Ali shakhatreh MD

OUTLINE Introduction Types Non Invasive Invasive

INTRODUCTION Cardiac diseases are complex in nature New and advanced diagnostic tests and tools are constantly being introduced Involves tests used both inside and outside of body Comprehensive in nature Simplified the diagnosis of complex cardiac diseases

TYPES NON INVASIVE TESTS INVASIVE/INTERVENTIONAL TESTS

NON INVASIVE TESTS Blood Tests Carotid & Extremity Vascular Testing CAT Scans Echocardiography Electrocardiograms (EKG)

NON INVASIVE TESTS Holter and Event (Loop) Monitoring Exercise Stress Tests MRIs Nuclear Cardiology Tests

BLOOD TESTS Antistreptolysin-O test Arterial blood gases Blood fat profile Blood calcium test BNP blood test C-reactive protein test

BLOOD TESTS Complete blood count Electrolyte panel Erythrocyte sedimentation rate (ESR) Cardiac enzyme tests Glucose test.

BLOOD TESTS INR/prothrombin time tests Serum myoglobin test. Total serum protein

BLOOD TESTS BLOOD FAT PROFILE Cholesterol HDL (good cholesterol) LDL (bad cholesterol) Triglycerides

BLOOD TESTS BLOOD FAT PROFILE Cholesterol Desirable: Less than 200 mg/dL (5.18 mmol/L) Borderline high: mg/dL (5.18 to 6.18 mmol/L) High: 240 mg/dL (6.22 mmol/L) or higher

BLOOD TESTS BLOOD FAT PROFILE HDL Cholesterol Low risk: Less than 40 mg/dL (1.0 mmol/L) for men and less than 50 mg/dL (1.3 mmol/L) for women Average risk: mg/dL ( mmol/L) for men and between mg/dl ( mmol/L) for women Less than average risk: 60 mg/dL (1.55 mmol/L) or higher for both men and women

BLOOD TESTS BLOOD FAT PROFILE LDL Cholesterol Optimal: Less than 100 mg/dL (2.59 mmol/L) Near/above optimal: mg/dL ( mmol/L) Borderline high: mg/dL ( mmol/L) High: mg/dL ( mmol/L) Very high: Greater than 190 mg/dL (4.90 mmol/L)

BLOOD TESTS BLOOD FAT PROFILE Triglycerides Desirable: Less than 150 mg/dL (1.70 mmol/L) Borderline high: mg/dL( mmol/L) High: mg/dL ( mmol/L) Very high: Greater than 500 mg/dL (5.6 mmol/L)

BLOOD TESTS ELECTROLYTE PANEL Measure the amount of potassium, sodium, chloride and magnesium. In order to assess how well the heart and cardiovascular system are functioning.

BLOOD TESTS CARDIAC ENZYME TESTS Creatine kinase-MB Lactate dehydrogenase Troponin Myoglobin

TestsNormal valuesBegins risepeak Values return Total CK38–174 units/L for men 96–140 units/L for women within four to six hours 24 hours within three to four days. CK-MB:10–13 units/Lwithin three to four hours10–24 hourstwo to four days. Troponin T:less than0.4ng/mL.within two to four hours10–24 hourswithin five to 14 days Troponin Iless than 0.4 ng/mL.within two to four hours10–24 hours.within five to 14 days. Myoglobinless than 110 ng/mL.within one to two hoursfour to eight hours within 12–24 hours.

BLOOD TESTS INR/PROTHROMBIN TIME TESTS Measures how long it takes blood to clot. People taking anticoagulants like warfarin may have this test done regularly. Normal Value-12–15 seconds /0.8–1.2

CAROTID & EXTREMITY VASCULAR TESTING Carotid Ultrasound Lower Extremity Doppler Upper Extremity Doppler

Carotid Ultrasound

CAROTID & EXTREMITY VASCULAR TESTING Carotid Ultrasound Screening patients for carotid artery disease. Image and record the appearance of atherosclerotic plaque within the carotid arteries. Technology borrowed from submarine warfare The type and amount of blockage directly correlates with a patients risk of stroke. Determine which patients should, or should not undergo carotid endarterectomy.

