CARDIAC DIAGNOSTIC AND INVESTIGATIVE PROCEDURE

1. Diagnostic
Investigations of
Cardiovascular
System

2. Introduction
• Diagnostic investigations
in cardiology are methods of
identifying heart conditions
associated with unhealthy,
pathologic, heart function.

3. C TYPES OF CARDIAC DISORDERS
ASSOCIATED TEST
Non Invasive Test Invasive test
C COMMON SERUM ENZYME TEST
Creatinine kinase test lactate
dehydrogenase test Troponin test
AST test.

4. C DIAGNOSTIC TESTS: NON INVASIVE
PROCESS:
1. chest x ray 2.ECG
3.Echocardiography 4.MRI scans
INVASIVE PROCESS:
Incision of the body by the external subject.
1.High speed computed Axial tomography.

5. Electrocardiographic Tests
Electrocardiographic tests are noninvasives tests
which uses the electrocardiogram to evaluate the
electrical activity generated by the heart at rest
and with activity

6. Ambulatory Monitors
EKG/ECG
Exercise Stress Test
Metabolic Exercise Stress Test
Electrocardiographic Tests

7. Ambulatory Monitors
Ambulatory monitors are small, portable
electrocardiograph machines that are able to
record the heart’s rhythm. Each type of monitor
has unique features related to length of recording
time and ability to send the recordings over the
phone

8. Ambulatory Monitors
assess heart rhythm over time
correlate symptoms with heart rhythm
diagnose abnormal heart rhythms:
what kind they are, how long they last, and
what may cause them guide treatment for
abnormal heart rhythms

9. Types of Ambulatory Monitors
Holter
Loop Recorder
CardioNet (mobile cardiac outpatient telemetry)
Transtelephonic transmitter

10. Holter Monitor
(also called Ambulatory ECG)
A Holter monitor is a portable ECG
recorder that is worn during normal
daily activities, including sleeping. It
can be worn up to 24 hours.

11. Holter Monitor
Electrodes are placed on the skin of the chest.
Wires are attached from the electrodes to a box
about the size of a portable tape player and worn
on a belt or shoulder strap. The electrical
impulses are continuously recorded and stored in
the Holter Monitor

12. Holter Monitor
The patient is asked to keep a diary of activities
and symptoms, such as fluttering feelings in the
chest (palpitations), rapid heartbeats, and any
episodes of dizziness or faintness.

13. Loop Recorder
(also called an Event Recorder)
This device, similar to a Holter monitor, is worn
during normal daily activities including sleeping;
however, it is worn for a longer period of time. It
can be removed during showers and baths. It is
used for arrhythmias that occur less frequently.

14. Loop Recorder
When the patient feels symptoms, they depress a
button and the recorder is activated. The monitor
records the event for the 60 seconds prior to
pushing the button and up to 40 seconds after
the arrhythmia is over. The loop recorder can
store up to three events.

15. Loop Recorder
The rhythm can be sent immediately or saved
and transmitted later, over the phone line. The
technician will give the recordings to the doctor
for review. If the reading indicates an emergency,
the technician will instruct the patient to go to
the emergency room

16. Technician instructing on Loop
Recorder

17. CardioNet
(Mobile Cardiac Outpatient Telemetry)
CardioNet mobile telemetry allows continuous
heartbeat monitoring as the patient goes about
daily activities. Most people are on the CardioNet
service from 7 to 14 days.

18. CardioNet
(Mobile Cardiac Outpatient Telemetry)
This device consists of a small sensor attached
to three electrode pads, worn on a belt clip. The
sensor sends each heartbeat to a handheld
monitor that can be tucked into a pocket or purse.

19. CardioNet
(Mobile Cardiac Outpatient Telemetry)
When the monitor detects a heart rhythm
problem — whether the patient feels it or not — it
automatically transmits your ECG to the
CardioNet monitoring center. A cardiac
technician analyzes each transmission, responds
appropriately to each event and transmit
diagnostic reports to the doctor.

