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SPDX Prelims

Special Diagnostics and Procedures (Our Lady of Fatima University)

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I – LABORATORY SAFETY 2. CHEMICAL HAZARDS

2.1. Corrosive Hazards
Safety Irreversible injuries to the skin or eyes by direct
-the condition of being protected from or unlikely to cause contact or to the tissue of the respiratory and
danger, risk, or injury gastrointestinal tracts if inhaled or ingested.

Laboratory Safety
- necessitates the effective control of all hazards that exist 2.2 Irritants
in the clinical laboratory at any given time.
2.3 Reactive Hazards
Substances that, under certain conditions, can
spontaneously explode or ignite or that evolve
INSTITUTIONS ASSOCIATED WITH LABORATORY SAFETY:
heat or flammable or explosive gases.
1.) Occupational Safety and Health Administration(OSHA)
2.) Center for Disease Control and Prevention (CDC)
3.) The Clinical and Laboratory Standards Institute (CLSI)
2.4 Carcinogenic Hazards
-formerly National Committee for Clinical Laboratory
Substances that have been determined to be
Standards [NCCLS])
cancer-causing agents.
- provides excellent general laboratory safety and infection
control guidelines
4.) The Joint Commission (TJC; formerly the Joint Commission on
Accreditation of Health Care Organizations [JCAHO])
2.5 Fire Hazards
5.) Department of Health (DOH)
- Flammable and Combustible Materials
-Among the most hazardous materials in Clinical Laboratory
UNIVERSAL PRECAUTIONS and STANDARD PRECAUTIONS - Classified according to flash point

Universal Precautions Flammable Hazards - Flash point above 37.8°C (100°F)

- "All patients are considered to be possible carriers of
blood borne pathogens"

- "Wearing of Personal Protective Equipment when

handling/collecting blood and bodily fluids contaminated
with blood..."
Combustible Hazards – Flash point equal or above 37.8°C (100°F)
Body Substance Isolation Guidelines
2.6 Radiation Hazards
- "Consider all body fluids and moist body substances to be
- Encountered in Clinical Laboratory when
infectious"
procedures using radioisotopes are used.
Standard Precautions
- Combines major features of Universal Precautions and BSI
Guidelines

3 ELECTRICAL HAZARDS
LABORATORY HAZARDS
-Potential hazards associated with the use of
1. BIOLOGICAL HAZARDS 3. ELECTRICAL HAZARDS electrical appliances and equipment.
2. CHEMICAL HAZARDS 4. PHYSICAL HAZARDS
5. CRYOGENIC HAZARDS - May be direct or indirect hazards
1. BIOHAZARDS
- microorganisms w/c are potentially harmful; frequently
present in Clinical Laboratory Specimens
4. PHYSICAL HAZARDS
Ergonomic Hazards
Mechanical Hazards
Compressed Gas Hazards

5. CRYOGENIC HAZARDS

References: Clinical Chemistry - Principles, Techniques, Correlations, 7E (2013), Henry's Clinical Diagnosis and Management by Laboratory Methods
22nd ed 2011, Notes, SZP, RMT (2015)
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SAFETY MEASURES FOR LABORATORY HAZARDS 4. Radiation Hazards

- Regular and systematic monitoring
1. For Biohazards: - Decontamination of laboratory equipment, glassware, and
- Adhere to Universal/Standard Precautions work areas
- Personal Protective Equipment - Records must be maintained as to the quantity of
- Handwashing radioactive material

Spills 5. Fire Safety

• Alert others in area of the spill.
• Use mechanical devices to pick up broken glass
• Absorb the spill with paper towels, gauze pads, or tissue.
• Clean the spill site using a common aqueous detergent.
• Disinfect the spill site using approved disinfectant or 10% bleach,
using appropriate contact time.
• Rinse the spill site with water.
• Dispose of all materials in appropriate biohazard containers

2. For Chemical Hazards:

Follow Safety Data Sheet

-Major source of safety information for employees who may use

hazardous materials in their occupations.
CLASSIFICATION OF FIRES AND FIRE EXTINGUISHER
SDS information requirements includes the following: CLASS
OF TYPE OF HAZARD TYPE OF EXTINGUISHER
- Product name and identification FIRE
- Hazardous ingredients Ordinary Combustibles Type A
-cloth, paper, plastics and - (Pressurized Water)
- Permissible exposure limit A
wood Type ABC (Dry Chemical)
- Physical and chemical data
- Health hazard data and carcinogenic potential
Type BC (Carbon Dioxide)
- Primary routes of entry Flammable Liquids
B Type ABC (Dry Chemical)
- Fire and explosion hazards - grease, gasoline, oils
- Reactivity data Halon
- Spill and disposal procedures Electrical Equipment Type BC (Carbon Dioxide)
C
- PPE recommendations Type ABC (Dry Chemical)
- Handling
- Emergency and first aid procedures Flammable Metals Metal X
- Storage and transportation precautions -Mercury, Magnesium,
D
- Chemical manufacturer’s name, address, and tel. number Sodium and Lithium Fought only by
- Special information section firefighters
Detonation
E
3. Storage and Handling of Chemicals -Arsenal Fire Allowed to burn out

Acronyms to Remember during a Fire Hazard:

I. RACE
II. PASS

References: Clinical Chemistry - Principles, Techniques, Correlations, 7E (2013), Henry's Clinical Diagnosis and Management by Laboratory Methods
22nd ed 2011, Notes, SZP, RMT (2015)
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NFPA CLASSIFICATION SYMBOL (NFPA DIAMOND) 8. Fume Hoods and Biosafety Cabinets

Fume Hoods
Required to contain and expel noxious
and hazardous fumes from chemical
reagents. Fume hoods should be
visually inspected for blockages.

