Chapter 1: cardiovascular testing

1. Lesson 1
Cardiovascular testing
Tsegaye Melaku (BPharm, MSc)
[Assistant Professor of Clinical Pharmacy]
tsegayemlk@yahoo.com or tsegaye.melaku@ju.edu.et +251913765609December, 2019
Pharmacotherapy of Cardiovascular Disorders

2.  Session Tips
 Differentiate types of cardiovascular testing
 Type of murmur (systolic/diastolic) Vs specific valvular abnormalities.
 How echo, EC(K)G used for CVD dx, Rx, prognosis
 Clinical importance of cardiac biomarkers
 Other investigation modalities
 When to order these CV testing
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3.  Estimate average heart rate of the following mammals (beats/min)
 Estimated size of your heart?
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Human Whale
Camel Lion
Cat Mouse
Elephant Neonates (human)
9
40
376
70
28
200
30 150

4.  Height? Width ?
 Beats per day?
 Beats 2.5 billion times in an average 70 yrs. Lifetime
 Pumps about of blood each day
 Pumps blood through miles of vessels
 Suffers 7.2 mil. CAD deaths worldwide each year
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4.8 inches tall 3.35 inches wide   12 x 9 cm
~100,000 times
2000 galloons/7600 liters
62,000

5.  CO (ml/min) = HR (75 beats/min) x SV (70 ml/beat)
– CO = 5250 ml/min (5.25 L/min)
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6.  Components
 Heart: hollow muscular organ
 Blood
 Vessels
– Arteries: Away from heart
– Veins: toward heart
– Capillaries: Link arterioles to veins
» sites of o2, nutrients & waste exchange
• Pinocytosis/diffusion
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8.  Heart :
– Provides the driving force for the cardiovascular system
– Organ at the center of the circulatory system.
– It pumps blood around the body
– ~ the size of your fist
– Weight ~ 250-300g
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12.  Heart walls:
 Epicardium
– Outermost layer
– Fat to cushion heart
 Myocardium
– Middle layer
– Primarily cardiac muscle
 Endocardium
– Innermost layer
– Thin and smooth
– Stretches as the heart pumps
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14.  CVD afflicts an estimated 80 million people (i.e.~1 in 3 adults)
– Accounts for 35% of all deaths: US data
 Total cost of CVD (HTN, CHD, HF, and stroke)~ $475.3 billion.
 Atherosclerosis: cause of most CVD events.
– Typically present for decades before symptoms appear
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17.  Thorough history,
 Comprehensive P/E
 Appropriate testing,
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– Identify sub-clinical CVD
– Assess symptomatic CVD for the risk of an adverse event
– Help in appropriate management

18.  Elements of a comprehensive history:
– Chief complaint,
– Current symptoms, …HPI
– Past medical history,
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– Family history,
– Social history…..
– Review of systems
 Diet/physical activity/tobacco/alcohol/illicit drug
 Duration/quality/frequency/severity/progression/precipitating &
relieving factors, associated symptoms, & impact on daily activities

