Transcript Echocardiography - Eastern Washington University

Cardiac Medical
Diagnostic Tests
Program Instructions
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Press  key or left mouse button to move
forward through the program.
Press  key to go back one step in the
program.
Click on box in the lower right corner for
answers to review questions.
Self-Study Instructions
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Read and the information provided for
each medical diagnostic test or procedure.
Note the general purpose, description, and
components of the test or procedure.
Consider the implications for physical
therapy assessment and / or intervention.
Answer the review questions at the end of
each section.
Cardiac Enzyme Profile
Description
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Laboratory blood test used to determine
the concentration of myocardial proteins.
CK is an enzyme found in high
concentrations in heart and skeletal
muscle.
CK-MB is the isoform of CK found
specifically in heart muscle. (CK-BB =
brain isoform, CK-MM = skeletal muscle
isoform)
Description (continued)
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Trop I is a cardiac isoform of a muscle
protein (subunit of the 3 part troponin
complex) involved in myosin-actin cycling.
Trop T is a cardiac isoform of a muscle
protein (subunit of the 3 part troponin
complex) involved in myosin-actin cycling.
Description (continued)
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Myoglobin is small protein found in cardiac
and skeletal muscle that binds to oxygen.
LDH-1 is the cardiac fraction of an enzyme
found in high concentrations in the heart,
skeletal muscle, RBCs, liver, kidney, lung,
and brain.
*LDH-1 is not typically included in a Cardiac
Profile anymore.
Example Report
CARDPRO
Low
Normal
CK
CK-MB
High
Flag
Reference
200
*
30-180 U/L
4
10-13 U/L
Trop I
10
*
<1.5-3.1 g/L
Trop T
3.2
*
<0.1-0.2 g/L
Myoglobin
76
50-120 g/mL
LDH-1
208
9.8-65 U/L
Purpose
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To diagnosis acute myocardial
ischemia/infarction.
To determine amount of myocardial
muscle damage and prognosis following
acute myocardial infarction.
Procedure
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5-10 mL of venous blood are collected in a
heparinized needle and syringe.
PT Considerations
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Use cardiac profile test results to estimate
time since precipitating cardiac event and
determine when exercise initiation is
appropriate.
Onset
Peak
Return
4-6 hrs
12-24 hrs
3-4 days
Trop I
3 hrs
14-18 hrs
5-7 days
Trop T
3-5 hrs
~24 hrs
14-21 days
2 hrs
3-15 hrs
18-24 hrs
12-24 hrs
2-5 days
6-12 days
CK / CK-MB
Myoglobin
LDH-1
PT Considerations (continued)
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Determine appropriate type of exercise
assessment and intervention based on
degree of myocardial damage reflected in
peak level of CK / CK-MB rise.
Consider that rises in some of the indices
are not specific to cardiac damage
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Isolated rises in CK and or myoglobin may be
due to skeletal muscle damage.
Trop I and T are very specific indicators.
Isolated increases in LDH-1 suggest ruling out
of AMI.
PT Considerations (continued)
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Postpone exercise in patients with severe cardiac
enzyme elevations and signs or symptoms of
significant dysrhythmia or heart dysfunction.
Monitor cardiac profile indices frequently to
determine if additional cardiac or skeletal muscle
damage is occurring with intervention and
modify activity appropriately.
Watch for signs and symptoms of exerciseinduced cardiac ischemia or heart failure in
patients with elevated cardiac protein markers.
Review Question #1
Which cardiac enzyme is the first to be
elevated following an AMI?
a. myoglobin
b. CK
c. CK-MB
d. Troponin I
e. Troponin T
Click here for
answer
Review Question #2
Which cardiac enzyme is the most specific
indicator of AMI?
a. myoglobin
b. CK
c. CK-MB
d. Troponin I
e. LDH
Click here for
answer
Lipid Panel
Description
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Laboratory blood test used to assess
amount and type of serum lipid.
Total cholesterol (TOT CHOL) reflects the
blood lipid synthesized by the liver and
used to form bile salts and hormones.
Triglyceride (TG) is the blood lipid carried
by serum lipoproteins which has
atherogenic properties.
Description (continued)
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Low density lipoprotein (LDL) is the
fraction of lipoprotein that is atherogenic.
High density lipoprotein (HDL) is the
fraction of lipoprotein that assists in
decreasing atherogenic plaque deposits in
blood vessels.