Biosafety Cabinets

Biological safety cabinets

(BSCs) remove particles
that may be harmful to the
employee who is working
with potentially infectious
biologic specimens

9. Chemical Storage Equipment

– Safety carriers should always be used to transport glass

bottles of acids, alkalis, or organic solvents in volumes
larger than 500 mL,

– Approved safety cans should be used for storing,

dispensing, or disposing of flammables in volumes greater
6. Signage and Labeling than 1 quart.
-to alert laboratory personnel to potential hazards
-to identify specific hazards that may arise because of emergencies – Steel safety cabinets with self-closing doors or explosion-
proof refrigerators
- Manufacturers of laboratory chemicals

All in-house prepared reagents and solutions should be labeled in a

standard manner and include the chemical identity, concentration,
hazard warning, special handling, storage conditions, date
prepared, expiration date (if applicable), and preparer’s initials.

7. Safety Equipment
– Safety showers, eyewash stations, and fire extinguishers
– Periodical testing and inspection

– Other items that must be available for personnel include fire

blankets, spill kits, and first aid supplies.
– Mechanical pipeting devices must be used for manipulating all
types of liquids in the laboratory, including water.

References: Clinical Chemistry - Principles, Techniques, Correlations, 7E (2013), Henry's Clinical Diagnosis and Management by Laboratory Methods
22nd ed 2011, Notes, SZP, RMT (2015)
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WEEK 3: STRESS TESTING

STRESS TESTING probability CAD on the basis of age, gender

- Use to measure heart’s ability to respond to and symptoms
external stress in controlled clinical
PRIOR HISTORY OF CORONARY HEART DISEASE
environment.
- Patients undergoing initial evaluation with
TYPES suspected or known CAD(complete right
 EXERCISE bundle branch block or less than 1mm of
- Treadmill resting ST depression)
- Bicycle - Patients with suspected or known CAD, now
 PHARMACOLOGICAL presenting significant change in clinical
- Adenosine - given to create a coronary status.
“steal” by temporarily increasing flow in - Low risk, unstable angina patients 8 to 12
non-diseased segments of the coronary hrs. after presentation who have been free
vasculature at the expense of diseased of active ischemia or heart failure
segments. symptoms.
- Dipyridamole - Intermediate risk, unstable angina patients
- Dobutamine – administered to increased 2 to 4 days after presentation who have
MVO₂ been free of active ischemia or heart failure
- Isoproterenol symptoms
 OTHERS
VALVULAR HEART DISEASE
- Pacing
1. CHRONIC AORTIC REGURGITATION –
INDICATIONS OF STRESS TESTING assessment of functional capacity and
- Abnormalities not present at birth systematic responses in patients with a history
- Estimate functional capacity of equivocal symptoms
- Estimate prognosis of CAD 2. AORTIC STENOSIS – testing asymptomatic
- Likelihood of CAD patients with recommendation of aortic valve
- Extent of CAD replacement for those with exercise induced
- Effect of treatment symptoms or abnormal blood pressure
response.
INDICATIONS OF PHARMACOLOGICAL STRESS
3. MITRAL STENOSIS – class 1 recommendation
TESTING
for stress echocardiography
- Patients who cannot exercise due to
- Discordance between symptoms and
physical or psychological limitations.
stenosis severity
- If the choses test is not available
- Threshold values for intervention
METHODS OF DETECTING ISCHEMIA DURING STRESS a. Mean transmitral pressure against gradient
TEST >15mmHg during exercise.
- Electrocardiography b. A peak pulmonary artery systolic pressure
- Echocardiography >60mmHg during exercise.
- Myocardial perfusion imaging 4. MITRAL REGURGITATION – asymptomatic
- Positron emission tomography patients with sever MR, exercise stress echo
- Magnetic resonance imaging (MRI) helps identify:
a. Patients with subclinical latent LV dysfunction
INDICATIONS
b. Worsening of MR severity
OBSTRUCTIVE CAD
c. Marked increased in pulmonary arterial
- Adults patients with right bundle branch
pressure.
block or less than 1mm of resting ST
d. Impaired exercise capacity
depression with an intermediate pretest

