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Cardiac Medical Diagnostic Tests Program Instructions Press key or left mouse button to move forward through the program. Press key to go back one step in the program. Click on box in the lower right corner for answers to review questions. Self-Study Instructions Read and the information provided for each medical diagnostic test or procedure. Note the general purpose, description, and components of the test or procedure. Consider the implications for physical therapy assessment and / or intervention. Answer the review questions at the end of each section. Cardiac Enzyme Profile Description Laboratory blood test used to determine the concentration of myocardial proteins. CK is an enzyme found in high concentrations in heart and skeletal muscle. CK-MB is the isoform of CK found specifically in heart muscle. (CK-BB = brain isoform, CK-MM = skeletal muscle isoform) Description (continued) Trop I is a cardiac isoform of a muscle protein (subunit of the 3 part troponin complex) involved in myosin-actin cycling. Trop T is a cardiac isoform of a muscle protein (subunit of the 3 part troponin complex) involved in myosin-actin cycling. Description (continued) Myoglobin is small protein found in cardiac and skeletal muscle that binds to oxygen. LDH-1 is the cardiac fraction of an enzyme found in high concentrations in the heart, skeletal muscle, RBCs, liver, kidney, lung, and brain. *LDH-1 is not typically included in a Cardiac Profile anymore. Example Report CARDPRO Low Normal CK CK-MB High Flag Reference 200 * 30-180 U/L 4 10-13 U/L Trop I 10 * <1.5-3.1 g/L Trop T 3.2 * <0.1-0.2 g/L Myoglobin 76 50-120 g/mL LDH-1 208 9.8-65 U/L Purpose To diagnosis acute myocardial ischemia/infarction. To determine amount of myocardial muscle damage and prognosis following acute myocardial infarction. Procedure 5-10 mL of venous blood are collected in a heparinized needle and syringe. PT Considerations Use cardiac profile test results to estimate time since precipitating cardiac event and determine when exercise initiation is appropriate. Onset Peak Return 4-6 hrs 12-24 hrs 3-4 days Trop I 3 hrs 14-18 hrs 5-7 days Trop T 3-5 hrs ~24 hrs 14-21 days 2 hrs 3-15 hrs 18-24 hrs 12-24 hrs 2-5 days 6-12 days CK / CK-MB Myoglobin LDH-1 PT Considerations (continued) Determine appropriate type of exercise assessment and intervention based on degree of myocardial damage reflected in peak level of CK / CK-MB rise. Consider that rises in some of the indices are not specific to cardiac damage Isolated rises in CK and or myoglobin may be due to skeletal muscle damage. Trop I and T are very specific indicators. Isolated increases in LDH-1 suggest ruling out of AMI. PT Considerations (continued) Postpone exercise in patients with severe cardiac enzyme elevations and signs or symptoms of significant dysrhythmia or heart dysfunction. Monitor cardiac profile indices frequently to determine if additional cardiac or skeletal muscle damage is occurring with intervention and modify activity appropriately. Watch for signs and symptoms of exerciseinduced cardiac ischemia or heart failure in patients with elevated cardiac protein markers. Review Question #1 Which cardiac enzyme is the first to be elevated following an AMI? a. myoglobin b. CK c. CK-MB d. Troponin I e. Troponin T Click here for answer Review Question #2 Which cardiac enzyme is the most specific indicator of AMI? a. myoglobin b. CK c. CK-MB d. Troponin I e. LDH Click here for answer Lipid Panel Description Laboratory blood test used to assess amount and type of serum lipid. Total cholesterol (TOT CHOL) reflects the blood lipid synthesized by the liver and used to form bile salts and hormones. Triglyceride (TG) is the blood lipid carried by serum lipoproteins which has atherogenic properties. Description (continued) Low density lipoprotein (LDL) is the fraction of lipoprotein that is atherogenic. High density lipoprotein (HDL) is the fraction of lipoprotein that assists in decreasing atherogenic plaque deposits in blood vessels. Example Report CHOLPRO High Flag Reference TOT CHOL 287 * <200 mg/dL TG 150 * 10-140 mg/dL LDL 188 * 60-160 mg/dL * 29-77 mg/dL HDL Low 16 Normal Purpose To determine risk of atherosclerotic