Tests associated with cardiac disorders

4. Cardiac disorders :
primary diagnosis :
Auscultation.
Detecting abnormal
heart sounds.
Blood pressure –
sphygmomanometer.

5. SIGNS AND SYMPTOMS:
 Chest pain.
 Dyspnea with or
without orthopnea.
 Paroxysmal
nocturnal dyspnea.
 Cyanosis.
 Fatigue.
 Palpitations.
 Cough.
 Edema.
 Syncope.
 Abnormal
heart sounds.

6. DIAGNOSIS OF CARDIAC
DISORDERS:















7. HEART SOUNDS:
 Stethoscope is the commonest instrument
used.
 FIRST SOUND: (L-U-B-B)
 Occurs at the onset of ventricular systole.
o DURATION: 0.1 – 0.17 sec
o CAUSES:
 Occurs due to sudden closure of the AV
valves.
 Ejection of blood from the ventricles & the
vibration transmitted to the walls of the
pulmonary artery & aorta.

8. o SIGNIFICANCE:
 Indicate the condition of myocardium.
 Indicates proper closing of AV valves.
o CLINICAL IMPLICATIONS:
 INCREASED FIRST SOUND:
 Hypertrophy.
 SHORT & LOW PITCHED FIRST
SOUND:
 Myocardial weakness.

9.  SECOND SOUND: (DUP)
 Occurs at the onset of the diastole.
o DURATION: 0.1 -0.14 sec
o CAUSES:
 Caused by the sudden closure of the semi lunar valves in the
aorta & pulmonary artery.
o SIGNIFICANCE:
 Indicates the end of systole & beginning of diastole.
 Its pitch is directly proportional to the BP.
 Indicates proper closing of semilunar valves.
o CLINICAL IMPLICATIONS:
 DECREASED DIASTOLIC PERIOD: ( PAUSE)
 Increased heart rate.

10.  THIRD SOUND:
o DURATION: 0.04 sec
o CAUSES:
 Sudden rush of atrial blood.
o SIGNIFICANCE:
 Indicates ventricular filling.
 FOURTH SOUND:
o DURATION: 0.01 sec
o CAUSE:
 Contraction of atria
o SIGNIFICANCE:
 Indicates the ending of ventricular filling.

11. LABORATORY TESTING :
1. BLOOD TESTS :
 SERUM CHOLESTROL :
o Total cholesterol : 150 – 200 mgs
o TGL : Up to 170 mgs
o HDL : 35 – 55 mgs
o LDL : Up to 170 mgs
o VLDL : 20 – 40 mgs

12.  CLINICAL IMPLICATION :
• Elevated cholesterol level
(HYPERCHOLESTEROLEMIA )
 Coronary heart disease
 Hypothyroidism
 Diabetes mellitus
 Cholestasis
 Hepatocellular disease
 Biliary cirrhosis
 Glomerulonephritis
 Werner’s syndrome
 Obesity
 Chronic renal failure

13. • Decreased cholesterol level:
( HYPOCHOLESTEROLEMIA )
Myleoproleferative diseases
Hyperthyroidism
 Malnutrition
Megaloblastic anemia
Severe burns
Inflammation
Infection
Chronic obstructive lung disease
Mental retardation

14.  HIGH DENSITY LIPOPROTEIN CHOLESTEROL :
 Normal value : 35 -55 mgs
 CLINICAL IMPLICATIONS :
o ↓ HDL-C Values:
 Uremia
 Hepatocellular disease
 Chronic renal failure
 Cholestasis
 Diabetes mellitus
o ↑ HDL-C Values:
 Atherosclerosis
 Myocardial occlusion

15.  LOW DENSITY LIPOPROTEIN (LDL)
 Normal value : Up to 170 mgs
 CLINICAL IMPLICATIONS :
o Increased LDL levels:
 Premature CHD
 Hyperlipidemia
 Nephrotic syndrome
 Chronic renal failure
 Porphyria
 Myocardial infarction
 Coronary artery occlusion
 Anorexia nervosa

16. oDecreased LDL levels :
Hypoproteinemia
Tangier disease
Hyperthyroidism
Chronic anemias
Severe hepatocellular disease
Reye’s syndrome
Acute stress
Inflammatory joint disease
Chronic pulmonary disease