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5. PROSTHETIC HEART VALVES – stress  Peak exercise capacity is decreased when the ratio
echocardiography confirms or excludes the of measured to predicted VO₂ max is <85 to 90%.
presence of hemodynamically significant
METABOLIC EQIVALENT(MET)
prosthetic valve stenosis or patient prosthesis
- A unit of oxygen uptake in a sitting, resting
mismatch (PPM)
person.
RHYTHM DISORDERS - 1 MET = 3.5 VO₂ ml O₂/kg/min of body
- Evaluation of congenital complete heart weight
block in patients considering increased - Measured VO₂ in ml O₂/kg/min divided by
physical activity or participation in 3.5 VO₂ ml O₂/kg/min determines the
competitive sports. number of METs associated with activity
- This measurement is useful to determine
CONTRAINDICATION FOR STRESS TESTING
exercise prescriptions, assess disability,
- Acute myocardial infarction (within 2 days)
and standardize the reporting of
- High risk unstable angina
submaximal and peak exercise workloads
- Uncontrolled cardiac arrythmias causing
when different protocols are used.
symptoms or hemodynamic compromise.
- Symptomatic severe aortic stenosis GENERAL CONCERNS
- Acute pulmonary embolus or pulmonary A. SAFETY PRECAUTIONS AND EQUIPMENTS
infarction NEEDS
- Acute myocarditis or pericarditis o Treadmill - should have front and side rails for
- Acute aortic dissection subjects to study themselves.
- Should be calibrated monthly.
TYPES OF EXERCISE
- Emergency button should be readily
A. ISOTONIC/DYNAMIC
available to the staff only.
 Weightlifting
B. PATIENT PREPARATION
 Swimming
o History of lightheaded or fainting while
 Rock climbing
exercising should be ask.
 cycling
o Family history and general medical history,
B. ISOMETRIC/STATIC
making note of any considerations that may
 Holding a static push-up position
increase the risk of sudden death.
 Holding a dumbbell in one hand
o Physical exam prior to testing to rule out
 Pushing against an immovable object
significant outflow obstruction
C. RESISTIVE
o Instruct the patient not to eat or smoke at least
CARDIOPULMONARY EXERCISE TESTING 2hrs before the test.
 Involves measurement of respiratory oxygen o Unusual physical exertion should be avoided.
uptake (VO₂), carbon dioxide production(VCO₂), o Drugs taken (medications should be brought
and ventilatory parameters during a symptom- along so that it can be identified and recorded)
limited exercise test. C. CHOOSING A TEST TYPE
 VO₂ max – product of maximal arterial-venous D. CHOOSING THE TEST PROTOCOL
oxygen difference and cardiac output and o DYNAMIC PROTOCOLS - more frequently used
represents the largest amount of oxygen a person to assess cardiovascular reserve and those
can use while performing dynamic exercise suitable for clinical testing should include a low
involving a large part of total muscle mass. intensity warn-up phase.
- Decreases with age, less in women, and o In general 6 to 12 mins of continuous
diminished by degree of cardiovascular progressive exercise during which the
impairment and by physical inactivity myocardial oxygen demand is elevated to the
patients maximal level is optimal for diagnostic

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WEEK 3: STRESS TESTING

and prognostic purposes. The protocol should occlusive disease and who cannot perform
include recovery or cool down period. bicycle or treadmill exercise.
 Patients are instructed to walk down a 100-foot
VARIOUS PROTOCOLS
corridor at their own pace, attempting to cover
TREADMILL
as much ground as possible in 6 minutes.
 BRUCE  At the end of the 6-minute interval, the total
 CORNELL distance walked is determined and the
 BALKE WARE symptoms experienced by the patient are
 Acip recorded
 mAcip  MEASUREMENTS
 NAUGHTON  ECG
 WEBER  Exercise capacity (METS – metabolic equivalent)
 Symptoms
BICYCLE ERGONOMETER  Blood pressure
E. PATIENT MONITORING  Heart rate response & recovery
F. REASONS TO TERMINATE A TEST
G. POST TEST MONITORING
Positive test
a. A flat or down sloping depression of the ST
 BRUCE – normally used segment > 0.1 mV below baseline (i.e the PR
 has 3 minute periods to allow achievement of segment ) and lasting longer than 0.08s
steady state before workload is increased for
next stage b. Upsloping or junctional ST segment changes are
 older individuals /cardiac disease patients, the not considered characteristic of ischemia and
protocol can be modified by TWO 3 minute do not constitute a positive test.
warm up stages at 1.7mph and 0% grade and
Negative test
1.7mph and 5% grade
- Target heart rate (85% of maximal predicted
heart for age and sex ) is not achieved .

False positive:
a. In asymptomatic men < 40 years.
b. In patients taking cardioactive drugs
c. In patients with intraventricular conduction
disturbances, ventricular hypertrophy,
abnormal potassium levels.

False negative:
a. In patients with obstructive diseases limited to
circumflex coronary artery(lateral portion is
not well represented on the surface 12 lead
ECG.)

