Miscellaneous Cardiology Topics · The presumptive differential of coronary artery disease is...

Cardiology

Testing

Sandra Keavey, DHSc,

DFAAPA, PAC

Before We Start CPR

Let’s go a few weeks back in time….

Call

911

History

Let’s get the history.

HistoryTell me about

your chest pain.

HistoryAn elephant is

standing on my chest.



I feel tired and

short of breath.



I feel tired and

short of breath.

The pain is going

down my arm.

The Story

Chest pain

Don’t expect the Hollywood Heart Attack.

Therefore eliciting the history is YOUR responsibility.

Patients may downplay their symptoms but they were

worried enough to be seen.

Ask about…….

What does it feel like? Had similar pain before?

Where is the pain? If recurrent, same location?

When did it start? Intermittent?

How does it get better or worse? Rest vs activity?

Associated symptoms- weakness, nausea,

diaphoresis, dyspnea, lightheadedness.

Pain….. please Sharp

Dull

Squeezing

Crushing

Pressure

Sore

Irritation

Tingle

Cramp

Ache

“Discomfort”

Different

More Pain..

In describing pain ask about

heaviness, pressure, squeezing,

aching

Discomfort in the chest, back,

neck, shoulders, or arms, wrists,

elbows, between the shoulder

blades

Aching in the jaw, throat, or even

gums or earlobes

Fatigue, shortness of breath, loss of

drive or lack of energy

Pretty good story…even with no cardiac

history or co-morbid conditions.

When you hear chest pain it is angina or a heart attack until you convince yourself it’s not.

History is paramount in creating a list of differential diagnoses that will guide testing and management.

It will allow you to have information to convince a patient to have testing they may not want or that testing they do want is not indicated.

Be sure you document the interview.

What Constitutes a “Good Story”?

When did it start? Minutes or hours

What were you doing? Activity

What happened when you sat down or stopped? Stopped, eased up

Where is the pain? Precordium

Where does it go? Shoulders, neck, back

What symptoms are associated with it? Nausea, weakness, diaphoresis, dyspnea, “not right”

Is this pain similar to what you have had before? Yes

History of CAD, Angina, DM? Yes

A“Bad Story”?

When did it start?

Days or weeks, constantly there.

What were you doing?

It hurts all the time, doesn’t change with activity.

What happened when you sat down or stopped?

Still hurt.

Where is the pain?

All over.

How long does it last?

Seconds or days

Where does it go?

All over.

What symptoms are associated with it? ROS



The presumptive differential of coronary artery disease is included after the patient's medical history is carefully reviewed, a physical exam is performed, and the patient's symptoms are evaluated.

Due to the potential morbidity and mortality associated with CAD/AMI if it is being considered it must be worked up.

Tests used to confirm a diagnose coronary artery disease include:

electrocardiogram stress tests cardiac catheterization imaging tests such as a chest x ray , echocardiography , or

computed tomography (CT) blood tests to measure blood cholesterol, triglycerides, and other

substances- not to be discussed today.



The presumptive differential of coronary artery disease is included after the patient's medical history is carefully reviewed, a physical exam is performed, and the patient's symptoms are evaluated.

Due to the potential morbidity and mortality associated with CAD/AMI if it is being considered it must be worked up.

Tests used to confirm a diagnose coronary artery disease include:

electrocardiogram stress tests cardiac catheterization imaging tests such as a chest x ray , echocardiography , or

computed tomography (CT) blood tests to measure blood cholesterol, triglycerides, and other

substances

And liability

More History…

Dyspnea on exertion frequently precedes other symptoms of cardiac ischemia or heart failure.

Arrhythmia Duration: sudden short episodes (minutes) suggest paroxysmal tachycardia; longer duration (hours to days) with irregularities suggests atrial dysrhythmia.

Lightheadedness or chest pain while sitting elevates the likelihood of pathology

For MI’s chest pain with associated with radiation, worse with exertion, relieved by rest, nausea, diaphoresis, dyspnea, feeling faint or syncope increase the likelihood of pathology

Is this pain similar to when you had your prior heart attack?

Important History…

Do you have a history of heart disease?

Ever had a heart attack?

Are you diabetic?

Have you ever been worked up for chest pain?

Have you had a stress test?

A cardiac catheterization?

How long ago? Results?

Have you ever had stents placed?

Bypass surgery?

Are you on blood thinners? ASA? Clopidigrel (Plavix)

(or equivalent)? Warfarin?