20. Patient wearing CardioNet
system

21. Transtelephonic Transmitter
Transtelephonic transmitters are not worn
continuously.
They are used only during the phone-monitoring
period. In the past, this type of transmitter was
used for monitoring pacemaker function.
However, now it is used for patients with
arrhythmias to monitor certain events indicated
by their doctor.

22. Transtelephonic Transmitter
The electrode may be a finger electrode, wrist
bracelet or chest plate. The patient dials the
center and places the telephone into a
transmitter. After the transmission is completed,
the nurse or technician will ask questions about
the patient’s symptoms and current medications.

23. Patient testing transtelephonic
transmitter

24. Electrocardiography
• The recording produced
by this procedure is
termed an
electrocardiogram
(ECG or EKG from the
German
Electrocardiography (ECG / EKG) is a
transthoracic interpretation of the
electrical activity of the heart over a period
of time, as detected by electrodes attached
to the outer surface of the skin and
recorded by a device external to the
body(electrocardiograph).

25. Working
:
• The ECG device detects and amplifies the tiny electrical
changes on the skin that are caused when the heart
muscle depolarizes [ contracts ]during each heartbeat.
• This depolarization is detected as tiny rises and falls in
the voltage between two electrodes placed on either
side of the heart which is displayed as a wavy line
either on a screen or on paper.

26. Lead System
• Consists of electrodes used in pairs
▫ Eg: LA+ and RA-, Active and indifferent
• The output from each pair is known as a
lead.
• Each lead is said to look at the heart from a
different angle.
• Usually, ECG is recorded
in 12 leads:
▫ Bipolar
▫ Unipolar

27. Bipolar leads
• Electrodes are connected to two limbs one being a
positive pole and other being a negative pole
• The limb leads form the points of Einthoven's triangle
• They are:
• Limb lead I: LA+, RA-
• Limb lead II: RA-, LL+
• Limb lead III: LA-, LL+

29. Unipolar leads
• Here the electrodes have two poles, one is active and
the other inactive.
• They are:
▫ Augmented limb leads
▫ Precordial leads
• The negative pole is produced by connecting the
electrodes, RA; LA; and LL, together, via a simple
resistive network.
• Positive pole is active and negative pole inactive

30. Augmented limb leads
• They are: aVR , aVF, aVL
• Lead augmented vector right (aVR):
• +ve electrode: right arm
• -ve electrode: left arm & left foot
• Lead augmented vector left (aVL):
• +ve electrode: left arm
• -ve electrode: right arm & the left foot
• Lead augmented vector foot (aVF):
• +ve electrode: left foot.
• -ve electrode: right arm & left arm

31. Precordial
leads
• Active electrode-placed directly on 6
points on
the chest.
• Electrodes do not require augmentation.
• They are:
▫ V1:4th
intercostal space near right
sternal margin.
▫ V2:4th
intercostal space near the left
sternal
margin.
▫ V4: left 5th intercostal space on
midclavicular line.
▫ V3: between V2 and V4.
▫ V5: left 5th
intercostal space on
anterior axillary line.
▫ V6: left 5th
intercostal space on mid
axillary line.

32. Procedur
e
• Patient lies down on his back.
• Several areas on skin of arms,
legs, and chest are cleaned and
shaved, and small patches i.e
electrodes are attached to
these areas.
• The patches are connected by
wires to the ECG machine
• The heart's electrical signals
are printed into wavy lines on
paper.
• Variations in size and length
of the different parts of the
tracing may indicate a
problem in the part of the
heart associated with that
particular lead.

