Diagnostic Methods Final

NSTEMI

EKG may not show ST elevations, but they have elevated troponins

What can you use for diagnosis an MI?

Myoglobin, CK, CK-MB, LDH, Tropinin I and Troponin T (test of choice)

Creatinine Kinase

It’s an enzyme in the muscle.

Increases for rhabdomylosis, MI, myocarditis, muscle trauma.

Rises within 3-5 hrs of MI. A normal CK is reassuring but an elevated CK is NOT specific enough for MI diagnosis

Helpful for pts who already have an elevated baseline troponins - almost always high in pts with dialysis

CK-MB

Troponin I and T are what?

different subunits of proteins in muscle. Lab doesn’t always tell you what their testing. Some POC troponins exist but are less sensitive under 3 hrs from onset of symptoms and can be incredibly expensive.

ALWAYS get 2 troponins at least 3 hrs apart. A single troponin is a lawsuit

When do troponins begin to come up?

about 4 hrs after MI. Peaks at 8-12 hrs.

it can come up with stents surgery as well, etc.

SHOULD NOT increase in muscular dystrophy. It is specific to cardiac muscle

Lactate Dehydrogenase (LDH)

an enzyme that catalyzes the conversion of lactate and pyruvate.

We only use if we want to know if someone has had an acute MI or subacute MI.

not normally used

What are the lipids?

–Total cholesterol

–LDL

–HDL

–non-HDL Cholesterol = LDL + VLDL

–VLDL

–Triglycerides

–TC/HDL ratio

–Apolipoprotein B

what are risk factors for heart disease?

–At risk of heart disease:

•Smoking (cigarettes)

•Sedentary lifestyle

•Being overweight or obesity

•Poor diet

•Men over 45 years or women older than 55 years

•Hypertension (>140/90)

•Positive immediate family history of premature heart disease (under 55 for men and under 65 for women)

•Pre-existing heart condition

•Diabetes or prediabetes

Lipids are soluble or not in blood stream?

insoluble

so they are packed in lipoproteins

HDL vs LDL

HDL is good

LDL is bad

Why shouldn’t lipids be measured after someone has been ill?

if they are acutely ill - lipids may be low.

same with pregnancy and stress

For ill people, we want their LDL to be below what?

70

when can you know right away that your total cholesterol is inaccurate?

Triglycerides are over 400 mg/dL

what is the desirable total cholesterol?

under 200 mg/dL

High Density Lipoprotein (HDL-C)

test for the good Cholesterol (HDL)

HDL has antiatherogenic and antiinflammatory properties. Some labs report a total cholesterol to HDL desirable ratio of 5:1

what are triglycerides risk factors for?

CAD and pancreatitis

T/F fasting specimen is required for triglycerides

True

normal is less than 150

Metabolic syndrome is diagnosed by what 3 things?

need 3 of the following:

1. Low HDL-C (high cholesterol)

2. Triglycerides over 150 mg/dL

3. Glucose over 100 mg/dL

4. Waist circumference over 102 cm in men and 88 cm in women.

5. Blood pressure equal or over 130/85 mm Hg

What is the most commonly used lipid used to assess CV risk?

LDL-C - must be a fasting test

what is optimal LDL?

under 100 mg/dL

VLDL is what?

it is atherogenic and correlated to CAD and peripheral artery disease.

what is APOb attached to ? APOa?

APO B is attached to all the bad cholesterols, APOa is attached to HDL

APOb

elevated means increased risk of CAD and artherogenicity. and increased of risk of fatal MI

What are the 2 forms of heart failure?

Heart can’t pump (systolic failure)

or thickened heart that cannot fill - hypertrophic cardiomyopathy (diastollic failure)

what do you use to test heart failure?

ANP and BNP → BNP is pretty much exclusively used

These word to decrease sodium/volume in the blood. Decreases blood pressure

Aldosterone

keeps sodium gets rid of potassium

keeps fluid → increases BP

What is the normal level of BNP? what level is 90% specific for heart failure?

