CARDIAC TESTS AND MEASURES

HIGH frequency sounds-diaphragm

what part of the stethoscope is used to listen to high frequency sounds

bell

what part of the stethoscope is used to listen to low frequency sounds

normal heart and lung sounds

what type of heart and lung sounds fall under high frequency sounds using the diaphragm

Abnormal heart sounds use bell

what type of heart and lung sounds fall under low frequency sounds using the bell

- Aortic: right sternal border, 2nd intercostal space

- Pulmonic: left sternal border, 2nd intercostal space

- Tricuspid: left sternal border, 4th intercostal space

- Mitral: left midclavicular line, 5th intercostal space

- Erb's Point: left sternal border, 3rd intercostal space

What are the primary locations of auscultation

right sternal border, 2nd intercostal space

where do we listen/auscultate for the aortic valve

left sternal border, 2nd intercostal space

where do we listen/auscultate for the pulmonic valve

left sternal border, 4th intercostal space

where do we listen/auscultate for the tricuspid valve

left midclavicular line, 5th intercostal space

where do we listen/auscultate for the mitral valve

Aortic

what auscultation point is located at the right sternal border, 2nd intercostal space

Pulmonic

what auscultation point is located at the left sternal border, 2nd intercostal space

Tricuspid

what auscultation point is located at the left sternal border, 4th intercostal space

Mitral

what auscultation point is located at the left midclavicular line, 5th intercostal space

Erb's point

It is best for identifying murmurs, and it's just the single best point to listen to heart sounds.

left sternal border, 3rd intercostal space

where is Erb's point

Erb's point

what auscultation point is located at the left sternal border, 3rd intercostal space

- Closure of the AV valves (Mitral and Tricuspid)

- Indicates onset of systole

what does the S1 "Lub" heart sound indicate

S1 "Lub"

What heart sound marks the closure of the AV valves and indicates the onset of systole

- Closure of the semilunar valves (Aortic and Pulmonary)

- Indicates onset of diastole

what does the S2 "Dub" heart sound indicate

S2 "Dub"

What heart sound marks the closure of the semilunar valves and indicates the onset of diastole

Indicative of valvular disease

What do Murmurs/Clicks indicate as heart sounds

- abnormal heart sound between S1 and S2

- semilunar valve stenosis

- AV valve regurgitation

- AV not closed

- Semilunar valve not open

What does a systolic murmur indicate

- abnormal heart sound between S2 and S1

- semilunar valve regurgitation

- AV valve stenosis

- AV valve not open

- Semilunar valve not closed

What does a diastolic murmur indicate

- S3: ventricular gallop

- S4: atrial gallop

- Pericardial friction rub

What other abnormal heart sounds that we might hear might indicate concerns with the actual heart muscle as a whole.

pathologic state

volume overload or heart failure, specifically with reduced ejection fraction

what does the S3 ventricular gallop heart sound indicate

abnormal S3 ventricular gallop heart sound

- Benign, compliant heart: children, athletes, pregnancy

- Dilated ventricle: volume overload, HFrEF

in children, athletes, or individuals who are pregnant

Within what populations might the S3 heart sound be benign

S4 heart sound

this sound indicates heart failure with restrictive characteristics, where the ejection fraction is preserved, but we no longer are actually able to fill the ventricle.

after the S2 heart sound

When auscultating when might you hear the S3 heart sound

before the S1 heart sound

When auscultating when might you hear the S4 heart sound

Pericarditis or Pericardial effusion

what does a Pericardial friction rub heart sound indicate

leather rubbing together

what does a Pericardial friction rub heart sound, sound like

sitting because it grants access to the front and the back

what is the best position to perform lung auscultation in

- Must be in direct contact with skin

- Compare R to L in cephalocaudal direction

- Need a minimum of one breath per region

what are key considerations for performing lung auscultations

- Loud, excessively soft, or absent sounds

- Crackles, wheezes, pleural rubs

what do abnormal lung sounds, sound like

movement of fluid in the alveoli when airways reopen

what do crackling lung sounds indicate

7

how many points of auscultation for the lungs are on the front

6

how many points of auscultation for the lungs are on the back

Electrocardiogram

- Simple, routine, often the first test

- Non-invasive, no risk

- Measures Heart rate and rhythm

- Detects abnormalities in EKG patterns

dysrhythmia

what does Alterations in timing/frequency of electrical activity seen on an Electrocardiogram indicate

ischemia/infarct

what do ST segment depressions/elevations seen on an Electrocardiogram indicate

hypertrophy

what does an increase in voltage (QRS complex) seen on an Electrocardiogram indicate

