cardiology (investigations & imaging sings in cardiac diseas

8/22/2019 Cardiology (Investigations & Imaging Sings in Cardiac Diseas

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By: Dr. M. Abdulwahhab



1. ECG.

2. Serum cardiac markers (SCM).

3. Cardiac catheterization.



1. Radiography.

2. CT. 3. US4. MRI. 5. Nuclear imaging.6. Echocardiography.

7. Angiography.



Angiography



ECG interpretation is not much difficult, it is

very important tool of investigation;therefore spend a lot of time in ECG readingduring posting in cardiology unit.

If ECG interpretation is weak it will becomedifficult for a physician to deal with cardiac emergencies with accuracy.



This equipment is a battery powered cassettetape recorder which is for continuous recordingof one or more ECG leads for 24 h.

This technique is useful in detecting transient episodes of arrhythmia or ischemia whichseldom occur during the short time taken for routine 12-lead ECG recording.

Brief paroxysm of tachycardia, an occasional pause in rhythm or intermittent ST segment changes may be identified.



It is also an event recorder that is used to

record less frequent arrhythmias. Pt is provided with a pocket-sized device

that can record & store a short segment.



1. Cardiac arrhythmias.

2. Conduction defects. 3. Myocardial ischemia.4. MI. 5. Myocardial hypertrophy.6. Electrolyte imbalance. 7. Toxicity of certain drugs.



Necrosis of myocytes loss of their membrane integrity diffusion of intracellular macromolecules into thecardiac interstitium & ultimately into thecardiac microvasculature & lymphatics.

Eventually, these macromolecules are

detectable in the peripheral circulation. The term currently used to collectively

describe these macromolecules is serumcardiac markers (SCM).



The characteristics of an ideal cardiac marker for myocardial infarction ( MI ):I. Present early , in conc. in the myocardium &

is absent in non-myocardial tissue & serum(sensitive & specific).II. Rapidly released into the blood at the time of

myocardial injury, there should be a relationbetween its level & the extent of myocardial

injury.III. Persists in the blood for a sufficient length of

time.IV. Easy, inexpensive & rapidly measured.



1. Confirm the Dx of acute MI whendiagnosis by ECG is unclear (no ST-segment elevation).

2. Detection & risk assessment of pts withunstable angina. 3. Providing prognostic information: as a

noninvasive assessment of the likelihood

that the pt has undergone successful reperfusion when thrombolytic therapy isadministered.



CK is an enzyme presents in activity in cardiac,skeletal muscle & brain tissue.

There are 3 CK isoenzymes:

1. CK-BB (brain tissue) > 95% of total CK.2. CK-MB (myocardium mainly & skeletal muscles to a

less extent) < 5% of total CK. 3. CK-MM ( conc. in skeletal muscle & also found in

the heart) not found.

Exercise, muscles trauma total Ck (not specific). Because of poor specificity of total CK for myocardium, measurement of CK-MB is muchbetter for diagnosis of AMI.



Total CK & CK-MB in AMI;

Although CK-MB is more specific for myocardium than

total Ck, however its level may in non cardiac

conditions.

levels of CK-MB may be found in patient with skeletal muscle injury, poliomyelitis, & RF.

To confirm greater cardiac specificity to CK-MB, a Ck-MB

ratio is calculated to differentiate cardiac from skeletal injury; CK-MB ratio = CK-MB x 100 / Total CK.

A ratio > 5% suggest cardiac damage.

However false values are still present.



Back to N Peak Initial rise

72 h 24-36 h 4-6 h CK-total

48 h 12-24 h 4-6 h CK-MB



CK-MB isoforms:

CK-MB exists in two isoforms; Ck-MB2 ( tissue form )which is converted to Ck-MB1 ( serum form ) by

carboxypeptidase. Normal CkMb2 / CkMB1 ratio is approximately 1.

