cardiac assessment

1. CARDIAC
DIAGNOSTIC TESTS
Prof.MahendraLamba
SandraShroffROFELcollegeof
Nursing,VAPI

2. Introduction
• Diagnostic investigations
are methods of identifying
heart conditions associated
with unhealthy, pathologic,
heart function.

3. Types
• Invasive
• Non invasive
▫ Electrocardiography
▫ Echocardiography/Ultraso
und
▫ Cardiac Angiography
▫ Intravascular Ultrasound
▫ Nuclear Heart Scan
▫ Chest X Ray
▫ Sphygmomanometer
▫ CT Scan
▫ MRI

4. Electrocardiography
• The recording produced by
this procedure is termed an
electrocardiogram
(ECG) from the German
Elektrokardiogramm).
Electrocardiography (ECG) is a
transthoracic interpretation of the electrical
activity of the heart over a period of time, as
detected by electrodes attached to the outer
surface of the skin and recorded by a device
external to the body(electrocardiograph).

5. • The ECG device detects and amplifies the tiny electrical
changes on the skin that are caused when the heart
muscle depolarizes [ contracts ]during each heartbeat.
• This depolarization is detected as tiny rises and falls in
the voltage between two electrodes placed on either side
of the heart which is displayed as a wavy line either on a
screen or on paper.

6. Procedure
• Patient lies down on his back.
• Several areas on skin of arms,
legs, and chest are cleaned and
shaved, and small patches i.e
electrodes are attached to these
areas.
• The patches are connected by
wires to the ECG machine
• The heart's electrical signals
are printed into wavy lines on
paper.
• Variations in size and length of
the different parts of the
tracing may indicate a problem
in the part of the heart
associated with that particular
lead.

7. Devices: Holter monitor, Event monitor, 12 lead
electrocardiograph

8. Cardiac Stress Test

9. Normal waves

10. Feature Description Cause
P wave Impulse travels from Atrial depolarization
the SA node towards [contraction]
the AV node, and
spreads from the right
atrium to the left atrium
QRS complex From beginning of Q
wave to end of S wave
Ventricular
depolarization
T wave Relaxation of ventricles Ventricular
repolarization

11. Featur
es
Descirption Cause
PR
interval
Onset of P wave to onset of Q wave Atrial depolarization and
conduction through AV node
QT
interval
Onset of Q wave and end of T wave Electrical activity in ventricles [
depolarization and repolarization]
ST
segment
End Of S wave and onset of T wave Ventricles already depolarized

12. Indications:
To measure:
• Any damage to the heart
• Heart disease
• The effects of drugs[Digitalis] or
devices (pacemaker) used to control
the heart
• The size and position of the heart
chambers
• Heart rate
• Heart rhythm
Symptoms like:
• Cardiac murmurs
• Syncope or collapse
• Seizures
• Perceived cardiac
dysrhythmias
• Angina, palpitations,
breathlessness.

13. Abnormal ECG
Helpful in diagnosing:
• Arrhythmias
▫ Myocardial infarction
• Hypertrophy of heart chambers
• Coronary Artery Disease
• Congenital heart disease
• Cardiac Ischemia
• Stable and Unstable Angina
• Infective endocarditis
• Valvular heart disease.
▫ Mitral regurgitation
Mitral stenosis
▫ Mitral valve prolapse
▫ Aortic stenosis
▫ Aortic insufficiency
▫ Pulmonary valve stenosis
▫ Tricuspid regurgitation
Pericarditis
• Aortic dissection
• Coarctation of the aorta
• Cardiac failure
• Hypertensive heart disease
• Cardiomyopathy-hypertrophic
/alcoholic/dilated/idiopathic/
peripartum
• Cardiac Tamponade
• Atrial Myxoma
• Myocarditis
• Primary amyloidosis
• Stroke
• Myocardial Infarction

15. Echocardiography
• It is the diagnostic
procedure which uses
ultrasound to produce
2D 0r 3D image slices of
the heart muscle.
• It determines size, shape,
movement of valves and
heart chambers and flow
of blood through the
heart.

