week 5 ischemic heart disease

one of the most common indications for an echo for a pt with IHD is to

assess left ventricular function

what 2 things are we looking at in the ventricle wall

thickening and motion

can we see coronary arteries well on echo

no :(

why is it important to ER pt’s with chest pain to assess wall motion

CAD

Diagnostic test for IHD

• EKG

• Excercise stress test

• Nuclear stress test

• Cardiac MRI

• Cardiac Cath

• Echo

• Excercise stress echocardiogram

What is Myocardial ischemia

lack of O2 to the heart muscle by blockage in coronary arteries

% Cornoary artery blockage for myocardial ischemia

70% narrowing

what are some onsets for ischemia

increased demand for O2

• Excertion

• emotional stress

• coronary arteries cant supply enough blood to muscle

hypokinesis

change in wall motion of affected area

is hypokinesis permanent

no

wall motion returns to normal when demand for O2 returns to normal

Angina def

chest discomfort due to ischemia (lack of O2 to myocardium)

angina symptoms

• chest tightness, pressure, heaviness

• radiating pain to left arm, jaw and back

• WOMEN

  • Nausea

  • vomiting

  • SOB

  • General uneasiness

sequence of myocardial ischemia

1. perfusion abnormalities

   • observed by NUCLEAR IMAGING

2. Diastolic and STRAIN abnormalities

3. Wall motion abnormalities

   • Echo

4. ECG change and ANGINA

   • EKG

5. Cardiac enzyme release

what is a Myocardial infarction

when occlusion in 1 or more of the coronary arteries leads to irreverable damage to myocardium

MI AKA

Heart attack

signs and symptoms of MI

• Angina

• chest heaviness, aching, pinching, squeexing, tightness, pressure

• nausea, vommiting

• numbness

• dizziness / fainting

• diaphoresis (Excessive unexplained sweating)

• Palpitations

• Radiating arm, back, shoulder, jaw pain

• dyspnea

• HF (SOB, Edema, cough)

• Sudden cardiac death

• ECG Changes

• WOMEN

  • Nausea, vommiting, SOB, General uneasiness, feeling unwell

causes of MI

• Rupture of atherosclerotic plaque

• SCAD (spontaneous coronary artery dissection)

  • more common in women

• coronary spasm

EKG for acute MI

ST Elevation

EKG for old MI

Q Waves

leading cause of death in men and women

MI *o*

echo for acute MI

• Normal wall thickness

• reduced / absent endocardial motion & wall thickening

• ST Elevation on ekg

echo for old MI

• Thinning and increased echogenicity due to scarring and fibrosis

• abnormal motion and absent wall thickening

• Q Waves on the EKG

progression of MI

1. heart muscle is affected

   • hypokinetic

   • akinetic

   • normal thickness

2. myocardium becomes thin and scarred (fibrotic) over time and appear brighter on echo

3. normal wall motion implies no ischemia at the time of imaging

4. Dresslers syndrome

   • form of pericarditis

   • small pericardial effusion after MI

   • Usually 1 - 12 weeks post MI

What is the best test for post MI patient with a murmur and what is assessed

echo

• MR

• VSD

• Ventricular rupture with pseudoaneurism

Ischemic MR after MI

• MC COMPLICATION OF MI***

• Ischemia and dialated cardiomyopathy

• cause by papilary muscle displacement and dilation of the annulus

• severe MR can occur with papillary muscle rupture

• tenting of MV LEAFLETS

  • (Normal closure is at the annulus)

VSD after MI

• Rupture of part of the IVS

• Evaluate using color looking for high velocity flow from left to right

• left to right because of increased LV Pressure

• obtain peak velocity using CW in MULTIPLE WINDOWS

Pseudoanuerism AKA

Contained rupture

What is a pseudoanurism

aneurism caused by a rupture

qualities of a pseudoaneurism

• narrow neck (<0.5cm) and lined with pericardium

  • NOT LINED WITH MYOCARDIUM

• may have thrombus

  • Perform off-axis magnified imaging (improved near field resolution)