An early of CK-MB2 / CK-MB1 ratio (> 1.5) has been found within 2-4 h after coronary occlusion & peaks in 4-

8 h & returns to normal within 24 h. Ck-MB isoforms are very sensitive early indicator of AMI

(within 2-4 h) compared with the conventional assays for CK-MB isoenzyme.



Disadvantages:

▪ CK-MB isoforms with acute skeletal muscle injury & after

extreme physical exercise.▪ Also false +ve results have been found in pulmonary edema.

▪ Rapid electrophoretic assays (for CK-MB isoforms) are not performed routinely in many labs.

▪ Thus their assay is technically difficult & can not be accepted as

emergency test in all laboratories.



During which a catheter, is inserted through

an artery or vein to diagnose cardiac or vascular abnormalities I is the "gold standard" against which all

other coronary diagnostic tests aremeasured.



It is the introduction of a catheter into thecirculation. Rt heart is catheterized by introducing the catheter into

peripheral vein (usually Rt femoral vein) & advancing it to the Rt atrium & Rt ventricle into the pulmonary artery;measured the pressure directly.

Lt heart catheterization is performed via the Rt femoral artery, catheter enters the Lt ventricle where pressures

are obtained, dye is injected for ventriculography toassess Lt ventricular function. Coronary angiography is performed by using especially

designed Rt & Lt coronary artery catheter.



During cardiac catheterization blood samples are

withdrawn to measure conc. of ischemic

metabolites (e.g. lactate) & oxygen to quantify

intracardiac shunts. This invasive procedure by using catheter Measurement of pressure in different chambers of heart. Blood oxygen content or saturation in different

chambers. Measurement of CoP.



1. Identification of CAD & assessment of its extent, &coronary spasm & thrombosis.

2. Lt ventricular dysfunction & ischemic MR. 3. Angiography & angioplasty for ACS.4. To rule out ischemic cause of CM.

5. To differentiate restrictive CM from constrictiveCM.

6. To assess extent & severity of valve disease (VHD). 7. For assessment of Lt & Rt ventricular function.8. ASD.9. VSD.10. Performed before surgical correction of CHD.11. Measurements of cardiac output or lung pressures.



1. Aortic Angiogram.

2. Coronary Angiography. 3. Coronary atherosclerosis.4. Congenital anomalies. 5. DSA of the bifurcation of aorta.



PDA



DSA = Digital

Subtraction Angiography.



X-Ray-Introduction

The heart absorbs much of the radiation, so it looks light on the film.

The main limitation of X-ray is that it is a

projection technique, so body structuresoverlap one another & thus often at least twoviews (e.g. PA & lat.) are required.

The standard is to obtain PA (post.-ant. view). Frequently, a "lat." film is obtained. This may help pickup, confirm, or rule out an

abnormality suspected in the other view.



X-Ray-Technique



It can be reliably assessed only from PA view of CXR, because in PA view cardiac shadow is larger.

The maximum transverse diameter of theheart is compared with the maximumtransverse diameter of the chest measured

from inside of the ribs; cardiothoracic ratio(CTR), it should be < 50%. Cardiomegaly & pericardial effusion

CTR.



CXR may show calcification of:

1. Pericardium.

2. Valves.

3. Aorta.4. Myocardium.



It may indicate Pul. HTN by enlargement of

hilar vessels, e.g. enlarged Rt lower lobeartery. Kerly’s B lines & pleural effusion may be

present in HF.



1. Cardiac Dilatation.

2. Pulmonary Vascular Changes.

3. Imaging Signs of Pericardial Diseases.



1. The C-T ratio.

2. Left atrial (LA) enlargement. 3. Left ventricular (LV) enlargement.4. Right ventricular (RV) enlargement. 5. 4 chambers enlargement.6. Cardiomegaly.



The C-T ratio should

be < 0.5, & thetransverse cardiac diameter should be< 15.5 cm.



Prominence of LAappendage on theLt heart border,

double of artial shadow to the Rt of sternum (double Rt

heart border). Lung congestion. Congestive MS. MI.