lesion development. To monitor treatment effectiveness. Procedure 5-10 mL of venous blood are collected in a heparinized needle and syringe. PT Considerations Determine patient CAD risk related to dyslipidemia based on test results. Use ECG monitoring for initial exercise assessment/intervention in patients with dyslipidemia since latent CAD may exist. Educate patients on the type and significance of the different blood lipids using their test results. Prescribe aerobic exercise for treatment of dyslipidemia. PT Considerations (continued) Monitor efficacy of exercise training for CAD risk factor reduction using lipid profile. Educate patient on dietary changes to reduce fat and cholesterol intake. Evaluate lipid profile cautiously in patients following an acute cardiac event because results may be invalid. Review Question #3 When interpreting blood lipid levels, it is detrimental for all fractions except which to be elevated? a. Total cholesterol b. TG c. LDL d. HDL Click here for answer Review Question #4 Total cholesterol levels at or above what value is abnormal and a risk factor for coronary heart disease? a. 200 mg/dL b. 140 mg/dL c. 170 mg/dL d. 77 mg/dL Click here for answer e. 110 mg/dL Coagulation Profile Description Laboratory blood test used to assess clot formation ability. PT measures clotting ability of factors I (fibrinogen), II (prothrombin), V, VII, and X. INR is the ratio of PT time to standard values. PTT measures clotting ability of all factors except VII and XIII. Example Report COAGPRO PT INR PTT Low Normal High Flag Reference 12 10-13 sec 2 2.0-3.0 65 60-70 sec Purpose To assess therapeutic range of anticoagulation therapy (PT for warfarin sodium/Coumadin and PTT for heparin). To screen for clotting factor deficiencies. Procedure 5-10 mL of venous blood are collected in a heparinized needle and syringe. PT Considerations Verify “PT” physician orders are for physical therapy, not prothrombin time. Avoid high intensity and high impact aerobic exercise when clotting time is increased. Use strengthening exercise employing low resistance with free weights / theraband and high repetitions when clotting time is increased. PT Considerations (continued) Avoid vigorous manual techniques, such as percussion and cross friction massage, and application of thermal modalities when clotting time is increased. Watch for bruising under skin in areas where exercise equipment contacts skin. Postpone exercise and manual interventions when PT or PTT > 2.5x reference range or INR > 3.0. PT Considerations (continued) DO NOT perform sharp or nonspecific (wet to dry dressing) debridement on wounds when clotting time is increased. Postpone exercise intervention until physician clearance is obtained when clotting time is decreased to minimize risk of emboli. Assess Homan’s sign in patients with decreased clotting time when a DVT is suspected. Review Question #5 If PT time is decreased in a patient taking Coumadin, would the dose be increased or decreased? a. increased b. decreased Click here for answer Review Question #6 When clotting time is increased which event(s) is(are) more likely to occur? a. hemorrhagic stroke b. embolic stroke c. acute myocardial infarction d. deep vein thrombosis Click here for answer(s) Cardiac Angiography Description Procedure in which a long catheter is inserted into a peripheral artery, usually the femoral or brachial. The catheter is then guided into the heart chambers or coronary arteries and contrast dye is injected to allow visualization of structures. Chamber pressures can also be directly measured. Example Images Purpose To determine to patency of the coronary arteries. To identify cardiac valve disease. Procedure Oral anticoagulant therapy is discontinued and heparin may be administered prior to the procedure. Patient does not receive a general anesthetic, but may be given a sedative and/or tranquilizer. Patient is positioned supine on a table that tilts. A local anesthetic is administered to the catheter insertion site. Procedure (continued) The catheter is inserted into the artery through an introducer sheath and advanced to the heart structures with guidance of fluoroscopy. When dye is injected into the catheter the patient experiences a