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1. Cardiac Diagnostics
2017
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2. Types of Tests
 Electrocardiogram (ECG)
 Holter Monitor
 Loop Recorder
 Graded Stress Test (GXT) ECG with Treadmill
 Stress Cardiolite
 Resting Echocardiogram – Transthoracic (TTE), Transesophageal (TEE)
 MUGA
 Stress Echocardiogram- Echo after Treadmill, or after Dobutamine
infusion
 Myocardial Perfusion Imaging: Cardiolite after exercise, or after
Persantine infusion, Thallium Viability
 Cardiac CT
 Cardiac MRI
 EP
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3. Electrocardiogram (ECG)
• A 12-Lead ECG shows 12 different views of the heart and
provides a complete picture of electrical activity
• Assists in identifying pathologic conditions
• The 12-Lead ECH must be assessed alongside other
clinical evidence
• Correlate the 12- Lead ECG with patient history, physical
assessment, lab results, medications
• See ECG PowerPoint for more information!
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4. Holter Monitor
• Ambulatory electrocardiography that allows recording of heart
activity when patient is following a normal routine at home
• It can record intermittent arrhythmias
• Patient wears a small tape recorder connected to bipolar
electrodes on their chest. The patient also keeps a diary of
daily activities and symptoms.
• Usually ordered upon discharge, patient wears it for 24-48
hours
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5. • The implantable loop recorder (ILR) is a subcutaneous
monitoring device for the detection of cardiac arrhythmias
• ILRs are most commonly utilized in the evaluation of
palpitations or syncope of undetermined etiology, particularly
when symptoms are infrequent (eg, less than once per month)
and/or other ambulatory monitoring has been unrevealing or
inconclusive
• These devices, which are typically implanted in the left
pectoral region and are MRI-conditional, store events when
the device is activated automatically according to
programmed criteria or triggered by the patient.
• Used for months-years
• (Ref: uptodate)
Implantable Loop Recorder

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8. GXT
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• GXT is a test that combines exercise with ECG and BP monitoring
• It increases myocardial demand via exercise to assess the ability of
the Coronary arteries to increase blood flow to meet the demand
(identifies the presence and extent of CAD)
• Assess prognosis and functional capacity
• Evaluate therapy effectiveness
• Risk stratify patients post MI
• Determine exercise capacity
(Moser & Reigel, 2008).

9. Graded Stress Test (GXT) ECG
with Treadmill
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10. GXT Prep
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11. GXT End Points
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12. Persantine Cardiolite (P-card)
• Myocardial perfusion imaging utilizes an intravenously
administered radiopharmaceutical imaging agent Technetium
sestamibi, otherwise known as MIBI, (trade name Cardiolite),
to image the distribution of blood in the myocardium.
• This test includes the administration of the drug dipyridamole
(trade name Persantine) to induce pharmacological
vasodilation and an increase in heart rate. This maximizes the
blood flow to the myocardium and simulates exercise
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13. Indications for P-Card
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• Candidates for Pharmacological Stress Testing (unable to use
treadmill):
• Orthopedic (hips & knees)
• Poor patient motivation to exercise
• Pts. on Beta-blockers
• Amputations
• LBBB
• Pacemaker Patients
• Paraplegics

14. P-Card Prep
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15. P-Card
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• Inpatients will come to department with IV of D5W @ 20-50 mL/hr. All
IV set-ups must have a 3-way stop cock and IV pump
• Heparin will not be stopped to administer dipyridamole or radionuclide.
Separate IV access is required
 Infuse Persantine over 5min
 Exercise Pt. for 4min via treadmill or “bag squeeze”
 Inject MIBI at 2min, continue exercise for 2 min more
 Nuclear med for the injection (rest portion of the exam). Patient then goes
directly to RACE for the cardio portion of the exam.This means that the patient is
off monitor for approx. 3 hours.
 LBBB or Pacemaker pts  Persantine and No Exercise (have them exercise
their feet, legs and arms to circulate the dipyridamole and the MIBI )

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17. Echocardiogram types
• TTE
• TEE
• Stress Echo
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18. Transthoracic Echo (TTE)
• Used to examine the size, shape and motion of cardiac
structures
• A transducer is placed on the chest (on an area without
bone/lung). The transducer directs sound waves toward the
heart which reflect these waves
• The transducer receives the echos and converts them to
electrical activity to be displayed on a screen for recording
• Safe, painless, reliable, can be frequently repeated, can be
done at the beside
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19. TTE Prep
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• No Prep
• Can be done portably if patient unstable