Important History…

Do you have a history of heart disease?

Ever had a heart attack?

Are you diabetic?

Have you ever been worked up for chest pain?

Have you had a stress test?

A cardiac catheterization?

How long ago? Results?

Have you ever had stents placed?

Bypass surgery?

Are you on blood thinners? ASA? Plavix (or

equivalent)? Warfarin?

The more concerned you

are about cardiac ischemia

the more detail you must

request.

You would think they would

tell you this.

And they will, if you ask.

A Heart Story

As experienced by the

staff of Heart Hospital

Cast

NP

Attending

PA

Intern

Resident

Fellow

Chester

Payne

A Heart Story

The patient has a

good chest pain story.

A Heart Story

The patient has a

good chest pain story.

What are your

initial orders?

A Heart Story

Vital signs, ASA, IV,

Monitoring, Labs

A Heart Story

Good management orders.

A Heart Story

How do we

evaluate his

chest pain?

A Heart Story

What is the gold

standard for

evaluation of

cardiac disease?

A Heart Story

Cardiac

catheterization

A Heart Story

A little premature

at this point.

What shall we

start with?

A Heart Story

EKG?

Electrocardiogram (ECG)

Order routinely in new patients when there is a history of…

Hypertension

CAD

Arrhythmia

Diabetes

Endocrine disorders

Over 50 to establish baseline

Electrocardiogram (ECG)

Order acutely when

patient has ….

Chest pain

Elevated BP

Arrhythmia

Dyspneic

Diaphoretic

Syncopal or near…

Weakness or ? of stroke

A Heart Story

EKG shows NSR, no ST

elevation or depression, no T-

wave inversion, normal

intervals, no Q waves.

A Heart Story

What does that mean?

A Heart Story

No acute cardiac

ischemia or arrhythmia

A Heart Story

Okay group, what should

we order to evaluate his

chest pain?

A Heart Story

Stress test

When To Do Stress Testing

If there are symptoms …..because……

Stress tests have a high degree of accuracy, but…

These tests are not risk free

These tests are not inexpensive $$$$$

So when??

If you have chest pain, shortness of breath, an irregular heartbeat or palpitations, or other symptoms of heart disease.

A case can also be made for people with diabetes or other risk factors who are just starting to exercise.

Stress Test Types

Treadmill test

Exercise test

Non-imaging test

Pharmacological

SPECT (imaging)

When to order what type of stress test?

Exercise

Tracers with imaging

Dobutamine stress?

Non-exercise

Pharmacologicalvs

Exercise testing is superior unless patient unable to use a treadmill.

And the patient must be able to reach 85% maximum heart rate.

Caveat

Increased stress is not

resulting in dilatation,

i.e. ischemia occurs.

Ischemia is everywhere……. Blood flow through exercising skeletal muscles can

be 15 to 20 times greater than through resting muscles.

The increased blood flow is the product of local, nervous, and hormonal regulatory mechanisms.

When skeletal muscle is resting, only 20% to 25% of the capillaries are open, whereas during exercise 100% of the capillaries are open.

Think of peripheral vascular disease, intermittent claudication, ischemic bowel.

Amazing!

The average heart (weighs 10 ounces) beats

72 times per minute

>100,000 times a day

38 million times a year

by 70 a staggering 2.5 billion beats.

Approximately 4-5% of the blood output of the heart goes to the coronary arteries

2.4 ounces/heartbeat

1.3 gallons/minute

1,900 gallons/day

700,000 gallons/year

48 million gallons by 70.

A Heart Story

What type of testing

should we do?

Kohli P , and Gulati M Circulation. 2010;122:2570-2580

There’s an app

for that!

Although this chart from a

paper published in 2010 and

focuses on women the

critical analysis is the same.

A Heart Story

Cardiac

catheterization

A Heart Story

Not yet. What test

should we order ?

A Heart Story

Treadmill with

myocardial imaging.

Exercise Stress Test w/ Myocardial

Imaging

So let’s put our patient

on the treadmill and

see how he does.

We will see how he

exercises

Take some before and

after cardiac images

Compare the results

Stage Minutes % Grade MPH Mets

1 3 10 1.7 5

2 6 12 2.5 7

3 9 14 3.4 10

4 12 16 4.2 13

5 15 18 5.0 15

6 18 20 5.5 18

7 21 22 6.0 20

Bruce Protocol

Maximum Heart Rate (MHR) is typically calculated with the formula

220-age or 220-age X85%.

