1. CARDIOVASCULAR MEDICINE
INVESTICATIONS OF CARDIOVASCULAR DISEASES BY
Dr. Arwa Mahmood Fuzi Al SarrafL
LECTURE 1

2. INVESTICATIONS OF CARDIOVASCULAR DISEASE OBJECTIVES
1- ECG
1. STANDARD 12 L. ECG (next 2 lectures)
2. EXERCISE STRESS ECG
3. AMBULATORY ECG – HOLTER MONITOUR
2- CARDIAC BIOMARKERS
3- CHEST X-RAY
4-ECHOCARDIOGRAPHY
1. 2 D. ECHO
2. DOPPLER ECHO
5- CT SCAN &MRI
6-CARDIAC CATHETARISATION
7-RADIONUCLIED IMAGING
1. BLOOD POOL IMAGING
2. MYOCARDIAL PERFUSION IMAGING

3. ELECTROCARDIOGRAPHY ECG
It is a test that record the electrical activity of the heart
from electrodes on the body surface

4. USES OF ECG It is used to diagnose the following conditions:
1- Cardiac arrhythmias & conduction defects
2- Myocardial hypertrophy
3- Ischemia &infarction
4- Pericardial diseases
5- Electrolytes imbalance
6- Certain drug toxicity.

5. EXERCISE (STRESS) ECG
A12 lead ECG is recorded during exercise on a treadmill or bicycle ergo meter.
INDICATIONS:
1. Confirm diagnosis of angina.
2. Evaluate stable angina.
3. Asses prognosis following MI
4. Assess outcome of coronary revascularization
5.Diagnosis of exercise induced arrhythmia

6. CONTRAINDICATION:
Unstable angina
Severe HF
Hypertension
Aortic stenosis
TEST IS POSITIVE IF:
Anginal pain occurs
BP falls or fails to rise
ST segment shift >1mm

7. AMBULATORY ECG (HOLTER MONITORING)
Continuous recording of one or more ECG leads obtained by attaching them to small portable tape recorder for 24 hrs or more.
It is useful for detecting transient episodes of arrhythmias or ischemia.

8. CARDIAC BIOMARKERS Brain natriuretic peptides:
Measured to asses myocardial dysfunction and ischemia.
Brain natriuretic peptides:
Secreted by the LV , it is elevated in LV systolic dysfunction to aid the diagnosis and asses prognosis and response to therapy in patients with heart failure.
Cardiac troponins ( I & T):
Structural cardiac muscle protiens that are released during myocyte damage and necrosis
It represent the corner stone of the diagnosis of acute MI

9. CHEST X - RAY CXR is useful for :
*Determine size & shape of the heart (cardiothoracic ratio <0,5).
*States of pulmonary blood vessels.
*Fields of the lungs.
Dilatation of individual cardiac chambers:
*Left atrial dilatation :prominence of laap, double cardiac shadow, widening of carina .
*Rt atrial enlargement projects from RT heart border to RT lower lung
*Lv dilatation: prominence of LT lower heart border, inc heart size
*Rv dilatation: inc heart size, displace apex upward.

12. ECHOCARDIOGRAPHY DEFINITION:
The application of US for imaging the heart.
HOW DOES IT WORK?
An echo sends high frequency sound waves into the chest to rebound from the heart walls & valves, the recorded waves form a moving image of the heart on TV screen.

13. ECHO TEGHNEQUES (1) STANDARED ECHO TECH. 2-D ECHO M-MODE DOPPLER
*Colour doppler (image flowing blood )
*Continuous wave doppler
*Pulsed wave doppler
(both measure velocity of flowing blood) .

16. ECHO TECH. (2) LATEST DEVELOPMENT IN ECHO TECH. Real time 3-d imaging
Tissue doppler
Other specialized tech.
STRESS ECHO
2-D echo after infusion of dobutamine, for pt unsuitable for stress ECG

17. METHODES OF PERFORMING ECHO
TRANSTHORASIC ECHO (TTE)
heart is imaged from outside through the chest wall ,the echo probe is placed on the chest wall of the subject & images are obtained, it is simple highly accurate test.
TRANSESOPHAGEAL ECHO (TEE)
insert specialized endoscope containing echo transducer into pt. esoph.& record pictures .it has advantage of giving better images ,b. the transducer is closer to the heart some of post. Structures of the heart are better imaged with TEE (aorta, pulm.art. ,valves & L.atrium).

18. WINDOWS &VIEWS OF TTE L.PARASTERNAL WINDOW APICAL WINDOW
Long axis view
Short axis view
APICAL WINDOW
4- chamber v.
5-chamber v.
Long axis &2- chamber v. of LV
SUBCOSTAL WINDOW
SUPRASTERNAL WINDOW
RT.PARASTERNAL WINDOW

19. INFORMATION GET BY ECHO
Heart chambers size
Chamber function
Valve motion &function
Intracardiac &extracardiac masses
Direction of blood flow, heamodynamic changes &pressure gradient in valve lesion.

20. CLINICAL APPLICATION OF ECHO
Assesment of valve function (native &prosthetic valves)
Asses LV function
Pericardial dis.(Pericarditis ,effusion&tamponade)
Endocarditis & myocarditis
IHD & complication of MI
Cardiac masses
Arrhythmias
Estimation of intracardiac& vascular pressures
Asses hypertensive cardiac changes (LVH)
Asses cardiac sources of embolism in CVA
Diagnoses of CHD

21. COMPUTED TOMOGRAPHIC IMAGING CT))
Useful for imaging the following:
Chambers of the heart.
The great vessels.
Pericardium
Surrounding structures.
Practical uses in:
Diagnosing aortic dissection.
The helical ct recently used for non invasive imaging of coronary art &coronary bypass grafts, coronary art. Calcification & calcified plagues.

24. MAGNATIC RESONANCE IMAGING (MRI)
Useful for imaging:
Aorta
Relationship of the great vessels to the cardiac chambers in cong. Hd
Detect infiltrative condition affecting the heart.
Quantify velocities across regugitant & stenotic valves
Regional wall motion
Asses myocardial viability.

26. CARDIAC CATHETERISATION
A specially designed catheter is inserted into a vein or artery & advanced into the heart under x-ray guidance.
Uses :
Measure intra cardiac pressures
Take blood samples from cardiac chambers.
Obtains angiogram by injecting contrast into chamber or blood vessel.

27. LEFT HEART CATH:
Cannulating the heart via the femoral, brachial or radial art.
Used to :
Asses coronary art disease and guide revascularization procedure
Asses mitral, aortic valve dis & aorta
Asses size and function of LV

28. Rt HEART CATH:
Used to:
Assess pulmonary art pressure
Detect intracardiac shunts
Measuring cardiac output
Measuring left atrial pressure (swan-ganz ) balloon cath to measure pulmonary wedge pressre

32. RADIONUCLIDE IMAGING
Study cardiac function non invasively by using Gamma Rays.
Types:
1- Blood pool imaging to assess vent function.
to calculate RT & LT ventricle ejection fraction.
2-Myocardial perfusion imaging.