19.  Chest pain: frequent symptom
– Angina/infarction, non-cardiac conditions (esophageal,
pulmonary, or musculoskeletal disorders)
– Quality/location/duration;
– Provoking or relieving factors (ascertain etiology)
– Example:
 Sensation of heaviness/pressure in the retrosternal area
 Radiate to the jaw, left shoulder, back, or left arm
 Typically lasts only a few minutes
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20.  Angina pain
– Precipitated by exertion, emotional stress, eating, cigarette
smoking, or exposure to cold,
– Relieved with rest or SL NTG
– Unstable angina pain is ↑ in severity, longer in duration, or
occurring at rest;
» Need prompt medical attention expeditiously.
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21.  CHF & pulmonary vascular congestion
– Complain of SOB (dyspnea) with exertion or even at rest
– Orthopnea, PND, and nocturia
 CHF & peripheral venous congestion
– Abdominal swelling (from hepatic congestion or ascites),
– Nausea, vomiting, lower extremity edema, fatigue, & dyspnea
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23.  With particular attention to the cardiovascular system
 Assessment
– Jugular venous pulse,
– Arterial pulses (Carotid & peripheral arterial pulses),
– Heart & lung exam (i.e., palpation, percussion, & auscultation),
– Inspection of the abdomen and extremities
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27. A. JVP:
 Indirect assessment of right atrial pressure
– Normal: 1 to 2 cm above the sternal angle
– Extent of elevation: assess the severity congestion,
– Diminution: assess the response to therapy
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29. B. Carotid arterial pulse
 Diminished pulsations (indicate):
– In ↓ SV, atherosclerotic narrowing of carotid artery,
– Obstruction to LV outflow, AS or HCM.
 Very forceful/hyperdynamic/"bounding“ pulsations:
– In ↑ stroke volume, Chronic AR,
– High CO [hyperthyroidism, marked anemia]
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30. C. Peripheral arterial pulses (Legs & arms)
– Diminished: in ↓ stroke volume, PAD
D. Chest
– Percussion of the posterior chest: pleural effusion
– Auscultation of anterior & posterior lung fields:
» Pneumonia/airway obstruction/pleural effusion/ pulmonary edema.
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31. E. Heart Sounds
– Typical "lub-dub" sound of the normal heart
– S1:precedes ventricular contraction
» Due to closure of the mitral & tricuspid valves
– S2: follows ventricular contraction
» Due to closure of the aortic & pulmonic valves
– Others [S3/S4/Murmur/gallop]:presence of underlying heart
disease
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32.  S3 sounds
– Aka ventricular gallop,
– Low-pitched sound heard at the cardiac apex
– Occur in early diastole (i.e. immediately after S2).
– Caused by vibrations that occur when blood rapidly rushes
from a "tense" atrium   stiff, noncompliant ventricle.
– Associated with decompensated HF or intravascular volume
overload.
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33.  S4 sound
– Dull, low-pitched sound
– Caused by the vibrations that occur when atrial contraction
forces blood into a stiff, noncompliant ventricle.
– Audible at the cardiac apex just before ventricular contraction
(i.e., just before S1)
– Occur with AS/arterial hypertension/HCM/CAD
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35.  Murmurs
– Auditory vibrations [turbulent blood flow] within the heart
chambers or across the valves.
– Based on timing & duration within cardiac cycle (systolic,
diastolic, or continuous), intensity (grade 1 to 6, from softest to
loudest), pitch (high or low frequency),
– May be some are “Innocent" or "physiologic"
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38.  Systolic murmurs
– Occur during ventricular contraction
– Begin with or after S1 and end at or before S2
– Can be mid-systolic or holosystolic (pansystolic)
 Mid-systolic murmurs: PS/AS/hypertrophic obstructive cardiomyopathy
 Holosystolic murmurs: when blood flows from a chamber of higher
pressure to one of lower pressure throughout systole
– In case of TR, MR, VSD
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39.  Diastolic murmurs
– Occur during ventricular filling
– Begin with or after S2
– High pitched: in AR & PR
– Low Pitched: in MS & TS stenosis
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NB: If murmur detected confirm the cause by Echo/MRI/Angiography

40.  Markers of Myonecrosis
– Cardiac troponin (cTn) : preferred
– Creatine kinase-MB (CK-MB)
– Myoglobin
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41.  Troponin [I & T]
– Contractile proteins found only in cardiac myocytes
– Most sensitive, tissue-specific
– Detectable in the blood 2 to 4 hrs of onset of sxs
– Remains detectable for 5 to 10 days
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44.  Provides supplemental information to the physical examination
 About position & size of the heart & its chambers /adjacent structures
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45.  Graphic recording of the electrical potentials generated by the heart
 Signals are detected by using electrodes attached to the extremities and
chest wall
 Used to detect:
– Arrhythmias, conduction disturbances,
– MI, metabolic disturbances (e.g., hyperkalemia),
– Increased susceptibility to sudden cardiac death (e.g., prolonged
QT interval)
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12 lead

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 5 wave forms: P, QRS, ST, T, and U
 4 sets of intervals: PR, QRS, QT/QTc, and RR/PP
 3 segments: PR, ST, and TP

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56.  P-wave:
– Depolarization of the atria
– Duration: ~0.12 seconds
 PR segment:
– Passage of impulse through AV node  bundle of His 
its branches
– Duration: 0.12 to 0.20 seconds.
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57.  QRS complex
– Electrical depolarization of the ventricles
– -Ve deflection (Q wave)  +Ve deflection (R wave) -ve
deflection(S wave)
– Duration: <0.12 second
 V1, V2: right ventricle: -Ve
 V5, v6: left ventricle: +Ve
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 ST segment
– Plateau phase
– Duration: 0.005- 0.15 sec
 T wave
– Repolarization of the ventricle
– Duration: 0.1 - 0.25 sec
 QT interval
– From QRS complex to end of the T wave
– Time required for ventricular depolarization & repolarization
– Duration: <0.44 second.
– Prolonged: electrolyte disturbances(hypoK+,hypoCa2+,hypoMg2+

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HR = 300 / (big squares + (0.2 × small squares))

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Tachycardia
Bradycardia
Asystole
AF

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Atrial flutter

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LVH

66.  Evaluate cardiac function and structure
 Non-invasive, inexpensive, safe, devoid of ionizing radiation, & portable
 Detect valvular abnormalities, intra-cardiac thrombi, pericardial
effusions, & congenital abnormalities.
 Assess chamber sizes, function, and wall thickness
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67.  Two approach
– Transthoracic echo (TTE)
– Transesophageal echo (TEE)
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68.  CT scan
 Positron Emission Tomography
 MRI
 Cardiac Catheterization & Angiography
– Aortography
– Coronary Angiography
– Left Ventriculography
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 Nuclear Cardiology
 Endomyocardial Biopsy
 Intravascular Ultrasound

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