ECG
•Cardiac arrhythmias
• Conduction defects
•Myocardial infarction or ischemia
•Myocardial hypertrophy Electrolyte imbalance
• Toxicity of certain drugs
ECG interpretation is not much difficult, it is very important tool of investigation: therefore spend a lot of time in ECG reading during posting in cardiology unit. If ECG interpretation is weak it will become difficult for a physician to deal with cardiac emergencies with accuracy. Unfortunately in Government Hospitals most of emergency medical officers are posted from skin, surgery, neurology and other specialties who are not trained in ECG reading, occasionally they're indeed unfit to he cure of responsible fete cardiac exigency that results in loss of case's life. This practice will be continued until merit( not influence) becomes the criteria for selection of medical directors. Be a safe physician,learn ECG.
There's nothing delicate in medical education except to find out sincere teachers who have tutoring chops and who are generous in transferring the practical knowledge to their scholars( unfortunately utmost of them are not → → greason g selection not grounded on merit)
CHEST X-RAY
Heart size
Heart size can be reliably assessed only from PA view of casketx-ray, because in AP view cardiac shadow is large. The maximum transverse periphery of the heart is compared with the maximum transverse periphery of the casket measured from inside of the caricatures this is called cardiothoracic rate( CTR) It should be lower than 50. Cardiomegaly and pericardial effusion beget an increase in cardiothoracic rate.
• Pericardial effusion produces spherical shadow.
• Left atrial dilatation manifests as elevation of left atrial accessory on the left heart border and a double atrial shadow to the right of the sternum( double right heart border).
• Left ventricular blowup manifests as increased CTR and an increased protuberance of the left heart border.
• Right atrial blowup manifests as protuberance of right border of heart into the right lower lung field.
• Right ventricular blowup manifests as increased CTR and an upward relegation of the apex of the heart.
• Blowup of pulmonary roadway manifests as a prominent bulge on the left heart border below the aortic knuckle
Clarification
X-ray chest may show calcification of pericardium, faucets, aorta and myocardium.
Lung fields
Lung fields may indicate pulmonary hypertension by blowup of hilar vessels eg. enlarged right lower lobe roadway. Kerly's B lines and pleural mes who aren't trained effusion may be present in cardiac failure.
ECHOCARDIOGRAPHY.
It is a touchy strategy for assurance of
•Size of all four chambers of heart.
•Left ventricular function (ejection fraction).
•Regional wall motion abnormalities due to
myocardial infarction, ischemia.
•Complexities of myocardial localized necrosis like papillary muscle brokenness, mitrale Rgurgitation, VSD, left ventricular aneurysm and left ventricular thrombus.
•Structural valve abnormalities e.g. stenosis and regurgitation.
•Cardiac output.
•Ventricular hypertrophy Pericardial effusion.
•Atrial and ventricular septal defects and other congenital defects.
Types of echocardiography
Two dimensional real time echocardiography This type of echocardiography is particularly valuable for detecting wall motion abnormality, intracardiac masses, such as thrombi and tumors or Stres endocarditic vegetations It is also helpful in In st detection of congenital heart diseases.
M-mod echocardiography
This type of echocardiography is particularly useful for the measurement of sizes of chambers of heart, calculation of ejection fraction and accurate timing of cardiac events such as opening and closing of valves.
Doppler echocardiography
Doppler echocardiography is valuable in detecting abnormal directions of blood flow eg aortic or gradient eg gradient across a stenosed aortic valve. There are three modes of Doppler mitral regurgitation and estimation of pressure gradient e.g. gradient across a stenosed aortic valve. There are three modes of Doppler echocardiography:
1.Pulse wave Doppler (PW). 2. Continuous-wave Doppler (CW)
3. Color Doppler
Experience sharing: a good echo machine should
have all three components.
1. Two-dimensional real time echocardiography
2. M-mod echocardiography
3. Doppler echocardiography
Machines available in request have price ranging fromRs. 10,00000 to 100,00000 and echo charges are generally Rs. 1000 to 2500 in Karachi. Low priced machines don't have Doppler. important of the echo results are driver dependent, thus when you're pertaining the case for echo you must know how well- professed is the driver in performing echo.
Trans- Esophageal Echocardiography( TEE)
In this fashion an ultrasound inquiry, in the shape of endoscope is passed into the esophagus and deposited behind the heart. It's veritably helpful in detecting veritably small leafages not detected on transthroacic( generally performed) echocardiogram. Thrombus in left patio or atrial accessory in cases of mitral stenosis and atrial fibrillation. ASD not detected by transdroracic.
Stress Echo
In stress echocardiography echo is done during exercise or just after the exercise, or after pharmacological stress by administration of Dobutamine Stress Test( DSE) is now generally performed to descry stress convinced segmental wall stir abnormalities( an index of ischemia).
Contrast Echo
Intravenous discrepancy agents or agitated saline are used intravenously to assess intramyocardial inflow pattern; veritably helpful in discovery and to see the direction of inflow in shunts similar as ASD, VSD( left to right or right to left).
AMBULATORY ECG( Holter monitoring)
This outfit is a battery powered mail tape recording archivist which is used for nonstop recording of one or further ECG leads for 24 hours. This fashion is useful in detecting flash occurrences of arrhythmia or ischemia which infrequently do during the short time taken for routine 12- lead ECG recording. detail paroxysm of tachycardia, an occasional pause in meter or intermittent ST member changes may be linked.
