CARDIOPT: TOPIC 2 ACCURACY FOR DIAGNOSIS OF CAD

IMAGING FOR CARDIOVASCULAR SENSITIVITY SPECIFICITY

DISEASES Exercise 68% 77%
Treadmill
CARDIOVASCULAR IMAGING Stress 83% 93%
• Nuclear Cardiology ECHO
SPECT (Tc- 90% 77%
• Echocardiography
99m)
• Cardiac Magnetic Resonance
PET (Rb-82, 93% 82%
• Cardiac Computed Tomography N-13)
COMPARATIVE SPATIAL RESOLUTION CTA (64- 96% 93%
MDCT)

APPLICATIONS OF NUCLEAR
CARDIOLOGY
• Coronary Artery Disease
• Assessment of LV/RV Function
• Cardiomyopathy/Myocarditis
• Valvular Heart Disease
• Cardiac Shunts
• Secondary Hypertension
ARTHEROSCLEROSIS AND IMAGING • Pulmonary Hypertension
MODALITIES • Assessment of Cardiac Transplant

NUCLEAR STUDIES FOR DIAGNOSIS OF

CAD
 • Assessment of pericardial conditions
(difficult echo)
• Assessment of pulmonary veins prior to
radiofrequency ablation
• Assessment of coronary veins prior to
biventricular pacing
CTA ACCURACY OF MDCT FOR CAD

INCREMENTAL PROGNOSTIC VALUE OF

MPI

CTA LIMITATIONS
• Rapid (>80bpm) and irregular HR
• High calcium scores (>800-1000)
• Stents
• Contrast requirements (Cr > 2.0 mg/dl)
• Small vessels (<1.5mm) and collaterals
• Obese and uncooperative patients
• Radiation Exposure
CARDIAC MRI
• Anatomy and Morphology
• Function and Wall motion
CARDIAC CT
• Scar/Viability
APPLICATIONS OF CARDIAC CT • Perfusion
• Angiography
• Diagnosis of Coronary Artery Disease
• Coronary MRA
(Intermediate Probability)
• Plaque
• Suspected Coronary Anomalies
• Assessment of grafts prior to redo
CABG
• Assessment of complex congenital heart
disease (difficult echo)
• Suspected Aortic Dissection
• Suspected Pulmonary Embolism
• Assessment of Cardiac masses (difficult
echo)
DIAGNOSIS OF CAD o Resting ECG or patient not able
to exercise