• surgical repair recommended

True anuerism characterics

• Diastolic contour abnormality

  • outward bulging of the wall in a severyly infarcted area

• systolic dyskinesis

  • wall moves out while the other walls contract in

• Lined by thin myocardium

• Smooth transition from normal myocardium to thinned area

• MOST COMMON IN APICAL OR INFEROBASAL WALLS

• Wide neck

  • GREATER THAN 0.5 cm

• may have thrombus

  • perform off-axis magnified imaging (improved near field resolution)

pericardial Effusion

• can occur after MI

  • Dresslers syndrome

• Non-specific response

• Usually benign but can indicate pericarditis, possible dissection or LV Rupture

• sometimes can develop tamponade physiology

Right ventricular infarction

• most common with INFERIOR MI

• RV Hypokinesis

• Variable degrees of dilation

Left Ventricular thrombi

• clotting formation in area of low flow

low flow examples increasing risk of LV Thrombi

• Severly reduced akinetic area

• aneurism

• appearance of spontaneus echo contrast (smoke)

where do you have to image very carefully for left ventricular thrombi and why

LV and APEX

• Can be small or large

• can be confused with other structures

  • trabeculation, tendon, chord

• use high res settings for better near field resolution

• use off axis planes (short-axis apical views)

• use multiple imaging planes

ST Depression

Ischemia

Normal sinus rythym

ST Elevation

acute MI

Q Waves

OLD MI

Q Waves after an inferior MI

(Usually RV)

what is each color

blue- lateral

• I, aVL

• V5, V6

yellow - inferior

• II, III, aVF

Green - septal

• V1, V2

Red- Anterior

• V3, V4

LAD Occlusion will cause MI and Akinesis of

• anterior septum

• anterior wall

• apex

Right coronary artery occlusion will cause MI and Akinesis of

• Inferior septum

  • Base and mid

• Inferior wall

Circumflex artery occlusion will cause MI and Akinesis of

• Anterolateral wall

  • (Lateral wall)

• Inferolateral wall

A4C

• Inferoseptal wall

  • APICAL Septal - LAD

  • Mid - RCA or LAD

  • Basal - RCA

• Anterolateral

  • LAD or CX

• RV Free wall

  • RCA

• Apical tip

  • LAD

A2C

• Anterior wall

  • Apical- LAD

  • mid - LAD

  • Basal- LAD

• Inferior wall

  • Apical - LAD

  • MID -RCA

  • Basal - RCA

• RV Free wall

  • RCA

• Apical tip

  • LAD

ALAX (A3C)

• Anteroseptal

  • LAD

  • LAD

  • LAD

• Inferolateral (posterior)

  • Apical - LAD

  • Mid - RCA or CX

  • Basal - RCA or CX

• RV Free wall

  • RCA

• Apical tip

  • LAD

LAD

• Anterior

• Anteroseptal

RCA

• Inferior

• Inferoseptal

Antero lateral

• LAD or CX

Inferolateral

• RCA or CX

LAD

• Anterior

• Anteroseptal

RCA

• Inferior

Antero lateral

• LAD or CX

Inferolateral

• RCA or CX

• RV Free wall

  • RCA

• anterior

  • LAD

• septal

  • LAD

• inferior

  • LAD or RCA

• Lateral

  • LAD or CX

Regional heart motion abnormalities:

a segment of the heart does not thicken, contract, and move inward during systole