warm, flushing sensation. When the procedure is finished the catheter and introducer sheath are removed. Procedure (continued) Arterial hemostasis is achieved with direct pressure, a collagen plug, or sutures. PT Considerations Explain the procedure to the patient. Postpone activity until arterial hemostasis has been definitively achieved. With direct pressure ~ 8-12 hours. With a collagen plug ~6 hours. With sutures ~1/2-2 hours. PT Considerations (continued) Review results of angiography and planned medical management with the patient. Consider the degree of coronary artery involvement to determine how much and what type of exercise the patient can participate in safely. PT Considerations (continued) Avoid resistance exercise for 2 weeks after the procedure. Assess the catheter insertion site for drainage before and after activity. Apply direct pressure to the catheter site if bleeding starts or a large bulge forms rapidly under the skin. Assess ipsilateral lower extremity pulses, temperature, strength, and sensation frequently. PT Considerations (continued) Educate the patient on activity restrictions after cardiac angiography. For 2 days no driving or climbing >2 flights of stairs. For 2 weeks no pushing/pulling/lifting >10 lbs, immersing catheter insertion site in water, sitting for >2 hours at a time, participating in activities that may cause injury to the upper leg. PT Considerations (continued) Educate the patient on signs and symptoms to monitor after cardiac angiography. Increased pain at the catheter insertion site, low back, or abdomen. Ipsilateral leg / foot changes including coolness, paleness, numbness, tingling, pain, or weakness. Bleeding from or rapid swelling under the catheter insertion site. Signs and symptoms of infection (drainage, redness, tenderness, heat, swelling). Extension of ecchymosis around catheter insertion site. Review Question #7 How long are bed rest orders typically followed after cardiac catheterization when direct pressure only is used to obtain hemostasis? a. 20-24 hours b. 8-12 hours c. 2-4 hours Click here for d. ½-1 hour answer Review Question #8 Which artery is most commonly used as the insertion site for cardiac catheterization? a. carotid b. descending aorta c. radial d. femoral e. popliteal Click here for answer Echocardiography Description Ultrasound procedure used to create dynamic images of the heart. M-mode echocardiography records motion of heart structures dynamically. 2-D echocardiography give a crosssectional view of heart structures. Description (continued) Spectral Doppler echocardiography measures flow of blood through the heart and can detect turbulent blood flow and septal defects. Color Doppler echocardiography (blue and red) shows the direction of blood flow through the heart and can identify valve regurgitation and shunts. 2D M-Mode Echocardiography Right Ventricle Right Atrium Left Ventricle Left Atrium Color Doppler Echocardiography Retrograde Flow (red) ECG Signal Antegrade Flow (blue) Procedure Patient is positioned in supine or sidelying on the left. ECG is monitored during the procedure. Water-soluble gel is applied on the patient’s chest were the sound head will be placed. The procedure takes 20-45 minutes. PT Considerations Explain the procedure to the patient. Resume activity soon after procedure. Use test results to compliment information obtained during the patient assessment (heart sounds, blood pressure, exercise tolerance). PT Considerations (continued) Watch for signs and symptoms of exercise-induced heart failure in patients with valve pathology, septal defects, or ventricular wall motion abnormalities. Review Question #9 Echocardiography is used to generate images of what heart structures? a. lumen of coronary arteries b. myocyte microstructure c. ventricular wall d. valve leaflets e. sinoatrial node Click here for answer(s) Review Question #10 Echocardiography generates images of the heart using what? a. x-rays b. lasers c. sound waves d. magnetic fields e. opaque dye Click here for answer(s) Electrocardiography (12-lead) Description Procedure that records the electrical activity of the heart from 12 different leads. A standard ECG consists of six limb leads (I, II, III, AVF, AVL, AVR) and six