COMMON CARDIAC DIAGNOSTIC

PROCEDURES.
 INTRODUCTION
• Diagnostic procedures are the medical procedure performed to detect,
diagnose, or monitor diseases, disease processes, susceptibility, or to
determine a course of treatment
• These test are used to check if a person's health is normal
• They may be invasive or non invasive
 INVASIVE PROCEDURES
• Invasive procedure are the medical procedure that invades (enters) the
body, usually by cutting or puncturing the skin or by inserting instruments
into the body.
• An invasive medical procedure involves operating on a patient or
examining the inside of their body.
 INVASIVE PROCEDURES

➢Coronary angiogram
➢Renal /Peripheral angiogram
➢Right/Left heart catheterization
➢Electrophysiological Study
 NON INVASIVE PROCEDURES
• A non-invasive procedure is a conservative method that does not require
incision into the body or the removal of tissues
 NON INVASIVE PROCEDURE
➢ECG
➢Echo
➢TMT
➢Holter
➢ABP
➢CT Angiogram
➢TEE
 ELECTROCARDIOGRAM(ECG)
• An electrocardiogram or ECG - is a simple and useful test which records the
rhythm, rate and electrical activity of our heart.
 INDICATION:

• Chest pain.
• Epigastric pain.
• Back, neck, jaw or arm pain without chest pain.
• Palpitations.
• Syncope or near syncope.
• Exertional dyspnea.
 Types of ECG
• Standard 12 lead ecg
• Right sided ecg, dextrocardia ecg
• Posterior lead ecg
• Rhythm strip ecg
• Magnet ecg
 ECHOCARDIOGRAPHY
• An echocardiogram (echo=sound + card=heart + gram=drawing) is
an ultrasound test that can evaluate the structures of the heart, as well as the
direction of blood flow within it
• It is a type of ultrasound test that uses high- pitched sound waves to produce an
image of the heart
• The sound waves are sent through a device called a transducer and are reflected off
the various structures of the heart
• These echoes are converted into pictures of the heart that can be seen on a video
monitor
 HELPFUL IN DIAGNOSIS OF
• blood clots in the heart chambers
• fluid in the sac around the heart
• problems with the aorta, which is the main artery connected to the heart
• problems with the pumping function or relaxing function of the heart
• problems with the function of your heart valves
• pressures in the heart
 TYPES OF ECHOCARDIOGRAPHY

1. Transthoracic echocardiography
2. Transesophageal echocardiography
3. Stress echocardiography
4. Three-dimensional echocardiography
5. Fetal echocardiography
 TRANSTHORACIC
ECHOCARDIOGRAPHY
 TRANSTHORACIC ECHO
✓ most common type of echo
✓Non invasive, taking place entirely outside body.
✓uses a handheld transducer to scan your heart.
 PREPARATION
• No special preparations are necessary
 STRESS ECHOCARDIOGRAPHY

