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Interpretation of Investigation Results
Transcript of Interpretation of Investigation Results
Checks electrical activity of the heart.
Electrical activity of the heart translates into line tracings
Tests used to diagnose CVD
Chest X ray
Magnetic resonance imaging (MRI) scans
Computerised tomography (CT) scans
1. Electrocardiogram (ECG)
- 0.12 seconds (3 small squares)
If longer than 0.12 s– ventricular origin
If shorter than 0.12 s -supra-ventricular origin
T Wave- ventricular relaxation-repolarization
Inverted T waves
- common abnormality
T-waves can be altered by many different processes
Should not be used alone for a diagnosis
- if it is > 5mm in the standard leads
10mm in the precordial leads
An overview on detection, diagnosis and monitoring of cardiovascular disorders (CVD) and their treatment
Interpretation of Investigation Results
Department of Pharmacy Practice,
School of Pharmacy, IMU
What we can observe from an ECG?
If there are 4 squares in an R-R interval (300/4) - 75 bpm
If the R-R interval is inconsistent -the rhythm is irregular
An irregular rhythm with no distinct 'p waves' suggests
Are P-waves present?
Do they occur regularly?
(does a P-wave precede each QRS complex?)
Does the P-waves look normal?
(Smooth, rounded & upright)
From “P wave”
P-waves are absent
& there is
an irregular rhythm
it may suggest
EXERCISE ECG TEST
An indication for cardiac assessment
Prior to non-cardiac surgery
Indirectly detects myocardial ischemia,
To check the physiological consequence of a mismatch between
myocardial oxygen supply & demand.
Exercise ECG; ECG - exercise treadmill; EKG - exercise treadmill; Stress ECG; Exercise electrocardiography; Stress test - exercise treadmill
Who needs this test?
Symptoms suggesting myocardial ischaemia
Acute chest pain
Recent ACS treated without coronary angiography
Prior coronary revascularization
Valvular heart disease
Newly diagnosed heart failure or cardiomyopathy
Certain cardiac arrhythmias
Exercise-induced angina or angina equivalents
S3, S4 /heart murmur during exercise
Symptoms occurring during the exercise stress test
Fatigue, legs tired, chest pain/pressure, shortness of breath
Discontinue the test if these symptoms are severe.
Positive Clinical Findings
Monitoring of sounds produced by the heart and blood circulation
A fundamental tool
Short ‘‘beats’’ (S1, S2, S3, and S4)
S1 and S2
are always audible -
S1 Occurs at the end of the isometric contraction period -
S2 occurs after the isovolumetric relaxation period -
S2 -composed of A2 and P2 (aortic and pulmonary parts).
‘‘Single S2’’/ ‘‘split S2’’ (heard as two ‘‘beats’’)
2. Heart auscultation
Occur during either systole/diastole
Continue through both periods.
Caused by turbulence in blood ﬂow/ the vibration of tissues.
“Click” and “snap”
Distinctive features of some heart defects.
Systolic ejection click
Occurs shortly after S1
With the opening of the
Occurs in mid-systole,
With prolapse of the
Occurs shortly after S2
With the opening of the
mitral and tricuspid
Chest X Ray
Creates pictures of the organs and structures inside the chest,
Heart, lungs, and blood vessels.
Signs of heart failure & lung disorders
Other causes of symptoms not related to CHD.
A non-invasive diagnostic test
To detect abnormalities in the heart chambers, myocardium and valves.
used to create a moving picture
Three main techniques
, gives the impression of a moving picture.
- uses a single static beam and appears as horizontal lines.
- uses pulsed wave, continuous wave and colour.
What an Echocardiogram Can Do?
irregularities in the size
of the heart.
strength of the heart's ability
To pump blood through the chambers.
thickness of the heart muscle
Examine the four
to determine if each is
volume of blood
that is circulating through the heart.
Aimed at acquiring flow rates and helps to identify any obstruction
An Indicator of
normal biological processes,
pathogenic processes or
pharmacological responses to a therapeutic intervention
Characteristics of an ideal biomarker
Safe and easy
Modifiable with treatment
Consistent across gender and ethnic groups
4. Bio markers
What happens during cardiac injury?
