This document provides information on various cardiovascular tests used to assess heart function and identify heart disorders. It discusses the following tests: medical history and physical examination, laboratory tests of cardiac enzymes and biomarkers, chest radiography, electrocardiography, echocardiography, exercise stress testing, pharmacologic stress testing, and cardiac catheterization. For each test, the document outlines the procedure, what is evaluated, and normal versus abnormal findings.

1. CARDIOVASCULAR TESTING
SUBJECT: CLINICAL PHARMACY
NAME: Atika Siddiqua
CLASS: PharmD
COLLEGE: Sultan ul Uloom
College of Pharmacy, Hyderabad.
GUIDED BY:
Dr. S.P. Srinivas Nayak, Assistant
professor, SUCP.

2. CARDIOVASCULAR TESTING
Cardiovascular tests are used to assess the function of the heart and to identify the disorders
associated with the pathological heart function. Following are the tests used to assess cardiovascular
function:
1. History
2. Physical Examination
3. Laboratory Tests- Cardiac Biomarkers And Enzymes
4. Chest Radiography
5. Electrocardiography
6. Echocardiography
7. Exercise Stress Testing
8. Pharmacologic Stress Testing
9. Electrophysiologic Study
10. Cardiac Catheterization
11. Angiography
12. Computed Tomography
13. Magnetic Resonance Imaging

3. 1. HISTORY:
A comprehensive history should be taken, which includes:
• The chief complaint (current symptoms- their duration, quality, frequency, severity
and impact on daily activities)
• Medical history (previous Cardiovascular problems and comorbid conditions)
• Family history of cardiovascular disorders
• Social history (diet, amount of regular physical activity, tobacco use, alcohol intake,
and illicit drug use)
2. PHYSICAL EXAMINATION:
A comprehensive physical examination should be done, with particular attention to
cardiovascular system, which includes:
• Vital signs
 B.P: Hypertension or Hypotension
 Heart rate: Tachycardia or Bradycardia
 Rhythm: Regular or regularly irregular or irregularly irregular

4.  Respiratory rate: Tachypnoea
 Temperature: Fever
• Examination of the Chest (palpation, percussion and auscultation):
In the patient with chest pain, a thorough lung examination should be performed to
exclude a pulmonary cause.
 Palpation: The anterior chest wall is palpated to assess for the presence of
tenderness in the sternal area.
 Percussion: Percussion of the posterior chest is done to determine if a
pleural effusion is present.
 Auscultation: Auscultation of the lungs is performed to assess for the
presence of pneumonia, airway obstruction, pleural effusion, or pulmonary
oedema.
• Examination of the heart (sounds and murmurs):
 Normal heart sounds include: -S1 - on closure of mitral and tricuspid valves
-S2 - on aortic and pulmonary valves
 Abnormal heart sounds or Gallops: -S3 - immediately after S2 (early diastole)
-S4 - just before S1 (ventricular contraction)

5.  Murmurs: Murmurs are auditory vibrations that occurs as blowing,
whooshing or rasping sound resulting from turbulent blood flow within the
heart chambers or across the valves.
Types of murmurs:
1. Innocent or physiological murmurs: They result from rapid, turbulent
blood flow in the absence of cardiac disease. They are also heard
commonly in healthy children (who often have an increased cardiac
output) and may persist into young adulthood. Fever, anxiety, anaemia,
hyperthyroidism, and pregnancy increase the intensity of a physiologic
murmur.
2. Abnormal murmurs:
- Can be graded from 1 to 6 i.e., from softest to loudest; based on
intensity.
- Can be classified as follows based on duration:
i. Systolic murmurs: occur during ventricular contraction. They begin
with or after S1 and end at or before S2, depending on the origin of
the murmur. They are classified based on time of onset and
termination within systole: midsystolic or holosystolic (pansystolic).

6. ii. Diastolic murmurs: occur during ventricular filling. They begin with or
after S2, depending on the origin of the murmur.
iii. Continuous murmurs: begin in systole and continue without
interruption into all or part of diastole.

7. 3. LABORATORY TESTS- CARDIAC ENZYMES & BIOMARKERS:
These are proteins that are released from the recently necrotic myocytes into the blood
due to myocardial infarction or injury and can be detected by specific bio-chemical
assays.
• CARDIAC TROPONIN: Troponin is a protein complex consisting of three units: TnC,
TnI, TnT. These contractile proteins (cTn I & cTnT) are found only in cardiac
myocytes, hence cTn is preferred marker, since, it is the most sensitive and tissue
specific biomarker. cTn is detectable in the blood 2 to 4 hours after the onset of
symptoms and remain detectable for 5 to 10 days.
• CREATINE KINASE: It is also known as creatine phosphokinase (CPK) or
phosphocreatine kinase. It plays an important role in the intracellular energy
transport from mitochondria to myofibrils. CKP consists of two protein subunits for
muscle (M) and for brain (B), which combine to form 3 isoenzymes- CK-MM, CK-
MB, CK-BB. CK-MB can be detected in the blood 2 to 4 hours after onset of
symptoms and remains detectable in the blood for 48 to 72 hours.