17. 2. ENZYME TESTS :
ENZYME NORMAL
LEVEL
DISEASE
CONDITION
SGOT Up to 40 U/LT Myocardial
Infarction
LDH M→82-285 U/LT
W→103-227
U/LT
Congestive cardiac
failure
CPK M→<190 U/LT
W→>165 U/LT
Various heart
disease

18. AST / SGOT :
 NORMAL VALUES:
 MEN : 14 – 20 U/L
 WOMEN : 10-36 U/L
 CLINICAL IMPLICATIONS:
 Increased AST levels occur in MI:
 Increased to 4-10 times the normal value.
 AST level reaches a peak in 24 hrs & returns to normal
by post MI day 3-7.
 Secondary rise in AST levels suggest extension or
recurrence of MI.

19.  Increased AST levels occur in liver diseases:(10-100
times normal)
 Acute hepatitis & chronic hepatitis ( ALT > AST)
 Active cirrhosis( drug induced ; alcohol induced :(
AST >ALT)
 Hepatic necrosis & metastasis
 Primary or metastatic carcinoma
 Alcoholic hepatitis
 Reye’s syndrome
 Other diseases with elevated AST levels:
 Hypothyroidism
 Trauma & irradiation of skeletal muscle

20.  Shock
 Hemolytic anemia
 Decreased AST levels:
 Azotemia
 Chronic renal dialysis
 Vitamin B6 deficiency

21. LDH ( LACTATE DEHYDROGENASE)
 NORMAL VALUES:
 MEN : 82-285 U/L
 WOMEN : 103-227 U/L
 CLINICAL IMPLICATIONS:
 Increased LDH levels:
 High levels occur within 36-55 hrs after MI &
continue longer than elevations of SGOT or CPK (
3-10 days)
 In pulmonary infarction increased LDH occurs
within 24 hrs of pain onset . The pattern of normal
SGOT & elevated LDH levels of 1-2 days after an
episode of chest pain – pulmonary infarction.

22.  Congestive heart failure
 Liver diseases ( cirrhosis, alcoholism, acute viral
hepatitis )
 Cancer , leukemia
 Hypothyroidism
 Lung diseases
 Skeletal muscle diseases
 Megaloblastic & pernicious anemias , hemolytic
anemia, sickle cell disease
 Seizures
 Shock, hypotension
 Renal infarction

23. LACTATE DEHYDROGENASE
ISOENZYMES :







24.  CLINICAL IMPLICATIONS:
DISEASE LD1 LD2 LD3 LD4 LD5
Myocardial
infarction
√ √
Pulmonary
infarction
√ √
Congestive
heart failure
√ √
Viral hepatitis √ √
Toxic
hepatitis
√ √

25. DISEASE LD1 LD2 LD3 LD4 LD5
Leukemia √ √
Pancreatitis √ √
Carcinomato
sis
(extensive)
√ √
Megaloblasti
c anemia
√ √
Hemolytic
anemia
√ √
Muscular
dystrophy
√ √

26.  First diagnostic test in cardiac work shop.
 Provides global information about position
& size of the heart & chambers &
surrounding anatomy.
 The std CXRs for evaluation of lungs &
heart are standing posteroanterior & lateral
views taken at maximal inspiration.
 Portable CXRs – less satisfactory.

27.  The PA CXR outlines superior vena cava , right
atrium on the right & left sides , aortic knob
,main pulmonary artery, left atrial appendage
& left ventricle.
 In the lateral view CXR visualizes right
ventricle , inferior vena cava & left ventricle.
 Cardiac enlargement is determined by cardio
thoracic ratio.

30. ELECTROCARDIOGRAM ( ECG ) :





31. 




32. 