16. • A transducer containing crystals converts electrical
energy into an ultrasound beam.
• This beam is directed towards heart.
• The beam is reflected when it strikes the surface between
tissues of different densities.
• Reflected ultrasound/echo is converted to electrical energy
which constructs image based on
▫ Intensity of echos
▫ Time taken for echoes to return

17. Procedure
• Trans-thoracic echocardiogram(TTE):
▫ Echocardiogram of the heart through the thorax
external to the body.
▫ Non-invasive, painless, highly accurate and quick.

18. • Trans-esophageal echocardiogram(TEE)
▫ Echocardiogram of the heart through a catheter
placed in the esophagus which is attached to an
ultrasound transducer.

19. ▫ Invasive and must be performed
under supervision.
• Doppler echocardiography:
▫ Assessment of
Cardiac valve areas and function
Abnormal communications
between the left and right side of
the heart
Valvular regurgitation
Calculation of the cardiac output
and ejection fraction.
Heart valve defect

20. Indications
Assessment of
▫ Pericardial effusion
▫ Congenital Heart Defects
▫ Valvular heart diseases
▫ Myocardial Infarction
▫ High blood pressure/ Hypertensive heart disease
▫ Hypertrophic cardiomyopathy
▫ Intracardiac tumors and blood clots
▫ Aortic regurgitation/stenosis/aneurysm and dissection
▫ Calcification of valves
▫ Rheumatic mitral valve disease
▫ Cardiac failure
VSD

21. Advantages
• No known risks or
side effects.
• No radiation
involved.
• Both 2D and 3D
images can be viewed.

22. Cardiac Angiography
• Cardiac
Angiography or arteriography is
a medical imaging technique used to
visualize the lumen of the blood
vessels [ arteries, veins] and the heart
chambers.
• This is traditionally done by inserting
a catheter followed by injecting a
radio-opaque contrast agent[dye
which absorbs the x-rays] into the
blood vessel and imaging using a
camera and X-ray based techniques.

23. Procedure
• Cardiac Catheterization + X ray fluoroscopy
• Patient lies on his back on the X-ray table.
• A round cylinder or rectangular box that takes the pictures
during fluoroscopy will be moved under the patient during
the test.
• The place where the catheter is inserted is shaved and
cleaned.
• The doctor numbs the area with a local anesthetic.

24. • A needle is put into the femoral artery
/vein [near groin] or brachial
artery/vein[above elbow].
• A guide wire is put through the needle
into the blood vessel and the needle is
removed.
• The thin flexible catheter is placed over
the guide wire and moved into the
blood vessel.
• The catheter is then guided through
the blood vessels until it reaches the
area to be studied [aorta, coronary
arteries, left ventricle and atrium and
inferior vena cava , right atrium and
ventricles, pulmonary artery etc

25. • The fluoroscope is used to watch
the movement of the catheter in
the blood vessels.
• When the catheter is in place,
Iodine dye is injected through it.
• Several X-ray pictures are taken
one after another which may either
be still images, displayed on
a image intensifier or film, or
motion images stored digitally on
computer.
• Duration: 1-3 hrs
• The catheter is taken out after the
angiogram, and pressure is put on
the needle site for 10 to 15 minutes
to stop any bleeding.

26. Side effects:
▫ A tear in a blood vessel (which can cause
blockage or internal bleeding)
▫ Haemorrhages
▫ Aneurysms
▫ Stenosis
▫ Pattern of blood flow to a tumor.
▫ Abnormal position of blood vessels
▫ Abnormal branching of blood vessels
since birth
▫ Changes in the blood vessels of injured
heart.
• Presence or absence of atherosclerosis
within the walls of the arteries cannot be
clearly determined.

