Chest pain: Now what? 60 50 70 Diagnostic Testing: What to ...€¦ · Renal insufficiency Diabetic...

Chest pain: Now what?

Kristine A. Scordo, PhD, RN, ACNP-BC

KAScordo © For student use only page 1

Diagnostic Testing: What to Order When

Kristine A. Scordo, PhD, RN, ACNP-BC, FAANP

Professor and Director, Adult-Gerontology Acute Care Nurse Practitioner Program

ACNP TriHealth and Kettering Hospitals

1

Disclosure

Kristine Scordo, PhD, RN, ACNP has no financial relationships with commercial interests to disclose

Any unlabeled/unapproved uses of drugs or products referenced will be disclosed

2

A patient presents to us with a chief complaint

Why do we order tests?

What tests to order? Based on what?

What do we hope to achieve as we get the result of the test?

What if there are multiple tests that are related to this complaint?

What if we are considering 6 or 7 possible diagnoses that might explain this chief complaint?

3

0

10

20

30

40

50

60

70

Chief

Complaint

History Physical

Exam

Diagnostic

Tests

Reduction in the number of diagnostic hypotheses

as clinical information is gained.

4

Diagnostic Testing: Shooting at a Target

5

How valuable is the test to my clinical decision making?

Of what value is the test?

Remember-who ever orders the test….owns the test!




How Accurate is the Diagnostic Test?

sensitivity

a sensitive test rarely yields a false-

negative result

likelihood that diseased pt has a + test

specificity

likelihood that a healthy pt has a - test

test with high specificity has few false-positive results

7

True-positives

False-Negatives

False-positives

True-negatives

Test Result Present Absent

Disease

Positive

Negative

8

More Factoids to Consider

9

Appropriate Use Criteria

appropriate uncertain inappropriate

https://www.graphicstock.com/images

10

ACU Defined

“An appropriate diagnostic or therapeutic procedure is one in which the expected clinical benefit exceeds the risks of the procedure by a sufficiently wide margin such that the procedure is generally considered acceptable or reasonable care.”

11

Ratings

Rarely appropriate

1,2,3

May be appropriate

4,5,6

Appropriate care

7,8,9

Committee determine ratings based on clinical guidelines and review of current evidence.

12




J Am Soc Echocardiogr 2011;24:229-67

www.acc.org

13 © KAScordo 2015 14

AND most of all know your friendly radiologists—they are

incredible resources to help you determine which test is best

for the clinical situation

Special thanks to Dr. Weinberg, Radiologist TriHealth Cincinnati OH for providing many of the pictures for this lecture.

© KAScordo 2015 15

Types of Diagnostic Imaging Tests

https://www.graphicstock.com/

16

X-rays

CT scans

MRI/MRA scans

Nuclear medicine scans

Ultrasound

PET/CT

17

50+/- Shades of Gray

Plain film radiography remains as the 1st order diagnostic imaging modality

18




Brief word on X-rays

X-ray Shoe Fitter, Pedoscope and Foot-o-Scope

19

1920-1970….BANNED

20

Plain films

Pt acutely ill looking may need emergent surgery abdominal series can be safer than CT

Patient stable, no suspicion of bowel obstruction, vomiting with abd pain in setting of previous abd surgery and/or little diarrhea

21

Large bowel obstruction

© KAScordo 2015 22

Chest X-ray

Inexpensive, noninvasive modality

One PA and lateral exam = 5 mrem

Average annual US radiation = 360 mrem

One chest X-ray = cosmic radiation received in

10 weeks at seal level; 5 weeks in Denver

10 hours of air flight

23

Free air under diaphragm; most likely due to perforation ofabdominal viscus---needs surgery----refer!

24




Diagnosis?25 26

A broken central venous catheter has migrated into the right lower lobe pulmonary artery

27

AND….this is the X-ray you should not see in the ED…..

28

29

CT, CTA, MRI, MRA, US etc. FACTOIDS




Which diagnostic tests are radiation free?