• uses ultrasound imaging of the heart to assess the wall motion in response to
physical stress
 PREPARATION
• Verification of patient and prepare patient .Pt should be in NPO
• Assemble all article
• Ensure emergency trolley
• Informed consent
• 12 lead ECG
• Prepare dobutamine for infusion
 DOBUTAMINE STRESS ECHO
• Keep patient in supine position
• Start infusion as instructed by physician
• Monitor BP every 3 min and SOS
• Monitor for targeted heart rate(220-age)
• Wait for recovery at baseline stage (ECG,HR Echo)
 3-D ECHO
• uses either transesophageal or transthoracic echocardiography to create a 3-
D image of your heart
• involves multiple images from different angles
• This technology is particularly helpful for identifying problems with heart
valves, replacement heart valves, and the heart’s lower left chamber (left
ventricle
FETAL ECHOCARDIOGRAPHY
 FETAL ECHOCARDIOGRAPHY
• The test is considered safe for an unborn child because it doesn’t use
radiation, unlike an X-ray
• Fetal echocardiography is used on expectant mothers sometime during weeks
18 to 22 of pregnancy.
• The transducer is placed over the woman’s abdomen to check for heart
problems in the fetus
 Indication of Fetal Echo
• Family history of heart disease
• Exposers to known cardiac teratogens
• Chromosomal abnormalities
• Maternal diseases(diabetes,phenylketoneuria, collagen diasease, rubella)
• Polyhydraminous
• Maternal auto immune disease
TREADMILL TEST
 TREADMILL TEST
• Treadmill test is also called a stress test, exercise electrocardiogram, graded
exercise test, or stress ECG
• It is used to provide information about how the heart responds to exertion.
It usually involves walking on a treadmill at increasing levels of difficulty,
while electrocardiogram, heart rate, and blood pressure are monitored.
 INDICATONS
• Symptoms suggesting myocardial ischemia
• Recent ACS treated without coronary angiography or incomplete revascularization
• Known CAD with worsening symptoms
• Prior coronary revascularization (patients 5 years or longer after CABG or 2 years
or less after PCI
• Valvular heart disease (to assess exercise capacity and need for surgical intervention)
• Newly diagnosed heart failure or cardiomyopathy
 CONTRAINDICATION
• Acute myocardial infarction (within 2 days)
• High-risk unstable angina
• Symptomatic severe aortic stenosis
• Symptomatic heart failure
• Acute pulmonary embolus or pulmonary infarction
• Acute myocarditis or pericarditis •
 CONTRAINDICATIONS(CONTD)
• Acute aortic dissection
• Electrolyte abnormalities
• Tachy or Brady arrhythmias
• Mental or physical impairment
• Hypertension (>200/100 at rest)
• Neuromuscular and musculoskeletal disorder exacerbated by exercise
 PREPARATIONS
• 12 lead ECG ,ECHO,vital sign before procedure.
• Patients should be instructed not to drink, eat caffeinated beverages or
smoke 3 hour before testing & to wear comfortable shoes and clothes.
• Unusual physical exertion should be avoided
• Brief history & physical examination should be performed
• 5. Informed consent is taken
 WHEN TO STOP
• Moderate to severe angina
• Increasing nervous system symptoms (ataxia, dizziness)
• Signs of poor perfusion (cyanosis or pallor)
• Sustained ventricular tachycardia
• ST elevation (≥1.0 mm)
• ST depression (>2 mm) • Drop in SBP of (≥10 mmHg) BP without ischemia
• Heart block or brady arrhythmias
• Technical difficulties in monitoring ECG or SBP
• Fatigue, shortness of breath, wheezing, leg cramps
ABP
 ABP

• Ambulatory Blood Pressure Monitoring (ABPM) is a diagnostic test to

determine the presence of hypertension by taking measurements during
normal daily activities, over a span of 24 consecutive hours.
• It helps to diagnose as well as monitor high blood pressure, usually defined
as a systolic pressure of 140 mm Hg or more and a diastolic pressure of 90
mm Hg or more.
 DIAGNOSIS

• To distinguish random elevation of blood pressure (eg. white coat HTN)

• To predict cardiovascular events, mortality or end organ disease.
• To monitor blood pressure in renal disease, which can help prevent
cardiovascular morbidity and further aggravation of renal disease that can
result from poorly controlled blood pressure.
• To monitor the effects of drugs on your blood pressure
 PROCEDURE

➢A device that is about the same size as a portable radio is attached to a belt
or strap worn on your body. It collects information throughout the 24-hour
period transferred to a computer.
➢ A BP cuff that is attached to the device around your upper arm. The cuff
inflates at certain intervals throughout the day and night.
➢After 24 hours, you can remove the device and BP cuff and return the
equipment
HOLTER
 HOLTER
• The Holter monitor is a type of portable electrocardiogram that records the
electrical activity of the heart continuously over 24 hours.
• A Holter monitor is a wearable device and type of ambulatory
electrocardiogram that records your heart’s rhythm and rate activity
 PREPARATIONS
➢Part preparation
➢Informed consent
➢No oils and lotions
 INSTRUCTIONS

• Do not use electronic devices

• Routine work can be continued
• Record any event of chest pain,SOB,palpitations,dizziness
• Avoid bathing
 CT ANGIOGRAM
• CT angiography is a type of medical test that combines a CT scan with an
injection of a special dye to produce pictures of blood vessels and tissues in
a part of body. The dye is injected through an intravenous (IV) line started in
arm or hand.
 DIAGNOSIS
• To find an aneurysm
• To find narrowed blood vessels
• To find abnormal blood vessel formations inside your brain
• To identify blood vessels damaged by injury
• To find blood clots that may have formed in your leg veins and traveled into
your lungs.
• To evaluate a tumor that is fed by blood vessels
 PREPARATION
❖ Check for precautions
❖Clothing
❖Contrast media
❖History of any allergic reactions
❖Nil per oral
❖Diabetics and medications
 DURATION
• A CT angiogram usually takes 30 to 60 minutes but could take up to 2 hours.
 COMPLICATIONS