34. NORMAL DURATIONS:





36. ECG CONVENTIONS & INTERVALS :








38. NORMAL VOLTAGE MEASURMENTS :

39. 12 lead ECG
6 limb leads & 6 precordial (chest ) leads
6 limb leads
1. Standard bipolar lead
2. Standard unipolar lead
Standard bipolar lead

40. Standard unipolar lead :
6 chest leads :

41. RECORDING OF ELECTRICAL
IMPULSES
CLINICAL VALUE OF ECG:

43. STANDARD BIPOLAR LEADS:

44. STANDARD UNIPOLAR LEADS:

45. CHEST LEADS:

46. CLINICAL IMPLICATIONS :
1)
2)
3)
4)
5)
TYPICAL ABNORMALITIES :

47. CLINICAL IMPLICATION ASSOCIATED WITH
WAVES,COMPLEX & INTERVALS OF
ELECTROCARDIOGRAPHY :
I. P WAVE

 NORMAL VALUE :
 CLINICAL IMPLICATIONS:



48. II. PR INTERVAL :

 NORMAL VALUE :
 CLINICAL IMPLICATIONS :

III. QRS COMPLEX :




49.  NORMAL VALUE :
 CLINICAL IMPLICATIONS :


IV. ST WAVE:


50.  CLINICAL IMPLICATIONS:


v. Hypertrophy of heart
vi. Pulmonary infarction
vii. Altered K , Ca, Mg levels
viii. Pericarditis
ix. Ventricular hypertrophy

51. DRUGS THAT CHANGES ECG:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o

52. AMBULATORY ECG MONITORING :
 Also known as Holter monitoring.
 During AEM patient wears a portable
ECG recorder.
 3 types of monitors are available.
 Continuous monitor - record an ECG strip
over the duration of the test.
 Intermittent recorder - continuously
monitor the ECG but only record
preprogrammed abnormal ECG events.

53.  Real time analytical recorder -record
through out the monitoring period and
analysis each beat as it occurs.
 Monitors digitize , encode and store the
information in a solid state memory or on a
magnetic tape
 Clinical values of ambulatory ECG includes
 Aid to detect ,document ,characterize
and evaluate arrhythmias and other ECG
abnormalities.
 ECG abnormalities include ST segment
deviation , QRS complex ,PR intervals.

55. ECHOCARDIOGRAM
Ultrasound imaging of the heart
Transducer
reflection refraction

58. DOPPLER ECHOCARDIOGRAPHY
Depends on the principle that sound
waves reflected from moving objects such
as intra cardiac red blood cells undergo
frequency shift.
The greater the frequency faster the blood
is moving.
Used for studying the pressure changes on
either side of the valve & abnormal
directions of blood flow.

60.  An ultrasound probe in the shape of an
endoscope is passed into the oesophagus and
positioned immediately behind the left
atrium.
 Helps in detecting
 *patient with valve dysfunction.
 *congenital abnormalities .
 *patient with systemic embolism.

62. CARDIAC CATHETERISATION :







64. ANGIOGRAPHY :




66. COMPUTED TOMOGRAPHY :







68.  Very expensive.
 Technician places a small sticky electrode
patches on your chest and back.
 These electrodes are attached to ECG
monitor.
 Used for detecting
 -CHF
 -MI

70. RADIOLOGY :
Chest radiograph is useful for
determining the size and shape
of the heart.
Cardiothoracic ratio should be
less than 0.5.
Transverse cardiac diameter
should be less than 15.5cm.

71. RADIONUCLIDE IMAGING
Gamma emitting radionuclide with
a short half life.
Gamma rays are detected by means
of a planar or tomographic camera.
Blood pool imaging.
Myocardial perfusion imaging.

72. BLOOD POOL IMAGING :
The isotope is injected
intravenously and mixes with the
circulating blood.
The gamma camera detects the
amount of isotope emitting blood
in the heart at different phases of
the cardiac chambers.
By linking the gamma camera to
the ECG it is possible to collect
information over multiple cardiac
cycle.

73. MYOCARDIAL PERFUSION
IMAGING :
This technique involves
obtaining scintiscans of
the myocardium at rest &
during stress after the
administration of an
intravenous radioactive
isotope such as thallium.

75. REFERENCES:
PHARMACOTHERAPY –A
PATHOPHYSIOLOGIC APPROACH-
JOSEPH T DIPIRO.
DAVIDSONS PRINCIPLES AND
PRACTICE OF MEDICINE-
CHRISTOPHER HASLET-19th ed
MEDICAL SURGICAL NURSING –
SHAFER 5th ed
ESSENTIALS OF
PHARMACOTHERAPEUTICS-F.S.K
BARAR-4th ed.
A MANUAL OF LABORATORY &
DIAGNOSTIC TESTS –FRANCES
FISCHBACH , 8th ed.
www.ascp.com/publications