By: Dr. M.

Abdulwahhab

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ECG. Serum cardiac markers (SCM). Cardiac catheterization.

1. 2. 3. 4. 5. 6. 7.

Radiography. CT. US MRI. Nuclear imaging. Echocardiography. Angiography.

Angiography

ECG interpretation is not much difficult, it is very important tool of investigation; therefore spend a lot of time in ECG reading during posting in cardiology unit. If ECG interpretation is weak it will become difficult for a physician to deal with cardiac emergencies with accuracy.

This equipment is a battery powered cassette tape recorder which is for continuous recording of one or more ECG leads for 24 h. This technique is useful in detecting transient episodes of arrhythmia or ischemia which seldom 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. 2. 3. 4. 5. 6. 7.

Cardiac arrhythmias. Conduction defects. Myocardial ischemia. MI. Myocardial hypertrophy. Electrolyte imbalance. Toxicity of certain drugs.

Necrosis of myocytes loss of their membrane integrity diffusion of intracellular macromolecules into the cardiac interstitium & ultimately into the cardiac microvasculature & lymphatics. Eventually, these macromolecules are detectable in the peripheral circulation. The term currently used to collectively describe these macromolecules is serum cardiac 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 relation between its level & the extent of myocardial injury. III. Persists in the blood for a sufficient length of time. IV. Easy, inexpensive & rapidly measured.

1.

2. 3.

Confirm the Dx of acute MI when diagnosis by ECG is unclear (no STsegment elevation). Detection & risk assessment of pts with unstable angina. Providing prognostic information: as a noninvasive assessment of the likelihood that the pt has undergone successful reperfusion when thrombolytic therapy is administered.

CK is an enzyme presents in activity in cardiac, skeletal muscle & brain tissue. There are 3 CK isoenzymes:

1. 2. 3.

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

CK-BB (brain tissue) > 95% of total CK. CK-MB (myocardium mainly & skeletal muscles to a less extent) < 5% of total CK. CK-MM ( conc. in skeletal muscle & also found in the heart) not found.

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.

Initial rise

Peak

Back to N

CK-total

4-6 h

24-36 h

72 h

CK-MB

4-6 h

12-24 h

48 h

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 48 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 are measured.

It is the introduction of a catheter into the circulation.

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 to assess 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Identification of CAD & assessment of its extent, & coronary spasm & thrombosis. Lt ventricular dysfunction & ischemic MR. Angiography & angioplasty for ACS. To rule out ischemic cause of CM. To differentiate restrictive CM from constrictive CM. To assess extent & severity of valve disease (VHD). For assessment of Lt & Rt ventricular function. ASD. VSD. Performed before surgical correction of CHD. Measurements of cardiac output or lung pressures.

1. 2. 3. 4. 5.

Aortic Angiogram. Coronary Angiography. Coronary atherosclerosis. Congenital anomalies. 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 structures overlap one another & thus often at least two views (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

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 the heart is compared with the maximum transverse 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. 2. 3. 4.

Pericardium. Valves. Aorta. Myocardium.

It may indicate Pul. HTN by enlargement of hilar vessels, e.g. enlarged Rt lower lobe artery. Kerlys B lines & pleural effusion may be present in HF.

1. 2. 3.

Cardiac Dilatation. Pulmonary Vascular Changes. Imaging Signs of Pericardial Diseases.

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The C-T ratio. Left atrial (LA) enlargement. Left ventricular (LV) enlargement. Right ventricular (RV) enlargement. 4 chambers enlargement. Cardiomegaly.

The C-T ratio should be < 0.5, & the transverse cardiac diameter should be < 15.5 cm.

Prominence of LA appendage on the Lt 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 the heart PDA. Coarctation of the aorta. MI. AS AI.

Prominence of cardiac to the Rt of sternum, upward displacement of the apex of the heart, & CTR. Epstein anomaly. TOF. ASD. Congenital PS Hypertensive MS.

Increase heart size & displaces the apex upwards. Fallots Tetralogy.

Increase heart size & displaces the apex upwards. Fallots Tetralogy.

Projection of the Rt border of the heart into the Rt lower lung field.

Lt HF.
1. 2. 3. 4.

Rt HF.
1. 2. 3. 4. 5. 6. 7. 8.

IHD. Systemic HTN. M & A valve disease. Cardiomyopathies. Lt HF. Chronic lung disease. Pul. embolism or HTN. Tricuspid valve disease. Pul. Valve disease. Lt-to-Rt shunt (ASD or VSD). Mitral valve disease with pul. HTN. Isolated Rt ventricular cardiomyopathy.

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Interstitial edema. Alveolar edema. Acute HF.

Vascular redistribution in HF. Pul. HTN.

Vascular redistribution in HF. Pul. HTN.

Pul. HTN.

Prominent bulge on the Lt heart border below the aortic knuckle. Pul. HTN. Pul. artery stenosis. Hypertensive MS. PDA. ASD. LA enlargement. RV enlargement.

VSD with Eisenmengers syndrome. Pul. HTN.

Normal size of the heart.

1. 2. 3. 4.

Pericardial effusion. Extensive pericardial calcifications. Rib notching. Dextrocardia.

globular shadow.
DDx:
1.
2.
1. 2. 1. 2. 3.

Viral pericarditis.
Coxsakie B. Echovirus. Septicaemia. Pneumonia. Staph. aures. Histoplasmosis. Candida.

Bacterial pericarditis.

3. 4. 5. 6. 7.

Fungal pericarditis.
1. 2.

