Susan Posky

(Investigating Cardiac Function)

CARD 313

Dr. Rahaf Waggass

Assistant Professor

CARD 313 1
 Objectives

Relevant weekly objectives

• List the major methods of investigating cardiac pump function, with
reference to the anatomy of the heart and normal values for intracardiac
volumes and pressures.
Lecture Objectives
By the end of the lecture the students should be able to:
• Describe the radiological features of heart failure
• List the advantages and disadvantages of:
o echocardiography
o nuclear imaging
o magnetic resonance imaging
o invasive angiography
CARD 313 2
• Laboratory tests to assess cardiac function.

• Radiological tests to assess cardiac function.

CARD 313 3
Why we need laboratory and radiological tests
to assess cardiac function?

• The diagnostic sensitivity and specificity of the

clinical history and physical examination for
diagnosing patients with heart failure is
relatively poor.

CARD 313 4
 Goals of laboratory and radiological tests

• To determine that there is some abnormality

of cardiac structure or function that explains
the patient’s symptoms.
• To identify abnormalities that may lead to
specific interventions.
• To determine the severity and prognosis of
heart failure.

CARD 313 5
 Routine laboratory tests

• CBC
• Urea and electrolytes
• Renal and liver function
• Natriuretic peptide

CARD 313 6
 Why CBC?

• To detect Anemia.
Anemia may aggravate heart failure caused by
its increase in cardiac output which is
associated with an increase in myocardial
volume overload.

CARD 313 7
 Why electrolytes?

• Serum electrolytes are usually normal in mild to

moderate heart failure but may become abnormal in
severe failure or when drug therapy is increased.
• K+ is usually normal but prolonged use of loop
diuretics or thiazides may lead to hypokalemia.
• The degree of hyponatremia is a marker for the
severity of heart failure. Sodium restriction in
addition to diuretics use can cause hyponatremia.

CARD 313 8
 Why LFT?

• LFT is often abnormal in heart failure as result

of hepatomegaly.
• AST and ALT levels are increased.
• Prothrombin Time (PTT) may be prolonged.
• Rarely hyperbilirubinemia may occur.

CARD 313 9
 Why renal tests?

• Urinalysis should be done in all patients to

search for bacterial infections,
microalbuminuria and microhematuria.
• Specific attention should be paid to urine
concentration and excretion volume in
patients with renal impairment and diuretics
therapy.
• Deterioration in glomerular filtration rate
(GFR) predict cardiac mortality more
powerfully than NYHA functional class.
CARD 313 10
 Natriuretic peptides

• ANP and BNP are both secreted in response to

increasing cardiac wall tension.
• ANP and BNP levels are elevated in patients
with systolic dysfunction.
• BNP is useful in distinguishing between
cardiac and noncardiac causes of dyspnea.
• Provides prognostic information in patients
with chronic heart failure.
• NT-BNP level changes can be used to predict
CARD 313 11
response of traetment.
 Radiological tests

• CXR
• Echocardiography
• Nuclear imaging
• Computed tomography imaging (CT)
• Magnetic resonance imaging (MRI)
• Invasive angiography

CARD 313 12
CARD 313 13
 CXR findings in heart failure

• Cardiomegaly
• Prominanat upper lobes blood vessels
• Pulmonary edema (Bat’s wings)
• Kerley B lines
• Pleural effusion

CARD 313 14
CARD 313 15
 Echocardiography

• The preferred diagnostic method for assessing

the anatomy and function of the heart,
studying myocardium and pericardium, and
evaluating regional wall motion.

CARD 313 16
 Advantages of echocardiography

• Cheap
• Safe
• Non-invasive
• Applicable at bedside
• Excellent for serial studies
• Assess both global and regional LV function.

CARD 313 17
 Disadvantages of echocardiography

• Operator dependant.
• Suboptimal in obese patients, patients with
surgical dressings or patients on mechanical
ventilation.

CARD 313 18
 Ventricular function

• Ejection fraction (EF):

EF%=(LVEDV-LVESV)X100/LVEDV
Normal values 54%-75%
• Shortening fraction (FS):
FS=(LVED-LVES)/LVED
Normal values between 0.28-0.42

CARD 313 19
 Systolic dysfunction

• Reduced EF.
• Enlarged LV.
• Thin LV wall.
• Mild or moderate mitral regurgitation

CARD 313 20
 Diastolic dysfunction

• Normal EF.
• Normal LV size.
• Thick LV wall, Dilated atria.
• No or minimal mitral regurgitation.