Example Report
CHOLPRO
High
Flag
Reference
TOT CHOL
287
*
<200 mg/dL
TG
150
*
10-140 mg/dL
LDL
188
*
60-160 mg/dL
*
29-77 mg/dL
HDL
Low
16
Normal
Purpose
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To determine risk of atherosclerotic lesion
development.
To monitor treatment effectiveness.
Procedure
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5-10 mL of venous blood are collected in a
heparinized needle and syringe.
PT Considerations
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Determine patient CAD risk related to
dyslipidemia based on test results.
Use ECG monitoring for initial exercise
assessment/intervention in patients with
dyslipidemia since latent CAD may exist.
Educate patients on the type and
significance of the different blood lipids
using their test results.
Prescribe aerobic exercise for treatment of
dyslipidemia.
PT Considerations (continued)
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Monitor efficacy of exercise training for
CAD risk factor reduction using lipid
profile.
Educate patient on dietary changes to
reduce fat and cholesterol intake.
Evaluate lipid profile cautiously in patients
following an acute cardiac event because
results may be invalid.
Review Question #3
When interpreting blood lipid levels, it is
detrimental for all fractions except which
to be elevated?
a. Total cholesterol
b. TG
c. LDL
d. HDL
Click here for
answer
Review Question #4
Total cholesterol levels at or above what
value is abnormal and a risk factor for
coronary heart disease?
a. 200 mg/dL
b. 140 mg/dL
c. 170 mg/dL
d. 77 mg/dL
Click here for
answer
e. 110 mg/dL
Coagulation Profile
Description
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Laboratory blood test used to assess clot
formation ability.
PT measures clotting ability of factors I
(fibrinogen), II (prothrombin), V, VII, and
X.
INR is the ratio of PT time to standard
values.
PTT measures clotting ability of all factors
except VII and XIII.
Example Report
COAGPRO
PT
INR
PTT
Low
Normal
High
Flag
Reference
12
10-13 sec
2
2.0-3.0
65
60-70 sec
Purpose
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To assess therapeutic range of
anticoagulation therapy (PT for warfarin
sodium/Coumadin and PTT for heparin).
To screen for clotting factor deficiencies.
Procedure
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5-10 mL of venous blood are collected in a
heparinized needle and syringe.
PT Considerations
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Verify “PT” physician orders are for
physical therapy, not prothrombin time.
Avoid high intensity and high impact
aerobic exercise when clotting time is
increased.
Use strengthening exercise employing low
resistance with free weights / theraband
and high repetitions when clotting time is
increased.
PT Considerations (continued)
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Avoid vigorous manual techniques, such
as percussion and cross friction massage,
and application of thermal modalities
when clotting time is increased.
Watch for bruising under skin in areas
where exercise equipment contacts skin.
Postpone exercise and manual
interventions when PT or PTT > 2.5x
reference range or INR > 3.0.
PT Considerations (continued)
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DO NOT perform sharp or nonspecific (wet
to dry dressing) debridement on wounds
when clotting time is increased.
Postpone exercise intervention until
physician clearance is obtained when
clotting time is decreased to minimize risk
of emboli.
Assess Homan’s sign in patients with
decreased clotting time when a DVT is
suspected.
Review Question #5
If PT time is decreased in a patient taking
Coumadin, would the dose be increased or
decreased?
a. increased
b. decreased
Click here for
answer
Review Question #6
When clotting time is increased which
event(s) is(are) more likely to occur?
a. hemorrhagic stroke
b. embolic stroke
c. acute myocardial infarction
d. deep vein thrombosis
Click here for
answer(s)
Cardiac Angiography
Description
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Procedure in which a long catheter is
inserted into a peripheral artery, usually
the femoral or brachial.
The catheter is then guided into the heart
chambers or coronary arteries and
contrast dye is injected to allow
visualization of structures.
Chamber pressures can also be directly
measured.
Example Images
Purpose
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To determine to patency of the coronary
arteries.
To identify cardiac valve disease.
Procedure
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Oral anticoagulant therapy is discontinued
and heparin may be administered prior to
the procedure.
Patient does not receive a general
anesthetic, but may be given a sedative
and/or tranquilizer.
Patient is positioned supine on a table that
tilts.
A local anesthetic is administered to the
catheter insertion site.