33. Devices: Holter monitor, Event monitor, 12
lead electrocardiograph

34. Cardiac Stress
Test

35. Normal waves

36. Feature Description Cause
P wave Impulse travels from Atrial depolarization
the SA node towards [contraction]
the AV node, and
spreads from the right
atrium to the left atrium
QRS complex From beginning of Q
wave to end of S wave
Ventricular
depolarization
T wave Relaxation of ventricles Ventricular
repolarization

37. Featur
es
Descirption Cause
PR
interval
Onset of P wave to onset of Q wave
Isoelectric line
Atrial depolarization and
conduction through AV node
QT
interval
Onset of Q wave and end of T wave Electrical activity in ventricles [
depolarization and repolarization]
ST
segment
End Of S wave and onset of T wave
Isoelectric line
Ventricles already depolarized

38. Purpose:
Indications:
To measure:
• Any damage to the heart
• Heart disease
• The effects of drugs[Digitalis] or
devices (pacemaker) used to
control the heart
• The size and position of the heart
chambers
• Heart rate
• Heart rhythm
Symptoms like:
• Cardiac murmurs
• Syncope or collapse
• Seizures
• Perceived cardiac
dysrhythmias
• Angina, palpitations,
breathlesness.

39. Abnormal ECG
Helpful in diagnosing:
• Arrhythmias
▫ Tachycardia/Bradycardia
▫ Ectopic heart beat
▫ Heart block-BBB
▫ Atrial flutter and
fibrillation
▫ Extrasystole
▫ Paroxysomal tachycardia
▫ Wolff-Parkinson-White
syndrome
• Myocardial infarction
• Hypertrophy of heart chambers
• Coronary Artery Disease
• Congenital heart disease
▫ Tetralogy of Fallot
• Infective endocarditis
• Valvular heart disease.
▫ Mitral
regurgitation
▫ Mitral stenosis
▫ Mitral valve prolapse
▫ Aortic stenosis
▫ Aortic insufficiency
▫ Pulmonary valve stenosis
▫ Tricuspid regurgitation
• Pericarditis
• Aortic dissection
• Coarctation of the aorta
• C ardiac failure
• Hypertensive heart disease
• Cardiomyopathy-hypertrophic
/alcoholic/dilated/idiopathic/
peripartum
• Cardiac Tamponade
• Atrial Myxoma
• Myocarditis

40. • Myocardial Infarction:
▫ Ischaemia-Raised ST segment convex upwards.
▫ Injury-Inverted T -waves peaked and
symmetrical

41. A test used to measure the performance of the
heart and lungs while they are under physical
stress. The test involves walking on a treadmill or
pedaling a stationary bike at increasing levels of
difficulty, while being closely monitored.
Metabolic Exercise Stress Test (also
called metabolic stress test)

42. Metabolic Exercise Stress Test
(also called metabolic stress test)
∙ determine how fit the heart and lungs are
∙ determine if symptoms of shortness of breath or
chronic fatigue are due to a medical problem (such
as heart or lung disease) or due to poor fitness
∙ measure the heart’s ability to do work (functional
capacity)
∙ determine if certain surgical treatments are
appropriate
∙ evaluate the effectiveness the cardiac treatment
plan
∙ help develop a safe and effective exercise program

43. Metabolic Exercise Stress Test (also
called metabolic stress test)

44. Laboratory testing
Laboratory tests include a number of blood tests used
to diagnose and monitor treatment for heart disease.
Full Blood Count (FBC)
Cardiac troponins
Electrolytes, urea and creatinine Liver Function
Tests (LFTs) Thyroid Function Tests (TFTs)
Brain Natriuretic Peptides (BNP or N-terminal pro
BNP)

45. Full Blood Count (FBC)
A full blood count can identify presence of
infection, anaemia and other blood disorders.
Mild anaemia
is common in heart failure and if left untreated
may contribute to worsening of the condition
and to a poorer prognosis. In cardiac disease,
thrombocytopaenia (low platelet count) may be
caused by medications such as diuretics or
heparin.