8. • SERUM MYOGLOBIN: It is a heme protein with small molecular weight and is used
as an early marker. It is released rapidly within 1 hour following myonecrosis and
returns to normal in 24 hours.
• C-REACTIVE PROTEIN: It is an acute phase reactive protein produced by liver. CRP
concentrations are measured accurately by a highly sensitive CRP (hs-CRP) assay.
• B- TYPE NATRIURETIC PEPTIDE (BNP): It is a cardiac specific peptide first
identified in porcine brain extracts and hence the name Brain Natriuretic Peptide.
It is a neuro hormone released by ventricular myocardium in response to volume
overload.
• N- TERMINAL PRO BNP: It is a more stable form of BNP. It is formed by the
enzymatic cleavage of pre-pro-BNP, a precursor of BNP.
• LACTATE DEHYDROGENASE (LDH): LDH is an enzyme that catalyses the reversible
formation of lactate from pyruvate in the final step of glycolysis. The major
limitation to LDH is the lack of specificity as it is found in many organs like Heart,
liver, lungs, kidney, skeletal muscle, RBC and lymphocytes. It has five major
isoenzymes (LDH 1 - LDH 5). It rises in 24 to 48 hours, peaks at 2-3 days, and
returns to normal in 8- 14 days after onset of chest pain.

9. • ASPARTATE AMINOTRANSFERASE (AST): It is an enzyme that transfers the amino
group in amino acid synthesis. It is widely distributed in the liver, heart, skeletal
muscle, RBCs, kidney and pancreas. Serum AST levels rises within 12 hours of onset
of pain, peaks in 24 to 48 hours and returns to normal in 3 to 4 days.

10. Sl.
No.
COMPONENT REFERENCE
VALUE
1. Cardiac Troponins (cTn)
Troponin I (cTnI) >/= 0.3 ng/ml
Troponin T (cTnT) >/= 0.1 ng/ml
2. Creatine Kinase (CK), total
Males 55-170IU/L
Females 30-135 IU/L
3. Creatine Kinase-MB,
(CKMB)
</= 6 ng/ml
4. C- Reactive Proteins (CRP) 0.2-3.0 mg/l
5. B-type Natriuretic Peptide
(BNP)
100 pg/ml
6. N- Terminal pro BNP 300 pg/ml
7. Lactate Dehydrogenase
(LDH)
115-221 U/L
8. Aspartate
Aminotransferase (AST) /
(SGOT)
12-38 U/L

11. 4. CHEST RADIOGRAPHY:
Chest radiography is a standard study in evaluating patients presenting with symptoms
suggestive of heart failure or ACS. Chest X- ray uses small amount of radiation to produce
images of the heart, lungs and the chest bones on a radiogram. Chest X-ray provides
detailed information about the position and size of the heart, its chambers as well as its
adjacent structures. In addition, the presence and degree of pulmonary congestion
indicates elevated left ventricular end diastolic pressure (LVEF) resulting from infarction
of the left ventricle.
■ Views:
 Postero - anterior view: The X ray beam from the machine comes from the
posterior (back) and moves through the anterior (front) of the chest while
the patient is standing.
 Lateral view: The X rays penetrate the chest from the sides while the patient
is standing sideways with his arms raised up.

12. POSTEROANTERIOR VIEW LATERAL VIEW
5. ELECTROCARDIOGRAPHY (ECG):
The electrical activity of the heart can be recorded by placing electrodes on the chest
and this recording is called as an Electrocardiogram (ECG). Normal ECG wave form is
composed of following waves:
• P-waves: represent atrial depolarization
• QRS complex of waves: represent ventricular depolarization
• T- waves: represent ventricular repolarization

13. ECG may be demonstrated into additional key components known as intervals or
segments:
• PR interval: time from the onset of P wave to the start of QRS complex of waves.
It represents conduction through AV node. Normal duration: 0.12 to 0.16 secs.
• ST segment: time from the ending of OQS complex of waves to the starting of T
wave. Normal duration: 0.08 to 0m12 secs.
• QT interval: time from the starting of QRS complex of waves to the ending to T
wave. Normal duration: 0.40 secs.