• Cardiac arrhythmias
• Cardiac tamponade
• Embolism from blood clots at the tip of the catheter to the brain or other organs
• Heart attack
• Injury to the artery
• Infection
• Kidney damage from contrast (dye)
• Low blood pressure
• Reaction to the contrast material
• Stroke
TRANS OESOPHAGEAL ECHO
 TRANSOESOPHAGEAL ECHO
✓A specialized probe containing an ultrasound transducer at its tip is passed
into the patient's oesophagus.
✓Conscious sedation and/or localized numbing medication may be used to
make the patient more comfortable during the procedure.
 PREPARATION

• NPO for 4 to 6 hours before your exam

• Take any prescribed medications with only a sip of water.
• A visitor is compulsory .
 MCQs..
1. The most commonest type of echocardiography is..
a. Transthoracic echocardiography
b. Transesophageal echocardiography
c. Stress echocardiography
d. Fetal echocardiograph
2. Indication of Treadmill test are all except:
a. Newly diagnosed heart failure or cardiomyopathy
b. Prior coronary revascularization
c. Acute myocardial infarction (within 2 days)
d. Known CAD with worsening symptoms
3. Fetal echocardiography is recommended at which gestational age?
• 12-14 wks
• 8-10 wks
• 18-22 wks
• 22-24 wks
INVASIVE PROCEDURES
RENAL ANGIOGRAM
 INTRODUCTION
• A renal angiogram is an imaging test to look at the arteries in kidneys
 DIAGNOSIS
• Bulging of a blood vessel (aneurysm)
• Narrowing of a blood vessel (stenosis)
• Spasm of a blood vessel (vasospasm)
• An abnormal connection between arteries and veins (arteriovenous malformation)
• Blood clot (thrombosis)
• Blockage
• Tumors
• Bleeding (hemorrhage)
• Complications from a kidney transplant
 RISK FACTORS
• Pregnancy
• allergic to contrast dye or iodine
• kidney failure or other kidney problems
 COMPLICATIONS
• Bleeding
• Injury to nerves
• Blood clot (embolus)
• Swelling caused by a collection of blood (hematoma)
• Infection
• Temporary kidney failure
• Damage to an artery
PERIPHERAL ANGIOGRAPHY
 DEFINITION
• A peripheral angiogram is a test that uses X-rays and contrast dye to help
find narrowed or blocked areas in one or more of the arteries that supply
blood to legs, feet, or in some cases, arms and hands.
• The test is also called extremity angiography
• It is a broad term used to describe a study of the peripheral circulation
• It is a common, relatively painless, nonsurgical procedure performed by an
interventional cardiologist.
 TERMS
• the arteries of the aorta (Aortogram)
• renal arteries (Renal angiogram),
• legs (Lower Extremity Angiogram), or arms
• (Upper Extremity or Subclavian Angiograms)
 COMPLICATIONS

• Bruising, bleeding or tenderness at the area punctured

• Injury or damage to an punctured artery caused by the thin tube (catheter)
• Blood clot at the location of the needle puncture
• allergic reactions to the dye that may manifest itself with itching, rash or
breathing problems.
 COMPLICATIONS
• Heart attack
• Blood clots
• Infection
• Kidney damage
• Stroke
• Bruises
• Bleeding
• Arrhythmia
• Allergic reaction to the dye
• Air embolism
LEFT HEART CATHETERISATION
 DEFINITION
• Left heart catheterization involves the passage of a catheter (a thin flexible
tube) into the left side of the heart to obtain diagnostic information about
the left side of the heart or to provide therapeutic interventions in certain
types of heart conditions..
 PURPOSES