46. Laboratory Findings
Troponin I
Earliest increase - 4-6 hours
Peak hours 10-24
Duration of increase 4-7 days
Specificity 95%
Sensitivity at peak >98%
Cardiac troponin is a serum biomarker used for the diagnosis of acute
myocardial infarction (MI) and prognosis. Diagnosis of acute MI is
dependent upon rise and fall of the biomarker, in addition toclinical
findings or ECG changes.
Serial troponins are frequently done to determine the peak troponin post
MI, which has prognostic value. Cardiac troponins may be elevated in the
presence of inflammatory conditions (e.g. acute myocarditis), structural
heart disease, coronary vasospasm and non-cardiac conditions (e.g. sepsis,
chronic kidney disease).

47. Laboratory Findings
CK Total
Earliest increase 4-8 hours
Peak hours 24-36 hours
Duration of Increase 36-48 hours
Specificity 57-88%
Sensitivity at peak 93-100%

48. Laboratory Findings
CK-MB
Earliest increase 3-4 hours
Peak hours 15-24
Duration of Increase 24-36 hours
Specificity 93-100%
Sensitivity at peak 94-100%

49. Electrolytes, urea and creatinine
Electrolytes, urea and creatinine tests identify electrolyte
disturbances and define renal function.
Abnormal potassium (hyper- or hypo-kalaemia) may be
secondary to renal impairment, potassium
sparing medications and excessive diuresis and may
contribute to cardiac arrhythmias.
Hyponatraemia (low blood sodium) is common in heart
failure and is usually the result of fluid retention in
excess of sodium stores.
Elevated serum creatinine suggests renal impairment
and in cardiac disease may be secondary to medications;
angiography (dye related), and progression of heart

50. Liver Function Tests (LFTs)
Liver function tests identify abnormal liver
function. Medications such as amiodorone and
statins may provoke liver dysfunction. Chronic
poor cardiac output may also disrupt liver
function.
Congestive hepatomegaly may contribute to
cardiac cirrhosis and subsequent
hypoalbuminaemia, hypoglycaemia and
increased prothrombin time
in heart failure.

51. Thyroid Function Tests (TFTs)
TFTs identify hyper- or hypo-thyroidism.
Although rare, thyroid dysfunction may cause or
precipitate heart failure or precipitate atrial
fibrillation.
Amiodorone may cause hypo- or hyper-
thyroidism.

52. Brain Natriuretic Peptides (BNP or
N-terminal pro BNP)
BNP assists in the differentiation between cardiac and
non-cardiac causes of dyspnoea especially when
echocardiography is not available. A BNP or N-
terminal proBNP level < 100pg/ml makes diagnosis of
heart failure unlikely. Elevated (>600 pg/ml) BNP or N-
terminal proBNP indicates heart
failure decompensation is likely and is associated with
severity of disease, risk of hospitalisation and survival.
The tests are more useful in detecting heart failure
with reduced ejection fractions (HFREF) rather than

53. Echocardiography
• It is the diagnostic
procedure which uses
ultrasound
waves(fq>20000 Hz) to
produce 2D 0r 3D
image slices of the heart
muscle.
• It determines size, shape,
movement of valves and
heart chambers and flow
of blood through the
heart.

54. Workin
g
• A transducer containing piezoelectric crystals converts
electrical energy into an ultrasound beam
• This beam is directed towards heart.
• The beam is reflected when it strikes the surface between
tissues of different densities.
• Reflected ultrasound/echo is converted to electrical energy
by piezoelectric crystals which constructs image based on
▫ Intensity of echos
▫ Time taken for echoes to return

55. Procedur
e
• Trans-thoracic echocardiogram(TTE):
▫ Echocardiogram of the heart through the thorax
external to the body.
▫ Non-invasive, painless, highly accurate and
quick.

56. • Trans-esophageal echocardiogram(TEE)
▫ Echocardiogram of the heart through a catheter
placed in the esophagus which is attached to
an ultrasound transducer.