T WAVE CHANGES
 The 6-Minute Walk Test Influenced by:
 Used for patients who have marked left  Body position
ventricular dysfunction or peripheral arterial  Respiration

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 Hyperventilation
 Drug Rx
 Myocardial ischemia
 Necrosis

Pseudonormalization of T wave:

 Usually, non-diagnostic and consider ancillary

imaging in such cases.

MAXIMAL WORK CAPACITY

 In patients with known or suspected CAD, a
limited exercise capacity is associated with an
increased risk of cardiac events and in general
the more severe the limitation, the worse the
CHRONOTROPIC INCOMPETENCE
CAD extent and prognosis.
 Chronotropic incompetence is determined by
 In estimating functional capacity the amount of
decreased heart rate sensitivity to the normal
work performed (or exercise stage achieved)
increased in sympathetic tone during exercise
expressed in METs and not the number of
heart rate to at least 85% of age predicted
minutes of exercise, should be the parameter
maximum.
measured.
 Heart rate reserve is calculated as follows –
 Major reduction in exercise capacity indicates
significant worsening of cardiovascular status. % HRR used = (HRpeak- HRres) / (220-age-HRres)

BLOOD PRESSURE RESPONSE  Abnormal heart rate recovery refers to a

 The normal exercise response is to increase relatively slow deceleration of heart rate
systolic blood pressure progressively with following exercise cessation. This type of
increasing workloads to a peak response response reflects decreased vagal tone and is
ranging from 160 to 200mmHg with the higher associated with increased mortality.
range of the scale in older patients with less
compliant vascular systems. TERMINATION EXERCISE TESTING

 Failure to increase systolic blood pressure

beyond 120mmHg or a sustained decrease
greater than 10mmHg repeatable within 15
seconds or a fall in systolic blood pressure
below standing resting values during
progressive exercise when the blood pressure
has otherwise been increasing appropriately, is
abnormal .

HEART RATE RESPONSE

 Peak HR > 85% of maximal predicted for age.
 HR recovery >12 bpm (erect)
 HR recovery >18 bpm (supine)

PROGNOSTIC VALUE OF STRESS TESTING

Parameters associated with adverse prognosis or
multi- vessel disease :

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 Duration of symptom-limiting exercise <5 METs  Echocardiography

 Radionuclide imaging
 Failure to increase sBP ≥120mmHg, or a
sustained decreased ≥ 10mmHg, or below rest STRESS ECHOCARDIOGRAPHY
levels, during progressive exercise Compares pre & post:

 ST segment depression ≥2mm, downsloping ST  Regional contractility

segment, starting at <5 METs, involving ≥5
 Overall systolic function
leads, persisting ≥5 min into recovery
 Volumes
 Exercise-induced ST segment elevation (aVR
excluded)  Pressure gradients

 Angina pectoris at low exercise workloads  Filling pressures

 Reproducible sustained (>30 sec) or  Pulmonary pressures

symptomatic ventricular tachycardia
 Valvular function
LIMITATIONS OF TREADMILL STRESS TEST
STRESS ECHO - LIMITATIONS
 Non-diagnostic ECG change
Factors which effect image quality:
 Women – false positives
 Elderly – more sensitive/less specific  Body habitus
 Diabetics – autonomic dysfunction
 Lung disease
 Hypertension
 Inability to exercise  Breast implants
 Drugs – digoxin; anti-anginals
NUCLEAR SPECT IMAGING
 Sensitivity 68%  Radio-tracer injection
 Specificity 77%
 Isotopes:
NON-CORONARY CAUSES OF ST SEGMENT
DEPRESSION A) Thallium-201
 Anaemia
B) Technetium 99m (sestamibi)
 Cardiomyopathy
 Digoxin  Myocardial uptake
 Glucose load
 Photon emission captured by gamma camera
 Hyperventilation
 Hypokalaemia  Rest & redistribution phases
 Intraventricular conduction disturbance
 Pharmacologic protocols available
 Mitral valves prolapse.
 Pre-excitation syndrome  Digital presentation
 Severe aortic stenosis
 Severe hypertension
 Severe hypoxia
 Severe volume overload (aortic or mitral
regurgitation)
 Sudden excessive exercise
 Supraventricular tachycardias

ANCILLARY TECHNIQUES TO ENHANCE

CONTENT

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WEEK 3: STRESS TESTING

 This results in improved spatial resolution,

compared with SPECT .
 PET can be used to assess myocardial
perfusion and myocardial metabolic activity
separately by using different tracers
coupled to different molecules.