27. Intravascular Ultrasound
• Principle:
▫ Coronary catheterization+ Ultrasound
• Ultrasound transducer attached at the
tip of catheter guided through coronary
arteries from femoral/brachial artery.
• Proximal end of catheter attached to
ultrasound equipment
• Evaluates
▫ Coronary plaques—structure and
composition [not seen in angiography]
▫ Wall of blood vessel
▫ Connective tissue surrounding vessel

28. Nuclear Heart Scan
• A nuclear heart scan is a type of medical test where a safe, radioactive
material called a tracer is injected through a vein into the bloodstream.
• The tracer travels to the heart and releases energy, which special cameras
outside of the body detect to create pictures of different parts of the heart.
• Using computer, the images are made to appear structure of heart.

29. Procedure
Pretest
• The radioactive tracer is injected into the
bloodstream through the intravenous line.
• ECG are attached to the body to check the
heart's electrical activity during the test.
• An exercise stress test maybe done as a part of
nuclear heart scan
• If Patient is unable to exercise, medicine is used to
make the heart beat faster. This is called a chemical
stress test.

30. • Before the exercise or the chemical stress test stops, the
tracer is again injected through the IV line.
• The patient then lies very still on a table.
• The nuclear heart scan camera, called a gamma
camera, which is put in several positions around the
body.
• The computer collects the pictures of the heart nearby
or in another room.
• Two sets of pictures is taken. One is taken right after
exercise /chemical stress test and the other is taken after
a period of rest.
• Each set of pictures takes about 15 to 30 minutes.

32. Types
Two main types:
• Single positron emission
computed tomography
(SPECT)
• Cardiac positron emission
tomography (PET)

33. Uses
Detects :
• The flow of blood throughout the heart
muscle --myocardial perfusion
scanning.
• To look for damaged heart muscle due
to a previous heart attack, injury,
infection, or medicine---myocardial
viability testing.
• Pumping action of heart to the body--
ventricular function scanning.

34. Uses
Also evaluates:
▫ Coronary Artery Disease
▫ Heart valve diseases
▫ Past heart attack (myocardial infarction)
▫ Poor pumping function and heart failure
• Decides whether coronary angiography or cardiac
catheterization will be helpful.
• Decides whether angioplasty or coronary artery
bypass grafting (CABG) will be needed
• Monitors procedures or surgeries, such as CABG or a
heart transplant

35. Indications
Conditions under which the test may be
performed:
▫ Atrial septal defect
▫ cardiomyopathy
▫ Heart failure

36. Chest X ray
A chest X-ray uses a very small amount of radiation to produce an
image of the heart, lungs, and chest bones on film.

37. Procedure
• Patient has to remove all clothes and metallic jewelry from the waist
up and put on a hospital gown for the test.
• Patient then stands very still with his chest against the cassette that
contains the film.
• The X-ray machine sends a beam of ionizing radiation through an
X-ray tube.
• This energy passes through the chest and is absorbed on film to
create a picture.
• Bones and other dense areas show up as lighter shades of
gray
• Areas that don't absorb the radiation appear as dark gray.
• The entire test takes no more than 10 to 15 minutes.

38. Views
PA or postero-anterior view:
• Patient stands with his chest
against the container of the film
• The X-ray beam from the
machine comes from the
posterior/back and moves
through the chest to the
anterior/front.
Lateral view:
• Patient stands sideways in front
of the film with arms raised up.
• The X rays penetrate the chest
from the sides.

39. Uses
• Helps to diagnose heart diseases such as
▫ Cardiomegaly
▫ Aneurysm of aorta
▫ Acute Myocardial Infarction
▫ Heart failure
▫ Pericardial effusion with Tamponade
• Evaluates placement of devices (pacemakers,
defibrillators) or catheters, chest tubes placed
during hospitalization.

40. Cardiomegaly
Heart failure

41. Cardiac CT Scan (CCT)
• Computerised Tomography (CT) is a
medical imaging method employing
tomography, created by computer
processing.
• Tomography refers to imaging by sections or
sectioning, through the use of any kind of
penetrating wave [radiation].
• A three-dimensional image of the inside of
the heart is generated from a large series of
two-dimensional X-ray picture taken around a
single axis of rotation.
• In simpler terms, it is an imaging method that
uses x-rays to create cross-sectional pictures of
the heart.