Cardiomyocyte membrane integrity- disrupted
Intracellular constituents released into the extracellular space
Biologically active cytosolic and structural proteins in the systemic circulation (present in palsma/serum)
The cTn complex of 2 subunits: I, and T
Control calcium mediated interaction of actin and myosin,
Lead to the contraction & relaxation
Highly specific for myocardial damage.
Troponin I : less than 10 µg/L
Troponin T : 0–0.1 µg/L
Creatine kinase (CK)- MB
1 of 3 major creatine kinase isoenzymes,
Its high conc. is unique to the myocardium.
Released rapidly after myocardial necrosis;
Not released in ischaemia alone
Normal range : 0 - 5 U/L
A small cytoplasmic heme protein in high concentration
Found in all muscles.
Limited specificity in renal insufficiency and skeletal muscle trauma
Earliest marker to rise after AMI (<2 h from the onset of chest pain)
A normal (negative) result is 0 - 85 ng/mL.
An enzyme released in the blood with cell injury.
Used as a late marker to detect a heart attack.
Also elevated with liver and kidney disease and megaloblastic anemia
Normal range : 45 - 90 U/L
What Abnormal Results Mean?
Ischemia, Cerebrovascular accident (such as a stroke),
Hemolytic anemia, Infectious mononucleosis, hepatitis
Low blood pressure, Muscle injury,
Cancer, Pancreatitis, Tissue death
Effective biomarkers of heart failure & myocardial dysfunction
BNP and N-terminal pro-B-type natriuretic peptide – most relevant
Natriuretic peptides work as
BNP counteract the physiologic abnormalities of heart injury and myocardial dysfunction.
Normal results: Symptoms are likely due to something other than heart failure.
What Abnormal Results Mean?
Worse outlook (prognosis) for the person.
B-Type Natriuretic Peptide (BNP)
(ruptured atherosclerotic plaques)
interleukin-6, CRP, white blood cell count, and TNF-alpha
Released by macrophages and neutrophils during acute inflammation
Involved with the
oxidation of lipids
destruction of the vasodilator nitric oxide
An acute-phase protein produced by the liver
Upregulated in conjunction with the inflammatory response
High Sensitivity C-RP- in the blood
IL-1β , IL-1Ra, IL-6
- proinflammatory markers
Markers of fibrosis -galectin-3, Gal-3
Fatty acid binding protein
Small cytoplasmic protein (15 kDa)
Released from cardiac myocytes following an ischemic episode.
Early biomarker for myocardial infarction,
Detected in the blood within one to three hours of ACS.
- biochemical marker for atherosclerosis.
Modified low-density lipoprotein
Platelet Function Test
Measures the rate of blood clotting.
To check antiplatelet medications are working at intended level/not.
Used to measure total cholesterol levels, LDL (or “bad”) cholesterol,
HDL (good) cholesterol and triglycerides.
When all types of blood fat are checked - lipoprotein profile.
Also called a pericardial tap -- means using a needle to get a sample of the fluid in the sac surrounding the heart.
A heart MRI is a great way for doctors to get a look -- from the outside -- at how your heart is working.
Mr.AA, visiting your Clinical Pharmacy Dept. His ECG shows prolonged P-R interval, ST segment elevation and ventricular arrhythmia. What may be a possible Diagnosis?
The P-R interval - 0.12-2.0 sec
Are they consistent throughout the ECG?
A prolonged P-R interval -
A shortened P-R interval -
Wolf Parkinson White Syndrome.
We share responsibility for ensuring safe and effective drug therapy.
Lab data - additional information a pharmacist
To ensure appropriate treatment and monitor patients’ response
To monitor adverse effects to ensure patients’ safety (Review of INR for warfarin patients); or
To screen patients for untreated health conditions
- atrial contraction,
pumping blood into the ventricles.
- ventricular contraction-
- transit time for the electrical signal
to travel from the sinus node to the ventricles.
- ventricular relaxation (repolarization)
What is meant by the term myocardial infarction?
A. Heart Failure
B. Heart attack
C. Cardiac arrest
Sudden cardiac arrest means that the heart ...