 Agents used-

o Oxygen 15(half time 2mins)

o Nitrogen -13(half-life 10 mins)

o Carbon -11(half time 20 mins)

o Flourene -18(half 110 mins)

THALLIUM- 201 SCAN o Because Rubidium – 82 with a half-life of 75
seconds, does not require a cyclotron and
 Myocardial perfusion problems are
can be generated on site, it is frequently
separated from non-viable myocardium by
used with PET scanning, especially for
the fact that thallium eventually washes out
perfusion images.
of the myocardial cells and back into the
circulation . LIMITATIONS OF NUCLEAR SPECT
 If a defect detected on initial thallium IMAGING
imaging disappears over a period of 3-24  Time-consuming
hours, the area is presumably viable .
 Artifacts
 A persistent defect suggests a myocardial
scar.  Radiation

TECHNETIUM – 99M(sestamibi)  Breast attenuation

 The technetium – 99m(sestamibi) based  Risk of iatrogenic malignancy

agents take advantage of the shorter half -
 Consider:
life ( 6 hours; thallium 201’s is 73 hours)
 This allows for use of a larger dose, which  age
results in higher energy emissions and
 gender
higher quality images.
 Technetium 99m’s higher energy emissions  background
scatter less and are attenuated less by chest
wall structures, reducing the number of MRI CARDIAC STRESS TEST
artifacts.  Useful for:

POSITRON EMISSION TOMOGRAPHY  Patients unable to exercise.

 ECG uninterpretable
 Is a technique using tracers that
simultaneously emit two high energy  Unsuitable for DSE
photons.
 A circular array of detectors around the  No radiation
patient can detect these simultaneous  Not currently available
events and accurately identify their origin
in the heart. STRESS TEST MACHINES AND EQUIPMENTS

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WEEK 3: STRESS TESTING

The laboratory must have basic equipment such

as a 12-lead ECG, blood pressure monitoring capacity, a
treadmill or bicycle for ergometry, a precision
intravenous delivery system for pharmacological stress
testing as well as an adequate echo table; additionally,
emergency equipment is mandatory. The ultrasound
machine should contain transducers with high 2-D
resolution; most important is a digital image acquisition
system which facilitates performance and interpretation
through side-by-side display of synchronized rest and
stress images.

ECG

An electrocardiogram (ECG) stress

test monitors a person's heartbeat at rest and during
exercise, most commonly while a person walks on a
treadmill. A physician observes the person, monitors
the exercise level, and makes recordings until the
person's heart nears a maximum predicted heart rate.

Bicycle
Cycle ergometry is an alternative to
treadmill testing for those patients who have
orthopedic, peripheral vascular, or neurological
limitations that restrict weight bearing. It can also serve
as a less expensive, portable substitute for testing.

The normal ranges of blood pressure response

to exercise stress testing are as shown in Figure
1. Normal systolic and diastolic responses to
exercise stress testing should not exceed 220 and 100
mm Hg, respectively. Systolic blood pressure of >230
mm Hg is generally considered hazardous.

TERMINOLOGIES
 ACC – American College of Cardiography
 AHA – American Heart Association
 CAD – coronary artery disease
 ECG - - Electrocardiography
 MET – Metabolic equivalent
 MRI – magnetic resonance imaging
 PPM - patient prosthesis mismatch
 Prognosis – most likely to be the outcome
(educated prediction)

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WEEK 4: ELECTROCARDIOGRAPHY

BRIEF HISTORY

 The 12 lead EKG was innovated via multiple

innovations over two centuries.
 Dr. Luigi Giovanni was the first to point out
electrical activity in animal tissue in 1786 in
Italy.
 Heart electrical activity was demonstrated in
frogs in the 19th century.
 In 1877, Augustus Waller demonstrated the first
electrocardiogram (although the term was not
penned until after) using a capillary
electrometer and electrodes, relating electrical
activity to ventricular contraction.
 It was Dr. Willem Einthoven from the How is the test performed?
Netherlands who innovated the EKG for clinical  You will be asked to lie down. The health care
use by refining the electrometer and delineating provider will clean several areas on your arms,
PQRST waves. He used three limb leads, which legs, and chest, and then will attach small
became known as Einthoven’s triangle. patches called electrodes to those areas. It may
Einthoven received the Nobel Prize in be necessary to shave or clip some hair, so the
physiology and medicine for his work in creating patches stick to the skin. The number of patches
the first iteration of the clinical EKG and used may vary.
foundation.  The patches are connected by wires to a
machine that turns the heart's electrical signals
into wavy lines, which are often printed on
paper. The doctor reviews the test results.
 You will need to remain still during the
procedure. The provider may also ask you to
hold your breath for a few seconds as the test is
being done.
 It is important to be relaxed and warm during
an ECG recording because any movement,
including shivering, can alter the results.
 Sometimes this test is done while you are
exercising or under light stress to look for
changes in the heart. This type of ECG is often
ELECTROCARDIOGRAPHY(ECG) called a stress test.
Electrocardiography is the process of producing an  Make sure your provider knows about all the
electrocardiogram (ECG or EKG). It is a graph of voltage medicines you are taking. Some drugs can
versus time of the electrical activity of the heart using interfere with test results.
electrodes placed on the skin.  DO NOT exercise or drink cold water
immediately before an ECG because these
actions may cause false results.

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WEEK 4: ELECTROCARDIOGRAPHY

An ECG is often the first test done to determine

whether a person has heart disease. Your provider may
order this test if:

 You have chest pain or palpitations

 You are scheduled for surgery
 You have had heart problems in the past
 You have a strong history of heart disease in the
How will the test feel? family
An ECG is painless. No electricity is sent through the
body. The electrodes may feel cold when first applied.
In rare cases, some people may develop a rash or
irritation where the patches were placed.