BNP- 0-100

if it is over 400 then it is specific for heart failure

• pt may not be able to breath when laying flat

what is NT-proBNP

it is the biologically inactive precursor to BNP. Increasess BNP in pts with volume overload or other stress on the heart.

when should aldosterone be checked? when is it increased? decreased?

early morning. pt should also be salt-depleted and upright.

increased: primary hyperaldosteronism

decreased: primary or secondary hypoaldosteronism

what is the most sensitive test for primary hyperaldosteronism?

aldosterone urine

what is D-dimer

terminal fibrin degradation product

used for determining blood clots (like pulmonary embolisms)

very nonspecific

C-reactive prootein (CRP) tells you what?

inflammation, very non specific.

it is an independent risk factor for atherosclerotic disease.

what is homocysteine?

an amino acid that is higher in men than women

high is a risk factor for CAD

Catecholamines

epinephrine, dopamine, norepinephrine

24 h urine collection

used as screening for pheochromocytoma (rare catecholamine producing tumor) - can be used for neuroblastomas and ganglioneuromas

VMA (Vanillylmandelic Acid)

urine test

low sensitivity

used to screen children for neuroblastoma and to monitor pts

Cortisol

comes from adrenal glands

stress increases cortisol

serum test

time dependent - different times of the day have different normal levels

increased in Cushings

decreased in Addisons

what leg is the ground lead?

right leg

which leads are augmented?

leads with an a in front of it

aVF, aVL, aVR

sinus is what?

a P-wave before every QRS

Normal P wave amplitude

<2.5 mm

duration <120ms

PR interval is what?

the delay at the AV node

should be less than 1 large box

How many boxes should Ventricles be?

less than 3 boxes

what does a slurred upstroke after P wave indicate?

WPW - delta wave

the bundle of kent conducts too quickly

what do bunny ears on QRS mean?

an issue with ventricular depolarization and an RSR’ pattern in V1-V3

what is appropriate discordance?

abnormal depolarization should be followed by abnormal repolarization which appears as the QRS and T wave going in different directions. IN RBBB this manifests as ST depression or T wave inversion in V1-V3

RBBB with LAFB in the context of chest pain indicates what?

Concordant ST segment and blockage in LAD

what is an incomplete RBBB pattern on an EKG?

defined as RSR’ pattern in V1-V3 with QRS that is under 120 ms

normal variant commonly seen in children

LBBB criteria

QRS >120 ms

dominant S wave in V1

Broad monophasic R wave in lateral leads (I, aVL, V5-V6)

Abscence of Q waves in lateral leads

Left ventricular hypertrophy criteria

Sokolow-Lyon Criteria: S1 in V1 + the tallest R wave in V5 or V6 is over 35 mm → LVH

PACs (premature atrial contraction) vs PVC (premature ventricular contraction)

can tell the difference by the width of the QRS. if you get a premaure beat without a P wave it is not depolarizing the atria.

why is QT interval important?

this is the area the heart is very sensitive to getting hit.

QT should be less than halfway between the beats.

what is the problem with a long QT ?

this vulnerability is prolonged repolarization is irregular and pts have higher risk of ventricular arrythmias and sudden cardiac death

→ Torsades de Pointes

posterior ST elevation is what coronary artery?

RCA or LCx

what does ST aVR elevation mean??

means Left MAIN artery occlusion

Pericarditis on EKG

widespread ST elevation with reciprocal ST depression and PR elevation in AVR (can sometimes be seen in V1 too)

Wellen’s Dyndrome

a pt with CP and has deep inverted T waves or biphasic Twaves in V2-V3

at high risk of critical blockage in LAD

If you see U waves, what test should you get?

basic metabolic panel → check potassium for hypokalemia

type I heart block

prolonged PR interval

delayed conduction in the atria

Mobitz I

Progressive PR + dropped beat

fatigue with resultant failure or intermittent failure of the bundle of his

Mobitz II

Fixed PR interval, dropped beat

fatigue with resultant failure or intermittent failure of the bundle of his

3rd degree

no relation between P waves and QRS

complete failure of the Bundle of His

Echo

US with Doppler - tells you blood flow

Transthoracic Echo (TTE) across the chest

Transesophageal echo (TEE) across the esophagus

Stress Echo - making you workout or give you meds and looking at heart

you can see the chambers of the heart, valves, annd certain pathologic conditions

what is the echo of choice for most pts? and what is the indication?

TTE

indications: ACS/Chest pain
SOB/Dyspnea on exertion

MI

CHF

Valvular disease

Murmurs

Cardiomyopathies

Pre/post surgical

Cadiac Tamponade

Structural abnormalities

A bubble study

looking at the anatomy of the heart - looking for holes where blood is flowing abnormally

looking for patent foramen ovale (PFO) or ventricular septal defect (VSD) or patent ductus arteriosus (PDA) or other shunt.

when is a stress echo indicated?

pt with known or suspected CAD

assessment of myocardial viability

evaluation of dyspnea on possible cardiac origin

evaluation for pulmonary artery HTN as pulm artery systolic pressure

radionuclide myocardial perfusion imaging (rMPI)

evaluates cardiac perfusion and function

indications:

evaluation of CP in pts with known or suspected coronary artery disease

Cardiac CT or Calcium scores

see cardiac arteries and you can get a calcium score to see how much plaque has built up

when would you use cardiac MRI?