Procedure (continued)
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The catheter is inserted into the artery
through an introducer sheath and
advanced to the heart structures with
guidance of fluoroscopy.
When dye is injected into the catheter the
patient experiences a warm, flushing
sensation.
When the procedure is finished the
catheter and introducer sheath are
removed.
Procedure (continued)
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Arterial hemostasis is achieved with direct
pressure, a collagen plug, or sutures.
PT Considerations
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Explain the procedure to the patient.
Postpone activity until arterial hemostasis
has been definitively achieved.
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With direct pressure ~ 8-12 hours.
With a collagen plug ~6 hours.
With sutures ~1/2-2 hours.
PT Considerations (continued)
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Review results of angiography and
planned medical management with the
patient.
Consider the degree of coronary artery
involvement to determine how much and
what type of exercise the patient can
participate in safely.
PT Considerations (continued)
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Avoid resistance exercise for 2 weeks after
the procedure.
Assess the catheter insertion site for
drainage before and after activity.
Apply direct pressure to the catheter site if
bleeding starts or a large bulge forms
rapidly under the skin.
Assess ipsilateral lower extremity pulses,
temperature, strength, and sensation
frequently.
PT Considerations (continued)
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Educate the patient on activity restrictions
after cardiac angiography.
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For 2 days no driving or climbing >2 flights of
stairs.
For 2 weeks no pushing/pulling/lifting >10
lbs, immersing catheter insertion site in water,
sitting for >2 hours at a time, participating in
activities that may cause injury to the upper
leg.
PT Considerations (continued)
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Educate the patient on signs and symptoms
to monitor after cardiac angiography.
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Increased pain at the catheter insertion site, low back,
or abdomen.
Ipsilateral leg / foot changes including coolness,
paleness, numbness, tingling, pain, or weakness.
Bleeding from or rapid swelling under the catheter
insertion site.
Signs and symptoms of infection (drainage, redness,
tenderness, heat, swelling).
Extension of ecchymosis around catheter insertion site.
Review Question #7
How long are bed rest orders typically
followed after cardiac catheterization
when direct pressure only is used to
obtain hemostasis?
a. 20-24 hours
b. 8-12 hours
c. 2-4 hours
Click here for
d. ½-1 hour
answer
Review Question #8
Which artery is most commonly used as the
insertion site for cardiac catheterization?
a. carotid
b. descending aorta
c. radial
d. femoral
e. popliteal
Click here for
answer
Echocardiography
Description
Ultrasound procedure used to create
dynamic images of the heart.
 M-mode echocardiography records
motion of heart structures
dynamically.
 2-D echocardiography give a crosssectional view of heart structures.
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Description (continued)
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Spectral Doppler echocardiography
measures flow of blood through the heart
and can detect turbulent blood flow and
septal defects.
Color Doppler echocardiography (blue and
red) shows the direction of blood flow
through the heart and can identify valve
regurgitation and shunts.
2D M-Mode Echocardiography
Right
Ventricle
Right Atrium
Left
Ventricle
Left Atrium
Color Doppler Echocardiography
Retrograde
Flow (red)
ECG
Signal
Antegrade
Flow (blue)
Procedure
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Patient is positioned in supine or sidelying
on the left.
ECG is monitored during the procedure.
Water-soluble gel is applied on the
patient’s chest were the sound head will
be placed.
The procedure takes 20-45 minutes.
PT Considerations
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Explain the procedure to the patient.
Resume activity soon after procedure.
Use test results to compliment information
obtained during the patient assessment
(heart sounds, blood pressure, exercise
tolerance).
PT Considerations (continued)
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Watch for signs and symptoms of
exercise-induced heart failure in patients
with valve pathology, septal defects, or
ventricular wall motion abnormalities.
Review Question #9
Echocardiography is used to generate
images of what heart structures?
a. lumen of coronary arteries
b. myocyte microstructure
c. ventricular wall
d. valve leaflets
e. sinoatrial node
Click here for
answer(s)
Review Question #10
Echocardiography generates images of the
heart using what?
a. x-rays
b. lasers
c. sound waves
d. magnetic fields
e. opaque dye
Click here for
answer(s)
Electrocardiography (12-lead)
Description
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Procedure that records the electrical
activity of the heart from 12 different
leads.
A standard ECG consists of six limb leads
(I, II, III, AVF, AVL, AVR) and six
precordial leads (V1, V2, V3, V4, V5, V6).