Cardiomemo:
RADIONUCLIDE SCANNING
( Nuclear imaging)
Thallium 201 scanning
Thallium 201 scanning when fitted provides information regarding infarction andnon-infarction myocardium.
• Fixed disfigurement in perfusion shows myocardial infarction while the reversible disfigurement indicates myocardial ischemia.
• originally the radioisotope is fitted during exercise, surveying blights indicate zones of ischemia or hypoperfusion if the myocardium is feasible( i.e. no infarction).
•Now the checkup is performed latterly during rest, stuffing of these blights indicates a reversible ischemia and if the blights persist indeed at rest it means these are infracted areas. overlook charges are aboutRs. 3000. Advanced rates in private sector.
Technetium-99- labeled sestamibi
can be used rather of thallium if viability of myocardium is to be determined.
suggestions:
Thallium scanning is indicated :
•When resting ECG makes an exercise ECG delicate to interpret(e.g. due to LBBB).
•In cases to descry myocardial infarction in whom exercise testing( ETT) isn't individual(eg. positive test in asymptomatic cases), or isn't allowede.g. in pack branch block, left ventricular hypertrophy or case taking digitalis.
•To localize the region of ischemia.
•To distinguish ischemic from infrared myocardium.
MUGA SCAN( Blood pool scanning)
This isotope is fitted IV that mixes with circulating blood. The gamma camera detects the quantum of isotope- emitting blood in the heart at different phases of cardiac cyclee systole and diastole.
Clinical uses:
•MUGA scan is used for detection pf ventricular aneurysm.
•Left and right ventricular ejection fraction can be measured accuractaly. Ejection fraction indication ventricular function.
CARDIAC CATHETERIZATION
is the preface of a catheter into the rotation.
•Right heart is catheterized by introducing the catheter into a supplemental tone( generally the right femoral tone) and advancing it to the right patio and right ventricle into the pulmonary roadway. The pressures in the right heart chambers and pulmonary roadway can be measured directly.
•Left heart catheterization is generally performed via the right femoral roadway, catheter enters the left ventricle where pressures are attained, color is fitted for ventriculography to assess left ventricular function. Coronary angiography is performed by using especially designed right and left coronary roadway catheters. During cardiac catheterization blood samples are withdrawn to measure attention of ischemic metabolites(e.g lactate) and oxygen to quantify intracardiac shunts. This invasive procedure by using catheter gives the following information.
• dimension of pressure in different chambers of heart.
• Blood oxygen content or achromatism in different chambers.
• dimension of cardiac affair.
Clinical Uses:
1. Identification of coronary roadway complaint and assessment of its extent. Coronary spasm and thrombosis.
2. Left ventricular dysfunction and ischemic mitral regurgitation.
3. Angiography and angioplasty for acute coronary pattern.
4. To rule out ischemic cause of cardiomyopathy.
5. To separate restrictive cardiomyopathy from constrictive pericarditis. 6. To assess extent and severityof stopcock complaint .
7. For assessment of left and right ventricular function( abnormality similar as heart failure).
8. It detects atrial and ventricular septal blights. It's performed before surgical correction of natural heart complaint.
CORONARY ANGIOGRAPHY
Coronary angiography is performed during cardiac catheterization. It's the visualization byx-ray discrepancy material( color) fitted into the highways. Coronary angiography is performed by preface of catheter from femoral roadway, which is guided under radiological control( fluoroscope) to the left and right coronary highways and left ventricle. Differ medium is fitted white videotape images of the recordings are made( on CD).
Clinical uses:
It detects and estimates the inflexibility of coronary roadway stenosis, thus revascularization can be performed with by- pass operation or angioplasty. suggestions Angiography is veritably generally performed procedure now a days. Medical scholars and croakers of other specialties must know the proper suggestions of angiography thus they can guide and counsel their cases confidently. suggestions are given below according to the clinical situations.
1. Asymptomatic patient:
substantiation of high threat on noninvasive testing( EGG, ETT, Thallium checkup, Echo).
2. Nonspecific or atypical chest pain:
opinion of ischemic heart complaint is made confidently in maturity of cases withnon-invasive testing. Angiography should be performed only if there are high- threat findings on noninvasive testing.
3. Stable angina:
substantiation of high threat on noninvasive testing or pain not relieved by medical treatment.
4. Unstable angina :
high or moderate threat cases refractory to original acceptable medical treatment or intermittent symptoms after original stabilization.
5. After angioplasty:
suspected abrupt check or subacute stent thrombosis after angioplasty or intermittent angina or high threat criteria on non- invasive testing within 9 months of angioplasty and 12 months of bypass operation.
6. After myocardial infarction:
as an volition to thrombolytic remedy within 12 hours of onset of symptoms.
7. Perioperative evaluation beforenon-cardiac surgery :
in cases with suspected or known coronary roadway complaint.
8. Before valve surgery:
in grown-ups to rule out coronary roadway complaint, as the bypass grafting is possible in the same operation. Heart failure cases with heart failure having angina or substantiation of ischemia on noninvasive