The test is resulted in the time patient is actively walking on the

treadmill in minutes.

MET Significance MET (metabolic equivalent) is a term used to represent the

intensity of exercise.

One MET equals the uptake of 3.5 ml of oxygen per kilogram of

body weight per minute

1 is the basal rate ( while sleeping)

2 walk 2 mph on level surface

4 4 mph on level surface or

what it takes to perform the activities of daily living.

Poor prognosis if <65

Limit immediate post MI

10 As good a prognosis with medical therapy as CABG

13 Excellent prognosis, regardless of other exercise responses

16 Aerobic master athlete

20 Ultra aerobic athlete

MET Activity Level

Light (<3 ) Moderate (3-6) Heavy (>6)

Sleeping (1.0) Walking briskly Jogging @ 6mph (10)

Walking – slowly (2.0) Cleaning—heavy (3.0–3.5) Shoveling (7.0–8)

Sitting (1-1.5)

Working on computer (1.5)

Windows, vacuuming, mopping Carrying heavy loads (7.5)

Standing Mowing lawn-walk power

mower (5.5)

Bicycling fast @14–16 mph (10.0)

Cooking, washing dishes (2.5) Bicycling @ 10–12 mph) (6.0) Basketball game = 8.0

Fishing-sitting (2.0) Badminton—recreational (4.5) Soccer casual (7.0)

Playing most instruments (2.0–2.5) Tennis—doubles (5.0) Tennis—singles (8.0)

Modified Bruce

Protocol

Starts at a lower workload than the

standard test and is typically used

for elderly or sedentary patients.

It is also used prior to discharging a

NSTEMI patient.

The first two stages of the Modified

Bruce Test are performed at a 1.7

mph and 0% grade and 1.7 mph

and 5% grade

The third stage corresponds to the

first stage of the Standard Bruce

Test protocol.

Absolute Contraindications

Acute myocardial infarction within 48 hours

Unstable angina not yet stabilized with medical therapy

Uncontrolled cardiac arrhythmia, which may have significant hemodynamic responses (e.g. ventricular tachycardia)

Severe symptomatic aortic stenosis, aortic dissection, pulmonary embolism, and pericarditis

Multivessel coronary artery diseases that have a high risk of producing an acute myocardial infarction

Decompensated or inadequately controlled congestive heart failure

Uncontrolled hypertension (blood pressure>200/110mm Hg)

Severe pulmonary hypertension

Acute aortic dissection

Acutely ill for any reason

Severe asthma or COPD

Physically unable to safely complete treadmill test

Relative Contraindications

Known left main coronary artery stenosis

Moderate aortic stenosis

Hypertrophic obstructive cardiomyopathy

Other forms of outflow tract obstruction

Significant tachyarrhythmias or bradyarrhythmias

High-degree atrioventricular block

Electrolyte abnormalities

Mental or physical impairment leading to inability to exercise adequately.

Reliability of an Exercise Stress Test?

If a patient is able to achieve the target heart rate, a regular treadmill stress test is capable of diagnosing important disease in approximately 67% or 2/3 of patients with coronary artery disease.

The accuracy is lower (about 50%) when patients have narrowing in a single coronary artery or higher (greater than 80%) when all three major arteries are involved.

Approximately 10% of patients may have a "false-positive" test (when the result is falsely abnormal in a patient without coronary artery disease).

Exercise stress testing has a lower diagnostic value in patients who cannot achieve an adequate heart rate and blood pressure response.

Diagnostic Value of Various Stress

Testing Modalities in Women

Stress Testing Modality Sensitivity Specificity NPV PPV

Exercise ECG 31-71 66-78 78 47

Exercise Echocardiography 80–88 79-86 98 74

Exercise SPECT 78-88 64-91 99 87

Pharmacological

echocardiography

76-90 85-94 68 94

Pharmacological SPECT 80-91 65-75 90 68

•Values are percentages. PPV indicates positive predictive value.

Diagnostic Value of Various Stress

Testing Modalities in Women

Stress Testing Modality Sensitivity Specificity NPV PPV

Exercise ECG 31-71 66-78 78 47

Exercise Echocardiography 80–88 79-86 98 74

Exercise SPECT 78-88 64-91 99 87

Pharmacological

echocardiography

76-90 85-94 68 94

Pharmacological SPECT 80-91 65-75 90 68

•Values are percentages. PPV indicates positive predictive value.