14. The classic ECG changes consistent with acute presentation of myocardial ischemia or infarction are:
(1) T-wave inversion,
(2) ST-segment elevation, and
(3) ST-segment depression

15. PROCEDURE:
1. 12 LEAD ECG: It is the standard and conventional method which uses multiple
leads to record the electrical potential difference between electrodes placed on
the surface of the body. 12 leads are used out of which 6 are limb leads (I, II, III,
aVR, aVL, aVF) and 6 chest leads (V1 to V6). Different leads provide specific
information on different aspects of heart chambers and coronary artery.
4 types of leads used are:
• Bipolar leads: Electrodes are connected to two limbs one being a positive
pole and other being a negative pole. They are: Limb leads I, II, III.
• Unipolar leads: They have two poles, one being an active and other being
inactive. The positive pole is active and the negative pole is inactive. It is of 2
types:
1. Augmented limb leads: They are limb leads aVR, aVL, aVF.
 Augmented vector right (+ve electrode: right arm, -ve electrode:
left arm and left foot.)
 Augmented vector left (+ve electrode: left arm, -ve electrode: right
arm and left foot)

16.  Augmented vector foot (+ve electrode: left foot, -ve electrode:
right arm and left arm)
2. Precordial leads: They are Active electrodes placed directly on 6 points
in the chest and do not require augmentation. They are:
LEAD LOCATION
V1 4th intercostal space near right sternal
margin
V2 4th intercostal space near left sternal
margin
V3 between V2 and V4
V4 5th intercostal space at the midclavicular
line
V5 Anterior axillary line directly lateral to
V4
V6 anterior axillary space directly lateral to
V5
Leads V1 and V2 are called right sided precordial leads, leads V3 and V4
are midprecordial leads, and leads V5 and V6 are called left sided
precordial leads.

17. LIMB LEADS CHEST LEADS

18. STANDARD 12 LEAD ECG

19. 2. AMBULATORY ECG OR HOLTER MONITORING: AECG is used to detect
abnormalities during ordinary activities. During continuous Holter monitoring, the
patient wears a portable ECG recorder, which is attached to 2 to 4 leads placed on
the chest wall. The device is typically worn for 24 to 48 hours, after which the
continuous ECG recording is scanned by computer to detect abnormalities or
arrhythmias.
Holter monitor with ECG reading
Electrodes Heart
ECG reading showing heart rhythm
Holter monitor

20. 6. ECHOCARDIOGRAPHY:
It is a diagnostic procedure which uses ultrasound waves (frequency >20000 Hz) to
produce 2D or 3D images of the heart muscle. It determines the size, shape, movement
of valves and heart chambers and flow of blood through the heart.
WORKING:
High frequency sound waves transmitted from a hand-held transducer bounce off the
tissue and are reflected back to the transducer, where the waves are collected and used
to construct a real time image of the heart, displayed on an electric monitor.
PROCEDURE:
Two types of approaches used are:
1. Transthoracic Echocardiography (TTE): It is performed with the transducer
positioned on the anterior chest wall. It is non-invasive, painless, highly accurate and
quick.
2. Transesophageal Echocardiography (TEE): It is performed with the transducer placed
in the esophagus. It is invasive procedure and must be performed under supervision.

21. TTE
Esophagus
Transesophageal echocardiogram (TEE)
bound
waves Echocardiogram monitorTEE
transducer
Heart
TEE
Following transducer placement, several modes are possible:
1. 2-dimensional Echocardiography (2D ECHO): The placed transducer records the
images in multiple views of the heart, and each view provides a wedge-shaped image.
2. 3-dimensional Echocardiography (3D ECHO): It uses an ultrasound probe with an
array of transducers to be able to slice the heart in an infinite number of planes in an
anatomically appropriate manner and to reconstruct 3D images of the anatomic
structures.

22. 3. Doppler Echocardiography: It is used to detect the velocity and direction of blood
flow by measuring the change in frequency produced when ultrasound waves are
reflected from the RBCs. Colour enhancement allows the velocity and direction of the
blood flow to be visualized with different colours. Blood flow towards the transducer is
displayed in red and blood flow away from the transducer is displayed in blue. Increased
velocity is displayed in brighter shades of each colour.
2D ECHO

23. 3D ECHO

24. 7. EXERCISE STRESS TESTING:
Normally, the coronary arteries dilate to four times their usual diameter in response to
increased metabolic demands for oxygen and nutrients. Coronary arteries with
atherosclerosis, however, dilate much less, compromising blood flow to the myocardium
and causing ischemia.
PROCEDURE:
• In an exercise test, the patient walks on a treadmill or pedals a stationary bicycle.
• Exercise intensity is increased according to the established protocols, for example,
in Bruce protocol, the speed and grade of the treadmill is increased every 3 mins.
• Following are monitored during the test, ECG, heart rate, heart rhythm, B.P,
ischemic changes including chest pain, dyspnoea, dizziness, leg cramping and
fatigue.
• A resting supine and standing ECG is recorded, together with the resting B.P. The
reason for terminating the exercise is noted.
• The exercise test laboratory should be equipped with full resuscitation equipment
including a defibrillator.