Ultrasound

MRI

CT

31

Comparative radiation doses from diagnostic imaging*

Clinical Advisor Dec 2013

Diagnostic Study Average dose in millisieverts(mSv)

Equivalent dose in CXR

Cervical spine series 0.3 15

Mammogram 0.6 30

KUB 0.6 30

Lumbar spine series 2.0 100

Ventilation/perfusion scan 2.0 100

IVP 3.0 150

Bone scan 4.4 220

Technetium sestamibi scan 6-12 300-600

Cardiac Catheterization 5-50 250-2,500

Barium enema 8 400

CT-abd & pelvis 15-20 750-1,000

Thallium scan 12-24 600-1,200

Gallium scan 40 2,000

32

Computerized Tomography (CT)

©KAScordo33

Why a CT?

provides good detail about bony structures and some detail of soft tissues

answers the question ‘What does it look like?’

best suited for viewing bone injuries, diagnosing lung and chest problems, and detecting cancers

34

My patient is loaded with tattoos and metal body piercings?

Can he get a CT scan?

http://www.shutterstock.com 35

Additional Factoids

Patients with metal implants can get CT scan.

A person who is very large (e.g. over 450 lb) may not fit into the opening of a conventional CT scanner or may be over the weight limit for the moving table.

36




Contrast vs Non-contrast

IV contrast improves tissue contrast (distinguishes one organ from the next) and greatly aids in identifying masses or inflammatory/infectious processes

IV contrast usually administered during imaging of brain, particularly for evaluation of suspected intracranial masses or infection

37

IV Contrast:NOT Indicated or Necessary

Acute head trauma

Acute neurological deficits (acute strove/CVA)

Suspected intracranial hemorrhage

Hypertensive bleed

Acute subdural/epidural hematoma

Evaluation of uncomplicated sinusitis

38

Important test to check prior to IV contrast is…..

Creatinine

Contrast Induced Nephropathy

39

Patient-related Risk FactorsAgeRenal insufficiency

Diabetic nephropathy

Volume depletion

Hypotension

Low cardiac output/HF

Renal transplant

Hypoalbuminemia (




Normal head CT without contrast

Head CT with contrast(brain abscess)

https://www.youtube.com/watch?v=vAIVaeGd2aI43

Head CT

Pre and post contrast imaging of the brain usually preformed for

Suspected intracranial/neck mass or tumor

Suspected intracranial infection

Increased intracranial pressure

Detection or evaluation of calcifications

Evaluation of salivary stones

Foreign body

44

Chest CT

View lung apices to adrenal glands

IV contrast opacifies pulmonary vessels-distinguished them from lymphadenopathy or pulmonary masses

IV contrast aids in detection of aortic dissections, penetrating thoracic ulcers & other vascular processes

45

Chest CT without contrastBronchiectasis

Chest CT with contrastRight PE

46

Chest CT-contrast

Pre-contrast images helpful in evaluation of pulmonary nodule (w/wo)

Esophageal tear

Lung mass, pleural effusion, cough, hemoptysis, infection, emphysema

47

CT abdomen

Can order oral contrast in setting of elevated creatinine

Contrast not needed when evaluating for ureteral calculi or retroperitoneal hematoma.

For all other purposes IV/oral contrast is strongly desirable

Always do CT abdomen and pelvis together48

https://www.youtube.com/watch?v=vAIVaeGd2aI




CT Abdomen:PO and IV contrast

Acute appendicitis-NPO rectal contrast

Diverticulitis

Abscess, FUO

Difficulty swallowing, possible esophagus mass

Abdominal pain, bloating, fluid build up, lower extremity swelling

Adrenal mass or cyst-PO contrast and w/wo IV contrast

GI bleed IV contrast only

49

CT scan in a patient with sub diaphragmatic abscesspost splenectomy

50

High Resolution CT of the Chest (HRCT)*

Detect diffuse lung disease

Guide type and location of lung biopsy

Investigate hemoptysis

Assess distribution of emphysema in pts considered for lung volume reduction

Evaluate disease reversibility (fibrosing lung disease)

* No need for contrast51

High-resolution Multislice CT Lung Scanning

52

HRCT used to diagnosis…

Pulmonary fibrosisSarcoidosisLymphangitic/hematogenous metastasesSubacute hypersensitivity pneumonitisSilicosisEmphysemaBronchiectasisKaposi's sarcomaPCPAsbestosisHemoptysis

53

Interesting Factoid re CT…..