Prominence of left lower heart border, the convexity of the Lt heart border, CTR &enlargement of theheart

PDA. Coarctation of the

aorta. MI. AS AI.



Prominence of cardiac to the Rt of sternum, upward

displacement of theapex of the heart, & CTR.

Epstein anomaly.

TOF. ASD. Congenital PS Hypertensive MS.



Increase heart size

& displaces theapex upwards. Fallot’s Tetralogy.



Projection of the Rt border of the heart into

the Rt lower lung field.



Lt HF.1. IHD.2. Systemic HTN. 3. M & A valve disease.4. Cardiomyopathies.

Rt HF.1. Lt HF.2. Chronic lung disease. 3. Pul. embolism or HTN.4. Tricuspid valve disease. 5. Pul. Valve disease.

6. Lt-to-Rt shunt (ASD or VSD). 7. Mitral valve disease with pul.

HTN.8. Isolated Rt ventricular

cardiomyopathy.



1. Interstitial edema.

2. Alveolar edema.

3. Acute HF.



Vascular

redistribution in HF. Pul. HTN.



Pul. HTN.



Prominent bulge onthe Lt heart border below the aortic

knuckle. Pul. HTN. Pul. artery stenosis. Hypertensive MS. PDA. ASD. LA enlargement. RV enlargement.



VSD with

Eisenmenger’ssyndrome.

Pul. HTN.



Normal size of the

heart.



1. Pericardial effusion.

2. Extensive pericardial calcifications.

3. Rib notching.

4. Dextrocardia.



globular shadow. DDx:

1. Viral pericarditis.1. Coxsakie B.2. Echovirus.

2. Bacterial pericarditis.1. Septicaemia.2. Pneumonia.

3. Staph. aures.

3. Fungal pericarditis.1. Histoplasmosis.2. Candida.

4. Post-MI pericarditis. 5. Uraemic pericarditis.

6. TB pericarditis.

7. Malignant pericarditis.



TB pericarditis. Pericardial

constriction.



Coarctation of the

aorta.



CT-Introduction

It shows detailed images of any part . Ultrafast CT . This allows many different views & provides

much greater detail. Computed tomography is particularly useful

for imaging aorta.



CT-Technique



CT-Uses

1. Aortic atherosclerosis.

2. Coarctation of the aorta.

3. CT Coronary Angiography.



CTA revealed Lt ant. descendingartery (LAD)stenosis & normal Rt coronary artery.

l d d i



Ultrasound-Introduction

It is a diagnostic technique which uses high- frequency sound waves to create an imageof the internal organs.

It is one of the main advantages of acoustic medical imaging is its minimal disturbance

of normal tissue physiology. This allows ready use & repeated reuse of

this technique.

Ul d I l



Ultrasound-Intravascular

The use of ultrasound inside ablood vessel tobetter visualize theinterior of thevessel in order to

detect problemsinside the blood vessel.

MRI



MRI

It is a diagnostic technology that producedetailed images of organs & structureswithin the body.

MRI has many growing applications particularly for imaging vascular lesions.

N l M di i I d i



Nuclear Medicine-Introduction

It is a specialized area of radiology that usesvery small amounts of radioactivesubstances to examine cardiac function & perfusion.

Nuclear Medicine-Thallium 201



Nuclear Medicine Thallium 201scanning

Thallium 201 scanning when injected providesinformation regarding infarction & non-infarctionmyocardium. Fixed defect in perfusion MI while reversible defect

myocardial ischemia. Initially the radioisotope is injected during exercise,

scanning defects indicate zones of ischemia or hypoperfusion if myocardium is viable.

Now the scan is performed later during rest, filling of

these defects indicates a reversible ischemia & if thedefects persist even at rest it means these are infracted areas.

Scan charges are about 3000, high rates in private sector.