Extremity Doppler

CAROTID & EXTREMITY VASCULAR TESTING Extremity Doppler Uses a different variety of ultrasound and ultrasound equipment Assess the amount of circulation in the arms or legs. Does not image the inside of vessels Determine how much of the circulation is affected by the blockages Help to decide which patients might require some type of procedure to restore adequate blood flow.

Extremity Doppler

CAT SCANS

An imaging technique that produces detailed, cross- sectional pictures ("slices") of internal organs and body parts. Uses multiple x-ray images, taken from different angles, to create three-dimensional images of body structures

CAT SCANS

Helical CT

CAT SCANS MultiSlice CT

CAT SCANS Generally advised not to eat or drink for four to six hours before the test,if the test requires an injection of a special dye or a sedative. A CAT scan may take less than one minute.

ECHOCARDIOGRAPHY A test that uses sound waves to create a moving picture of theheart. The picture is much more detailed than X- ray image and involves no radiation exposure..soundheartX- ray Provides information about the size and shape of the heart and how well the heart's chambers and valves are working Echocardiography can detect possible blood clots inside the heart, fluid buildup in the sac around the heart (pericardium), and problems with the aortaaorta

ECHOCARDIOGRAPHY TYPES Color-Flow Doppler Echocardiograms Stress Echocardiogram (exercise and pharmacological) Transesophageal Echocardiogram

ECHOCARDIOGRAPHY

ELECTROCARDIOGRAMS Painless test in which electrodes are put on the chest, arms and legs to monitor and record the heart’s electrical activity. The record appears as a graph or series of wave lines on a monitor or a long strip of paper. An EKG gives information about the heart’s rate and rhythm. Suggest the presence of a past or current heart attack.

ELECTROCARDIOGRAMS

EXERCISE TOLERANCE TEST An EKG done while you are exercising on a treadmill or stationary bicycle. Results are compared with those from when you’re at rest. To show how your heart reacts to exercise and exertion.

ELECTROCARDIOGRAMS TREADMILL

ELECTROCARDIOGRAMS EXERCISE TOLERANCE TEST Indications C oronary artery disease Gauge exercise capacity in heart failure patients To diagnose heart-related causes of symptoms such as chest pain, shortness of breath or lightheadedness. Predict risk of dangerous heart-related conditions such as a heart attack.

ELECTROCARDIOGRAMS EXERCISE TOLERANCE TEST Hooked up to equipment to monitor the heart. Walks slowly in place on a treadmill. Then the speed is increased for a faster pace and the treadmill is tilted to produce the effect of going up a small hill. Can stop the test at any time if needed. Afterwards will sit or lie down to have their heart and blood pressure checked

HOLTER MONITORING

Also known as continuous EKG or Ambulatory EKG monitoring. Wearing a small, portable, battery operated EKG recorder, called a Holter monitor. Monitors the electrical activity of an ambulatory patient’s heart while the person goes about daily activities Records continuous EKG information, for one to five days, on a tape. This recorded data is then analyzed by doctors.

HOLTER MONITORING

USES to detect abnormal heart rhythms (arrhythmias) as well as cardiac ischemia heart rhythms to detect transient and short cardiac arrhythmias that might not be present during in-office EKG monitoring. to monitor pacemakers or evaluate how well medications are working especially antiarrhythmics

Diagnose and treat premature ventricular contractions,or PVCs Design effective antiarrhythmic treatment programs, usually using various antiarrhythmic medications. Monitor existing pacemakers, diagnose a lack of oxygen-rich blood flowing to the heart (cardiac ischemia) and measuring variability in the heart rate. Commonly using in heart attack and cardio myopathy patients HOLTER MONITORING

MAGNETIC RESONANCE IMAGING

An imaging technique that produces detailed, accurate, cross-sectional pictures ("slices") of internal organs and body parts. But it doesn’t use ionizing radiation and has no known biological risks.

MAGNETIC RESONANCE IMAGING WHY MRI ? Non invasive Provides much greater contrast between the different soft tissues of the body than CTcontrast considered generally safer than contrast-enhanced x-ray tests in unstable patients.