54




ACC 201555

Electron-Beam (Ultrafast)

Computerized Tomography

EBCT

©KAScordo 201456

CAC (Coronary Calcium Coronary) Screening

screen high-risk asymptomatic people for the development of CHD and cardiac events

to determine the progression or reversal of disease, as well as for the diagnosis of obstructive CAD in symptomatic patients.

a focused steam of electrons allows for visualization of coronary calcium and enables the non-invasive detection and localization of coronary plaques.

57Braunwald Heart Diseases 2012

58

ACC Appropriate Use Criteria

Inappropriate in asymptomatic, low-risk adults

appropriate in the low-risk subset with a family history of premature CHD (male first-degree relative,




Limitations

Approximately 50% to 70% of all plaques are calcified.

Coronary EBCT is unable to detect noncalcified and lipid-laden “vulnerable” plaque. Since calcium develops in an age-related manner, scores must be adjusted for age as well as for sex.

61

Magnetic Resonance Imaging (MRI)

62

MRI/MRA Ordering Guidelines

http://indigestible.nightwares.com/comics/ 63

Which of the following poses the strongest contraindication to cardiac MRI?

A. Hip arthroplasty

B. Mechanical aortic prosthesis

C. Cerebral aneurysm clip

D. Sternal wires from previous valve surgery

64

Which of the following poses the strongest contraindication to cardiac MRI?A. Hip arthroplasty

B. Mechanical aortic prosthesis

C. Cerebral aneurysm clip

D. Sternal wires from previous valve surgery

65

The Food and Drug Administration's definitions of "MR safe" and "MR compatible" have been revised to "MR safe," "MR conditional," and "MR unsafe."

"MR safe" indicates items that are nonmetallic, nonconducting, and nonmagnetic. No ferromagnetic materials.

"MR conditional" is an item with no known hazards in a specified MR environment with specific conditions.

"MR unsafe" is an item known to pose hazards in all MR environments.

66




The main dangers for implanted devices in patients undergoing MRI include device movement from the magnetic field or heating from radiofrequency energy.

Most contemporary orthopedic implants appear to be safe with MRI. The same is true for all prosthetic heart valves and the sternal wires that usually accompany them. While aneurysm clips can be either ferromagnetic or non-ferromagnetic, the potential for serious injury is significant enough that their presence serves as a strong contraindication.

67

Absolute contraindications for MRI

Cardiac pacemaker ?? Reports in non-pacemaker dependent pts

Implanted cardiac defibrillator

Aneurysm clips without safety documentation titanium (commercially pure or the titanium alloy types) OK

Carotid artery vascular clips

Neurostimulators

Implanted insulin/drug infusion pump

Cochlear/otologic implants

Bone stimulators

68

MRI

Metal Results (in) Injury

Some mascara and eye shadows contain ferrous materials…..tattoos may contain ferrous material—rare

issues with burns

http://www.mrisafety.com/TheList_search.asp

Safety list found at:

69

What “objects” can you take into a magnetic field?

Anything that doesn’t contain iron.

Brass

Aluminum

Plastic

70

71

MRI Contrast Agents in Renal Insufficiency

relatively newly described disease, Nephrogenic Systemic Fibrosis (NSF), has been linked with exposure to gadolinium contrast in patients with moderate to severe kidney failure

although very rare, be aware of this possible complication before considering MRI for patients with kidney disease

72




MRI

Procedure of choice to identify primary tumors, evaluate complications of infections, inflammatory conditions

Evaluate degenerative disk disease

Musculoskeletal MRI, ie., evaluation meniscal tears, rotator cuff tear, new symptoms following surgery

73

IV gadolinium contrast agent usually given EXCEPT for

Ischemic disease (TIA) and infarction

Cerebral

Basilar/posterior fossa

Headache

74

Claustrophobic Patients:ExplanationRelaxation techniquesMay need xanax 1 hour prior to procedure

75

MRI of the head w/o contrast

76

MRI with contrast

©KAScordo 2015 77

MRI with gadolinium-glioblastoma multiforme. Non-contrast (not seen) revealed presence of some hemorrhage.

78




How can you tell the difference between an MRI image and a CT scan image?

Most images will have at least one bone included.

Look at the CORTICAL bone which is the thick 'shell' of bone that makes up the outer surface of the bone.