57. ▫ Invasive and must be
performed under supervision.
• Doppler echocardiography:
▫ Waves reflected from RBCs
have different frequency than
that of transmitted waves.
▫ Determines direction and
velocity of blood flow.
▫ Assessment of
Cardiac valve areas and function
Abnormal communications
between the left and right side of
the heart
Valvular regurgitation
Calculation of the cardiac output
and ejection fraction.
Heart valve defect

58. Uses and Indications
Assessment of
▫ Pericardial effusion
▫ Congenital Heart Defects
▫ Valvular heart diseases
▫ Myocardial Infarction
▫ High blood pressure/ Hypertensive heart
disease
▫ Hypertrophic cardiomyopathy
▫ Intracardiac tumors [myxomas] and blood
clots
▫ Aortic regurgitation/stenosis/aneurysm and
dissection
▫ Calcification of valves
▫ Rheumatic mitral valve disease
▫ Cardiac failure
VSD

59. Advantages
• No known risks or
side effects.
• No radiation
involved.
• Both 2D and 3D
images can be
viewed.

60. Cardiac
Angiography
• Cardiac
Angiography or arteriography is
a medical imaging technique used to
visualize the lumen of the blood
vessels [ arteries, veins] and the
heart chambers.
• This is traditionally done by
inserting a catheter followed by
injecting a radio-opaque contrast
agent[dye which absorbs the x-rays]
into the blood vessel and imaging
using a camera and X-ray based
techniques such as fluoroscopy.

61. Procedur
e
• Cardiac Catheterization + X ray fluoroscopy
• Patient lies on his back on the X-ray table.
• Precautions
• A round cylinder or rectangular box that takes the
pictures during fluoroscopy will be moved under the
patient during the test.
• The place where the catheter is inserted is shaved and
cleaned.
• The doctor numbs the area with a local anesthetic.

63. • A needle is put into the femoral artery
/vein [near groin] or brachial artery/
vein[above elbow].
• A guide wire is put through the needle
into the blood vessel and the needle is
removed.
• The thin flexible catheter is placed
over the guide wire and moved into
the blood vessel.
• The catheter isthen guided through
the blood vessels until it reaches the
area to be studied [aorta, coronary
arteries, left ventricle and atrium and
inferior vena cava , right atrium
and ventricles, pulmonary arteryetc]--
-- Cardiac Catheterization

64. • The fluoroscope is used to watch
the movement of the catheter in
the blood vessels.
• When the catheter is in place,
Iodine dye is injected through it.
• Several X-ray pictures are taken
one after another which may
either be still images, displayed on
a image intensifier or film, or
motion images stored digitally on
computer.
• Duration: 1-3 hrs
• The catheter is taken out after the
angiogram, and pressure is put on

65. Uses
• Mainly used to detect abnormalities of
blood
flow :
▫ A tear in a blood vessel (which can
cause blockage or internal bleeding)
▫ Haemorrhages
▫ Aneurysms
▫ Stenosis
▫ Pattern of blood flow to a tumor.
▫ Abnormal position of blood vessels
▫ Abnormal branching of blood vessels
since birth
▫ Changes in the blood vessels of injured
heart.
• Presence or absence of atherosclerosis
within the
walls of the arteries cannot be clearly

66. Intravascular
Ultrasound
• Principle:
▫ Coronary catheterization+ Ultrasound
• Ultrasound transducer attached at the
tip of catheter guided through
coronary arteries from femoral/
brachial artery.
• Proximal end of catheter attached to
ultrasound equipment
• Evaluates
▫ Coronary plaques—structure and
composition [not seen in angiography]
▫ Wall of blood vessel
▫ Connective tissue surrounding vessel
• Prescribed for

67. Nuclear Heart Scan
• A nuclear heart scan is a type of medical test where a safe, radioactive
material called a tracer is injected through a vein into the bloodstream.
• The tracer travels to the heart and releases energy, which special
cameras outside of the body detect to create pictures of different parts of
the heart.
• Using computer software, the images are made to appear as if the heart is
moving.

68. Procedur
e
Pretest
• The radioactive tracer is injected into the
bloodstream through the intravenous line.
• ECG patches are attached to the body to check the
heart's electrical activity during the test.
Exercise
• An exercise stress test maybe done as a part of
nuclear heart scan
Chemical stress
• If Patient is unable to exercise, medicine is used to
make the heart beat faster. This is called a
chemical stress test.