CARD 313 21
CARD 313 22
CARD 313 23
CARD 313 24
 Nuclear Imaging

• Nuclear imaging is a technique for producing

images of various body parts using small
amounts of radioactive tracers. After
administration of the tracer, images of the
body part are obtained with a gamma camera,
which helps physicians in diagnosing
conditions.
CARD 313 25
• Cardiac nuclear imaging is useful in diagnosing
and assessing coronary artery disease. It is
also used to evaluate cardiomyopathy and
identify possible damage to the heart from
chemotherapy or radiotherapy.

CARD 313 26
 Benefits of nuclear imaging
• Nuclear imaging examinations offer
information that is unique including details on
both function and structure and often
unattainable using other imaging procedures.
• Nuclear imaging is less expensive than some
other forms of imaging.
• Minimally invasive.
• Gives information about cardiac function both
at rest and during exercise.
CARD 313 27
 Disadvantages of nuclear imaging
• Injection of the radiotracer may cause slight pain
and redness which should rapidly resolve.
• Allergic reactions to radiopharmaceuticals may
occur but are extremely rare and are usually mild.
• Nuclear imaging procedures can be time consuming.
• The resolution of structures of the body with
nuclear imaging may not be as high as with other
imaging techniques, such as CT or MRI.
• Not advisable during pregnancy.

CARD 313 28
CARD 313 29
CARD 313 30
 Computed tomography

• Computed tomography of the heart is not yet

routinely used in clinical practice. It may be
useful in the diagnosis of suspected coronary
heart disease, for follow-up of a coronary
artery bypass, for the evaluation of valvular
heart disease and for the evaluation of cardiac
masses.

CARD 313 31
 Advantages of Cardiac CT

• Fast.
• High resolution images.

CARD 313 32
 Disadvantages of cardiac CT.

• Contrast allergy.
• Radiation
• Artifacts formation.
• Can not be performed for pregnant ladies or
patients with renal failure.

CARD 313 33
CARD 313 34
 Cardiac MRI

• Gaining more use in the cardiac field due to

the significant information obtained of both
structure and function of the heart.

CARD 313 35
 Advantages of Cardiac MRI

• No ionizing radiation.
• High resolution and 3D images.
• No bone or air interference.
• Less operator dependant than
echocardiography.
• Less allergic and contrast induced
nephropathy than idonated contrast media.
CARD 313 36
 Disadvantages of Cardiac MRI
• Require more patient’s cooperation.
• Cant not be performed on claustrophobic patients.
• Longer examination time.
• Unsuitable for unstable patients.
• Cost.
• Can not be performed on patients with regular
pacemakers or metalic devices like cochlear implants.
• Less spatial resolution than CT which limits its use for
evaluating small structures like coronaries.
CARD 313 37
CARD 313 38
CARD 313 39
 Invasive angiography

• Cardiac catheterization and angiography are

tests in which catheters are placed into the
heart in order to evaluate the anatomy and
function of the heart and surrounding blood
vessels.

CARD 313 40
 Advantages of cardiac angiography

• Direct measurements of intracardiac

pressures and saturation and delineate
anatomy of the heart and blood vessels.
• Allows interventions if needed.

CARD 313 41
 Disadvantages

• Invasive.
• Radiation.
• Possible complications.

CARD 313 42
 Complications

• Bleeding at the site of entrance.

• Arrhythmias.
• Heart wall perforation.
• Allergic reactions to the dye used in
angiography.
• Injury to valves or vessels.

CARD 313 43
 Normal intracardiac pressures

• RA: 0-4 mmHg

• RV: 25 s/4 d mmHg
• PA: 25 s/10 d mmHg
• LA: 8-10 mmHg
• LV: 120 s/10 d mmHg
• Aorta: 120s/ 80 d mmHg

CARD 313 44
CARD 313 45
CARD 313 46
 References

• Braunwald’s heart disease. 8th edition

• Moss and Adams’ heart disease in infants,
children, and adolescents. 8th edition.

CARD 313 47
CARD 313 48