If the cortical bone is WHITE, you are looking at a CT scan. If the cortical bone is BLACK, you are looking at an MRI scan.

79

Example of CT scan (transverse pelvis)

80

Example of MRI scan (transverse pelvis)

81

Another MRI example (sagittal knee)

82

©KAScordo 2015

83

MRI Lumbar Spine

84




85

MRI

Diskitis Diskitis with OM 86

MRI

Liver (with contrast) Hepatic lesions

Evaluation of cirrhosis

Pancreas/biliary MRI (noncontrast) Pancreatic tumors

Complications of pancreatitis

Renal (with contrast) Detect renal tumors

87

Breast MRI

Both breasts scanned at same time

Carcinoma (with contrast) Strong FH breast carcinoma and/or difficult

mammogram

Known breast CA, assess extent of disease and assess contralateral breast

Implants (without contrast) Implant rupture

88

MRI Breast

89

MR Angiography (MRA)

minimally invasive

examine blood vessels

uses one of three imaging technologies

x-rays with catheters

computed tomography (CT)

magnetic resonance imaging (MRI)

may be performed with or without contrast material.

90




Gaemparli et al 2007. A: Perfusion polar maps of SPECT-MPI at stress and

rest show largely reversible anteroapical perfusion defect (arrowhead) B: 3D

volume rendered CA images show Coronary vessel tree with stenosis of mid-

LAD and proximal stenosis of first diagonal branch (DA1) C: Fused 3D

SPECT/CT images are able to identify DA1 stenosis at functionally relevant

lesions D:Findings were confirmed by invasive CA. 91

CT Angiography (CTA) Abdomen

AAA for endograft, r/o leaks

Pancreatic mass for resection

Evaluate SMA (superior mesenteric artery)

Splenic artery

Gastric artery

Renal artery

Portal vein

Hepatic artery

92

Abdominal Aorta on CT Angiography with 3-D Reconstruction

93

CT Pulmonary Angiography (CTPA)

Sensitivity ~90%, specificity ~90% in dx of acute PE

Rapid bolus IV injection of iodinated contrast media

Diagnosis of acute PE on contrast-enhanced

spiral CT based on presence of partial or complete filling defects within the contrast-enhanced lumen of the pulmonary arteries

94

Pulmonary MRA (two slices)

95

Renal insufficiency or hx of anaphylactoid reaction to contrast should have V/Q scan in place of CTPA

Need normal chest x-ray for V/Q scan

COPD and HF predictive value less for V/Q scan

96




Cardiovascular MRI/MRA (with contrast)

Myocardial ischemic-chronic

Infarct

Valvular evaluation

97

Cerebral/Vascular MRA (noncontrast)

Presence and extent of atherosclerotic occlusive disease

Etiology of intracranial hemorrhage

Vascular anatomy

Aneurysm

AVM, venous malformation

Vasculitis

Neoplasm vascular supply

98

Head MRA MRA Carotids

99

MRA Renal Arteries

Appropriate for resistant HTN 100

Whole body MRA-for atherosclerosis

101

MRA portal venous phaseMRA arterial phase

102

http://www.ucair.med.utah.edu/Graphics/HighResol_MRA_Ex2.pnghttp://www.ucair.med.utah.edu/Graphics/HighResol_MRA_Ex2.png




CTA vs MRI/MRACTA

• quicker than MRI and usually completed within 5 minutes

superior to MRI angiograms because they generally create more detailed images of the blood vessels being studied

CT angiograms carry the risk of radiation. This is a small but significant risk.

Suited for bone injuries, lung and chest imaging, cancer detection, widely used in ED

OK with metal

MRI

• provides better images of soft tissue (including most of the body's organs). Takes longer to complete

• MRI doesn’t use radiation; MRA doesn’t contain iodine (gadolinium)

• Suited for soft tissue evaluation e.g., ligament & tendon injury, spinal cord injury, brain tumors, etc.

• Metal contraindicated 103

Positron Emission Tomography (PET)

104

noninvasive, diagnostic imaging technique to measure metabolic activity of cells-looks at function

Detects alterations in biochemical processes suggesting disease before changes in anatomy are apparent on CT/MRI

Used to detect cancer/stage cancer, Alzheimer’s disease, neurological disorders, heart disease

105

Normal brain Image of the brain of a 9 year old

female with a history of seizures

poorly controlled by medication. PET

imaging identifies the area (indicated

by the arrow) of the brain responsible

for the seizures. Through surgical

removal of this area of the brain, the

patient is rendered "seizure-free."