If an exercise SPECT or exercise echo

is negative, you don’t have it.

Hah!

Radionuclide Imaging

Also known as a nuclear, thallium, Cardiololite or dual isotope stress test, depending upon the method used.

During exercise, healthy coronary arteries dilate (develop a more open channel) more than an artery that has a blockage.

This unequal dilation causes more blood to be delivered to heart muscle supplied by the normal artery.

In contrast, narrowed arteries end up supplying reduced flow to its area of distribution.

This reduced flow causes the involved muscle to "starve" during exercise. The "starvation" may produce symptoms (like chest discomfort or inappropriate shortness of breath), and EKG abnormalities.

When a "perfusion tracer" (a nuclear isotope that travels to heart muscle with blood flow) is injected intravenously, it is extracted by the heart muscle in proportion to the flow of blood.

How is a Nuclear Stress Test Done?

The patient is brought to the patient is placed

under a scanning camera.

Two sets of isotope images are obtained.

One at rest, and one following exercise.

The scanning camera rotates around the patient's chest, stopping to take individual pictures.

The patient needs to lay flat and still during the scanning period which takes approximately 11 to 20 minutes, depending upon the type of scanning camera.

Patients with severe claustrophobia should receive a mild tranquilizer before the test to minimize discomfort.

OR----

Inject the tracer

Take a picture (baseline image)

Stress the patient (physically or

chemically)

Inject more tracer

Take 2nd picture (test image)

Compare the images

The pictures or images are fed into a computer,

which reconstructs them as "slices" of a three

dimensional heart.

Areas that fall out side the expected normal

range is presented as a blacked out area.

How Are Nuclear Stress Images Read?

Area of

hypoperfusion



dimensional heart.




Area of

hypoperfusion



dimensional heart.




Area of

hypoperfusion

And here



dimensional heart.




Area of

hypoperfusion

And here

Here

Pharmacological Stress Test

A chemical stress test combines an intravenous medication with an imaging technique (isotope imaging or echocardiography) to evaluate the LV.

Stress causes normal coronary arteries to dilate, while the blood flow in a blocked coronary artery is reduced.

In these cases, the medication serves as a substitute for exercise by dilating the coronary vessels.

Patients frequently feel flushed or fluttery or short of breath with this medication.

This reduced blood flow may decrease the movement of the affected wall (as seen in a stress echo), or have reduced isotope uptake in a nuclear scan.

Stress Test Report DATE OF STUDY: MM/DD/YYYY REFERRING PHYSICIAN: John Doe, MD

REASON FOR EXAMINATION: Chest pain, shortness of breath and cardiomyopathy.

DESCRIPTION OF PROCEDURE:

The patient exercised on Bruce protocol for 8 minutes and 4 seconds, achieving a heart rate of 142, which is 81% of his age-predicted maximum heart rate. Resting heart rate was 80 with resting blood pressure of 134/92. With exercise, the blood pressure increased to 169/94 and the heart rate increased to 142.

Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left

ventricular hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain.

IMPRESSION:

1. Average exercise capacity.

2. Somewhat blunted heart rate response secondary to beta-blocker use.

3. Normal blood pressure response.

4. No clinical or electrocardiographic changes consistent with myocardial ischemia noted during this exercise stress test.

5. Sestamibi imaging results will be reported separately







IMPRESSION:






This information can be

helpful in evaluating study.







IMPRESSION:






How well the patient was

able to complete the test .







IMPRESSION:






Baseline EKG. Good information to have.





Electrocardiogram at rest revealed sinus rhythm with voltage criteria for left ventricular

hypertrophy with repolarization changes. With exercise, no significant electrocardiographic changes were noted. The patient stopped due to fatigue and shortness of breath and did not have exercise-induced chest pain.

IMPRESSION:






Did the patient stop

prematurely?







IMPRESSION:






This is certainly an

encouraging report

but the real answer is

in the images.

. Normal Nuclear Imaging Results

MYOCARDIAL PERFUSION IMAGING:

1. The overall quality of the scan was good.

2. There was no diagnostic abnormality on rest and stress myocardial perfusion imaging.

3. The left ventricular cavity appeared normal in size.

4. Gated SPECT images revealed no wall motion abnormalities.

5. Overall left ventricular systolic function was normal with calculated left ventricular ejection fraction of 60% at rest.

This is a good

result.

