diagnostic investigations in the remote context - nt cardiac care... · access to cardiac...

Diagnostic Investigations in the remote contextALEX KAETHNER – NT CARDIAC

Cardiac Care in the NT Annual Workshop

2017 is proudly supported by:

Diagnostic Investigations

▪ Overview

▪ Range of Investigations

▪ In clinic services

▪ Visiting services

Cardiac Care in the NT Annual Workshop - June 2017

Diagnostic InvestigationsSnapshot of tests

▪ Local tests

▪ ECG

▪ Holter monitor

▪ Exercise stress test

▪ Visiting tests

▪ Echocardiogram (TTE)

▪ Exercise Stress Echocardiogram

▪ Dobutamine Stress Echocardiogram

▪ 6 minute walk test

▪ Event monitor

▪ Pacemaker/device interrogation

▪ Trans-oesophageal Echocardiogram (TOE)*

▪ Loop Recorder Implantation*


Diagnostic InvestigationsECG

▪ Local tests▪ ECG


Diagnostic InvestigationsECG

▪ ACS (acute coronary syndromes) pathway

▪ ECGs performed in remote clinic sighted

by a Cardiologist within seconds/minutes


Diagnostic InvestigationsHolter monitor

▪ Holter monitor

▪ What is it?

▪ 24hr/48hr ECG monitoring

▪ Why perform it?

▪ Pts with palpitations, syncope etc

▪ Arrhythmias/pauses etc

▪ Who performs it?

▪ Monitors fitted in community clinic

by nursing staff (cardiac physiologists at NTC)

▪ Data transferred to NT Cardiac Darwin

for analysis and reporting.


Diagnostic InvestigationsHolter monitor

▪ Remote Holter monitor numbers

▪ 2012 – approx. 100 Holters fitted in remote locations

▪ 2016 – approx. 635 Holters fitted in remote locations

▪ Remote sites-▪ ASH, TCH, KDH, GDH, Angurugu, Gapuwiyak, Gunbalanya, Maningrida, Nguiu, Numbulwar, Ramingining,

Wadeye, Ali Curung, Borroloola, Elliott, Hermannsburg, Papunya, Yuendumu

▪ Lajamanu, Kalkarindji, Ngukurr, Galiwinku, Yirrkala, Milingimbi


Diagnostic InvestigationsExercise Stress Test

▪ Exercise Stress Test▪ What is it?

▪ Treadmill test for functional

capacity with continuous ECG

recording

▪ Why perform it?▪ Performed mainly for the

assessment of coronary artery disease

▪ Also dyspnoea, arrhythmias etc

(eg chronotropic incompetence)

▪ Who performs it?▪ Cardiac Tech, Nurse

▪ Cardiologist, or doctor with

cardiologist supervision.

▪ Performed at NTC, RDH, ASH, TCH, KDH, GDH


Diagnostic Investigations


Diagnostic InvestigationsEchocardiogram

▪ Echocardiogram

▪ What is it?

▪ Diagnostic ultrasound imaging of the heart

▪ Why perform it?

▪ Used to assess cardiac structure and function.

▪ Most commonly –

▪ ventricular size and function assessment (LV function)

▪ valvular assessment (valve leakage or blockages)


▪ Cardiac sonographers

▪ Cardiologists and other doctors do perform limited, focused scans with the correct basic training


Diagnostic Investigations Echocardiogram


1998/1999 2017

Diagnostic InvestigationsEchocardiogram


Diagnostic InvestigationsExercise Stress Echocardiogram (treadmill)

▪ What is it?

▪ Treadmill test for functional capacity with continuous ECG

recording, and echocardiographic images (pre and post treadmill)

▪ Why perform it?

▪ Performed mainly for the assessment of coronary artery disease

▪ Echo component allows for extra assessment of valves and pulmonary artery pressure

▪ Also dyspnoea, arrhythmias etc (eg chronotropic incompetence)


▪ Cardiac Sonographer, Cardiologist and generally a nurse.

▪ Performed at NTC, ASH, TCH, KDH, GDH


Diagnostic InvestigationsExercise Stress Echocardiogram (treadmill)


Diagnostic InvestigationsDobutamine Stress Echocardiogram

▪ What is it?

▪ Pharmaceutical (dobutamine) stress test with continuous ECG recording, andechocardiographic images (at intervals during dobutamine infusion)

▪ Why perform it?

▪ Performed mainly for the assessment of coronary artery disease

▪ Echo component allows for extra assessment of valves and pulmonary artery pressure

▪ Also dyspnoea, arrhythmias etc

(eg chronotropic incompetence)

▪ Performed when pt unable to walk on t/mill


▪ Cardiac Sonographer and Cardiologist

▪ Performed at NTC, ASH, TCH, KDH, GDH


Diagnostic InvestigationsDobutamine Stress Echocardiogram


Diagnostic InvestigationsSix minute walk test


▪ Six minute walk test

▪ What is it?▪ Simple functional test

▪ Patient walks for 6 minutes

on a measured course (eg 25m corridor)

▪ HR, BP, oxygen sats, resp. rate,

and levels of exertion measured

▪ Why perform it?▪ Functional capacity in cardiac

and respiratory disease

▪ Used to guide therapeutic treatment

(eg pulm. HT medications)

▪ Who performs it?▪ Cardiac Tech, Nurse or

other health worker

Diagnostic InvestigationsPacemaker/device Interrogation

▪ What is it?

▪ Interrogation of pacemaker, ICD (internal defibrillator) or loop recorder

▪ Why perform it?

▪ To check for any dangerous rhythms, pauses and battery life of device


▪ Appropriately trained Cardiac Tech, Cardiologist

▪ (Some devices now have function for home monitoring)


Diagnostic InvestigationsTrans-oesophageal Echocardiogram (TOE)

▪ What is it?

▪ Specialist cardiac ultrasound from inside the oesophagus, behind the heart.

▪ Why perform it?

▪ For better assessment of cardiac structures when TTE results unclear

▪ Common referrals for endocarditis, mitral valve assessment, LAA clot presence


▪ Cardiologist (sometimes ICU, anaesthetics)


Diagnostic InvestigationsEvent monitor

▪ What is it?

▪ A small device to capture ECG readings during symptomatic episodes

▪ Patient activates the recording as symptoms occur

▪ Worn for up to 4 weeks

▪ Why perform it?

▪ Used when symptoms not captured

on 24hr/48hr Holter monitor

▪ Fills the gap between Holter monitor and

loop recorder


▪ Cardiac tech/nurse to fit the device

▪ Patient downloads readings as events occur


Diagnostic InvestigationsLoop recorder Implantation

▪ What is it?

▪ A small device implanted under the skin

▪ Why perform it?

▪ To record suspected arrhythmias not detected on Holter/event monitoring


▪ Specialist Cardiologist


Summary

▪ Access to cardiac diagnostic services in the remote setting has come a long way

▪ Provision of diagnostic services is a collaboration between all parties involved (NTC, Community Clinics, Hospitals, CNCs, SONT, IT services, HF, RHD etc)


Thank you!

PRESENTATION AT THE CARDIAC CARE IN THE NT ANNUAL WORKSHOP

DARWIN, JUNE 2017

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