106

Image of heart post-myocardial

infarction. The arrow points to

necrotic areas.

The patient will not benefit from

CABG.

Normal heart

107

Preparation

NPO 4-6 hours, except water

May take medications

No regular insulin within 4 hours of administration

Patients on certain insulin preparations may have half dose

Take serum glucose level, needs to be below 200 (Need to reschedule if above 200)

Elevated glucose level competes with F-18FDG

Elevated insulin levels = increased muscle uptake

108




Nuclear Scintigraphy

109

Bone Scan

110

Nuclear scintigraphy of the bone (Bone Scan)

images the metabolic activity of the skeleton

commonly utilizes the radionuclides technetium-99m (Tc-99m) or fluoride-18 (F-18)

111

Indications

Determine the source of bone pain

example, a long-distance runner may have foot pain due to a fracture or a sprain—scan helps determine if a bone injury or a tendon sprain is the cause of the pain.

Bone scans can also be useful in the evaluation of systemic diseases such as

cancer or nonspecific widespread bone pain.

Radionuclide bone scanning is the preferred method for evaluating the entire skeleton for the presence of multiple lesions. 112

Low specificity

patients with severe osteoporosis, tracer uptake by the bone may be too low, and false-negative results may be produced

false positives with trauma or recent surgery

113

111In-Leukocyte Scintigraphy (tagged white cells)

Detect sites of infection/inflammation in patients with FUO

Localize unknown source of sepsis and to detect addition site(s) of infection in patients with persistent or recurrent fever and a known infection site

Survey for site(s) of abscess or infection in a febrile postop patient without localizing signs or symptoms

Detect site(s) and extent of inflammatory bowel disease

114




111In-Leukocyte Scintigraphy (tagged white cells)

Detect and f/u osteomyelitis-especially when with metallic hardware or joint protheses

Detect osteomyelitis in diabetic patients when degenerative or traumatic changes, neuropathic osteoarthropathy or prior OM have caused increased bone remodeling

Detect OM involving the skull in post-operative patients and for f/u of therapy

Detect mycotic aneurysms, vascular graft infections and shunt infections

115

71 year-old man with a history of surgical fusion of his right ankle. He now presents with a draining wound from the right ankle and hindfoot. Evaluate for osteomyelitis.

©KAScordo 2015 116

Ultrasound

117

Types of UltrasoundObstetrical

Abdominal/Pelvic/Transvaginal

Gallbladder

Abdominal pain/AA

Cycts/fibroids/ectopic pregnancy/vaginal bleeding

Doppler

Arterial – PVD/carotid disease

Venous –r/o DVT

Soft tissue, head and neck

Thyroid

Cysts

Nodules

Tumors 118

Abdominal Ultrasound

Right upper quadrant pain, pelvic pain and abdominal pain in the pregnant patient

In younger pts with suspected ureteral stones or acute appendicitis

Initial test of choice in children’s hospital

Best for gallbladder disease

119

Cardiac Ultrasound

120




Siemens

Philipshttp://www.echo-web.com/

Types of Echocardiographic Exams

122

Transthoracic echocardiogram (TTE)

ultrasound of different frequencies is transmitted from a transducer placed on

patient’s anterior chest wall

2D, 3D & 4D

http://www.echo-web.com/

Indications for TTE

diagnosis of and guiding treatment for: coronary artery disease

valvular heart disease

heart failure

hypertensive heart disease

congenital abnormalities

complications of pulmonary disease

tumors/masses

cardiac trauma

pericardial disease

ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography.Available at: www.acc.org/clinical/guidelines/echo/index.pdf. 124

Goals of the Focused Cardiac Ultrasound (FoCUS) in the Symptomatic ED Patient

Assessment for the presence of pericardial effusion

Assessment of global cardiac systolic function

Identification of marked RV and LV enlargement

Intravascular volume assessment

Guidance of pericardiocentesis

Confirmation of transvenous pacing wire placement

125

To obtain the most useful information…

essential to provide

adequate clinical information

reason you’re requesting an echo

specific question being asked

ex:

60-year-old male with breathlessness & previous AWMI awaiting general anesthesia for elective hip replacement; for assessment of LV function

70 year-old female with systolic murmur; r/o AS

126

http://www.acc.org/clinical/guidelines/echo/index.pdf




Disadvantages of TTE

inadequate surface examinations chest deformities (pectus excavatum)

COPD (hyperinflated lungs)

obesity

midline thoracotomies (adhesions)

thick chest wall

difficult to evaluate intracardiac source of embolization

difficult to evaluate prosthetic valves

127

Transesophageal Echocardiography (TEE)

transducer mounted on the tip of a flexible gastroscope

transducer positioned in esophagus behind the heart

allows real-time imaging of the

heart

images obtained are not limited by interference from the chest wall

©KAScordo 2012

128

Indications for TEE

Aortic dissection/aneurysm

Valvular disease

Evaluate prosthetic valves

Infective endocarditis

Congenital heart disease: ASD/VSD

Intracardiac mass

Evaluate sources of embolization

129

IVDU with large vegetation mitral aortic intervalvular fibrosa

©KAScordo

Aortic insufficiency

©KAScordo 131

Stress Testing

132




ECHO

CT

SPECT

MRIPET

TMET

Multimodality Stress TestingNoninvasive Testing for Coronary Artery Disease

Pixabay.comPixabay.com

Graded Exercise Testing: Protocols

treadmill

arm ergometer

bicycle ergometer

isometric

135

Graded Exercise Testing: Indications

evaluation of chest pain

determination of prognosis and severity of disease

evaluation of medical and surgical therapy

screening for latent coronary disease

early detection of labile hypertension

evaluation of CHF

evaluation of arrhythmias

evaluation of functional capacity136

Evaluation of Hypertension

Exercise testing can identify patients with abnormal BP response destined to develop HTN

Identification of such patients may allow preventive measures that would delay or prevent the onset of this disease.

In asymptomatic normotensive subjects, an exaggerated exercise systolic and diastolic BP response during exercise, exaggerated peak systolic BP greater than 214 mm Hg, or elevated systolic or diastolic BP at 3 minutes into recovery is associated with significant increased long-term risk of HTN

137

Contraindications to GXT: Absolute

Acute myocardial infarction (within 2 days)Unstable angina Uncontrolled cardiac arrhythmias causing

symptoms or hemodynamic compromiseSymptomatic severe aortic stenosisUncontrolled symptomatic heart failureAcute pulmonary embolus or pulmonary

infarctionAcute myocarditis or pericarditisAcute aortic dissection

138




Relative ContraindicationsLeft main coronary stenosis

Moderate stenotic valvular heart disease

Electrolyte abnormalities

Severe arterial hypertension (systolic BP >200 mm Hg and/or diastolic BP >110 mm Hg)

Tachyarrhythmias or bradyarrhythmias

Hypertrophic cardiomyopathy and other forms of outflow tract obstruction

Mental or physical impairment leading to inability to exercise

High-degree atrioventricular block

Weight >350 pounds 139

Graded Exercise Stress Testing: Patient Preparation

no food, tobacco, alcohol or caffeine for at least 3 hours prior to test

wear comfortable walking shoes and loose fitting clothing

medications

unless evaluating therapy, withhold beta-blockers two days prior to test, or other drugs that depress AV conduction

140

Appropriate foot wear for stress testing??

Fletcher et al. Exercise Standards for Testing and Training A Statement for Healthcare Professionals From the AHA Circulation, 2001;104:1694

142

©KAScordo 2010

143

LM 70%LAD 80%

LCx 80%RCA 90%

144




Interpretation-beyond ST-segment

Functional capacity

For every 1MET increase, decrease 13%

mortality

HR dynamics

HR recovery

Chronotropic response

Ventricular ectopy

Ectopy during recovery-marker of risk

Duke score145

Interpretation:Poor prognostic findings

Low workload

Mets 2mm

ST segment depression in multiple leads

Prolonged ST depression after Exercise (>6 min)

ST Elevation without abnormal Q wave

Increase in complex ventricular ectopy

Exercise-induced typical Angina

Frequent ventricular ectopy 146

Remember….

