[06.11] Overview of CV Diagnostics V2

Echocardiography

Which imaging modality is considered the primary method for assessing cardiac structure and function?

Echocardiography, Myocardial Perfusion Imaging, Cardiac Computed Tomography, and Magnetic Resonance Imaging

What four major imaging modalities are discussed for the diagnosis of cardiovascular disease (CVD)?

History taking and physical examination, blood and laboratory testing, and exercise testing

What are the tools that cardiac imaging diagnostics complement in the diagnosis, management, and prognosis of CV system diseases?

Transthoracic Echocardiogram (TTE)

Which type of echocardiogram uses a transducer placed on top of the chest?

High-frequency sound waves (ultrasound)

What does TTE use to penetrate the body and generate a 2D image?

Widespread availability, non-invasive, and no radiation exposure

What are the key advantages of echocardiography?

3D Transthoracic Echocardiogram (3DE)

Which echocardiography modality uses a waffle-like matrix array transducer to acquire a volumetric data set?

Assessment of morphology in valvular disease

What specific application has gained increasing clinical importance with 3DE?

Transesophageal Echocardiogram (TEE)

Which echocardiography modality involves a transducer located on the tip of an endoscope inserted into the esophagus?

Closer, less obstructed views of cardiac structures

What specific advantage does TEE provide over TTE in terms of image quality?

Valvular vegetations, intracardiac thrombi, and congenital abnormalities

What small lesions in the heart is TEE the test of choice for assessing?

Left atrial appendage

What specific cardiac structure is mentioned where TEE is used to assess for intracardiac thrombi?

Topical and systemic anesthesia

What is required for a Transesophageal Echocardiogram (TEE) procedure?

Esophagus perforation, aspiration, and anesthesia-related complications

What are the specific risks associated with TEE?

Intraoperative monitoring during cardiac surgery

What is a routine use for TEE outside of general diagnostics?

Stress Echocardiogram

Which modality is routinely used to assess cardiac function during exercise and identify myocardial ischemia or assess valve function under stress conditions?

Treadmill or bicycle exercise stress test, or pharmacologic stress test

What are the three general ways listed to stress the heart for a Stress Echocardiogram?

Bicycle exercise stress test

Which method of exercise stress testing is noted as not available in the Philippines?

Intravenous infusion of dobutamine

What is the pharmacologic method of choice for a stress test, using an inotropic/chronotropic agent?

Development of new regional wall motion abnormalities and reduced systolic wall thickening during stress

What is the hallmark finding of myocardial ischemia on stress echocardiography?

Anterior mid to mid apical segment weakens during dobutamine stress echocardiography

What finding is suggestive of MI in the LAD territory during dobutamine stress echo?

Widespread availability, no ionizing radiation, and relatively low cost

What are the advantages of Stress Echocardiography?

Point-of-Care/Handheld Echocardiogram (POCUS)

Which equipment offers diagnostic-quality imaging small enough to be carried on rounds?

Cardiologists, ER physicians, ICU intensivists, anesthesiologists, internists, and TMC CVI trainees

What types of medical professionals use POCUS?

Restriction of movement

What occurs in Mitral Valve Stenosis (MS) due to thick and calcified leaflets?

"Hockey stick" appearance

What distinct appearance is seen in the anterior mitral valve leaflet in rheumatic heart diseases and mitral valve stenosis (MS)?

"Fish-mouth deformity"

What observable appearance is noted in mitral stenosis when viewing the mitral valve from the anterior view using 3D imaging?

Hammocking

What term describes the motion of the redundant and floppy mitral valve in Mitral Valve Prolapse?

3D echo

What is the best way to evaluate metallic prosthetic valves, which appear very bright on CT?

Pannus formation, vegetation, or masses

What are the usual causes of obstruction in prosthetic mitral valves?

Bicuspid Aortic Valve

What congenital abnormality of the aortic valve is usually associated with thoracic aneurysms?

Calcify earlier and become severely stenotic

What is the typical long-term progression for bicuspid aortic valves?

Interatrial septum

Where is a mass almost always appreciated if it is a left atrial myxoma?

Moving during contractility

What characteristic movement of a mass attached to the interatrial septum is usually indicative of a myxoma?

Cardiac MRI

What imaging test is needed to confirm whether a mass is a myxoma or a thrombus?

Impair stroke volume, causing patients to present with syncope

What clinical issues can occur if a myxoma protrudes through the mitral valve and into the left ventricle?

Rheumatic heart disease

In which condition does degeneration/calcification start at the tip, leading to the "hockey stick" appearance in mitral stenosis?

Degenerative cases (elderly patients)

In which type of mitral stenosis does the calcification start at the annulus going to the tip?

Check for cardiac thrombus

What must be done in an echocardiogram of elderly patients presenting with atrial fibrillation and a rapid ventricular response who are hypotensive before shocking them?

Forward flow of blood

What does the appearance of blue indicate in ultrasound using color flow?

Regurgitation

What is indicated when there is a mixing of colors, such as red and blue, in the echocardiogram flow?

Transcutaneous aortic valve intervention (TAVI)

What procedure uses a catheter inserted through the groin and threaded up to the aorta to replace the aortic valve?

Radiopharmaceuticals (radiotracers)

What substances are injected intravenously and trapped in the heart and/or vascular cells during Radionuclide Myocardial Perfusion Imaging (SPECT)?

Gamma rays

What does the radioactivity of radiopharmaceuticals emit upon decay?

Single photon emission computed tomography (SPECT) scanner

What device detects the gamma rays emitted by the radiopharmaceuticals?