precordial leads (V1, V2, V3, V4, V5, V6). Example Report Purpose To detect cardiac dysrhythmias. To diagnose myocardial ischemia / infarction and determine regions of involvement. Procedure Patient is positioned supine. Skin is prepared for electrode placement (hair shaved, skin scrubbed with alcohol...). Self-adhesive electrodes placed on chest at ten sites. The procedure usually takes ~ 15 minutes. PT Considerations Explain the procedure to the patient. Resume activity soon after procedure. Use test results to compliment information obtained during the patient assessment (anginal threshold, blood pressure, exercise tolerance...). PT Considerations (continued) Watch for signs and symptoms of exercise-induced ischemia or heart failure in patients with ECG changes suggestive of myocardial injury / infarct. Monitor ECG closely during activity in patients with dysrhythmia. Review Question #11 During a 12-lead ECG how many electrodes are placed on the patient’s chest? a. 12 b. 10 c. 6 d. 4 e. 2 Click here for answer Review Question #12 Which cardiac disorder(s) could be diagnosed with ECG? a. myocardial infarction b. valve regurgitation c. myopathy d. atrial fibrillation e. coronary heart disease Click here for answer(s) Holter (Event) Monitoring Description Ambulatory ECG monitoring of patient’s heart rate and rhythm during activity and rest over a 24-48 hour period. Data is recorded and then scanned for abnormalities. Example Report Example Report (continued) (Courtesy of Burdick, Inc., 1997) Purpose To identify cardiac dysrhythmias and relate them to symptoms or activities. To diagnose Prinsmetal’s variant angina. To evaluate the effect of intervention on dysrhythmias. To check pacemaker function. Procedure Skin is prepared for electrode placement (hair shaved, skin scrubbed with alcohol...). Self-adhesive electrodes placed on chest at five to seven sites. The monitor (~ 1 pound) is attached to the electrodes via leads. Procedure (continued) The patient is given a diary to record activity and symptoms experienced during the data collection period. After the 24-48 hour period the monitor, cassette, and diary are obtained for analysis. PT Considerations Explain the procedure to the patient Continue normal activity during the procedure and make sure to document type of exercise intervention in the patient diary. Use test results to compliment information obtained during the patient assessment (heart sounds, blood pressure, exercise tolerance). PT Considerations (continued) Monitor ECG closely during activity in patients with dysrhythmia. Make sure monitor does not get wet and is not removed, even temporarily. Review Question #13 When a patient is wearing a Holter Monitor it is important to do what when he/she exercises? a. remove the monitor b. log the activity type c. secure the electrodes & recorder d. call the physician Click here for answer(s) Review Question #14 ECG activity is recorded for how long with Holter Monitoring? a. 10 minutes b. 1 hour c. 6 hours d. 24 hours e. 1 month Click here for answer Multigated Acquisition (MUGA) / Thallium Scan Description Procedure in which a radioactive substance (technetium-99, thallium) is used to tag the patient’s blood, allowing heart movement to be observed. The images are synchronized with ECG and the procedure can be done with stress testing. With this procedure, only areas of the heart that are perfused can be visualized. Example Images Nuclear scan of the heart at rest (thallium) and with stress (Tc-99) showing myocardial ischemia with stress. (Janenez, 1999) Purpose To evaluate heart size, structure, and dynamic function. To measure chamber volumes and ejection fraction. To determine the effect of disease (AMI, ventricular aneurysm...) on heart function. To screen for coronary artery disease. To determine symptom (angina) threshold. To evaluate cardiac capacity for work. Procedure Skin is prepared for electrode placement (hair shaved, skin scrubbed with alcohol...). Self-adhesive electrodes placed on chest for ECG monitoring. Patient is positioned supine with an IV line in place. Procedure (continued) Dipyridamole is administered via the IV over 4 minutes. Thallium is injected into the IV 3 minutes after dipyridamole infusion