25. EXERCISE STRESS TEST

26. 8. PHARMACOLOGIC STRESS TESTING:
Pharmacologic stress testing is indicated in those who are unable to do exercise or are
contraindicated to exercise stress test.
• Two vasodilating agents, dipyridamole and adenosine are administered
intravenously, to mimic the effects of exercise by maximally dilating the coronary
arteries.
 Dipyridamole causes coronary vasodilation by blocking the cellular uptake of
adenosine, thereby increasing the extracellular adenosine concentration.
 Since methylxanthines (i.e., caffeine and theophylline) block adenosine binding
and interfere with its action, foods and beverages containing caffeine should not
be ingested at least 24 hours before its administration.
 Dipyridamole is administered intravenously at 0.142mg/kg/min for 4 mins.
 Adenosine is administered intravenously at 0.140 mg/kg/min for 6 mins.
• Positive inotropic agents like dobutamine can also be used in patients in whom
vasodilators are contraindicated.

27.  Dobutamine is a synthetic catecholamine and is an inotropic agent that increases
heart rate and myocardial contractility, thereby increasing the myocardial oxygen
demands.
 Since beta blockers and calcium channel blockers may interfere with the heart rate,
they should be discontinued before the test.
 Dobutamine is administered intravenously by infusion at 5 mcg/kg/min for 3 mins,
followed by infusions of 10, 20, 30, 40 mcg/kg/min every 3 mins until a target
Heart rate is achieved.
9. ELECTROPHYSIOLOGIC STUDY (EPS):
An electrophysiologic study is an invasive test used to evaluate the
electrical conductivity of the heart to check for abnormal heart rhythm.
PROCEDURE:
A small, thin, wire electrode is inserted into the heart via femoral or
subclavian vein by using a special type of X ray movie called fluoroscopy
as the guidance. Once in the heart, the electrodes measure the electrical
signals of the heart and arrhythmias can be detected.

28. 10. CARDIAC CATHETERIZATION:
Cardiac catheterization involves the introduction of a catheter through the femoral or
radial artery, which is advanced to the heart chamber or large blood vessels guided by
fluoroscopy. Then intracardiac pressure, haemodynamic data and blood flow in the heart
chamber and coronary arteries is measured.
Catheter with balloon
Inflated balloonAlternative
compressessite
the plaque
Catheter
insertion site

29. 11. ANGIOGRAPHY:
Coronary angiography or angiocardiography or coronary arteriography is a technique
where contrast media is injected into the coronary arteries. On X ray exposure, heart
and blood vessels are outlined and examined to assess the location and severity of
coronary atherosclerotic lesions. Therapeutic interventions like Percutaneous Coronary
Intervention (PCI), angioplasty or stent placement may be performed during
catheterization.
12. CARDIAC CT SCAN (CCT):
Computerized Tomography, is A medical imaging method that uses a combination of X
rays and a computer to create pictures of organs, bones and other tissues. A series of
images from many angles are produced, and by using a computer a cross sectional
picture of the heart is produced. It is used to assess the cardiac structure and evaluation
of aortic and pulmonary disease.

30. 13. CARDIAC MAGNETIC RESONANCE IMAGING (CMR):
It is a medical imaging technology that uses powerful magnets and radio waves to create pictures of
the body. Single MRI images produced are called slices. Many images are produced which can be
combined to produce 3D models. MRI scanner is large tube inside which the patients lies during the
scan.
PRINCIPLE:
• The single proton of the nucleus of a hydrogen atom vibrates or resonates when exposed to
magnetic energy.
• When many hydrogen nuclei resonate in response to changes in a magnetic field, they emit
radiofrequency energy.
• The MRI machine detects this emitted energy, and converts it to an image.
• Hydrogen nuclei are used because hydrogen atoms are present in water molecules (H2O), and
therefore are present in every tissue of the body.
• Subtle differences in the hydrogen atoms between various parts of a tissue, emit different
amounts of energy.
• These energy differences show up as different shades of Gray on the MRI which is helpful in
detecting areas of cardiac tissue that have poor blood flow (in CAD) or that has been
damaged (in heart attack).

31. REFERENCES:
1. Pharmacotherapy: A Pathophysiologic Approach, 10e, Joseph T. DiPiro, Robert L.
Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey, Mc Graw Hill
publication.
2.https://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=14607
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