Normal test results most often include:

 Heart rate: 60 to 100 beats per minute

 Heart rhythm: Consistent and even

What Abnormal Results Mean

Why is the test performed?
An ECG is used to measure: Abnormal ECG results may be a sign of:

 Any damage to the heart  Damage or changes to the heart muscle

 How fast your heart is beating and whether it is  Changes in the amount of the electrolytes (such
beating normally. as potassium and calcium) in the blood
 The effects of drugs or devices used to control  Congenital heart defect
the heart (such as a pacemaker)  Enlargement of the heart
 The size and position of your heart chambers  Fluid or swelling in the sac around the heart
 Inflammation of the heart(myocarditis)
 Past or current heart attack
 Poor blood supply to the heart arteries
 Abnormal heart rhythms (arrhythmias)

Some heart problems that can lead to changes on

an ECG test include:

 Atrial fibrillation/flutter
 Heart attack
 Heart failure
 Multifocal atrial tachycardia
 Paroxysmal supraventricular tachycardia

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WEEK 4: ELECTROCARDIOGRAPHY

 Sick sinus syndrome measuring a specific electrical potential

 Wolff-Parkinson-White syndrome difference
 Leads are broken down into three types: limb;
augmented limb; and precordial or chest.
 The 12 lead ECG has a total of three limb leads
and three augmented limb leads arranged like
spokes of a wheel in the coronal plane (vertical),
and six precordial leads or chest leads that lie
on the perpendicular transverse plane
(horizontal).

Considerations

The accuracy of the ECG depends on the condition being

tested. A heart problem may not always show up on the
ECG. Some heart conditions never produce any specific
ECG changes.

Placement of the electrode

Electrodes
 the term leads is also sometimes used to refer
to the electrodes
 Electrodes are the actual conductive pads
attached to the body surface.
 Commonly, 10 electrodes attached to the body
are used to form 12 ECG leads, with each lead

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WEEK 5: ECHOCARDIOGRAPHY

ECHOCARDIOGRAPHY
 1842 – Christian Johann Doppler(1803-1853)
noted that the pitch of sound varied if the
source of the sound was moving
 1880 – ability to create ultrasonic waves with
the discovery of piezoelectricity by Curie and
Curie.
 1953 – Dr. Helmut Hertz of Sweden obtained
a commercial ultrasonoscope which was being
used for non-destructive testing. He then
collaborated with Dr. Inge Edler who was
practicing cardiologist. They use
ultrasonoscope to examine the heart.
PRINCIPLE OF IMAGE GENERATION
Generation of an Ultrasound Image
Echocardiography (echo or echocardiogram)

- a type of ultrasound test that uses high

pitched sound waves to produce an image of
heart.
- soundwaves are sent through a device called
a transducer(reflected off the various
structures of the heart).
- These echoes are converted into pictures that
can be seen in a video monitor.

NOTE: NO SPECIAL PREPARATION FOR THE TEST GRAY SCALE IMAGE

- Generated based on intensity of reflected
echo

BLACK Fluid or blood

WHITE Calcifications on cardiac
valves/pericardium
GRAY myocardium

Ultrasound Gel – applied to the transducer to allow

transmission of the sound waves from the transducer
to the skin.

Transducer – transforms the echo (mechanical

energy) into an electrical signal which is processed
and displayed as an image on the screen.

Piezoelectric effect - conversion of sound to electrical MACHINES

energy 5 BASIC COMPONENTS OF AN ULTRASOUND SCANNER

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1. Pulse Generator – applies high amplitude INDICATIONS OF 2D ECHO

voltage to energize crystals. a. Structural Imaging
2. Transducer – converts electrical energy to - Pericardial imaging (P. Effusion)
mechanical (ultrasound) energy and vice - L/R ventricles & cavities(RVH/LVH or wall
versa. motion abnormality or thrombi)
3. Receiver – detects and amplifies weak signals. - Images of valves (stenosis or prolapse)
4. Display – displays ultrasound signals in a - Great vessels (aortic dissections)
variety of modes. - Hypertension & traumatic heart diseases
5. Memory – stored video display - Arrythmias, palpitations, syncope or
neurological disease
TRANSDUCER
b. Hemodynamic Imaging through Doppler
- responsible for transmitting and receiving the
techniques
ultrasound signal.
- Blood flow through heart valves
- consist of a electrode and a piezo-electric
(stenosis/regurgitation)
crystal whose ionic structure results in
- Blood flow through the cardiac chambers
deformation shape when exposed to an
- Systolic and diastolic functions
electric current.
- Piezo electric(PE) crystals are composed of TYPES
synthetic material such as barium titanate  Transthoracic (standard echo)
which expand and contract to create - Left parasternal
soundwaves when exposed to electric current - Apical
from electrodes. Change shape when - Subcostal
subjected to mechanical energy which then - Suprasternal
detected by the electrodes as an electrical  Transesophageal
signal.  Intracardiac

ULTRASOUND PHYSICS
TEE and ICE: higher frequency soundwaves generate
high resolution images.