begins. Dobutamine is administered through an infusion pump. The dose and infusion rate is increased until the patient’s heart rate reaches 85% of age-predicted maximum. Thallium is injected when the desired heart rate is achieved. Procedures (continued) Patient is positioned supine with a gamma camera over the chest. The patient’s chest is scanned with a gamma camera 5-10 after thallium infusion. Typically the patient is scanned again 2-4 hours after the initial pharmacological stress procedure. PT Considerations Explain the procedure to the patient. Resume activity soon after procedure. Use test results to compliment information obtained during the PT assessment. Watch for signs and symptoms of exerciseinduced ischemia or heart failure in patients with test findings suggestive of myocardial injury. PT Considerations (continued) Use test data to determine optimal exercise prescription, especially intensity. Review Question #15 A MUGA scan can provide what specific information? a. cardiac tissue perfusion b. abnormal conduction pathways c. degree of coronary artery stenosis d. presence of septal defect e. ejection fraction Click here for answer(s) Review Question #16 Which agent is administered during a MUGA scan to increase heart rate? a. thallium b. dipyridamole c. dobutamine d. gamma rays e. saline Click here for answer Venography / Arteriography Description A fluoroscopic or x-ray procedure of the deep leg veins / arteries after injection of a contrast dye. Typically this procedure is preformed after Doppler ultrasonography to confirm venous / arterial obstruction or insufficiency. Example Image Peroneal Artery Anterior Tibial Artery Purpose To diagnose deep vein thrombosis. To evaluate vein patency for coronary artery bypass grafting. To identify venous / arterial pathology (congenital abnormalities...). Procedure Patient is positioned on a table that is tilted up at a 40-60 degree angle. A tourniquet is applied above the ankle. An IV line is established in a dorsal foot vein / artery. Contrast dye is injected via the IV over 2-4 minutes. Procedure (continued) X-ray films are taken or fluoroscopy is monitored. Normal saline is used to flush the contrast dye from the veins / arteries. The procedure takes ~½-1 hour. Assess Homan’s sign in patients when a deep vein thrombosis is suspected. PT Considerations Explain the procedure to the patient. Postpone activity and elevate the tested leg immediately following the procedure. Use test results to compliment information obtained during the PT assessment. DO NOT perform exercise involving a lower extremities with a deep vein thrombosis until medically cleared. Review Question #17 A venogram / arteriogram may be used to diagnose what vascular problem(s)? a. deep vein thrombosis b. chronic venous sufficiency c. peripheral arterial disease d. lymphedema e. arterial embolus Click here for answer(s) Review Question #18 A venogram may be used to assess vein patency prior to harvesting for what surgical procedure(s)? a. cardiac valve replacement b. carotid endarterectomy c. pacemaker placement d. coronary artery bypass Click here for answer(s) e. total knee replacement References Goodman C, Boissonnault W. Pathology: Implications for the Physical Therapist. Philadelphia, PA: WB Saunders; 1998. Hillegass E, Sadowsky S. Essentials of Cardiopulmonary Physical Therapy. Philadelphia, PA: WB Saunders; 1994. Kee J. Handbook of Laboratory Diagnostic Tests. Stamford, CN: Appleton & Lange; 1998. Polich S, Faynor S. Interpreting lab test values. PT Magazine 1996;January:76-88. Pollock ML, Schmidt DH. Heart Disease and Rehabilitation. Champaign, IL: Human Kinetics; 1995. Jinenez CE. Advantages of diagnostic nuclear medicine. Phys Sports Med 1999;27(13):51-57. McKinnis L. Fundamentals of Orthopedic Radiology. Philadelphia, PA: FA Davis; 1997. Merck Manual. Cardiovascular Disorders. Available at: Accessed on 2/22/00. Murphy M, Berding C. Use of measurements of myoglobin and cardiac troponins in the diagnosis of acute myocardial infarction. Crit Care Nurs 1999;19(1):58-66. Roos R. Noninvasive detection of coronary artery disease. Phys Sports Med 2000;28(1):51-64. Sussman C, Bates-Jensen B. Wound Care. Gaitherburg, MD: Aspen Publishers; 1998. The End