69. • Before the exercise or the chemical stress test stops, the
tracer is again injected through the IV line.
• The patient then lies very still on a padded table.
• The nuclear heart scan camera, called a gamma
camera,[sometimes doughnut shaped] is enclosed in a
metal housing which is put in several positions around
the body.
• The computer collects the pictures of the heart nearby
or in another room.
• Two sets of pictures is taken. One is taken right after
exercise /chemical stress test and the other is taken
after a period of rest.
• Each set of pictures takes about 15 to 30 minutes.

71. Type
s
Two main types:
• Single positron emission
computed tomography
(SPECT)
• Cardiac positron
emission tomography
(PET)

72. Uses
Detects :
• The flow of blood throughout the
heart muscle --myocardial
perfusion scanning.
• To look for damaged heart muscle
due to a previous heart attack,
injury, infection, or medicine---
myocardial viability testing.
• Pumping action of heart to the body--
ventricular function scanning.

73. Uses
Also evaluates:
▫ Coronary Artery Disease
▫ Heart valve diseases
▫ Past heart attack (myocardial infarction)
▫ Poor pumping function and heart failure
• Decides whether coronary angiography or
cardiac catheterization will be helpful.
• Decides whether angioplasty or coronary artery
bypass grafting (CABG) will be needed
• Monitors procedures or surgeries, such as CABG or

74. Indications
Conditions under which the test may
be performed:
▫ Atrial septal defect
▫ Dilated cardiomyopathy
▫ Idiopathic cardiomyopathy
▫ Peripartum cardiomyopathy
▫ Senile cardiac amyloid
▫ Heart failure

75. Chest X ray
A chest X-ray uses a very small amount of radiation to produce an
image of the heart, lungs, and chest bones on film.

76. Procedur
e
• Patient has to remove all clothes and metallic jewelry from the
waist up and put on a hospital gown for the test.
• Patient then stands very still with his chest against the cassette that
contains the film.
• The X-ray machine sends a beam of ionizing radiation through an
X-ray tube.
• This energy passes through the chest and is absorbed on film to
create a picture.
• Bones and other dense areas show up as lighter shades of
gray
• Areas that don't absorb the radiation appear as dark gray.
• The entire test takes no more than 10 to 15 minutes.

77. Views
PA or postero-anterior view:
• Patient stands with his chest
against the container of the film
• The X-ray beam from the
machine comes from the
posterior/back and moves
through the chest to the
anterior/front.
Lateral view:
• Patient stands sideways in front
of the film with arms raised up.
• The X rays penetrate the chest
from the sides.

78. Uses
• Helps to diagnose heart diseases such as
▫ Cardiomegaly
▫ Aneurysm and Coarctation of aorta
▫ Acute Myocardial Infarction
▫ Heart failure
▫ Pericardial effusion with Tamponade
▫ ASD, VSD, PDA
• Evaluates placement of devices (pacemakers,
defibrillators) or catheters, chest tubes
placed during hospitalization.

79. Cardiomegaly
Heart failure

80. Sphygmomanometry
• A sphygmomanometer is
a device used to measure
blood pressure. It is always
used in conjunction with a
stethoscope.
• A manual
sphygmomanometer consists
of an inflatable cuff to
restrict blood flow, a
measuring unit -the
mercury manometer or
aneroid gauge, and
inflation bulb and valve.

