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Colleen Walsh-Irwin, RN, MS, CCRN, ANP 8/28/2017

Cardiac Diagnostic Testing 1

Colleen Walsh-Irwin, DNP, RN, ANP-BC, AACCVeterans Affairs Medical Center

Northport, New York

At the end of this presentation, participants will be able to:

1- Describe when to order a regular stress test vs. a nuclear stress test

2- Understand the difference between ordering a MUGA vs. echocardiogram to evaluate EF

3- Discuss the risks/benefits of cardiac catheterization and when to refer a patient.

63 yo WM PMH HTN, DM, +smoker, +FH C/o chest pain on exertion BP 146/90 P 58 PE- WNL Meds- Atenolol, Metformin, Lisinopril EKG-NSR with abnormal ST segments



Regular Stress Testing

Single-Photon Emission Computed Tomography (SPECT) Myocardial Perfusion Imaging

Stress Echo

To rule out CAD

S/P MI

Evaluate exercise capacity

Standard exercise ECG testing is recommended for patients with an intermediate pretest probability of IHD who have an interpretable ECG and at least moderate physical functioning or no disabling co-morbidity.

Exercise stress with nuclear MPI or echocardiography is recommended for patients with an intermediate to high pretest probability of IHD who have an uninterpretable ECG and at least moderate physical functioning or no disabling co-morbidity

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STSguideline for the diagnosis and management of patients with stable ischemic heart disease



ECG abnormalities that reduce test accuracy ST segment abnormalities LV hypertrophy LBBB Ventricular-paced rhythm

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STSguideline for the diagnosis and management of patients with stable ischemic heart disease

Exercise preferred

Pharmacologic-◦ Dobutamine◦ Dipyridamole◦ Regadenoson◦ Adenosine

Indications◦ Same as exercise/ pharmacologic

Rest and stress images Exercise or pharmacologic



Indications◦Higher sensitivity and specificity than treadmill alone◦ Pharmacologic testing

Thallium or Technetium◦ Isotope injected intravenously

Cardiac magnetic resonance

Cardiac Computed Tomography

Positron Emission Tomography



Bruce Protocol Peak BP 210/96 Peak HR 133 7 METS 90% MPHR DP 28,000

2mm horizontal ST segment changes V3

2mm downsloping leads I, II, V6

4mm downsloping V4, V5



Cardiac catheterization revealed 3V CAD

Normal EF

S/P CABG X 3V

68 yo male PMH HTN, Afib seen in ETA for c/o SOB and LE edema

Medications: Digoxin, Diltiazem

Pt non-compliant

BP 176/100 P 118



+JVD

Lungs with rales 1/2 up b/l

S1 S2 irregular

2+ pitting edema of LE

Chem 7, CBC WNL

EKG - Afib 118 LVH

Chest x-ray- enlarged heart

EKG

Echocardiogram vs. MUGA

Stress Test- R/O CAD



Indications Can help to diagnose ◦ Infarct ◦ Ischemia◦ Left Ventricular Hypertrophy◦ Arrhythmias & Heart Blocks◦ Electrolyte Abnormalities◦ Drug Overdose

Indications◦ Assessment of LV function◦ Evaluation of valvular function◦ Assessment of ischemia/ infarct◦Diagnose Cardiomyopathy

◦Diagnose Pericardial Disease◦ Evaluation of tumors, thrombi, and vegetations◦ Evaluation of structural heart disease



Injection of radioactive substance

Evaluates LVEF

Can also measure RVEF

Pt admitted to tele Diuretics ACEI Beta- blockers D/C Diltiazem Anticoagulation

76 yo male PMH CAD S/P DES, DM, HTN

C/o increased DOE

BP 108/60 P 56

Echo reveals EF 30-40%



Angiographic examination of the coronary arteries

Estimation of systolic and diastolic function

Overall mortality risk is 0.14%

Patients with SIHD who have survived sudden cardiac death or potentially life-threatening ventricular arrhythmia should undergo coronary angiography to assess cardiac risk.

Patients with SIHD who develop symptoms and signs of heart failure should be evaluated to determine whether coronary angiography should be performed for risk.

Patients with SIHD whose clinical characteristics and results of noninvasive testing indicate a high likelihood of severe IHD and when the benefits are deemed to exceed risk.