Flow abnormalities (perfusion defects)

What type of abnormality is examined in SPECT, in contrast to the motion abnormalities examined in echocardiography?

Technetium-99m

What is the most used SPECT imaging agent, associated with the best image quality and lowest radiation dose?

Thallium

What SPECT imaging agent is associated with a higher radiation dose and a longer half-life?

Exercise stress (treadmill or bicycle)

What type of stress is generally preferred for Stress SPECT MPI because it is physiologic and provides additional information?

Coronary vasodilators (adenosine, dipyridamole, regadenoson)

What class of drugs are most commonly given for pharmacologic stress in SPECT MPI?

Adenosine

Which pharmacologic stress agent is most commonly used because it is short-acting?

Ejection Fraction (EF), End-Diastolic Volume (EDV), End-Systolic Volume (ESV), Stroke Volume (SV), Left Ventricular Ejection Fraction (LVEF)

What volumetric information is checked in SPECT imaging interpretation?

EF increases during stress

What is the normal response of the Ejection Fraction during stress in a SPECT scan?

Drop in EF or significant dilation of the ventricle disproportionate to the rest of the image

What SPECT finding during stress suggests something is wrong with the patient?

Reversible myocardial perfusion defect

What SPECT finding is indicative of ischemia?

Fixed perfusion defect

What SPECT finding reflects prior myocardial infarction?

Pregnancy

What is the only absolute contraindication listed for radionuclide MPI itself?

It often uncovers only coronary territories supplied by the most severe stenosis

What is a limitation of SPECT in CAD evaluation regarding stenosis severity?

Balanced ischemia or diffuse CAD

What conditions may be missed in SPECT MPI because it often uncovers only the most severe stenosis?

Obstructive coronary artery disease that needs revascularization

What type of CAD can SPECT rule out, even though it cannot rule out CAD entirely?

No significant difference between rest and stress images

What characteristic defines a normal SPECT study?

Black areas

How do perfusion defects appear on a SPECT scan?

Proportional to blood flow

What is the relationship between tracer uptake and blood flow in SPECT imaging?

A horseshoe or doughnut shape

How do the walls of the left ventricle typically appear in SPECT images?

LAD distribution

What information do polar maps show regarding perfusion defects?

Thin x-ray beam

What does CT use that passes through or goes around the body at many angles?

Detector array

What collects the x-ray beam information in CT before it is digitized into pixels?

Iodinated contrast agents

What is needed for most cardiovascular indications in Cardiac CT?

Bright white

How does bone appear in a CT image?

Black

How does air appear in a CT image?

Varying shades of gray

How do blood and muscle appear in a CT image?

CT Calcium Scoring

What is the simplest application of cardiac CT that does not require contrast?

Agatston score

What is used to quantify coronary calcium in CT Calcium Scoring?

Increased burden of atherosclerosis and CV mortality

What are high Agatston scores associated with?

Millisievert (mSv)

What is the unit of measure for radiation effective dose?

1 millisievert (mSv) or less

What is the reported effective radiation dose of the newest CT machines for calcium scoring?

⅓ of the annual background radiation exposure

How does the effective dose of the newest CT machines compare to the annual background radiation exposure humans usually receive?

3 mSv every year

What is the estimated annual background radiation exposure for humans?

Cancer patients

What patient population may want to avoid CT calcium scoring due to radiation exposure?

Diabetic patients who are high risk (intermediate/high risk)

What type of patient will benefit from CT calcium scoring, even with normal stress tests, ECG, and echo?

Hard plaque

What type of plaque does CT Calcium Scoring look for?

Coronary CT Angiography (CTA)

What imaging test is a clinically important alternative to stress testing in selected patients with suspected CAD?

To enlarge the coronary lumen

Why is sublingual nitroglycerin used prior to contrast injection during CTA?

Non-calcified plaques

What specific type of plaque is CTA critical in detecting, as they are harder to spot than calcified plaques?

More than 50%

What percentage of obstruction typically causes stress tests to be positive for Obstructive CAD?

Calcified plaque

Which type of plaque is described as stable, hard, and typically resulting in chronic chest pain (NO ST elevation MI)?

Non-calcified plaque

Which type of plaque is described as more worrisome, unstable, soft, easily broken off, and typically resulting in ST elevation MI?

Patients are usually older

What is the typical age profile of patients with calcified plaque?

Patients are usually younger

What is the typical age profile of patients with non-calcified plaque?

Volumes and ejection fractions

What measurements can be generated from CT, although they are not as accurate as echogram, SPECT, or MRI?

Non-ischemic cardiomyopathy

What condition might be surprisingly seen on CT in a patient with no CAD but a dilated LV and low ejection factor?

RCA originates from the right aortic sinus and LCA originates from the left aortic sinus

What is the normal anatomy for the origin of the coronary arteries?

Malignant course

What is the term for an anomalous coronary artery coursing in between the aorta and pulmonary artery, where it can get impinged?

TAVR planning

What preprocedural planning uses CT to take measurements for different valve sizes (23, 26, 28, and 30 mm)?

Myocardial infarction

What condition is left ventricular (LV) thrombus usually associated with in CT findings?

LA myxoma

What condition is most likely suspected if there is a mass in the interatrial septum on CT?

Transesophageal Echocardiogram (TEE)

Which imaging modality is noted as being best for viewing vegetations, as they are often missed in CT?

Radiofrequency (RF) energy pulses

What type of energy pulses are delivered in Cardiac Magnetic Resonance Imaging (CMR)?

Phased-array receiving coils

What collects the RF energy pulses placed on the patient’s body surface during CMR?

Gadolinium contrast agent

What contrast agent is used in CMR?