Francis Anthony B.

Losloso, RN
Diagnostic Test
(Dobutamine Stress Test and Resting Myocardial Perfusion Scan- Resting thallium scan)

Increased metabolic demands for oxygen and nutrients causes coronary

arteries to dilate to four times their usual diameter. With atherosclerosis, coronary arteries
dilate much less further decreasing blood flood to the myocardium leading to myocardial
ischemia. To determine such assessment findings, cardiac stress test may be used to
elicit increased metabolic demands. Cardiac stress test may be induced either by physical
and pharmacologic intervention. These are non-invasive ways to evaluate the
responsiveness of the cardiovascular system to stress. It may be useful to determine
presence of coronary artery disease, etiology of chest pain, functional capacity of the
heart after myocardial infarction and surgery, effectiveness of antianginal or
antiarrhythmic medications, dysrhythmias that occur during physical exercise and specific
goals for a physical fitness program. However, despite these benefits, contraindications
must be determined such as severe aortic stenosis, acute myocarditis or pericarditis,
severe hypertension, suspected left main coronary artery disease, heart failure and
unstable angina. Since severe life-threatening complications such as myocardial
infarction, cardiac arrest, severe dysrhythmias may occur, testing centers or facilities
must be equipped to handle and manage certain conditions and perform advanced
cardiovascular life support. It is important that everyone in the team are knowledgeable
and equipped with skills in handling these cases.

Stress test is usually combined with echocardiography to facilitate actual

cardiac performance while increase metabolic demand is elicited. In my exposure in the
cardiac diagnostic and rehabilitation center at the 6 th floor, I was fortunate to observe the
dobutamine stress test. The patient is a female patient in her 60s undergoing her
dobutamine stress test. Since she is a geriatric patient and unable to perform physical
activity or exercise, pharmacologic stress testing was necessary. Dobutamine is a
synthetic sympathomimetic that increases heart rate, myocardial contractility and blood
pressure, thereby increasing the metabolic demands of the heart. It is the drug of choice
when echocardiography is used because of its effects on altering myocardial wall motion
due to enhanced contractility.

Nursing consideration for patients who will undergo dobutamine stress test
are the following: patients are instructed not to eat or drink anything for at least 4 hours
before the test because some food may have an effect on the cardiac activity such as
caffeine, chocolate, alcohol etc., explaining the procedure is also important so that the
patient will have an overview of what will happen the entire procedure, acquiring a
baseline electrocardiogram, vital signs (heart rate, blood pressure, respiratory rate,
temperature and oxygen saturation) must be done for point of reference. During the
procedure after the drug has been administered, simultaneous activities will happen
wherein the physician or technician is viewing the heart through echocardiogram, the
cardiologist is assessing different views of the heart, the nurse is continuously monitoring
her vital signs while assessing her subjective complaints of feeling tired, chest pain etc.,
and the relative or caregiver may be present inside the room for psychosocial support.
The dobutamine effect will eventually cease, constant assessment for palpitations, feeling
of tiredness, vital signs are taken until it goes back to her baseline vital signs such as
heart rate. To further explore patient’s condition, conversation and history taking may take
place and be helpful to alleviate her anxiety. After procedure, patient may immediately
resume current diet and usual activities of daily living provided that the patient will take
note and immediately seek consultation when presence of chest pain or other cardiac
symptoms occur.

Another diagnostic procedure that I was able to understand was the resting
myocardial perfusion scan. Even though I was not able to see the exact procedure, the
radiologic technician explained to me the details of the procedure. On contrary to
dobutamine or other stress test, the patient was resting and stress was not induced, a
radioisotope thallium is used to assess myocardial perfusion which resembles potassium
and readily crosses into the cells of health myocardium. It is taken up more slowly and in
smaller amounts by myocardial cells that are ischemic from decreased blood flow.
However, thallium will not cross into the necrotic tissue that results from myocardial
infarction. Areas that do not show thallium uptake are noted as defects and indicate areas
of either infarction or stress-induced myocardial ischemia. Resting images are taken 3
hours later after stress induced scan to help differentiate infarction from ischemia.
Infarcted tissue is unable to take up thallium regardless of when the scan is take; the
defect remains the same size known as fixed defect, indicating that there is no perfusion
in the area of myocardium. Ischemic myocardium recovers in a few hours. Once perfusion
is restored, thallium crosses into the myocardial cells, and the area of defect on the resting
images is either smaller or completely reverse. Ideally, cardiac catheterization is
recommended after a positive test result to determine whether angioplasty or coronary
artery bypass graft is needed.

Nursing consideration such as keeping the patient comfortable all through-out

the resting scan may contribute and alleviating their anxiety. The patient may be
concerned about receiving a radioactive substance and needs to be reassured that these
trackers are safe, the radiation exposure being similar to that of other diagnostic x-ray
studies. It is also important to instruct them that they should remain still and be positioned
over their head for about 20 to 30 minutes.