Post-MI pericarditis. Uraemic pericarditis. TB pericarditis. 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. 2. 3.

Aortic atherosclerosis. Coarctation of the aorta. CT Coronary Angiography.

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

Ultrasound-Introduction

It is a diagnostic technique which uses highfrequency sound waves to create an image of 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.

Ultrasound-Intravascular

The use of ultrasound inside a blood vessel to better visualize the interior of the vessel in order to detect problems inside the blood vessel.

MRI

It is a diagnostic technology that produce detailed images of organs & structures within the body. MRI has many growing applications particularly for imaging vascular lesions.

Nuclear Medicine-Introduction

It is a specialized area of radiology that uses very small amounts of radioactive substances to examine cardiac function & perfusion.

Nuclear Medicine-Thallium 201 scanning

Thallium 201 scanning when injected provides information regarding infarction & non-infarction myocardium.

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 the defects persist even at rest it means these are infracted areas. Scan charges are about 3000, high rates in private sector.

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 to

interpret. In pts to detect MI in whom exercise testing (ETT) is not 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.

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.

Nuclear Medicine-Gamma Camera

Nuclear Medicine-Planner Imaging

Nuclear Medicine-Myocardial Perfusion Imaging

Echocardiography-Uses
1. 2. 3. 4.

5. 6. 7. 8. 9. 10.
11.

Size of the chambers. Pumping function (Lt ventricular-ejection function). Regional wall motion abnormalities due to MI or ischemia. Complications of MI; papillary muscle dysfunction, MR, VSD, Lt ventricular aneurysm & thrombus. Valve Function & abnormalities; S & R. CoP. CHD. Ventricular hypertrophy. Blood clots or masses within the heart. Active infection of the heart valves. Abnormalities of pulmonary circulation. Detection of pericardial diseases.

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.

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 a stenosed aortic valve. There are 3 modes of Doppler echo;
1. Pulse-wave Doppler (PW). 2. Continuous-wave Doppler (CW). 3. Color Doppler.

Echocardiography-Technique

A good echo machine should have all 3 components:

1. Tow-dimensional real time echo. 2. M-Mod echo. 3. Doppler echo.

Echocardiography-Technique

Echocardiography-Illustration

Echocardiography-Transesophageal

In this technique an US probe, in the shape of 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 appendage in pts of MS & atrial fibrillation. 3. ASD not detected by transthoracic echo.

Echocardiography-Transesophageal

Echocardiography-Transesophageal

Echocardiography-Stress

It is done during exercise or just after the exercise, or after pharmacological stress by administration of dobutamine, adenosine or dipyridamol. Dobutamine stress test (DST) is now commonly performed to detect stress induced segmental wall motion abnormalities (an indicator of ischemia).

Echocardiography-Contrast

IV contrast agents or agitated saline are used IV to asses intramyocardial flow pattern. It is very helpful in detection & to see the direction of flow in shunts such as ASD, VSD (Lt to Rt or Rt to Lt).

Echocardiography-Dopplar-Uses
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Cardiac short-axis images. Cardiac long-axis images. Hypertrophic CM. ASD. VSD. Fallots Tetralogy. MS. MVP. MR. AR. Coarctation of the aorta. IE. Lt Atrial Myxoma.

Echocardiography-Cardiac ShortAxis Images

Echocardiography-Cardiac LongAxis Images

Echocardiography-Hypertrophic CM

Echocardiography-ASD

Echocardiography-VSD

Echocardiography-Fallots Tetralogy

Echocardiography-MS

Marked LA enlargement.

Echocardiography-MVP

Echocardiography-MR

Echocardiography-AR

Echocardiography-AR

Echocardiography-Coarctation of The Aorta

Echocardiography-IE

Echocardiography-Lt Atrial Myxoma

Angiography-Introduction

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

Angiography-Arteriogram

Angiography-Coronary Angiography

Coronary angiography is performed during cardiac 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 to completely examine coronary anatomy & resolve potential vessel overlap.

Angiography-Coronary Angiography

Clinical uses:
Detect & estimate the severity of coronary artery

stenosis, therefore revisualization can be performed with bypass Op or angioplasty.

Angiography-Coronary 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 is made confidently in majority of pts with noninvasive testing. 3. Stable angina pain not relieved by medical Tx. 4. Unstable angina high or moderate risk pts refractory to initial adequate medical Tx or recurrent symptoms after initial stabilization.

Angiography-Coronary Angiography
5. After angioplasty suspected abrupt closure or

6.
7. 8. 9.

subacute stent thrombosis after angioplasty or recurrent angina or high risk criteria on noninvasive testing within 9 m. of angioplasty & 12 m. of bypass Op. After MI as an alternative to thrombosis therapy within 12 h. of onset of symptoms. PeriOp evaluation before non-cardiac surgery in pts with suspected or known CAD. Before valve surgery to rule out CAD as the bypass grafting is possible in the same Op. HF pts with HF having angina or evidence of ischemia on noninvasive testing.

Angiography-Coronary Angiography-ANT View

Angiography-Coronary Angiography-LAO View

Angiography-Coronary Angiography-RAO View

Angiography-Coronary X-Ray

Therapeutic Radiology

Angioplasty. Pacemakers. Closure of cardiac defects.

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 inside the vessel.

Angioplasty -PCI-Balloon Insertion

Angioplasty-PCI-Stent Insertion

Angioplasty-PCI Insertion

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 so beautiful as that there is no need for the clinical exam behind it. This is, of course, a treacherous road to follow.