Investigative procedures in cardiac diseases.

1. INVESTIGATIVE PROCEDURES USED IN PATIENTS
WITH CARDIAC DISEASES
Submitted by – Iffat Parveen
Class – Bpt 4th year
Subject – Physiotherapy in Cardiopulmonary Conditions
Submitted to – Dr. Jamal Ali Moiz
Submitted on – 19-01-2020
Centre for physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia

2. • Cardiovascular diseases are diagnosed using an array of laboratory tests and imaging studies. The primary
part of diagnosis is medical and family histories of the patient, risk factors, physical examination and
coordination of these findings with the results from tests and procedures.
• Some of the common tests used to diagnose cardiovascular diseases include:
1. Blood test
2. Chest X-ray
3. ECG
4. Stress testing
5. ECHO
6. CT
7. MRI

3. Blood Tests - Haematology and clinical chemistry
• When the muscle has been damaged, as in a heart attack, body releases substances in blood. Blood tests can
measure the substances and show if, and how much of, heart muscle has been damaged.
• Blood tests are also done to measure the level of other substances in blood, such as blood fats (e.g. cholesterol
and triglycerides), vitamins and minerals. Blood sample is taken from a vein in your arm. A laboratory then
tests it and sends the results to the doctor, who will explain the results.
• As anaemia can unmask angina or exacerbate heart failure, a full blood count is useful and helps guide the
safe use of antiplatelet therapies and anticoagulants.
• Measurement of the erythrocyte sedimentation rate and serology are indicated if connective tissue disease is
suspected.
• Urea and electrolytes are measured and liver function tests performed prior to starting therapies that may
impact on renal function or cause hepatotoxicity.
• Blood glucose and a lipid profile help identify patients with diabetes mellitus and assess cardiovascular risk.
C-reactive protein (CRP) and other protein markers like Apolipoprotein A1 and B are used to detect
inflammation that may lead to heart diseases
• In patients with acute chest pain, cardiac troponin is measured to determine whether there is myocardial injury
or infarction. Cardiac Troponin-T is one of the markers of heart attack.

4. Chest X-Ray (CXR)
A chest x-ray aides in the differentiation between respiratory and
cardiac causes of dyspnoea. In those with heart failure, common
findings include cardiomegaly, interstitial oedema, pulmonary
oedema and pleural effusions. Evidence of surgery (eg CABG,
valve repair, ICD implantation) is also detected on CXR.
• This is a test that shows the shape and size of the heart lungs
and major blood vessels. This test is seldom used in diagnosis
of heart diseases as it does not provide added information over
echocardiography and other imaging studies.
• The maximum width of the heart divided by the maximum
width of the thorax on a posteroanterior chest X-ray (the
cardiothoracic ratio) should normally be <0.5. An increased
cardiothoracic ratio is common in valvular heart disease and
heart failure. In heart failure this is often accompanied by
distension of the upper lobe pulmonary veins, diffuse
shadowing within the lungs due to pulmonary oedema, and
Kerley B lines (horizontal, engorged lymphatics at the
periphery of the lower lobes).
• A widened mediastinum may indicate a thoracic aneurysm.
Fig: Chest X-ray in heart failure. This shows
cardiomegaly with patchy alveolar shadowing of
pulmonary oedema and Kerley B lines (engorged
lymphatics, arrow) at the periphery of both lungs.

5. Electrocardiography (ECG)
• This is a simple and a painless test that records the heart’s electrical activity. The patient is strapped to the
instrument with several patches or leads placed over his or her chest, wrists and ankles. A small portable
machine records the activities of the heart on a strip of graph paper.
• It is a simple test that identifies heart rate, conduction disturbances, myocardial ischaemia and possible
structural defects.ECG aids in the diagnosis of underlying causes of heart disease such as coronary artery
disease or arrhythmias.
• Tall p wave – p pulmonale(right atrial enlargement), Widened p wave – p mitrale( left atrial enlargement)
• PR interval – normal range (0.12-0.20 sec). If > 0.20 sec– first degree heart block, if < 0.12 sec – Wolfe
parckinson wide syndrome
• QT interval – normal range(0.36-0.44 sec).If prolonged,indicative of hypokalemia,hypocalcemia.
• QRS complex duration normal is < 0.11 sec. If > 0.11 sec – bundle branch block
• ST segment elevation or depression may represent ischaemia or infarction.
• Large voltage QRS complexes, downward sloping ST segments and T wave inversion may represent chamber
hypertrophy.
• Rhythm disturbances such as atrial arrhythmias, heart block and intraventricular septal conduction delays are
common in heart failure secondary to cardiac remodelling and may also exacerbate heart failure.