- Holter: 24-hour continuous ECG monitoring

- Event: ambulatory EKG for infrequent episodes

what are the types of ambulatory monitoring of EKG

- Post-event monitoring

- Event/loop recorder

- Auto-triggered event recorder

what are the different types of Event ambulatory monitors

Dizziness, syncope, SOB

What are indications for the use of ambulatory monitors

- Correlation of activities/symptoms with arrhythmias

- Referral for further testing (exercise testing, echo, electrophysiological testing)

- Evaluation of medications or pacers

- Silent ischemia

what are the goals associated with the use of ambulatory monitors

Event/Loop ambulatory monitoring device

constantly recording, but does not save data until device is triggered by patient; then info stored for preset amount of time (30 sec before, 60 sec after)

Autotriggered ambulatory monitoring device

device triggered by patient AND record based on autodetection features programmed into device (ex. Afib, bradycardia)

Chest XR

what is the second test typically ordered followed by an electrocardiogram

- Differentiate lung disease from heart disease

- Enlargement of heart or pulmonary vessels

- Detect calcium deposits

- Dilation of aorta or aneurysm

- Pulmonary edema

what are indications for a Chest XR

Evaluate morphology, cardiac blood flow, and myocardial contractility

what are indications for the use of Magnetic Resonance Imaging (MRI)

Inject contrast to examine status of blood vessels

How can we make an MRI more invasive

angiogram

what other cardiac test can be performed by Injecting contrast to examine the status of blood vessels when doing an MRI

- less familiar than echo and nuclear scintigraphy

- cannot be done for people with metal implants/devices (joints, pacemaker, valve, clips)

what are the cons of MRI

- noninvasive with similar diagnostic accuracy of PET

- less expensive

- more widely available

- no radiation

- quick

what are the pros of MRI

Computed Tomography

- Computerized cross sectional Xray imaging

- Cardiac structures viewed in slides (~1mm-3mm apart)

- masses in CV system

- aneurysm

- pericardial thickening

what are indications for Computed Tomography

CT angiogram

CT scan done with contrast for vascular assessment

- noninvasive

- minimal radiation exposure

what are the pros of a CT scan

Echocardiogram

Use of reflected ultrasound to view internal structures and major vessels

- Regional motion of ventricle wall**

- Chamber size

- Chamber blood volume (with Doppler)

- Stroke volume/ EF estimates

- Thickness of cardiac musculature and septal walls

- Valve function

- Blood flow through the heart

what types of information can be obtained by an echocardiogram

- can be done when exercising

- minimally invasive (TTE)

- real-time imaging of heart activity and blood flow

- can add contrast

what are the pros of Echocardiogram

invasive if (TEE) transesophageal

what are the cons of Echocardiogram

transthoracic (TTE)

what form of echocardiogram can be performed when exercising

MUltiple Gated Acquisition (MUGA) Scan

- Radioactive tracer injected via IV

- gamma camera acquires images from the tracer using echocardiograph

Left side of the heart

what side of the heart is scanned during a MUltiple Gated Acquisition (MUGA) Scan

Determines ejection fraction and monitors diastolic function

what kind of information is provided by a MUltiple Gated Acquisition (MUGA) Scan

LVEF assessment for patients undergoing cardiotoxic chemotherapy

what are indications for the use of MUltiple Gated Acquisition (MUGA) Scans

Quantify and detect myocardial perfusion defects

what is a Perfusion Imaging (SPECT) used for

- Healthy heart - absorbed immediately

- Ischemic heart - takes longer

how are Perfusion Imaging (SPECT) scans interpreted

- Examine EF, regional function, and ventricular volumes

- R vs L contractility deficits

- Positive tests identify high risk populations

what are indications for the use of Perfusion Imaging (SPECT)

Positron Emission Tomography (PET) Scans

- VERY EXPENSIVE

- Gold standard for blood flow measurement and metabolic assessment of the heart

- Uses Persantine

Persantine…..used during a PET Scan

- Administer dipyramidole to vasodilate the coronary arteries when at rest, then give tracer

- the tracer will accumulate in active organs or tissues that are taken on camera

- CO & EF

- Shunt detection

- Angiography (vessel or ventricle)

- Pressures (LH and RH)

- Presence of disease

what information can be obtained by Cardiac Catheterization

Stress Tests

What is the Single most important non-invasive procedure to diagnose and manage CAD