- Waves do not travel far but allows for imaging

of finer details.
- TEE uses frequency of 7MHz, ICE uses 5-10
MHz.

TTE: Lower frequency sound waves generate lower

resolution images.

- Allows deeper penetration of waves through

more tissue, adequate for most situations.
- TTE uses frequency of 3 MHz.

Standard positions on the chest wall are used for

placement of the transducer called “echo windows”

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*marker oriented towards the right clavicle

ACOUSTIC WINDOW
(approximately 11 o’clock)

Structure Assessment
RV (right ventricle) Size and function
LV (left ventricle) Size and function
(septum)
Ao (ascending aorta) Size
AV (Aortic Valve) Motion, opening and
calcification
MV (Mitral Valve) Motion, opening and
calcification
Pericardium Fluids

1. Parasternal Long-Axis View (PLAX)

 Transducer position: left sternal edge; 2nd-4th
intercostal space.
 Marker dot direction: point towards right
shoulder.
 Most echo studies begin with this view.
 It sets the stage for the subsequent echo
views.
 Many structures seen from this view

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Parasternal Short Axis View (PSAX)

 Transducer position: left sternal edge; 2nd-4th
intercostal space.
 Marker dot direction: point towards left
shoulder(90ᵒ clockwise from PLAX view)
 By tilting transducer on an axis between the
left hip and right shoulder, short axis views
are obtained at different levels, from aorta to
LV apex.
 Many structures seen. *PLAXS-rotate clockwise 90degrees (inverted T to long
axis LV)

Papillary Muscle PM) Level

 PSAX at the level of the papillary muscles

showing how the respective LV segments are
identified, usually for the purposes of
describing abnormal LV wall motion
 LV wall thickness can also be assessed.
2. Apical 4-Chamver View (AP4CH)
 Transducer position: apex of the heart
 Marker dot direction: points towards left
shoulder.

*Marker is at around 3 o’clock

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AP5CH View

- Obtained by slight anterior angulation of the

transducer towards the chest wall.
- LVOT can then be visualised.

3. Sub-costal 4 Chamber View (SC4CH)

 Transducer position: under the xiphisternum
 Marker dot direction: points towards left
shoulder.
 The subject lies supine with head slightly low
(no pillow). With feet on the bed, the knees
are slightly elevated.
 Better images are obtained with the abdomen
Apical 2-Chamber View (AP2CH)
relaxed and during inspiration.
 Transducer position: apex of the heart  Interatrial septum, pericardial effusion,
 Marker dot direction: points towards left side descending abdominal aorta.
of neck (45ᵒ anticlockwise from AP4CH view)
 Good for assessment of LV anterior wall and
LV inferior wall

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*Transducer in right sub xiphoid area & side marker in All modalities follow the same principle of ultrasound
3 o’clock position differ in how reflected sound waves are collected and
analysed

1. Two-Dimensional Echo (2-D Echo)

- Used to “see” the actual structures and
motion of the heart structures of the heart
structures at work.
- Ultrasound is transmitted along several scan
lines (90-120), over a wide arc (about 90ᵒ) and
many times per second.
- The combination of reflected ultrasound
signals builds up an image on the display
screen.
4. Suprasternal View - A 2-D echo view appears cone shaped in the
 Transducer position: suprasternal notch monitor.
2. M-Mode Echocardiography
 Marker dot direction: points towards left jaw.
- Not a picture of the heart but rather a
 The subject lies supine with the neck
diagram that shows how positions of its
hyperextended. The head is rotated slightly
structures change during the course of the
towards the left.
cardiac cycle.
 The position of arms or legs and the phase of
- M-mode recordings permit measurement of
respiration have no bearing on this echo
cardiac dimensions and motion patterns.
window.
- Also facilitate analysis of time relationship
 Arch of aorta
with other physiological variables such as ECG,
and heart sounds.

Modes of ECHO
 A mode: basic mode – single scan line is
passed through the heart.
 B mode: repetitive scan lines
 M mode: movement of the heart can be
obtained as a time-motion or M mode
recording providing dynamic cardiac images.
 2D Echo: acquired multiple B mode scan lines
that are aligned in the appropriate anatomic
locations to form a wedge shaped sector
image that provides additional spatial
information in either superinferior or
mediolateral directions.
The Modalities of Echo 3. Doppler Echocardiography
The ff. modalities of echo are used clinically: - Is a method for detecting the direction and
1. Conventional Echo velocity of moving blood in the heart
 Two-Dimensional Echo (2-D Echo)  Continuous wave (CW) – useful for high
 Motion-mode Echo (M-mode Echo) velocity flow e.g., aortic stenosis
2. Doppler Echo  Pulsed wave (PW) – useful for low velocity
 Continuous wave (CW) Doppler e.g., MV flow
 Pulsed wave (PW) Doppler  Color flow (CF) – different colors are used to
 Color flow (CF) Doppler designate the direction of blood flow. Red is
flow toward, and blue is flow away from the
transducer with turbulent flow shown as a
mosaic pattern.