Example Report
Purpose
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To detect cardiac dysrhythmias.
To diagnose myocardial ischemia /
infarction and determine regions of
involvement.
Procedure
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Patient is positioned supine.
Skin is prepared for electrode placement
(hair shaved, skin scrubbed with alcohol...).
Self-adhesive electrodes placed on chest at
ten sites.
The procedure usually takes ~ 15 minutes.
PT Considerations
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Explain the procedure to the patient.
Resume activity soon after procedure.
Use test results to compliment
information obtained during the patient
assessment (anginal threshold, blood
pressure, exercise tolerance...).
PT Considerations (continued)
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Watch for signs and symptoms of
exercise-induced ischemia or heart failure
in patients with ECG changes suggestive
of myocardial injury / infarct.
Monitor ECG closely during activity in
patients with dysrhythmia.
Review Question #11
During a 12-lead ECG how many electrodes
are placed on the patient’s chest?
a. 12
b. 10
c. 6
d. 4
e. 2
Click here for
answer
Review Question #12
Which cardiac disorder(s) could be
diagnosed with ECG?
a. myocardial infarction
b. valve regurgitation
c. myopathy
d. atrial fibrillation
e. coronary heart disease
Click here for
answer(s)
Holter (Event) Monitoring
Description
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Ambulatory ECG monitoring of patient’s
heart rate and rhythm during activity and
rest over a 24-48 hour period.
Data is recorded and then scanned for
abnormalities.
Example Report
Example Report (continued)
(Courtesy of Burdick, Inc., 1997)
Purpose
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To identify cardiac dysrhythmias and relate
them to symptoms or activities.
To diagnose Prinsmetal’s variant angina.
To evaluate the effect of intervention on
dysrhythmias.
To check pacemaker function.
Procedure
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Skin is prepared for electrode placement
(hair shaved, skin scrubbed with
alcohol...).
Self-adhesive electrodes placed on chest
at five to seven sites.
The monitor (~ 1 pound) is attached to
the electrodes via leads.
Procedure (continued)
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The patient is given a diary to record
activity and symptoms experienced during
the data collection period.
After the 24-48 hour period the monitor,
cassette, and diary are obtained for
analysis.
PT Considerations
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Explain the procedure to the patient
Continue normal activity during the
procedure and make sure to document
type of exercise intervention in the patient
diary.
Use test results to compliment
information obtained during the patient
assessment (heart sounds, blood
pressure, exercise tolerance).
PT Considerations (continued)
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Monitor ECG closely during activity in
patients with dysrhythmia.
Make sure monitor does not get wet and
is not removed, even temporarily.
Review Question #13
When a patient is wearing a Holter Monitor
it is important to do what when he/she
exercises?
a. remove the monitor
b. log the activity type
c. secure the electrodes & recorder
d. call the physician
Click here for
answer(s)
Review Question #14
ECG activity is recorded for how long with
Holter Monitoring?
a. 10 minutes
b. 1 hour
c. 6 hours
d. 24 hours
e. 1 month
Click here for
answer
Multigated Acquisition (MUGA) /
Thallium Scan
Description
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Procedure in which a radioactive
substance (technetium-99, thallium) is
used to tag the patient’s blood, allowing
heart movement to be observed.
The images are synchronized with ECG
and the procedure can be done with stress
testing.
With this procedure, only areas of the
heart that are perfused can be visualized.
Example Images
Nuclear scan of the heart at rest (thallium) and with stress (Tc-99) showing myocardial
ischemia with stress. (Janenez, 1999)
Purpose
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To evaluate heart size, structure, and dynamic
function.
To measure chamber volumes and ejection
fraction.
To determine the effect of disease (AMI,
ventricular aneurysm...) on heart function.
To screen for coronary artery disease.
To determine symptom (angina) threshold.
To evaluate cardiac capacity for work.
Procedure
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Skin is prepared for electrode placement
(hair shaved, skin scrubbed with
alcohol...).
Self-adhesive electrodes placed on chest
for ECG monitoring.
Patient is positioned supine with an IV line
in place.
Procedure (continued)
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Dipyridamole is administered via the IV
over 4 minutes. Thallium is injected into
the IV 3 minutes after dipyridamole
infusion begins.
Dobutamine is administered through an
infusion pump. The dose and infusion
rate is increased until the patient’s heart
rate reaches 85% of age-predicted
maximum. Thallium is injected when the
desired heart rate is achieved.