not used for screening but for investivation of:

Congenital heart disease, intracardiac mass, etc.

what are cardiac caths used for?

used to evaluate the coronary arteries and the great vessels

a catheter is introduced through a peripheral vessels, contrast is injected under fluroscopy in the area of interest and used to visualize

4 types:

pulmonary, aortography, coronary angiography, angiocardiography

what is the medical field dedicated to treating cancer?

oncology

specialties within include medical, surgical, radiation, and interventional oncology

What are the two kinds of tumor staging?

clinical staging: non-invasive staging, including physical examination and imaging evaluation.

pathologic staging: refers to findings from tissue specimens and allows for the identificaiton of the microscopic extent of disease that may be subclinical or not apparent on physical examination or imaging.

What is TNM staging?

Tumor, node, metastasis staging

1. location of primary tumor

2. tumor size and invasive nature of the tumor

3. lymph node involvement

4. presence or absence of distant metastasis

T staging in TNM

T category describes the original (primary) tumor.

T1 is under 3 cm

T2 3-5 cm

T3 is 5-7 cm

T4 is over.

Size increases with number

TX = primary tumor cannot be evaluated

T0= can’t find tumor; no evidence as primary tumor

Tis= carcinoma in situ

N nodes staging in TNM

N category

NX= regional lymph nodes cannot be evaluated

N0= no regional lymph node involvement

N1-3= involvement of regional lymph nodes/extend of spread

M category in TNM staging

M0= no distant metastasis

M1= distant metastasis

PET scans

positron emission tomography

a radioactive tracer is injected into the veins to allow imaging. There are different tracers. Glucose is commonly used in cancer.

Depending on the tracer used, it will be absorbed in the area of the body using that molecule. This is a “hot spot”

used for initial staging. Is also used for follow up treatment and to monitor disease recurrence.

Biopsies

both tissue - incisional biopsy, excisional biopsy, punch biopsy, curettage biopsy, unplanned biopsy

and liquid biopsies - evaluate liquid or molecular evidence often of malignancy

incisional biopsy

the lesion is too big to excise for biopsy. A small deep wedge is removed from the lesion

excisional biopsy

the lesion is small enough to excise completely during the biopsy

exploratory biopsy

exposed portions of the lesion are removed

punch biopsy

punch used to biopsy the lesion and this can be either incisional or excisional

curettage biopsy

small amounts of tissue are excised and centrifuged and applied to agar

unplanned biopsy

lesion uncovered during surgery

needle biopsy

a type of biopsy using a needle

shave biopsy

raised lesions are sliced off the base being careful to avoid cutting too deep and causing permanent imprint in the skin.

fine needle cutting biopsy

performed using a trocar like needle to obtain a sample for histology. similar to fine needle aspiration but sample is easier to interpret

what does a biopsy tell us?

whether a tumor is benign or malignant

what type of malignancy

how many lymph nodes are involved

PET scans are used for what in cancer treatment?

for follow up

did we get it all ? any residual left?

Markers

another way to monitor cancer

a variety of substances that can be measured in tumor tissues, blood, or other bodily fluids.

can help with screening, detecting/diagnosis

Alpha Fetoprotein

Use to screen for neural tube defect

found in fetal life and some tumors.

it is not good enough to use for must screening

increases in hepatocellular carcinoma and testicular

CA 15-3 and 27-29

breast cancer

used to monitor response to treatment and recurrence

27-29 for metastases detection

CA19-9

pancratic, gallbladder, bile duct, and gastric cancers → used to monitor responset to treatment

CA 125

ovarian cancer

used when ovarian cancer is suspected, but not sensitive enough for early cancer, used to monitor response to treatment

CEA

increased in colorectal cancer

Catecholamine markers

screening for pheochromocytoma

VMA

detects pheocromocytomas

low sensitivity

used to screen children for neuroblastoma

used to monitor pts

Beta-hCG quantitative

normal is under 5 mlU/mL

increases in pregnancy and peaks at 9-12 weeks

decreased in threatened and spontaneous abortion

IgG

Ig GONE

increased in autoimmune diseases, some chronic/recurrent/parasitic infections

hihg levels can indicate: multiple myeloma, lymphoma, other malignancies

decreased in immunosuppressive therapy, genetic immunodeficiencies

IgM

early infections

high: lymphoma, Waldenstrom macroglobulinemia