82. Procedur
e
• Patient lies in supine or sitting position
with the Sphygmomanometer at level of
the heart
• The arm cuff is tied around the upper
arm above the cubital fossa
• Size of cuff should be appropriate for arm
• Cuff is attached to the mercury
manometer.
• 3 methods:
▫ Palpatory method:
Radial artery is palpated
Cuff is inflated until radial pulse disappears
Pressure is increased further by 20 mm Hg

83. Pressure is then released
slowly through opening
of valve
Mercury column is noted
when
the pulse reappears and is felt
Systolic pressure is obtained
▫ Auscultatory Method:
Stethoscope placed over the
brachial artery in cubital
fossa
Pressure is raised by 20 mm
Hg after pulse disappears to
occlude the Brachial artery
Pressure is released from cuff
through opening of the valve

84. • A series of sounds—Korotkoff’s sounds are heard
▫ 1st
phase:
Sudden clear tapping sound
Louder on releasing pressure
Appearance-Systolic pressure
▫ 2nd
phase:
Murmuring sound
▫ 3rd
phase:
Clear louder GONG type of sound
▫ 4th
phase
Mild muffled sound
▫ 5th
phase
Disappearance of sound
Diastolic Blood pressure

85. ▫ Oscillatory
method:
Pressure is increased above systolic
pressure –mercury column
remains still
When pressure is decreased—some
oscillations occur
When pressure is reduced
further--
Amplitude and duration of
oscillations suddenly increase--
Systolic BP
When further deflated – amplitude
and duration of oscillations is
reduced--- Diastolic BP
Inaccurate

86. Uses
Diagnosing
• Hypotension
• Hypertension
▫ Can be indicative of
Congestive Heart failure
Stroke
Myocardial Infarction

87. Cardiac CT Scan
(CCT)
• Computerised Tomography (CT) is a
medical imaging method employing
tomography, created by computer
processing.
• Tomography refers to imaging by sections
or sectioning, through the use of any kind of
penetrating wave [radiation].
• A three-dimensional image of the inside
of the heart is generated from a large series of
two-dimensional X-ray picture taken around
a single axis of rotation.
• In simpler terms, it is an imaging method that
uses x-rays to create cross-sectional pictures
of the heart.

88. Procedur
e
• The patient will be asked to lie on a
narrow table that slides into the center of
the CT scanner.
• Once he is inside the scanner, the
machine's x-ray beam rotates around him.
• A computer creates separate images of the
body area, called slices.
• Three-dimensional models of the body
area can be created by stacking the slices
together.
• Sometimes an iodine-based dye (contrast
dye) is injected intravenously during the
scan. The contrast dye travels through the

89. • These images can be stored/ viewed on a
monitor, or printed on film.
• Patient must be still during the exam,
because movement causes blurred images.

90. Uses:
Helps in evaluating:
• Calcium buildup in the walls
of the coronary arteries-
coronary calcium scan
• Coronary Artery Disease
• Problems with heart function
and heart valves.
• Aneurysm and Dissection of
Aorta
• Atrial Fibrillation
• Pericardial Disease
• Wall motion and Ejection
fraction
• Cardiac masses and post-
operative abnormalities

91. Indications:
The Patient is Asymptomatic
• Family history of coronary artery disease
• Persistent high triglyceride levels
• Other high risk factors such as smoking, diabetes,
etc.
• ECG abnormalities
• Abnormalities on a routine stress test
• Moderate to severe hypertension
• Earlier to non-coronary surgery in the adult
population such as
a. Pre-ASD repair

92. Indications
The Patient is Symptomatic :
• Atypical chest pain (right side,
shoulder tip, etc.)
• Suspected dilated cardiomyopathy
• Anomalous coronary arteries,
ectasia or aneurysms
Other:
• Post-bypass: assessing the status of
bypass grafts.
• Post-stent: for assessing in-stent
lumen.
• Tumors and cardiac neoplasms

93. Cardiac Magnetic Resonance
Imaging
• Cardiovascular magnetic
resonance imaging (CMR) /
cardiac MRI, is a medical imaging
technology that uses powerful magnets
and radio waves to create pictures of
the body.
• Single MRI images produced are called
slices.
• One exam produces dozens or
sometimes hundreds of images which
can be combined to produce 3D models.
• The images can be stored on a
computer or printed on film.

