, history of revascularization, medications including digoxin, beta-blockers, vasodilators, and other antihypertensive medications. • The test is negative if the patient reaches an age-specific pre-determined heart rate without chest pain or ST segment changes. STRESS ECHOCARDIOGRAPHY • • • Stress echocardiography is used to diagnose coronary artery disease by detecting cardiac wall motion abnormalities during exercise-induced myocardial ischemia different exercise modalities include treadmill and supine or upright bicycle ergometry For patients who cannot exercise, pharmacologic echocardiography with dobutamine incrementally increased to 20 μg/kg/min is used.

Table 2. Indications for pharmacologic stress echocardiography or stress SPECT Inability to achieve exercise level sufficient for treadmill testing (ie, 85% of predicted heart rate) Lung disease Arthritis Poor physical condition Psychological impairment Introduction of IV contrast or micro bubbles which can improve visualization

Observation of an ischemia-induced regional wall motion abnormality on echocardiography is considered a positive test result and is graded with respect to wall motion as normal, hypokinetic, akinetic, dyskinetic, or aneurysmal.

Segments of the ventricle that are less than 6 mm thick, or remain akinetic or dyskinetic despite dobutamine infusion are non-viable and represent scar tissue

Stress echocardiography may be useful in patients with significant cardiomyopathies for whom SPECT will be less sensitive, or in patients for whom echocardiography is desired for other reasons and is less useful when practitioners have limited experience performing the test.

CARDIOPULMONARY EXERCISE TEST • Non-invasive objective method of evaluating the cardiac and pulmonary response to exercise. The patient is connected to a 12-lead ECG and

exercised on a bicycle ergometer or treadmill, whilst breathing through a mouthpiece pneumotachograph • particularly helpful in the evaluation of cardiac failure

COMPUTED TOMOGRAPHY • • Based on calcium present in plaque in vessel. CT angiography is a modality that continues to improve with the introduction of 32- and 64-slice CT scanners and may eventually equal invasive angiography in the diagnosis of obstructing lesions. • CT Angiography is used to provide detailed information about the great vessels (e.g. aortic dissection), in defining cardiac anatomy in patients presenting for resternotomy (e.g. the position of the aorta in relation to the sternum) for evaluation of cardiac function, wall motion abnormalities, and proximal coronary artery stenosis. • Carries the risks of contrast nephropathy and high radiation exposure for the patient.

Magnetic resonance angiography
• • • High accuracy and reproducibility in the assessment of cardiac structure, function, perfusion and myocardial viability. Cardiac magnetic resonance angiography (MRA) allows visualization of coronary vessels without radiation or contrast dye. While cardiac MRI/MRA continues to evolve, it shows promise as the only imaging modality that can combine angiography with perfusion and wall motion assessments. • Gold standard for the assessment of ventricular mass and volume and also the procedure of choice in the analysis of cardiac anatomy in congenital heart disease, and the assessment of pericardial disease and intra-cardiac masses INVASIVE METHODS CARDIAC CATHERISATION

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Gold standard in diagnosing cardiac pathology prior to open cardiac surgery and in finding out coronary vessel pathology. Any degree of left ventricular dysfunction, valvular abnormality, severe pulmonary disease, impaired right ventricular function exists clinically, a right sided [swan-ganz] catheterization is done otherwise left side is done.

A 50% reduction in vessel diameter is equivalent to a 75% reduction in cross-sectional area, and represents a significant stenosis. Left ventricular ejection fraction, cardiac output, pulmonary vascular resistance and enddiastolic pressures may be measured during cardiac catheterization. In valvular lesions, the pressure gradient or regurgitant fraction across the valve may be estimated.

Contraindication? MEASUREMENT Systolic/diastolic Mean mean Systolic/end diastolic Systolic / diastolic mean Mean Systolic/end diastolic VALUE <= 140/90 mm Hg <= 105 mm Hg <= 6 mmHg <=30/6 mm hg <= 30/15 mm Hg <=22 mm hg <=12 mm hg <=140/12 mm hg 2.5-402 L/min/m2 <100 ml/m2 <=5.0ml/dl% 20-130 dynes sec/cm5(or) 0.25-1.6 woods units 700-1600 dynes sec/cm5 or 9-20 woods units

PARAMETERS Arterial or aortic pressure Right atrial pressure Right ventricular pressure Pulmonary artery pressure Pulmonary artery wedge Left ventricular pressure cardiac index end diastolic volume index Arteriovenous o2 content difference Pulmonary vascular resistance Systemic vascular resistance

RADIONUCLIDE PERFUSION IMAGING • used to visualize myocardial blood flow distribution using radionuclide such as thallium and technetium

When it is combined with single-photon emission computed tomography (SPECT), wall motion and left ventricular function can be evaluated simultaneously.

Thallium 201 is an intracellular cation that behaves similarly to potassium and has a half-life of 73 hours. Images are taken immediately after administration of the thallium and again 3-4 hours later.

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Technetium Tc 99m sestamibi, a calcium analogue has a shorter half-life (6 h) Patients who are unable to exercise may undergo a thallium stress test. A common protocol is to infuse dobutamine, 10–40 μg/kg/min Areas of decreased blood flow and nonviable myocardium have decreased thallium uptake and show up as defects on the initial images. Over time, the defects related to ischemic myocardium resolve on the subsequent images as myocardial blood flow normalizes. Persistent defects represent regions of scar from previous MI.

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A reversible perfusion defect on SPECT imaging is defined as a positive test indicated in patients who cannot exercise and in patients for whom exercise electrocardiography is not helpful because of resting ECG abnormalities or exertional ST depressions associated with left ventricular hypertrophy (LVH)

Less sensitive and specific in patients with single-vessel disease (particularly isolated disease in the circumflex artery), significant collateral formation, cardiomyopathy, and significant attenuation from breast or diaphragm tissue.

CARDIAC TEST IN WOMEN • • • Women are more likely to have non obstructive or single-vessel disease when compared with men, which decreases the diagnostic accuracy of stress testing Calcium scoring is limited because women tend to have 3- to 5-fold greater mortality rates for a given calcium score than men, SPECT imaging is technically limited in women because breast tissue and relatively small left ventricle size can generate false-positive results

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