MAGNETIC RESONANCE IMAGING

ANY USE IN CARDIOLOGY? Aortic disease Blockages within the coronary arteries (which supply oxygen-rich blood to the heart) A weakened heart muscle (cardiomyopathy)

MAGNETIC RESONANCE IMAGING ANY USE IN CARDIOLOGY? The severity of a heart attack Heart valve disease Disease in the arteries outside the heart, or peripheral arterial disease Heart defects present at birth (congenital)

MAGNETIC RESONANCE IMAGING ANY USE IN CARDIOLOGY? To assess patients’ progress after a heart attack To evaluate blockages in the coronary arteries (which could rupture and cause a heart attack) To detect an atrial myxoma (heart tumor)

NUCLEAR CARDIOLOGY TEST Produce images of the heart at work (during exercise) and at rest. Reveal problems in heart muscle and blood vessels, especially when the images of the heart at work and at rest are compared.

NUCLEAR CARDIOLOGY TEST TYPES Myocardial Perfusion Scans Pharmacologic Stress Tests Technetium-99m gated SPECT imaging Ventricular Function Studies Peripheral Vascular Studies Tilt table testing

NUCLEAR CARDIOLOGY TEST Myocardial Perfusion Scans

NUCLEAR CARDIOLOGY TEST MYOCARDIAL PERFUSION SCANS common test is done in two parts first part shows the heart during normal functioning, called "rest.“ During the second part, called "stress," the coronary arteries are dilated through exercise. You may walk on a treadmill or ride a stationary bicycle.

NUCLEAR CARDIOLOGY TEST MYOCARDIAL PERFUSION SCANS

NUCLEAR CARDIOLOGY TEST MYOCARDIAL PERFUSION SCANS USES Identify areas of the heart muscle that have an inadequate blood supply Quantify the extent of the heart muscle with a limited blood flow Provide information about the heart’s pumping function Ascertain the amount of scarring from a heart attack Evaluate the success of coronary bypass surgery or angioplasty

NUCLEAR CARDIOLOGY TEST PHARMACOLOGIC STRESS TESTS Thallium Dobutamine Persantine

INVASIVE TESTS Cardiac Catheterization Cardiac Biopsy Electrophysiology Studies (cardiac mapping Lower limb angiography

CARDIAC CATHETERIZATION

Test in which catheters (hollow tubes) are placed into the heart in order to evaluate the anatomy and function of the heart and surrounding blood vessel.

CARDIAC CATHETERIZATION Characteristics Performed in cardiac laboratory and special examination table. Local anesthesia is given,and catheter is inserted into blood vessels.

CARDIAC CATHETERIZATION SITES OF INSERTION Groin Inner bend of the elbow Wrist (palm side) Neck

CARDIAC CATHETERIZATION

GOALS Confirm the presence of a suspected heart ailment eg.stenosis,congenital heart failure etc. Quantify the severity of the disease and its effect on the heart Seek out the cause of a symptom such as shortness of breath or signs of cardiac insufficiency Make a patient assessment prior to heart surgery.

CARDIAC CATHETERIZATION RISKS Minor bleeding at the site of catheter insertion. Temporary heart rhythm disturbances caused by the catheter irritating the heart muscle. Temporary changes in the blood pressure. Cardiac tamponade, sudden blockage of a coronary artery. Stroke.

CARDIAC BIOPSY A cardiac biopsy is a procedure to take samples of heart tissue for evaluation. It is a outpatient procedure.

CARDIAC BIOPSY

INDICATIONS After a heart transplant, to check for rejection of your new heart. If a patient has a cardio-myopathy,it is done to find the cause

ELECTROPHYSIOLOGY The term “electrophysiology study” or “EP study” applies to any procedure that requires the insertion of an electrode catheter into the heart.

ELECTROPHYSIOLOGY Cardiac mapping

ELECTROPHYSIOLOGY Indications Heart rhythm disorders. Patient at a risk of sudden cardiac death. Evaluate the effectiveness of certain medications. Predict the risk of a future cardiac event. Assess the need for an implantable device (pacemakers) or treatment procedures

CONCLUSION Blood Chemistry and Physiology provides vital clues regarding actual or potential cardiac problems. Scans,USGs and MRIs are painless in nature. ECG provides clues regarding rhythm and pattern of heart beat. Cardiac Catherisation can be both diagnostic as well as therapeutic in nature. Electophysiology helps to predict the future events.

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