- Angina suggestive of CAD

- Diagnosis/detection of exercise-induced stable angina

- Evaluation of atypical chest pain

- Prognosis/severity of CAD

- Evaluate effects of medical/surgical therapy or intervention

- Evaluate arrythmias

- Evaluate HTN with activity

- Assess functional capacity

- Screen to provide exercise Rx

- Motivation for lifestyle change

what are indications for the use of exercise stress testing

- Post MI or CABG

- Identify high risk patient

- The Modified Naughton, modified Sheffield-Bruce, 5-meter walk test (gait speed), 6 MWT

- Indications for medical management prior to D/C, screening for cardiac rehab programs

what are indications for submaximal exercise testing

- Recent MI

- Acute pericarditis/myocarditis

- Resting/unstable angina

- Serious ventricular or rapid atrial arrythmias

- Untreated 2nd or 3rd- degree heart block

- Decompensated HF

- Acute illness

what are absolute contraindications to maximal exercise testing

- Aortic stenosis (moderate to severe)

- Known L main CAD

- Severe hypertension (SBP >200 or DBP >110)

- Acquired advanced or complete heart block

what are relative contraindications to maximal exercise testing

- Unstable angina at rest

- Severe HF (pulmonary crackles, S3 sound)

- Serious arrythmias at rest

- 2nd or 3rd degree heart block

- Disabling MSK abnormalities

- Valvular heart disease

- BP >180/105 mmHg

- Patient refuses to sign consent form

What are Contraindications to Low-Level exercise Testing (or any exercise in general)

detecting ischemia

during exercise testing, what is the main thing we are looking for

detecting ischemia, because the main thing we're looking for usually is coronary artery disease.

why do we utilize EKG alongside maximal exercise testing

ST depression

what is the main indicator of ischemia on an EKG

1.0 mm or greater horizontal or down-sloping ST segment depression

what is a positive stress test

>.5 but < 1.0 mm ST segment down-sloping

what is an inconclusive/equivocal stress test

< .5 mm horizontal or down sloping ST segment

what is a negative stress test

Exercise-induced ST segment depression >/= 2.0 mm

What is the single most predictive indicator of prognosis post- MI that can be seen during a stress test

stable angina

What is one of the main symptoms that someone with a coronary artery disease is going to present with

level 1 angina

Angina Level

- First perception of discomfort or pain in the chest area

- Generally, does not require one to stop physical activity

level 2

Angina Level

- Discomfort that increases in intensity, extends in distribution, or both, but is tolerable

- Patient slows activity to decrease angina level

level 3 angina

Angina Level

- Severe chest pain that increases to intolerable levels

- Patient must stop activity, take NTG, or both

level 4 angina

Angina Level

- The most severe pain imaginable (infarction-like pain)

- Sign of active MI

- Expired CO2

- Oxygen consumption

- Calorie expenditure

what type of information is recorded or measured during an Exercise Test + Ventilatory Gas Analysis

Metabolic cart: computer system samples

what is used to provide information regarding ventilatory, cardiac or metabolic limitations to exercise

- Sustained Vtach

- Rapid atrial arrythmias (Afib/flu)

- Development of 2nd or 3rd degree heart block

- Increased angina pain (2/4)

- Hypotensive blood pressure response (20 mmHg+)

- Extreme SOB

- Dizziness, mental confusion, lack of coordination

- Severe ST depression (>2.0mm)

- Pale and clammy skin (pallor and diaphoresis)

- Extremely elevated BP (SBP >250, DBP >115)

- Max HR achieved

- Presence of leg fatigue, cramps, claudication

- Patient requests termination

What are the Criteria for stopping MAXIMAL test

- Achievement of 6 METS

- 70-75% of age predicted HRmax

- Fatigue or dyspnea

- HR of 120-130 bpm

- Frequent unifocal or multifocal PVC's (9 or more per minute) or V tach

- ST segment depression of 1-2 mm

- Claudication pain

- Dizziness

- Decreased SBP > 10-15 mmHg

- HTN response: SBP > 200, DBP > 110

- Level 1 angina

What are the Criteria for stopping SUBMAXIMAL test

Pharmacologic Stress Test

For individuals that cannot undergo exercise testing, what is another form of a stress test called

If patient is unable to perform upright exercise

when would a Pharmacologic Stress Test be used

Pharmacologic Stress Tests

- Two phases - each phase 30-60 minutes long

- Immediately after exercise or injection (heart at work)

- 4 hours later - heart at rest

specific for detecting variant angina.

What is the Ergonovine Stimulation test used for