Nuclear Medicine-Technetium-99-



Nuclear Medicine Technetium 99labeled sestamibi

It can be used instead of thallium if viability of myocardium is to be determined.

Indications:

When resting ECG makes an exercise ECG difficult tointerpret.

In pts to detect MI in whom exercise testing (ETT) isnot diagnostic (+ve test in asymptomatic pts), or is

not allowed (e.g. in BBB), Lt ventricular hypertrophy or pt taking digitalis.

To localize the region of ischemia.

To distinguish ischemic from infracted myocardium.

N l M di i M S



Nuclear Medicine-Muga Scan

= Blood pool scanning. It is injected IV that mixes with circulating

blood.

The gamma camera detects the amount of isotope-emitting blood in the heart at different phases of cardiac cycle (systole &diastole).

Clinical uses: To detect ventricular aneurysm. Lt & Rt ventricular ejection fraction (ventricular

function) can be measured accurately.

N l M di i G C



Nuclear Medicine-Gamma Camera

N l M di i Pl I i



Nuclear Medicine-Planner Imaging

Nuclear Medicine-Myocardial



yPerfusion Imaging

E h di h U



Echocardiography-Uses

1. Size of the chambers.2. Pumping function (Lt ventricular-ejection function).

3. Regional wall motion abnormalities due to MI or ischemia.

4. Complications of MI; papillary muscle dysfunction, MR,VSD, Lt ventricular aneurysm & thrombus. 5. Valve Function & abnormalities; S & R.6. CoP.

7. CHD.8. Ventricular hypertrophy.9. Blood clots or masses within the heart.10. Active infection of the heart valves.

Abnormalities of pulmonary circulation.11. Detection of pericardial diseases.

E h di h T



Echocardiography-Types

1. Tow-dimensional real time echo; It is particularly valuable for detecting wall

motion abnormality, intracradiac masses, &

endocardiac vegetation. It is also helpful in detection of CHD.

2. M-Mod echo; It is particularly useful for the measurement of

sizes of chambers of heart, calculation of ejection fraction & accurate timing of cardiac events such as opening & closing of valves.

E h di h T



Echocardiography-Types

3. Doppler echo;

It is valuable in detecting abnormal directions

of blood flow, e.g. AR or MR, & estimation of

pressure gradient, e.g. gradient across astenosed aortic valve.

There are 3 modes of Doppler echo;

1. Pulse-wave Doppler (PW).2. Continuous-wave Doppler (CW).

3. Color Doppler.

Echocardiography Technique



Echocardiography-Technique

A good echo machine should have all 3components:

1. Tow-dimensional real time echo.

2. M-Mod echo.

3. Doppler echo.

Echocardiography Technique



Echocardiography-Technique

Echocardiography Illustration



Echocardiography-Illustration

Echocardiography Transesophageal



Echocardiography-Transesophageal

In this technique an US probe, in the shapeof endoscope is passed into the esophagus& positioned behind the heart.

It is very helpful in detecting:

1. Very small vegetations not detected on

transthoracic echo.

2. Thrombus in the Lt atrium or atrial appendagein pts of MS & atrial fibrillation.

3. ASD not detected by transthoracic echo.





Echocardiography Stress



Echocardiography-Stress

It is done during exercise or just after theexercise, or after pharmacological stress by administration of dobutamine, adenosineor dipyridamol.

Dobutamine stress test (DST) is now commonly performed to detect stress

induced segmental wall motionabnormalities (an indicator of ischemia).

Echocardiography Contrast



Echocardiography-Contrast

IV contrast agents or agitated saline areused IV to asses intramyocardial flow pattern.

It is very helpful in detection & to see thedirection of flow in shunts such as ASD,VSD (Lt to Rt or Rt to Lt).