Possible causes of regional wall motion abnormailities in ABSENCE OF CAD

• wall thickening / timing

• wall thickening is preserved, although its timing may differ from normal

Possible causes of regional wall motion abnormailities in ABSENCE OF CAD

• Abnormal electrical conduction

• conduction abnormalities

  • LBBB

• Ventricular pacing

• ventricular pre-excitiation

• post-pericardiotomy state

• pericardial constriction

• right ventriular pressure and volume overload

• external compression

• nonischemic dilated cardiomyopathy

• stress cardiomyopathy

• systemic disease such as sarcoidosis or hemochromotosis

avoid ________ in apical views

FORESHORTENING

How to avoid foreshortening in apical views

1. endocardial definition may be difficult due to attenuation from lung

2. Change patient position

3. Respiratory manuveurs

5 tips for imaging in apicals

1. avoid foreshortening

2. obtain extra views at different depths

3. perform off axis views of the APEX when wall motion abnormalities are present

4. Magnify of the APEX using high resolution to evaluate thrombus

5. Use contrast

benefits of contrast in apicial view

• aid in endocardial defintion

• presence of thrombus especially when wall motion abnormalities are pressent

qualitative evaluation of global & regional function in CAD

• Visual assessment of global and regional wall motion and systolic function

• Estimate (eyeball) ejection fraction EF

• Use all windows and many tomograophical views

semi-quantitative evalutation - wall motion score index 1-4

1. normal

   • endocardial inward motion and thickening and of wall in systole

2. hypokinetic

   • reduced endocardial motion and wall thickening in systole

3. Akinetic

   • absense of inward endocardial motionor wall thickening in systole

4. Dyskinenetic

   • outward motion “bulging” of the segment in systole, usually associated with thin, scarred myocardium

how to get an overall wall motion score

divide the sum of scores for each segment by the number of segments evaluated

what MUST be visualized to evaluate wall motion score

ENDOCARDIUM!!!

wall motion criteria for normal or hyperkinetic

normla thickening (usually 30% thickening from end diastole

wall motion criteria for hypokinetic

reduced thickening (usually10-30% thickening from end diastole)

wall motion criteria for akinetic

markedly reduced or no thickening (<10% thickening from end-siastole)

wall motion criteria for dyskinetic or aneurismal

dyskinesia:

aneurism:

dyskinesia: paradoxial thinning and / or outward motion during systole

Aneurism: diastolic deformation of the shape with dyskinetic movement

wall motion score for:

• normal or hyerkinetic

• hypokinetic

• akinetic

• dyskinetic or aneurismal

• normal or hyerkinetic

  • 1

• hypokinetic

  • 2^a

• akinetic

  • 3

• dyskinetic or aneurismal

  • 4

quantitative evaluation of ventricular function

• bi-plane tracing of the endocardium at end-systole and end-diastole in the apical views

• must have optimal ENDOCARIAL DEFINITION

• Method of discs- Simpsons

• More accurate and preffered method as long as good imaging of the ENDOCARDIUM

Stress echo for CAD

Echo alone can not assess for CAD

What does a stress echo use to diagnose ischemia

• Echocardiography (wall motion)

• Electrocardiogram

to diagnose ischmia

2 types of stress echoes:

both aim to do what?

• excercise

• debutamine (pharmalogic)

Both aim to raise HEART RATE and PRIODUCE ISCHEMIA

What will develop if ischemia is present in a stress echo

wall motion abnormalities

• reduced O2 to the area means less contraction and thickening

what do we need to evaluate during ischemia

WALL MOTION!!!

When are pressure gradients obtained

PEAK STRESS***

(Stenosis, Obstruction)

What is assessed on ALL Stress echos

PAP!!

what is echo used for to determine in the ER

Suspected MI or CHEST PAIN

Echo can indicate complications from the following conditinos (3)

• Regurgitation, effusion, ruptiure

echo can determine _____ and _____ of wall motion abnormalities

location and severity

echo is used to re-evaluate after what procdures

• CABG

  • Coronary artery bypass graft

• Stent

• Balloon angioplasty

presense of wall motion abnormalities can help distinguish between?

CAD or Dilated cardiomyopathy

End-stage ischemic cardiac disease

Global LV dysfunction develops due to multiple infarcts with some regional variation in wall motion

at end-stage it is difficult to differentiate between?

Dilated cardiomyopathy and end-stage ischmic cardiac disease

Dilated cardomyopathy usually affects

BOTH VENTRICLES

Dilated cardiomyopathy usually preserves

Function at the base

• basal posterior wall and lateral wall move best

Ischmic disease echo symptoms

• definte areas of akinesis or wall thinning

• normal right ventricuklar size and function, unless it had an infarct