. Normal Nuclear Imaging Results



2. There was no diagnostic abnormality on rest and stress myocardial perfusion imaging.


4. Gated SPECT images revealed no wall motion abnormalities.

5. Overall left ventricular systolic function was normal with calculated left ventricular ejection fraction of 60% at rest.

This is a good

result.

Supported by good

LV function.

. Abnormal Nuclear Imaging Results



2. There was a fixed perfusion defect in the apex and a reversible perfusion defect in the anterior left on stress myocardial perfusion imaging.


4. Gated SPECT images revealed mild septal hypokinesis and mild-moderate apical hypokinesis. Overall left ventricular systolic function was low with calculated ejection fraction of 40% at rest.

Fixed perfusion

defect means old.







Reversible means a lesion that is

likely causing the symptoms.







Hypokinesis is loss of

contractility. If permanent it is

from an old infarct.







Hypokinesis can be a result of

stunned myocardium in an

acute event and be reversible.

MUGA Scans

Using this scan the gamma camera acquires a series of pictures of the heart in synchrony with the patients ECG signals. The pictures record the heart's motion and determine if all of its segments are contracting properly. MUGA scanning may take 2 to 3 hours to obtain all the needed views and can be done both before and after you exercise.

Multigated acquisition (MUGA) scans are used routinely before and after receiving a heart transplant to assess how well the heart is working.

MUGA is also used to monitor the ejection fraction in people receiving chemotherapy, especially those receiving doxorubicin (Adriamycin).

However a MUGA does not provide information about the heart valves or the thickness of the ventricle.

A Heart Story

Cardiology Fellow, please

present the case for Dr. Z.

A Heart Story

48 yom with known CAD, DM uncontrolled presents with

substernal chest pain that is non-radiating. EKG, labs WNL but

myocardial perfusion scan shows perfusion defects.

A Heart Story

Excellent summary. So Dr. Z what do you want to do?

A Heart Story

Cardiac

catheterization.

Cardiac Catheterization

Cardiac catheterization or coronary angiography are invasive, diagnostic procedures that are performed to obtain information about the heart or its blood vessels.

These procedures involve directing a catheter or catheters into the right and/or heart chambers and into the origin of the coronary arteries.

During cardiac catheterization the pressure and blood flow in the cardiac chambers are measured.

Blood in these different chambers can also be collected to look for shunts or abnormal connections between chambers.

During coronary angiography contrast material is directly injected into the coronary arteries and the subsequent image recorded on x ray.

Cardiac Catheterization Indications

Cardiac catheterization is performed:

To determine whether the coronary arteries are

obstructed or narrowed.

To determine the severity of the coronary stenosis,

the number of coronary arteries involved and their

location.

To evaluate the severity of valve dysfunction.

Determine the need for cardiac surgery.

To evaluate congenital cardiac abnormalities.

Cardiac Cath Lab

Fluoroscopy is used to

visualize the vessels when

the dye is injected.

These images are saved

for review following the

procedure.

If blockages are found

angioplasty can be done

immediately.

Coronary Angiography

Angioplasty

Depending on the

severity of the lesions,

their locations the

decision is made

whether or not to try

angioplasty with

balloon or stent

placement or

schedule the patient

for bypass graft

surgery.

CABG

Coronary Artery Bypass Grafting

Whose coronary artery disease cannot be

adequately treated by cardiac medications

Cannot be treated with angioplasty

Who suffer from intractable or unstable angina

Other individuals who may

benefit from CABG after a

heart attack include those who

are suffering from cardiogenic

shock or who remain unstable

after PTCA.

While bypass surgery can limit

damage in people with an

acute heart attack, it does not

cure the underlying coronary

artery disease.

Many still require medications

after CABG. Lifestyle

modification and cardiac

rehabilitation is recommended.

Bypass surgery is performed in people

•With an evolving heart attack when pain and ECG findings are unstable

•Who failed angioplasty (They still have persisting pain or continue to be unstable after angioplasty)

•Who are undergoing repair of mechanical complications such as a tear in the wall dividing the ventricles (ventricular septal defect) or heart valve insufficiency ("leaky" heart valves)

CABG

Coronary Artery

Bypass Grafting

•These individuals usually have

•significant obstruction of the

three main coronary arteries

significant obstruction of the

left main artery

•depressed pumping action or

blockage of the left anterior

descending artery

Alternative Techniques

In off-pump coronary artery bypass or OPCAB,

bypass grafting is performed without the use of

the heart-lung machine. Surgery is performed

while the heart is still beating, although the heart

rate is slowed and the heart partially held in place

using surgical instruments.