Echocardiography Dopplar Uses



1. Cardiac short-axis images.2. Cardiac long-axis images.

3. Hypertrophic CM.4. ASD.

5. VSD.6. Fallot’s Tetralogy. 7. MS.8. MVP.9. MR.

10. AR.11. Coarctation of the aorta.12. IE.13. Lt Atrial Myxoma.

Echocardiography-Dopplar-Uses

Echocardiography-Cardiac Short-



Axis Images

Echocardiography-Cardiac Long-



1

2 3

Axis Images

Echocardiography-Hypertrophic CM



Echocardiography-Hypertrophic CM

Echocardiography-ASD



Echocardiography-ASD

Echocardiography-VSD



Echocardiography-VSD

Echocardiography-Fallot’s



Tetralogy

Echocardiography-MS



Echocardiography-MS

Marked LAenlargement.

Echocardiography-MVP



Echocardiography-MVP

Echocardiography-MR



Echocardiography-MR

Echocardiography-AR



Echocardiography AR

Echocardiography-AR



Echocardiography AR

Echocardiography-Coarctation of



The Aorta

Echocardiography-IE



Echocardiography IE

Echocardiography-Lt Atrial



Myxoma

Angiography-Introduction



Angiography Introduction

It is an X-ray of the arteries & veins to detect blockage or narrowing of the vessels.

Angiography-Arteriogram



Angiography Arteriogram

Angiography-Coronaryi h



Angiography

Coronary angiography is performed duringcardiac catheterization.

It is the visualization by X-ray contrast material (dye) injected into the arteries.

It is performed by introduction of catheter from femoral artery, which is guided under radiological control to the Lt & Rt coronary arteries & Lt ventricles.

It requires multiple separate views tocompletely examine coronary anatomy &resolve potential vessel overlap.

Angiography-CoronaryA i h



Angiography

Clinical uses:

Detect & estimate the severity of coronary artery

stenosis, therefore revisualization can be

performed with bypass Op or angioplasty.




Angiography

Indications:1. Asymptomatic pt evidence of high risk on

noninvasive testing (ECG, ETT, Thallium scan,Echo).

2. Nonspecific or atypical chest pain Dx of IHD ismade confidently in majority of pts withnoninvasive testing.

3. Stable angina pain not relieved by medical Tx.

4. Unstable angina high or moderate risk ptsrefractory to initial adequate medical Tx or recurrent symptoms after initial stabilization.




Angiography

5. After angioplasty suspected abrupt closure or subacute stent thrombosis after angioplasty or recurrent angina or high risk criteria onnoninvasive testing within 9 m. of angioplasty & 12

m. of bypass Op.6. After MI as an alternative to thrombosistherapy within 12 h. of onset of symptoms.

7. PeriOp evaluation before non-cardiac surgery in pts with suspected or known CAD.

8. Before valve surgery to rule out CAD as thebypass grafting is possible in the same Op.

9. HF pts with HF having angina or evidence of ischemia on noninvasive testing.

Angiography-CoronaryA i h ANT Vi



Angiography-ANT View

Angiography-CoronaryA i h LAO Vi



Angiography-LAO View

Angiography-CoronaryA i h RAO Vi



Angiography-RAO View

Angiography-Coronary X-Ray



g g p y y y

Therapeutic Radiology



Angioplasty.

Pacemakers.

Closure of cardiac defects.

p gy

Angioplasty



The use of a small balloon on the tip of a

catheter inserted into a blood vessel to open

up an area of blockage or pot a stint insidethe vessel.

g p y

Angioplasty -PCI-Balloon Insertion



g p y

Angioplasty-PCI-Stent Insertion



g p y

Angioplasty-PCI Insertion



g p y

Pacemaker



Closure of Cardiac Defects



Closure of PDA.

Remember



You must know & think critically of how these imaging tests may fit into clinical

practice.

Think also in terms of more global

socioeconomic issues.

Take Care



There is a sense that the images are sobeautiful as that there is no need for the

clinical exam behind it.

This is, of course, a treacherous road to

follow.

cardiology (investigations & imaging sings in cardiac diseas

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