94. Principl
e
• The single proton of the nucleus of a hydrogen atom
vibrates ,
or "resonates," when exposed to bursts of magnetic energy.
• When many hydrogen nuclei resonate in response to changes
in a magnetic field, they emit radiofrequency energy.
• The MRI machine detects this emitted energy, and converts it
to an image.
• Hydrogen nuclei are used because hydrogen atoms are
present in water molecules (H2O), and therefore are present
in every tissue in the body.
• Subtle differences in the hydrogen atoms between various
parts of a tissue - emit different amounts of energy.
• These energy differences show up as different shades of gray
on the MRI which is helpful in detecting areas of cardiac
tissue that have poor blood flow (coronary artery disease) or
that has been damaged (heart attack).

96. Procedur
e
• Patient is asked to wear a hospital gown or clothing without
metal items or ornaments
• Patient will lie on a narrow table, which slides into a large
tunnel-shaped scanner.
• Sometimesa dye is usually injected before the test
intravenously in the hand or forearm to see images more
clearly
• Small devices, called coils, may be placed around the head,
arm, or leg, or other areas to be studied. These devices help
send and receive the radio waves, and improve the quality of
the images.
• During the MRI, the person who operates the machine will
watch you from another room.
• An intercom in the room allows patient to speak to the
monitoring person at any time.

97. Closed MRI
Open MRI

98. Uses
• Helps in visualising
▫ Heart muscle scar or fat without using a contrast
agent
▫ Heart function using cine imaging
▫ Infarct imaging using contrast
▫ Perfusion defects
▫ Congenital Heart Defects
▫ Aortic Dissection
▫ Cardiac tumor
▫ Cardiomyopathies
▫ Thrombus
▫ Pericarditis

99. ▫
Assessing
Volume of blood flow and
Ejection fraction
Damage caused by Heart
attack
Heart Failure
Coronary Artery Disease
▫ Distinguishing between
"stable
atherosclerotic plaques and
"vulnerable" plaques.
▫ Visualising blood vessels
and the flow of blood
through them -- magnetic
resonance angiography
(MRA).

100. Advantages
• Safe, non-invasive test
• MRI uses radio waves, without ionizing radiation or X
rays
• Unlike CT does not carry any risk of causing cancer.
• The images generated remarkably complete, detailed
and precise
• MRI has the potential of replacing other cardiac tests
like:
▫ Echocardiogram,
▫ NH scan,
▫ Thallium scan
▫ Diagnostic cardiac catheterization.

101. Myocardial Biopsy
An invasive procedure that involves using a
bioptome (a small catheter with a grasping device
on the end) to obtain a small piece of heart
muscle tissue that is sent to a laboratory for
analysis.

102. Myocardial Biopsy
myocardial biopsy is used to:
∙ evaluate or confirm the
presence of rejection after
heart transplant
∙ diagnose myocarditis
(inflammation of the heart
muscle)

103. An EP Study is a recording of the electrical
activity of the heart. This test is used to help
determine the cause of rhythm disturbances and
the best treatment.
During the test, arrhythmia can be reproduced
and various medications given to see which one
controls it best.
Electrophysiology Study (EP)

104. the EP study is used to:
∙ determine the cause of an
abnormal heart rhythm
∙ locate the site of origin of an
abnormal heart rhythm
∙ decide the best treatment for an
abnormal heart rhythm
Electrophysiology Study (EP)

105. Electrophysiology Study (EP)
Several catheters are inserted into the vein in the
groin
Guided by the fluoroscopy machine, the catheters
are threaded to the heart.
The catheters sense the electrical activity in the
heart and are used to evaluate the heart’s
conduction system.
A pacemaker is used to give the heart electrical
impulses through one of the catheters to increase
heart rate.

106. References
:Books:
• Essentials of Medical Physiology - Sembulingam
• Hutchinson’s Clinical Methods – Michael Swash
• Practical Medicine – P. J Mehta
• Macleod’s Clinical Examination – Douglas,
Nicol, Robertson
Internet:
• www.google.com
• www.wikipedia.org