6. Ambulatory ECG monitoring
Continuous ECG recording over 24–48 hours can be used
to identify symptomatic or asymptomatic rhythm
disturbances in patients with palpitation or syncope. If
symptoms are less frequent, it may be necessary to use
patient-activated recorders that record the heart rhythm
only when the patient is symptomatic; the device is
activated by the patient
Fig: Electrocardiography (ECG). A 12-lead ECG
lead placement. B Normal PQRST complex.C
Acute anterior myocardial infarction. Note the ST
elevation in leads V1–V6 and aVL, and
‘reciprocal’ ST depression in leads II, III and aVF.
Fig:Printout from a 24-hour ambulatory electrocardiogram
recording, showing complete heart block. Arrows indicate
visible P waves. At times, these are masked by the QRS
complex or T wave.

7. Exercise Stress Testing
• For this test, the patient is made to work hard e.g. run on a
treadmill or exercise while the leads of ECG are placed over their
body. The test detects the effects of the exercise on the heart.
• Exercise stress testing may identify myocardial ischaemia,
haemodynamic/ electrical instability, or other exertion-related signs
or symptoms.
- Note: cardiac “stress” may also be induced using medications, when
an individual is unable to perform the exercise test as required.
• An exercise ECG is useful in the diagnosis and functional
assessment of patients with suspected coronary artery disease.
Down-sloping ST segment depression, particularly when it occurs
during minor exertion.
• In patients with athereosclerosis and coronary heart diseases
the arteries that are narrowed by plaques cannot supply
adequate blood to the heart muscles while it is beating faster.
This may lead to shortness of breath and chest pain. The ECG
pattern, arrhythmias etc. also show the possibility of a
coronary artery disease.

8. Echocardiography
• Another noninvasive method of evaluating the heart uses the physical properties of sound & uses sound
waves to create a moving picture of the heart. In this test, a probe is rolled over the chest and the machine
creates the image of the heart on the monitor. This provides information on the blood flow,
structure,functions, valves and chambers of the heart. Motion mode (M-mode) and two-dimensional (2-0)
images are highly reliable methods of evaluation.
- Stress echocardiography
• Stress echo assesses patients with suspected or known myocardial ischaemia. Exercise or medication is
used to stress the heart. Cardiac function is then evaluated using echocardiography pre and immediately
post stress. Myocardial response may be described as
• hypokinetic (decreased), dyskinetic (impaired) or akinetic (absent).
• This test is valuable in assessment of
viable/ischaemic myocardium in known
CVD being considered for revascularisation.

9. Radionuclide studies - Nuclear cardiac stress test
• This test is sometimes called an ‘exercise thallium scan’, a ‘dual isotope treadmill’ or an ‘exercise nuclear
scan’.
• A radioactive substance called a ‘tracer’(Technetium-99) is injected intravenously into bloodstream and
detected using a gamma camera to assess left ventricular function.
• The doctor uses this picture to see how much blood flows to your heart muscle and how well your heart
pumps blood when you are resting and doing physical activity. This test also helps the doctor to see if heart
muscle is damaged. Thallium and sestamibi are taken up by myocardial cells and indicate myocardial
perfusion at rest and exercise.