20. TTE Results
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21. TEE
• In transesophageal echocardiography, ultrasonography is
combined with endoscopy to allow a better view of heart
structures
• Patients are given procedural sedation and a transducer is
attached to the end of a gastroscope and inserted into the
esophagus (allows for images of the posterior of the heart).
• Produces high quality images of the thoracic aorta
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22. TEE Indications
• Evaluate valve disease or repairs
• Diagnose and assess:
• Thoracic/aortic disorders
• Endocarditis/ vegetations
• Intracardiac thrombi (usually done pre cardioversion)
• Tumors
• Congenital heart disease
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23. TEE Prep
• Complete checklist (if going for cardioversion must complete
cardioversion checklist as well)
• NPO at midnight
• Saline Lock of IV running (if ordered)
• Usually completed in the cath lab by the procedure nurse
• On return, no food or drink until gag reflex returns
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24. MUGA
• Radionuclide ventriculography (RVG, RNV) or radionuclide
angiography (RNA) is often referred to as a MUGA (multiple-
gated acquisition) scan. It is a type of nuclear imaging test.
This scan shows how well your heart is pumping.
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25. Stress Echo
• TTE with exercise (treadmill)
• Baseline echo completed first
• Treadmill test at prescribed rate, after reaching peak exercise
heart rate (220-age) the exam is stopped and the patient is
allowed to rest and a repeat ECG and BP are completed
• Same end points as GXT
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26. Stress Dobutamine Echo
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• The same as a stress echo except is dobutamine is infused to
simulate exercise.
• Used for patients unable to tolerate excercise.

27. Stress Dobutamine Echo
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29. CT Coronary Angiography
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• A minimally invasive way to determine imaging of the
coronary artery lumen and thus CAD characteristics by
using x-ray techniques to produce multiple images of the
body.

30. CT Coronary Angiography
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31. Cardiac MRI
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• MRI allows for 3 dimensional images of the cardiac structures
• Show tissue characteristics without lung or bone interference
• Contraindications: internal surgical clips, pacemaker/ICD, gold
fillings, other metal objects in his/her body.
• May need to obtain order for metoprolol if HR>50 bpm and
patient is not on a BB or CCB
• Patients need to remove all jewellery
• Require a 20 gauge IV in the left ACF

32. MRI Checklist
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33. Thallium Scanning
 Used for myocardial viability assessment
 Determines ischemia vs. Scar
 No patient prep
 Inject pt with 201Thallium (radioactive substance) and
image
-10 min later, and at 4-6 hours
 MIBI may be used but 201Thallium better
• Area of damage shows up as a cold spots. The isotope
enters healthy myocardial tissue but doesn’t enter areas of
poor blood flow. Thus cold spots look dark and represent
reduced myocardial perfusion. 33

34. Electrophysiological Studies
(EP)
• This test is used to diagnose & find the underlying cause of
arrhythmias that have been refractory to conventional
treatment
• It involves passing 2-3 temporary electrode catheters into the
right side of the heart (usually positioned high in the right
atrium, bundle of his, apex if RV)
• These electrodes stimulate (pace the heart and record the
electrical conduction and reaction the pacing stimulus
• The results determine if patient needs ablation (SVT/AFIV) or a
permanent pacer or ICD (VT)
• KGH in-patients are flown to RJH in Victoria for this test (they
have to find their own way home) 34

35. • Please refer to “Test and Surgical Prep Quick reference” for
test prep – it is posted on the unit and is in your orientation
binder.
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36. Questions?
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37. References
• Moser, D.K. & Riegel, B. (2008). Cardiac nursing. St. Louis, MI: Saunders.
• Rawnsley, D. (2016). Cardiac Diagnostics. (PowerPoint Presentation).
TREADMILL STRESS TESTING: TERMINATION (2014 ). KGH guideline (site specific
document).
MYOCARDIAL PERFUSION STRESS TESTING: PHARMACOLOGICAL PERSANTINE
CARDIOLITE (2014). Interior Health Clinical Practice Standard and Procedure.
MYOCARDIAL PERFUSION STRESS TESTING : NON PHARMACOLOGICAL
(CARDIOLITE)(2014). Interior Health Clinical Practice Standard and Procedure.
STRESS ECHOCARDIOGRAM (2014). Interior Health Clinical Practice Standard and
Procedure.
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