• Collect blood samples from the heart

• Determine pressure and blood flow in the heart's chambers
• Examine the arteries of the heart (coronary angiography)
• Take x-ray pictures of the left ventricle (main pumping chamber) of the
heart (ventriculography)
 PROCEDURE
• Live x-ray pictures are used to help guide the catheters up into your heart and
arteries.
• Dye injected into your body highlight blood flow through the arteries. This
helps show blockages in the blood vessels that lead to your heart.
• The catheter is then moved through the aortic valve into the left side of your
heart. The pressure is measured in the heart in this position The catheter is
then moved through the aortic valve into the left side of your heart. The
pressure is measured in the heart in this position.
 DURATION
• The procedure may last from less than 1 hour to several hours.
RIGHT HEART CATHETERISATION
 DEFINITION
• Also known as pulmonary artery catheterization.
• It is a cath procedure to see how well or poorly your heart is pumping and to
measure the pressures in your heart and the main blood vessels in lungs.
 RHC IMPORTANCE FOR
• Heart failure.
• Shock
• Congenital heart diseses
• Heart valve disease
• Cardiomyopathy
• Pulmonary hypertension
• Heart transplant
 PROCEDURE
• In a right-heart cath, doctor guides a small, hollow tube called a pulmonary artery
(PA) catheter to the right side of heart.
• The doctor passes the tube into pulmonary artery.
• Then observes blood flow through your heart and measures the pressures inside
your heart and lungs.
• can also take indirect measurements of pressures on the left side of your heart.
• cardiac output also determined during a right-heart cath.
 COMPLICATIONS
• Bruising of the skin at the site where the catheter is inserted
Excessive bleeding
• Partial collapse of your lung if your neck or chest veins are used to insert the
• catheter
• Other, rare complications may include:
• Abnormal heart rhythms, such as ventricular tachycardia
•
 COMPLICATIONS CONTD
• Cardiac tamponade rarely resulting in death
• Low blood pressure
• Infection
• Air embolism (air leaking into your heart or chest area), rarely resulting in
• death
• Blood clots at the tip of the catheter that can block blood flow
 DIFFERENCES BETWEEN RHC N LHC

• Catheterization of the left side of the heart is performed by passing the

catheter through the artery.
• In catheterization of the right side of the heart, the catheter passes
through the veins.
ELECTROPHYSIOLOGICAL STUDY
An EP study can help determine the cause of heart rhythm problems (arrhythmias). Sometimes it's done to predict the risk of sudden cardiac death.
An EP study can help determine the cause of heart rhythm problems (arrhythmias). Sometimes it's done to predict the risk of sudden cardiac death.
An EP study can help determine the cause of heart rhythm problems (arrhythmias). Sometimes it's done to predict the risk of sudden cardiac death.

• An electrophysiology (EP) study also called invasive cardiac

electrophysiology is a series of tests that examine your heart's electrical
activity.
• An electrophysiological study (EP study) is a test used to evaluate your
heart's electrical system and to check for abnormal heart rhythms.
 INDICATIONS
• evaluation of syncope,
• diagnosis of an arrhythmia,
• evaluation of patients with WPW syndrome and
• risk stratification of sudden cardiac death.
 PATIENT PREPARATION
• Part preparations
• Informed consent
• Stopping Anti-arrhythmics– 2-3 days
• • Fasting – 6 hrs
• • IV access
• • ECG electrodes for 12 lead ECG Monitoring
• • Pulse Ox/NIBP/Invasive BP
• • Conscious sedation
 RISKS
• Bleeding or infection
• Bleeding around the heart caused by damage (perforation) to the heart tissue
• Damage to your heart valves or blood vessels
• Damage to your heart's electrical system, which could require a pacemaker to correct
• Blood clots in your legs or lungs
• Heart attack
• Stroke
• Death (rarely)
CORONARY ANGIOGRAPHY
Coronary angiography is an invasive diagnostic procedure which is also the
most accurate method( the gold standard) for evaluating and defining coronary
artery disease(CAD).It is used to identify the exact location and severity of
CAD via the catheter under the guidance of fluoroscope.
 Indications:
• Acute MI
• Unstable angina
• Chronic stable angina (uncontrolled by medication)
• Abnormal stress test
• Ventricular arrythmias
• Left ventricular dysfunction
• Valvular heart disease
• Preoperative coronary assessment for cardio vascular surgery
• Periodic follow up after cardiac transplantation
 Contraindications:
• Coagulopathy
• Active bleeding
• Malignant hypertension
• Acute or chronic renal failure
• Severe anemia ( Hb < 10gm/dl of blood)
• Electrolyte imbalance
•
 CONTRAINDICATIONS contd
• Fever
• Active systemic infection
• Uncontrolled rhythm disturbances (arrhythmias)
• Uncompensated heart failure
• Transient Ischemic attack
• Patient unable to cooperate or does not desire procedure
 Complications
• 1. Life threatening complications are rare (~1 in 1000) but more common in
patients with serious disease, eg. Left main stem disease, aortic or peripheral vascular
disease.
• MAJOR COMPLICATIONS
• 1. MI
2.Stroke
• 3. Renal failure
• 4. Aortic or coronary dissection
• 5. Cardiac rupture
• 6. Air embolism
• 7. Arrythmia
• 8. Peripheral vascular damage
•
• MINOR COMPLICATIONS:
• 1. Haematoma (at the puncture site)
• 2. Angina
• 3. Vaso vagal reaction
• 4. Allergies to contrast agents and drug