10. Computed Tomography
• A computed tomography (CT) scan of the chest provides a series of cross-sectional x-ray images. CT helps to
detect the calcium deposits or calcifications in the walls of the coronary arteries. These are early markers of
atherosclerosis and coronary heart disease. This is not a routine test in coronary heart disease
• CT scan has been found to be a useful first-line diagnostic tool in the evaluation of mediastinal disease,
including mediastinal masses, staging of mediastinal cancers, and identification of cysts (Lillington, 1987).
• It provides identification of anatomical abnormalities such as aneurysms or valve dysfunction, as well as
providing information about pulmonary vein anatomy. Cardiac CT also provides information about patency of
grafts following CABG.
• Computed tomography (CT), with its superior temporal resolution of the coronary arteries, is particularly
useful for investigating symptomatic patients at low to intermediate risk of coronary artery disease. It can
reduce the need for invasive investigation in patients with a low probability of occlusive coronary disease
who require valve surgery.

11. Coronary Angiography and Cardiac Catheterization
It is an invasive test, with a small but serious risk to the patient.
• Coronary angiography investigates integrity of coronary arteries by insertion of a catheter into the coronary
vasculature and the use of dye to produce the image. Coronary angiography detects blockages in the large
coronary arteries.The presence, location and extent of vessel narrowing is identified on the image and likely
sources of symptoms (“culprit lesions”) may be identified.
• The cardiac catheterization laboratory requires an x-ray generator tube and image intensifier/cine camera.
Data are stored using 35mm file (Reagan, Boxt, and Katz, 1994). The procedure for cardiac catheterization of
the left side of the heart requires the threading of a catheter, guided by fluoroscopy, through the femoral artery
or brachial artcry 10 thc aorta. Direct measurements of chamber pressures, blood flow, and oxygen saturation
can be obtained.
• A fine catheter is introduced under local anaesthetic via a peripheral artery (usually the radial or femoral) and
advanced to the heart under X-ray guidance. Although measurements of intracardiac pressures, and therefore
estimates of valvular and cardiac function, are possible, the primary application of this technique is imaging
of the coronary circulation using contrast

12. • Cardiac ventriculography is when dye is injected
into the ventricle and the entire chamber becomes
outlined. Several cardiac cycles are recorded on
cine. It provides valuable information about
global and segmental wall motion, valve motion,
and the presence of abnormal anatomy
(Grossman, 1986).
• When selective coronary arteriography is
performed, radiopaque contrast material is
injected into the left main or right coronary artery.
Cine recordings are made after the injection, and
injections are repeated until the entire coronary
tree is visualized.

13. Cardiac Magnetic Resonance Imaging
(MRI)
• Cardiac MRI uses high intensity magnetic fields and radiofrequency and a computer to produce images with
high resolution. This gives a 3D image of the moving as well as still pictures of the heart.
• The image provides accurate information about cardiac volumes, muscle mass, contractility, tissue scarring
and ejection fraction. Location and size of myocardial infarction can be described with precision and may
provide useful information regarding patency of bypass grafts.
• The image can identify regional wall motion abnormalities (RWMA) and wall dyssynchrony, valve sclerosis,
stenosis or regurgitation and provide information regarding myocardial fibrosis and assists in the diagnosis of
amyloid cardiomyopathy, myocarditis and cardiac sarcoid.
• Magnetic resonance imaging (MRI) provides superior
spatial resolution and is the imaging modality of choice
for investigating the aetiology of heart muscle diseases
(cardiomyopathy).

14. Thankyou

15. References:
• Donna Frownfelter & Elizabeth Dean Principle and practice of Cardiopulmonary Physical
Therapy, 3rd edition,
• J Alastair Innes, Anna R Dover, Karen Fairhurst Macleod’s Clinical examination 14th edition.
• Atul Luthra. ECG made easy, 4tg edition.Jaypee.
• www.heartonline.org.au/resources
• https://www.news-medical.net/health/Cardiovascular-Disease-Diagnosis.aspx
• https://www.heart.org/en/health-topics/heart-attack/diagnosing-a-heart-attack/noninvasive-tests-
and-procedures
• https://healthywa.wa.gov.au/Articles/A_E/Common-medical-tests-to-diagnose-heart-conditions