Procedures (continued)
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Patient is positioned supine with a gamma
camera over the chest.
The patient’s chest is scanned with a
gamma camera 5-10 after thallium
infusion.
Typically the patient is scanned again 2-4
hours after the initial pharmacological
stress procedure.
PT Considerations
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Explain the procedure to the patient.
Resume activity soon after procedure.
Use test results to compliment information
obtained during the PT assessment.
Watch for signs and symptoms of exerciseinduced ischemia or heart failure in
patients with test findings suggestive of
myocardial injury.
PT Considerations (continued)
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Use test data to determine optimal
exercise prescription, especially intensity.
Review Question #15
A MUGA scan can provide what specific
information?
a. cardiac tissue perfusion
b. abnormal conduction pathways
c. degree of coronary artery stenosis
d. presence of septal defect
e. ejection fraction
Click here for
answer(s)
Review Question #16
Which agent is administered during a MUGA
scan to increase heart rate?
a. thallium
b. dipyridamole
c. dobutamine
d. gamma rays
e. saline
Click here for
answer
Venography / Arteriography
Description
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A fluoroscopic or x-ray procedure of the
deep leg veins / arteries after injection of
a contrast dye.
Typically this procedure is preformed after
Doppler ultrasonography to confirm
venous / arterial obstruction or
insufficiency.
Example Image
Peroneal
Artery
Anterior
Tibial
Artery
Purpose
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To diagnose deep vein thrombosis.
To evaluate vein patency for coronary
artery bypass grafting.
To identify venous / arterial pathology
(congenital abnormalities...).
Procedure
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Patient is positioned on a table that is
tilted up at a 40-60 degree angle.
A tourniquet is applied above the ankle.
An IV line is established in a dorsal foot
vein / artery.
Contrast dye is injected via the IV over 2-4
minutes.
Procedure (continued)
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X-ray films are taken or fluoroscopy is
monitored.
Normal saline is used to flush the contrast
dye from the veins / arteries.
The procedure takes ~½-1 hour.
Assess Homan’s sign in patients when a
deep vein thrombosis is suspected.
PT Considerations
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Explain the procedure to the patient.
Postpone activity and elevate the tested
leg immediately following the procedure.
Use test results to compliment
information obtained during the PT
assessment.
DO NOT perform exercise involving a
lower extremities with a deep vein
thrombosis until medically cleared.
Review Question #17
A venogram / arteriogram may be used to
diagnose what vascular problem(s)?
a. deep vein thrombosis
b. chronic venous sufficiency
c. peripheral arterial disease
d. lymphedema
e. arterial embolus
Click here for
answer(s)
Review Question #18
A venogram may be used to assess vein
patency prior to harvesting for what
surgical procedure(s)?
a. cardiac valve replacement
b. carotid endarterectomy
c. pacemaker placement
d. coronary artery bypass
Click here for
answer(s)
e. total knee replacement
References
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Goodman C, Boissonnault W. Pathology: Implications for the Physical Therapist.
Philadelphia, PA: WB Saunders; 1998.
Hillegass E, Sadowsky S. Essentials of Cardiopulmonary Physical Therapy.
Philadelphia, PA: WB Saunders; 1994.
Kee J. Handbook of Laboratory Diagnostic Tests. Stamford, CN: Appleton & Lange;
1998.
Polich S, Faynor S. Interpreting lab test values. PT Magazine 1996;January:76-88.
Pollock ML, Schmidt DH. Heart Disease and Rehabilitation. Champaign, IL: Human
Kinetics; 1995.
Jinenez CE. Advantages of diagnostic nuclear medicine. Phys Sports Med
1999;27(13):51-57.
McKinnis L. Fundamentals of Orthopedic Radiology. Philadelphia, PA: FA Davis;
1997.
Merck Manual. Cardiovascular Disorders. Available at: Accessed on 2/22/00.
Murphy M, Berding C. Use of measurements of myoglobin and cardiac troponins in
the diagnosis of acute myocardial infarction. Crit Care Nurs 1999;19(1):58-66.
Roos R. Noninvasive detection of coronary artery disease. Phys Sports Med
2000;28(1):51-64.
Sussman C, Bates-Jensen B. Wound Care. Gaitherburg, MD: Aspen Publishers; 1998.
The End