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CARDIAC INVESTIGATIONS

Dr Alicia Chan
Cardiologist, TQEH
Approach to cardiac patient
History
Exam
Investigations
Presenting complaints
Chest pain
Palpitations
Breathlessness
Dizziness and syncope
New murmurs
Chest pain - Causes
Cardiovascular Respiratory/chest GI Other

Angina PE Oesophagitis Chest


M<I Pneumonia Oesophageal spasm wall/musculoskeletal
Variant angina Pneumothorax Hiatus hernia Psychogenic
Syndrome X Acute asthma PUD Costochondritis
Aortic dissection Pneumomediastinu Biliary colic Cervical spondylosis
Thoracic aneurysm m Pancreatitis
Myo-pericarditis
Chest pain - Investigations
ECG
Resting rhythm
Previous MI/ischemia
Pericarditis
LVH
Right heart strain
CXR
Pulmonary/mediastinal masses
Pleural pathology
Focal lung disease eg collapsed segment
Pulmonary hypertension
Cardiomegaly
Abnormal aortic contour
Other investigations
Lab tests CBE, TFTs, liver and renal
function, lipids, glucose
Echo
Cardiac catherterization
CT/MRI chest
Barium studies/upper GI
endoscopy/abdominal US
Stress tests
Indications for selective populations only
Exercise treadmill testing
Nuclear medicine
Stress echo
Palpitations - Causes
Intermittent Intermittent Extrasystoles Augmented Non-
tachycardias bradycardias stroke volume cardiovascular

SVT Sinus node Anaemia Increased


VT disease Thyrotoxicosis awareness of
Intermittent AV normal rhythm
AF/flutter Pyrexia
block Aortic
regurgitation Anxiety/panic
attacks
Hyperventilation
syndrome
Diaphragmatic
flutter
Palpitations - Investigations
ECG
Resting rhythm
Evidence of previous MI
LVH
AV/ intraventricular block
Preexcitation
Large/bifid P waves

Ambulatory ECG/Holter monitor


Echo
Lab tests
- Hb, thyroid function
Electrophysiological study
Implantable event recorder/ loop recorder
Breathlessness - Causes
Cardiovascular LV systolic failure
LV diastolic failure
Right heart failure
Myocardial ischemia
Valvular Heart disease
Intracardiac and extracardiac shunts
Pericardial disease
Intermittent arrhythmias

Respiratory Obstructive lung disease


Upper respiratory tract obstruction
Interstitial lung disease
Respiratory infection
Intrathoracic malignancy
PE
Pleural effusions
Primary and secondary pulmonary hypertension

Other Anaemia
Metabolic acidosis
Hyperventilation syndrome
Breathlessness - Investigations
CBE
ECG rhythm, MI, LVH, right heart strain
CXR
Cardiomegaly/chamber enlargement
Pulmonary oedema
Pulmonary/mediastinal masses
Pleural pathology/ effusion
Focal lung disease
Pulmonary hypertension
Echo
Assess lV systolic and diastolic function
RV dialtation/impairment
Valve disease
Pericardial effusion
Optional investigations ABGs, lung function tests, EST
Rarely cardiac catheterization
Dizziness and Syncope - Causes
Cardiac causes
Bradycardia
Tachycardia
Myocardila ischemia
Vasovagal syndrome
Postural hypotension
LV outflow obstruction
Misc recurrent PE, atrial myxoma
Investigations
ECG
Exercise stress test
Ambulatory ECG
Echo
Tilt table testing
Electrophysiological study
Cardiac diagnosis?

YES NO

Consider: Neurological diagnosis?


Holter monitor
Echo
EPS YES NO

Consider: Consider:
EEG Tilt table testing
Carotid ultrasound ECG with carotid
CT/ MRI head sinus massage
New murmurs - Causes
Systole Midsystolic Mitral regurgitation
Physiologic
Flow
Pansystolic Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Ejection systolic Aortic stenosis
Outflow tract obstruction
Aortic sclerosis
Pulmonary stenosis

Diastole Early diastolic Aortic regurgitation


Pulmonary regurgitation
Graham-Steell (pulmonary
regurgitation)

Mid diastolic Mitral stenosis


Treicuspid stenosis
Austin-Flint
Myxoma

Presystolic Mitral stenosis

Continuous Patent ductus arteriosus


Arteriovenous fistula
Ruptured sinus of Valsalva
Venous hums
Investigations
Echo
ECG
AF
P mitrale
Conduction defects
AV block
LVH
CXR
Heart size, chamber enlargement
Aortic contoru
Pulmonary masses
Cardiac failure
Laboratory tests
CBE
TFT