Another alternative is the use of smaller incisions

that avoids splitting the breastbone. This is

referred to as Minimally Invasive Direct Coronary

Artery Bypass or MIDCAB.

If you didn’t enter

it in the chart it

didn’t happen.

If it can’t be read,

it didn’t happen

And the rest of the story …..

Get off me!!

I fainted because I

just won the lottery!!

Arrhythmias

Arrhythmias can be difficult to evaluate when they are episodic.

Mr. Dude the palpitations you describe

have not been seen on telemetry.

Arrhythmias

Arrhythmias can be difficult to

evaluate when they are episodic



What can we do? I can’t

stay in the hospital forever.

Arrhythmias

Arrhythmias can be difficult to

evaluate when they are episodic



What can we do? I can’t

stay in the hospital forever.

Let’s order an

event monitor.

Holter Monitor

A continuous tape recording of a patient's EKG.

Since it can be worn during the patient's regular daily activities, it helps the physician correlate symptoms of dizziness, palpitations (a sensation of fast or irregular heart rhythm) or black outs.

It is much more likely to detect an abnormal heart rhythm when compared to the EKG which lasts less than a minute.

It can also help evaluate the patient's EKG during episodes of chest pain, during which time there may be telltale changes to suggest ischemia

Commonly worn for 24 hours there are versions that can be worn 3-4 weeks (called event monitors).

Holter

Monitor

Implantable Cardiac Monitors

In cases where the patient is profoundly (such as syncope)but infrequently symptomatic an implantable monitor can be inserted under the skin.

Called loop recorders

Ms. Smithers

have you even

been told you

have a heart

murmur?

EchocardiogramMs. Smithers

have you even

been told you

have a heart

murmur?

No.

I will order an

echocardiogram.

Echocardiography

What is an Echocardiogram: An echocardiogram is a test in which ultrasound is used to examine the heart.

In addition to providing single-dimension images, known as M-mode echo that allows accurate measurement of the heart chambers, the echocardiogram also offers far more sophisticated and advanced imaging.

This is known as two- dimensional (2-D) Echo and is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle

Echocardiogram Evaluates-

Heart size

Heart function or ejection fraction

Presence of cardiac malformations

Presence of ventricular aneurysms

Presence of scars

Valve morphology

Presence of masses in the heart or

on the valves

Presence of pericardial fluid

Left Ventricular FunctionHyperdynamic Normal Mild LV

dysfunction

Moderate LV

dysfunction

EF (%) >65 55-65 45-54 30-44

Chest wall

LR

Echocardiography

Color-Flow Echocardiogram: This is the part of the Doppler

echocardiogram where we can determine the direction

of blood flow according to the color on the screen

.

Blood going away from the transducer looks blue, while

blood coming towards the echocardiogram transducer

looks red.

In addition, there may be a mosaic of colors if there is

turbulent flow as may be seen across a narrow blood

vessel or heart valve.

This is also helpful in detecting a leaky valve or a hole in

the heart.

This is a very sensitive instrument that may pick up a very

mild degree of leakage in normal heart valves.

This is what we call physiologic regurgitation (leakage).

Virtually all normal human beings have physiologic

regurgitation in one or more heart valves. The quality of the

study is somewhat

operator dependent.

Transesophageal Echocardiogram

A TEE is extremely useful in detecting blood clots, masses and tumors that are

located inside the heart.

It can also gauge the severity of certain valve problems and help detect

infection of heart valves, certain congenital heart diseases (like a hole

between the upper chambers of the heart, known as an ASD or atrial septal

defect) and a tear (dissection) of the aorta (major artery of the body).

TEE is also very useful in evaluating for clots inside the left atrium.

Resources

Articles on Chest Pain History

jama.jamanetwork.com/article.aspx?articleid=201900

www.ncbi.nlm.nih.gov/pmc/articles/PMC481842/

American College of Cardiology

www.cardiosource.org/acc

American Heart Association

www.heart.org

Up to Date

www.uptodate.com

http://jama.jamanetwork.com/article.aspx?articleid=201900

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC481842/

http://www.cardiosource.org/acc

http://www.heart.org/

Questions?

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Miscellaneous Cardiology Topics · The presumptive differential of coronary artery disease is...

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