Various tests to assess to assess Cardiac function.

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
➢ 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)
➢ 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:

4. 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).
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.
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.

5. • 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.
• 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.
Sl. No. COMPONENT REFERENCE VALUE
1. Cardiac Troponins (cTn)
Troponin I (cTnI) >/= 0.3 ng/ml
Troponin T (cTnT) >/= 0.1 ng/ml

6. 2. Creatine Kinase (CK), total
Males 55-170 IU/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)
12-38U/L
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.
POSTEROANTERIOR VIEW LATERAL VIEW
➢ Lateral view: The X rays penetrate the chest from the sides while the patient is
standing sideways with his arms raised up.
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

7. • T- waves: represent ventricular repolarization
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.
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

8. 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)
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.

9. STANDARD 12 LEAD ECG
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.
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:

10. 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. Transoesophageal Echocardiography (TEE): It is performed with the transducer placed in
the oesophagus. It is invasive procedure and must be performed under supervision.
TTE 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.

11. 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.
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.

12. 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.
➢ 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.
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.

13. 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.
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).
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=146078550