A. Stops beating
B. Beats dangerously slow
C. Has a cycle of beating and stopping
D. Skip beating
The term "heart failure" means the heart has stopped working.
The medical term for chest pain is...
If you are thin, eat right and exercise, you wont get heart disease.
"Broken heart syndrome" is a medical condition, and its symptoms are similar to those of a heart attack.
Heart Disease kills more men than women.
During heart attack, the heart stop beating.
The most common risk factor for heart disease
C. High cholesterol
YOU CAN READ THE FOLLOWING ARTICLES
Questions to create "curiosity"
WHAT IS THE FROM AN ECG?
CHECK THIS ONE..!
MATCH THE FOLLOWING
1. No P wave - [A] Bradycardia
2. Prolonged PR - [B] Wolf Parkinson white syndrome
3. Shortened PR - [C] Anxiety,
4. ST elevation - [D] hyperkalemia
5. ST depression - [E] Acute Myocardial Infarction
6. Taller T Wave - [F] Tachycardia
7. Increased HR - [G] Heart Block
8. Decreased HR - [H] Atrial fibrillation
WHICH OF THE FOLLOWING HEART SOUNDS INDICATES A DEFINITE CARDIAC ABNORMALITY ?
Where to focus?
P wave, QRS Complex, PR interval, ST segment, T wave
Troponin, Lactate dehydrogenase, myoglobin, B-Type Natriuretic Peptide , Myeloperoxidase, Fatty acid binding protein, Malondialdehyde
S1, S2, S3, S4
CHEST X- RAY
Mr.AA, visiting your Clinical Pharmacy Dept.
His ECG shows prolonged P-R interval, ST segment elevation and ventricular arrhythmia.
What may be a possible Diagnosis?
Why we (the pharmacist) need this Topic?
Keep it in your mind..!
This is NOT for the screening of Population
We must not provide an interpretation of the results of lab tests ordered by other health care providers to the patient unless it is relevant to the care being provided by the pharmacist
How a CVD diagnosed?
Medical history and family history
Clinical examination (Lab tests & imaging)
Coordination of these findings
An isoelectric line (neither elevated or depressed)
Abnormalities of the ST segment – pathological
> 1mm (1 small square) in relation to the baseline
Cause: Acute myocardial infarction
< 1mm (1 small square) in relation to the baseline
ST-depression lacks specificity, don’t jump to any diagnostic conclusions
Causes: Anxiety, Tachycardia, Digoxin toxicity, Haemorrhage, Hypokalaemia, Myocarditis,
Coronary artery insufficiency
Sinus rhythm disturbances
Sinus rhythm with a rate >100 beats per minute
With fast rates, 'P waves' may merge with preceding 'T waves' and be indistinct
Sinus rhythm with a rate <60 beats per minute
One or more missing beat; (no P waves or QRS complexes)-
Periods of sinus arrest, sinus tachycardia, or sinus bradycardia Sick Sinus Syndrome
Contraindications-EXERCISE ECG TEST
The patients with
Chest pain at rest or at night.
Any condition where the left ventricular output is reduced
Active systemic illness.
Abnormal baseline ECG,
Suspected or confirmed life-threatening arrhythmias.
S3 occurs shortly after S2
Associated with early diastolic ﬁlling of the ventricle.
An audible S3 -normal in the young (<35 years)
When S4 is audible, it occurs shortly before S1,
It is associated with late diastolic ﬁlling.
An audible S4 is always considered abnormal.
Why this topic?
To understand the diagnostic tests on cardiovascular system.
What I learn?
Clinical examination related to CVD ,
1. ECG and exercise testing
2. Heart sounds
4. Bio markers of myocardial damage
Relevant plasma chemistry
From “P wave”
An electrocardiogram can sometimes reveal problems with a patient’s medicines.
Many drugs have an effect on the heart, either therapeutically (eg, digoxin) or as a side effect (eg, amitriptyline causing tachycardia). These effects can often be detected with an electrocardiogram
A few questions to ask yourself
What is the patient’s heart rate (ie, tachycardic or bradycardic)?
Is the sinus rhythm regular (ie, is there atrial fibrillation?)
Are there any drug-induced ECG changes, eg, QT prolongation?
Is there any degree of heart block?