Evaluating a patient with cardiac symptoms and comorbidities is a lot like evaluating a used car

The exercise test is the test drive

False Positive GXT Causes

pre-existing EKG abnormalities

hypertension

medications

female gender-~10-15%

MVPS

anemia

vasoregulatory abnormalities

pericardial disorders

148

False Negative GXT Causes

submaximal target heart rate

single vessel disease; good collateral circulation

technical or observer error

149

Conditions lowering reliability of ECG marker of ischemia

female gender

arterial hypertension

repolarization abnormalities on resting EKG or after hyperventilation (LBBB, LVH, WPW)

drugs that affect ST-T segments

150




151 152

153

Nuclear Imaging

Sestamibi Exercise Stress Test

Thallium Exercise Stress Test

Positron Emission Tomography (PET)

Multigated Acquisition Scan (MUGA)

154

Nuclear Imaging: Factoids

Radioactive tracers are not dyes. They have no side effects.

The amount of radiation a patient receives in a typical nuclear imaging scan is very low, similar to the exposure received in a routine chest x-ray.

In most cases the tracers are injected IV. In some cases they may be given by mouth.

155

Cardiolite & Thallium GXT:Precautions

CAT scan, MRI, Upper GI, lung scan, or other tests requiring use of technetium – need to wait full 24 hours before scheduling Thallium or Cardiolite

Studies using isotopes with longer half-life (Gallium) require longer time interval

156




Imaging Interpretation

normal homogenous uptake of rediotracer throughout

myocardium

defect localized area with decrease in radiotracer uptake

reversible defect defect present on initial stress images, no longer

present on resting or delayed images

fixed defect defect unchanged and present on exercise

and rest images

157 Clinical Cardiovascular Imaging: A Companion to Braunwald's Heart Disease (2004) 158

Pulmonary Thallium-201 Uptake

increase in mean pulmonary transit time (>LVEDP) prolongs TI-201 contact with pulmonary endothelium

results in extraction of thallium by lungs

general marker of exercise induced LV dysfunction

159

Stress Testing

Combine with 2D echo or nuclear testing with radioisotopes (sestamibi)

160

Pharmacological Stress Testing

161

Stress echo with pharmacologic intervention

dobutamine

adenosine

dipyridamole

162




Adenosine

contraindications broncho-constrictive pulmonary disease

second or third degree AV block

hypotension

severe CHF (negative inotropic effect)

drug interference dipyridamole (potentiating effect)

theophylline/caffeine (antagonist effect)

163 American Ht Journal, 1991 164

The END References

Bradley, D., & Bradley, K. E. (2014). The value of diagnostic medical imaging. North Carolina Medical Journal, 75(2), 121-125. Braunwald et al. Heart Disease (2012). Saunders.

Campbell, R. M., Douglas, P. S., Eidem, B. W., Lai, W. W., Lopez, L., & Sachdeva, R. (2014).

Appropriate Use Criteria: ACC/AAP/AHA/ASE/HRS/SCAI/SCCT/SCMR/SOPE 2014 Appropriate Use Criteria for Initial Transthoracic Echocardiography in Outpatient Pediatric Cardiology. A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Academy of Pediatrics, American Heart Association, American Society of Echocardiography, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Pediatric Echocardiography. Journal Of The American Society Of Echocardiography, 271247-1266. doi:10.1016/j.echo.2014.10.002

Rauscher, I., Eiber, M., Fürst, S., Souvatzoglou, M., Nekolla, S. G., Ziegler, S. I., & ... Beer, A. J. (2014). PET/MR imaging in the detection and characterization of pulmonary lesions: technical and diagnostic evaluation in comparison to PET/CT. Journal Of Nuclear Medicine: Official Publication, Society Of Nuclear Medicine, 55(5), 724-729. doi:10.2967/jnumed.113.129247

Palestro et al. 2004. Society of nuclear medicine procedure guideline for In-leukocyte scintigraphy for suspected infection/inflammation.

Stainback, R. F. (2014). OVERVIEW OF QUALITY IN CARDIOVASCULAR IMAGING AND PROCEDURES FOR CLINICIANS: FOCUS ON APPROPRIATE-USE-CRITERIA GUIDELINES. Methodist Debakey Cardiovascular Journal, 10(3), 178-184. 166

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