Patent DES to RCA

New LAD lesion

S/P DES to LAD

Echo 2 months later reveals EF 50%

60 yo Female PMH COPD, OA, anxiety

C/o palpitations

Episodes occur ~ 3x/ month

Last up to an hour



Indications◦ Evaluate for arrhythmia◦ Evaluate treatment◦ Evaluate pacemaker therapy

Holter Monitoring Event Monitoring Loop Recorders Mobile Cardiac Telemetry (MCT) Internal Loop Recorder

Event Monitoring

Normal results

Refer for anti-anxiety treatment



Diagnosis of Aortic Dissection, Aneurysm and RupturePrior to cardioversion in patients who have suspected thrombus or are not candidates for anticoagulationEvaluation of conditions not adequately assessed on TTE

Ischemia

Viability

Sarcoid

High resolution three dimensional images

Diagnosis of diseases of the aorta and pericardium

Evaluation of congenital defects and masses



Potential applications include:◦ Evaluation of coronary anatomy and ventricular function◦ Assessment of viability◦ Evaluation of valve regurgitation

Contraindications:◦ Claustrophobia◦Non- MRI compatible devices

Coronary anomalies Congenital heart disease Right ventricular dysfunction Left ventricular dysfunction Prosthetic heart valves Anatomic mapping Pre-op cardiac surgery

Evaluate coronary anatomy For CT angiography, patient requirements may

include the ability to:◦ Hold still and follow breathing instructions.◦ Tolerate beta blockers.◦ Tolerate sublingual nitroglycerin.◦ Lift both arms above the shoulders.



Used to evaluate for neurocardiogenic syncope

BP & HR monitored supine and @ 80 degree tilt

Isuprel administered to induce effect

Assesses for susceptibility to ventricular arrhythmias

Excellent predictive value

A measure of repolarization beat-to-beat variability

Placement of electrode catheters Records intracardiac electrical signals Program electrical stimulation Evaluates atrial and ventricular

arrhythmias Ablation of atrial arrhythmias



Indications◦ Ventricular Tacchycardia◦ Long QT syndrome◦ AVNRT (AV nodal re-entrant tacchycardia)◦Wolf-Parkinson-White Syndrome

70 yo WF PMH HTN

C/o SOB with minimal exertion

C/o chest tightness assoc with SOB

Notes weight gain of 10 lbs over last week

◦ VS BP 148/78 P 90

◦ Mild JVD

◦ Lungs CTA

◦ S1 S2 nl -M/R/G

◦ 1+ pitting edema b/l LE



Cardiac enzymes negative

Regadenoson MPI◦ Normal perfusion◦ EF 62%◦ Normal gated analysis

Echocardiogram◦ LVH, normal LVEF

HR & BP control

Beta- blockers

Diuretics



50 yo WM PMH HTN, +FH BP controlled on Amlodipine Seen in ER for 1 complaint of CP after running

marathon Normal EKG R/O MI

Started on ASA 81mg Stress Test- Bruce Protocol◦ 12 minutes◦ Peak HR 150 Peak BP 180/88◦ MPHR 86% ◦ DP- 27,000◦ 13 METS



1mm horizontal ST segment depression◦ leads AVF, V5, V6

High exercise tolerance

Denies chest pain

54 yo WF PMH HTN c/o SOB

Medications: HCTZ, Lisinopril

Former smoker, + FH

PE significant for SEM



EKG

Stress test to rule out CAD

Echocardiogram◦ Assess LV function◦ Assess for valvular disease

Normal exercise stress test◦ 85% MPHR◦ DP- 26,200◦ 5 METS◦ No EKG changes

24 hour monitoring revealed minimal heart rate of 64 and maximum heart rate of 98

Occasional PVC’s numbering 10/hour

No diary was submitted



Mean aortic gradient of 40

Normal mitral, tricuspid and pulmonic valvedareas

Normal left ventricular function

Valve replacement

Taylor AJ, Cequeira M, Hodgson JM, Mark D, Min J, O’Gara P,Rubin GD. ACCF/SCCT/ACR/AHA/ASE/ASNC/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the Society for Cardiovascular Angiographyand Interventions, and the Society for Cardiovascular Magnetic Resonance. J AmColl Cardiol 2010

Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas P,Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB III, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2012;126:e354–e471.

Heller GV, Beanlands R, Merlino, DA, Travin, MI, Calnon DA, Dorbala, S, Hendel RC, Mann A , Bateman TM, Van Tosh A, ASNC Model Coverage Policy: Cardiac positron emission tomographic imaging. J Nucl Cardiol2013;20:916–47.

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