42. Procedure
• The patient will be asked to lie on a
narrow table that slides into the center of
the CT scanner.
• Once he is inside the scanner, the
machine's x-ray beam rotates around him.
• A computer creates separate images of the
body area, called slices.
• Three-dimensional models of the body
area can be created by stacking the slices
together.
• Sometimes an iodine-based dye (contrast
dye) is injected intravenously during the
scan. The contrast dye travels through the
blood vessels, which helps highlight them
on the x-ray pictures.

43. • These images can be stored/ viewed on a
monitor, or printed on film.
• Patient must be still during the exam, because
movement causes blurred images.

44. Uses:
Helps in evaluating:
• Calcium buildup in the walls of
the coronary arteries-
coronary calcium scan
• Coronary Artery Disease
• Problems with heart function
and heart valves.
• Aneurysm and Dissection of
Aorta
• Atrial Fibrillation
• Pericardial Disease
• Wall motion and Ejection
fraction
• Cardiac masses and post-
operative abnormalities
• Congenital Heart Diseases

45. Indications:
If Patient is Asymptomatic
• Family history of coronary artery disease
• Persistent high triglyceride levels
• Other high risk factors such as smoking, diabetes,
etc.
• ECG abnormalities
• Abnormalities on a routine stress test
• Moderate to severe hypertension

46. Indications
If Patient is Symptomatic :
• Atypical chest pain (right side,
shoulder tip, etc.)
• Suspected dilated cardiomyopathy
• Coronary arteries disease and
aneurysms
Other:
• Post-bypass: assessing the status of
bypass grafts.
• Post-stent: for assessing in-stent
lumen.
• Tumors and cardiac neoplasms

47. Cardiac Magnetic Resonance Imaging
• Cardiovascular magnetic
resonance imaging (CMR) /
cardiac MRI, 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.
• One exam produces dozens or
sometimes hundreds of images which
can be combined to produce 3D models.
• The images can be stored on a
computer or printed on film.

48. Principle
• The single proton of the nucleus of a hydrogen atom vibrates ,
or "resonates," when exposed to bursts of 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 in the body.
• 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 (coronary artery disease) or
that has been damaged (heart attack).

49. Procedure
• Patient is asked to wear a hospital gown or clothing without
metal items or ornaments
• Patient will lie on a narrow table, which slides into a large
tunnel-shaped scanner.
• Sometimes a dye is usually injected before the test
intravenously in the hand or forearm to see images more
clearly
• During the MRI, the person who operates the machine will
watch you from another room.
• An intercom in the room allows patient to speak to the
monitoring person at any time.
• The test most often lasts 30-60 minutes, but may take longer.

50. Closed MRI
Open MRI

51. Uses
• Helps in visualising
▫ Heart muscle scar or fat without using a contrast agent
▫ Heart function
▫ Infarct imaging using contrast
▫ Perfusion defects
▫ Congenital Heart Defects
▫ Aortic Dissection
▫ Cardiac tumor
▫ Cardiomyopathies
▫ Thrombus
▫ Pericarditis
▫ Stenosis of valves

52. ▫ Assessing
Volume of blood flow and
Ejection fraction
Damage caused by Heart
attack
Heart Failure
Coronary Artery Disease
▫ Distinguishing between
"stable
atherosclerotic plaques and
"vulnerable" plaques.
▫ Visualising blood vessels and
the flow of blood.

53. Advantages
• Safe, non-invasive test
• MRI uses radio waves, without ionizing radiation or X
rays
• Unlike CT does not carry any risk of causing cancer.
• The images generated remarkably complete, detailed
and precise
• MRI has the potential of replacing other cardiac tests
like:
▫ Echocardiogram,
▫ Thallium scan
▫ Diagnostic cardiac catheterization.