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RED Toward  Severe atlantoaxial joint disorders

BLUE Away  Orthopedic conditions that prevent neck
GREEN Superimposed when flexion
there is turbulent flow.
*Blue Away Red Towards (BART) Epicardial Imaging
- Application of an ultrasound probe directly to
the cardiac structures provides a high
resolution, non-obstructive view of cardiac
structures. Because this probes are placed
directly on the beating heart or vasculature,
they must be either sterilized or more
commonly placed in sterile insulating sheath
before use.

INTRACARDIAC ECHOCARDIOGRAPHY
- Involves a single-plane, high frequency
transducer (typically 10MHz) on the tip of a
steerable intravascular catheter, typically 9 to
Transesophageal Echocardiogram(TEE)
13 French in size.
- Used to assess posterior structures like LA or - Intravascular Ultrasound (IVUS) –
aorta Ultraminiaturized ultrasound transducers
- Clinical Success: mounted on modified intracoronary
 1st The close proximity of esophagus to the catheters. Both phased-array and mechanical
posterior wall of the heart makes this rotational devices have been developed.
approach ideal for examining several These devices operate at frequencies of 10 to
important structures. 30 MHz and provide circumferential 360-
 2nd The ability to position transducer in the degree imaging.
esophagus or stomach for extended periods
STRESS ECHO
provides an opportunity to monitor the heart
- A family of examination in which 2D
over time, such as during cardiac surgery.
echocardiographic monitoring is undertaken
 3rd although more invasive than other forms
before, during and after cardiovascular stress
of echocardiography, the technique has
- Cardiovascular stress – > exercise -
proven to be extremely safe and well
>pharmacological agents
tolerated so that it can be performed in
critically patients and very small infants BASIC PRINCIPLES OF STRESS ECHO
o Inadequate transthoracic images  ↑cardiac workload - ↑O₂ demands – demand
o Aortic disease supply mismatched – ischemia.
o Infective endocarditis  Impairment of myocardial thickening of
o Source of Embolism endocardial motion
o Valve prosthesis
o Intraoperative

CONTRAINDICATIONS
Esophageal pathology

 Severe dysphagia
 Esophageal stricture
 Esophageal diverticula
 Bleeding Esophageal varices
 Esophageal cancer

Cervical spine disorders CONCLUSION

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 Echocardiography provides a substantial o Caused by rheumatic heart disease.

amount of structural and functional o Check for abnormal thickening and
information about the heart. opening leaflets.
 Still frames provide anatomical detail.
Atrial Fibrillation
 Dynamic images tell us about physiological
function.  Can be related to valvular disease, CAD,
 The quality of an echo is highly operator diastolic dysfunction, or cardiomyopathy
dependent and proportional to experience  Echoes can assess any underlying problems
and skill, therefore the value information and guide treatment.
derived depends heavily upon who has  Best to control rate before study
performed it.  Patients with major structural abnormalities,
significant LV systolic dysfunction, or LA
INDICATIONS FOR ECHO
diameter >4.5 cm are less likely to maintain SR
Assessment of LV Function
after CV
 Most common reason an echo is ordered.
Stroke/TIA
 Most useful measurement in ejection fraction
o Difference in LV volume at end-  Up to 20% of CVA’s may be caused by cardiac
systole and end-diastole emboli.
o Normal range is 55%-65%  TTE rarely shows a direct source (such as
 Wall motion abnormalities (WMA) can be thrombus vegetations, or tumors
described.  Shows abnormalities which predispose a
 Hypokinesis – LV contraction diminished. patient to embolization (such as MV disease,
 Akinesis – no contraction PFO, or LV aneurysm)
 Dyskinesis – uncoordinated contraction  TEE is an effective screening tool to detect
LAA thrombus before CV of AF and AF
Murmurs
ablation procedures
 Abnormal heart sounds caused by abnormal
Infective Endocarditis
blood flow through the heart
o Valvular heart disease  Bacterial infection of heart valves
o Increased flow across normal valve o Established bacteria is called a
o Shunts due to congenital or acquired vegetation.
defects.  Damaged and abnormal valves are at higher
o Tumors risk.
 Acute (Staph) versus subacute (strep)
Aortic Valve Disease
 Symptoms: fever, murmur, emboli, stroke
 Aortic Stenosis  IV drug abuse can increase risk of bacterial
o Assess valve opening and mobility of endocarditis.
cusps  Can also be used in setting of suspected
- Note presence of calcium or thickening device system infection.
o Measures velocity of blood flow across
valve Assessment of Artificial Valves
o Calculate valve area.  Can be used for tissue and mechanical valves.
 Aortic Regurgitation  Check for regurgitation and leaking blood
o Assessed using Doppler. around valve annulus.
Mitral Valve Disease  Check velocity of blood flow through the valve

 Mitral Regurgitation
o Assess closure of valve leaflets
o Assess with Doppler
 Mitral Stenosis

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