EVALUATION OF CHEST PAIN SYNDROME

• Equivocal Test
MR ASSESSMENT OF MYOCARDIAL

MRI
• Pros
o No radiation
o Less Toxic Gadolinium Contrast
EVALUATION OF SUSPECTED CORONARY
• Cons
ANOMALIES
o Expensive
o Claustrophobic • CT Angiography
o Long acquisition time • MR Angiography
o Operator dependent
o Technical artifacts with 3T
o Problem in patients with metallic DIAGNOSIS OF ACUTE CHEST PAIN
prosthesis • Detection of CAD: Symptomatic – Acute
DIAGNOSTIC TESTING ACCORDING TO Chest Pain
CLINICAL NEED o Intermediate pre-test probability
of CAD. No ECG changes and
• Chest Pain Syndrome serial enzymes negative
o Intermediate likelihood for CAD
 ASSESSMENT OF COMPLEX CONGENITAL
HEART DISEASE
• Echocardiography
• Cardiac CT
• Cardiac MRI
ASSESSMENT OF PULMONARY VENOUS
ANATOMY BEFORE RADIOFREQUENCY
ABLATION
ASSESSMENT OF MYOCARDIAL VIABILITY
• Echocardiography
• Cardiac MRI • CT Angiography
• PET Metabolism / perfusion
POST CABG ASSESSMENT
• Thallium 201 / Tc-sestamibi SPECT
• Low dose dobutamine echo • MPI
• CT Angiography
ASSESSMENT OF CARDIAC FUNCTION
SUSPECTED AORTIC
• Echocardiography
ANEURYSM/DISSECTION
• Nuclear studies
• Cardiac MRI • Echocardiography
• Cardiac MDCT • CT Angiography
• Cardiac MRI
ASSESSMENT OF VALVULAR FUNCTION
SUSPECTED PULMONARY EMBOLISM
• Echocardiography
• Cardiac MRI • Echocardiography
• Nuclear Studies • CT Pulmonary Angiography
• Cardiac CT • Lung Perfusion Ventilation Scan
ASSESSMENT OF CARDIAC SHUNTS
• Echocardiography
• Nuclear first pass study
• Cardiac MRI
• Cardiac MCDT
ASSESSMENT OF CARDIAC MASSES
• Echocardiography
• Cardiac MRI
• Cardiac MDCT
ASSESSMENT OF PERICARDIAL
CONDITIONS
• Echocardiography (TTE; TEE) CONCLUSIONS
• Cardiac MRI • No simple recipe
• Cardiac CT • Appropriate usage of all available
technologies according to clinical need
ELECTROCARDIOGRAPHY THE SHAPE OF ECG
INTRODUCTION • Contraction of Atria – P Wave
• Ventricular Depolarization – QRS
• ECG or EKG
complex
• ECG is essential for diagnosis
• Ventricular Repolarization – T wave
• Essential in management of cardiac
rhythm
• Helps in diagnosis of chest pain
• Proper use of thrombolysis in treatment
of MI depend upon it
HISTORY
• 1842 – italian scientist Carlo Matteucci
realizes that electricity is associated with
the heart beat
• 1872 – french scientist Gabriel
Lippmann, invented the capillary
electrometer whch can measure
electricity by utilizing mercury
• 1876 – irish scientist Marey analyzes
the electric pattern of frog’s heart
• 1895 – William Einthoven, credited for
the invention of EKG
• 1906 – using the string electrometer
EKG, William Einthoven diagnoses
some heart problems
• 1924 – the noble prize for physiology or
medicine is given to William Einthoven
for his work on EKG
ELECTRICITY OF HEART
• Contraction of any muscle is associated
with electrical charges called
depolarization
• These changes can be detected by RELATIONSHIP BETWEEN THE NUMBER
electrodes attached to the surface of the OF LARGE SQUARES COVERED BY R-R
body INTERVAL AND THE HEART RATE
• Although the heart has 4 chambers,
from the electrical point it is having only R-R INTERVAL HEART RATE
2 (LARGE SQUARES) (beats/min)
1 300
THE WIRING DIAGRAM OF THE HEART 2 150
3 100
• SA
4 75
• AV node 5 60
• Bundle of His 6 50
• Bundle branches (left and right)
ECG RHYTHM SINUS TACHYCARDIA
NORMAL SINUS RHYTHM • Looking at the ECG you’ll see that:
o RHYTHM – regular
• Looking at the ECG you’ll see that:
o RATE – more than 100 bpm
o RHYTHM – regular
o QRS DURATION – normal
o RATE – (60-100 bpm)
o P WAVE – visible before each
o QRS DURATION – Normal
QRS complex
o P WAVE – Visible before each QRS
o P-R INTERVAL – normal
complex
• The impulse generating the heart beats
o P-R INTERVAL – Normal (<5 small
are normal, but they are occurring at a
squares. Anything above this would
faster pace than normal. Seen during
be 1st degree block)
exercise.
• Indicates that the electrical signal is
generated by the sinus node and
travelling in a normal fashion in the
heart.

ECG RULES
• If you follow Professor Chamberlains 10
rules they’ll give you an understanding
of what is normal:

SINUS BRADYCARDIA
• Looking at the ECG you’ll see that:
o RHYTHM – regular
o RATE – less than 60 beats per
minutes
RULE 1: PR interval should be 120 to
o QRS DURATION – normal
200 milliseconds or 3 to 5 little squares
o P WAVE – visible before each
QRS complex
o P-R INTERVAL – normal
• Usually benign and often caused by
patients on beta blockers
RULE 2: The width of the QRS complex RULE 6: The R wave must grow from
should not exceed 110ms, less than 3 V1 to at least V4. The S wave must
little squares grow from V1 to at least V3 and
disappear in V6.

RULE 3: The QRS complex should be RULE 7: The ST segment should start
dominantly upright in leads I and II. isoelectric except in V1 and V2 where it
may be elevated

RULE 4: QRS and T waves tend to

have the same general direction in the
RULE 8: The P waves should be upright
limb leads.
in I, II, and V2 to V6.

RULE 5: All waves are negative in lead

a VR.
RULE 9: There should be no Q wave or
a small q less than 0.04 seconds in
width in I, II, V2 TO V6.

RULE 10: The T wave must be upright

in I, II, V2 to V6.