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Interpretation of Investigation Results

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Marikannan Maharajan

on 28 March 2016

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Transcript of Interpretation of Investigation Results

A Painless test

Checks electrical activity of the heart.

Electrical activity of the heart translates into line tracings
72
ECG
bpm
Tests used to diagnose CVD
Electrocardiogram (ECG)
Echocardiogram
Chest X ray
Blood tests
Coronary angiography
Radionuclide tests
Magnetic resonance imaging (MRI) scans
Computerised tomography (CT) scans

1. Electrocardiogram (ECG)
QRS
QRS complex
- 0.12 seconds (3 small squares)

If longer than 0.12 s– ventricular origin

If shorter than 0.12 s -supra-ventricular origin


T waves
T Wave- ventricular relaxation-repolarization
Inverted T waves
- common abnormality

T-waves can be altered by many different processes
Lack specificity
Should not be used alone for a diagnosis

Taller
- if it is > 5mm in the standard leads
10mm in the precordial leads
Hyperkalemia
Myocardial Ischaemia 


An overview on detection, diagnosis and monitoring of cardiovascular disorders (CVD) and their treatment
Interpretation of Investigation Results
Dr. Mari
Kannan
Maharajan
Lecturer,
Department of Pharmacy Practice,
School of Pharmacy, IMU

What we can observe from an ECG?
Heart rate
If there are 4 squares in an R-R interval (300/4) - 75 bpm

Heart rhythm
If the R-R interval is inconsistent -the rhythm is irregular

An irregular rhythm with no distinct 'p waves' suggests
atrial fibrillation

Are P-waves present?
Do they occur regularly?
Is there
sinus rhythm
?
(does a P-wave precede each QRS complex?)
Does the P-waves look normal?
(Smooth, rounded & upright)
From “P wave”
If
P-waves are absent
& there is
an irregular rhythm
it may suggest
atrial fibrillation.
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.

Alternative Names
Exercise ECG; ECG - exercise treadmill; EKG - exercise treadmill; Stress ECG; Exercise electrocardiography; Stress test - exercise treadmill

Who needs this test?
Patients with
Symptoms suggesting myocardial ischaemia

Acute chest pain
WITHOUT
myocardial infarction

Recent ACS treated without coronary angiography

Prior coronary revascularization

Valvular heart disease

Newly diagnosed heart failure or cardiomyopathy

Certain cardiac arrhythmias

Ischaemia
Exercise-induced hypotension
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 -
normal
(lub dub)

S1 Occurs at the end of the isometric contraction period -
systole

S2 occurs after the isovolumetric relaxation period -
diastole
.

S2 -composed of A2 and P2 (aortic and pulmonary parts).

‘‘Single S2’’/ ‘‘split S2’’ (heard as two ‘‘beats’’)

2. Heart auscultation
Murmur
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
semilunar
valves,

Mid-systolic click
Occurs in mid-systole,
With prolapse of the
mitral
valve.

Snap

Occurs shortly after S2
With the opening of the
mitral and tricuspid
valves
Chest X Ray
Creates pictures of the organs and structures inside the chest,

Heart, lungs, and blood vessels.

CAN REVEAL
Signs of heart failure & lung disorders

Other causes of symptoms not related to CHD.
3. Echocardiogram
A non-invasive diagnostic test

To detect abnormalities in the heart chambers, myocardium and valves.

Ultrasound waves
used to create a moving picture

Three main techniques
Cross-sectional 2D
, gives the impression of a moving picture.
M-mode
- uses a single static beam and appears as horizontal lines.
Doppler
- uses pulsed wave, continuous wave and colour.

What an Echocardiogram Can Do?
Scan for
irregularities in the size
and
movement
of the heart. 

Measure the
strength of the heart's ability

To pump blood through the chambers. 

Evaluate the
thickness of the heart muscle
wall (hypertrophy).

Examine the four
heart valves
to determine if each is
working properly


Determine the
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

Objectively measurable

Characteristics of an ideal biomarker
Safe and easy
Cost efficient
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)
Troponin,

Creatine kinase-MB,

Myoglobin and

Lactate dehydrogenase.
TROPONINS
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.

Myoglobin
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
Lactate dehydrogenase
What Abnormal Results Mean?

Ischemia, Cerebrovascular accident (such as a stroke),

Heart attack

Hemolytic anemia, Infectious mononucleosis, hepatitis

Low blood pressure, Muscle injury,

Muscular dystrophy

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
protective hormones

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?
Heart failure,
Worse outlook (prognosis) for the person.
B-Type Natriuretic Peptide (BNP)
An
inflammatory enzyme
(ruptured atherosclerotic plaques)

Correlates with
interleukin-6, CRP, white blood cell count, and TNF-alpha

Released by macrophages and neutrophils during acute inflammation

Involved with the
oxidation of lipids
and
destruction of the vasodilator nitric oxide
.

Myeloperoxidase
C-reactive protein:

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.

Malondialdehyde
- biochemical marker for atherosclerosis.
Modified low-density lipoprotein

Other markers
Platelet Function Test
Measures the rate of blood clotting. 
To check antiplatelet medications are working at intended level/not.

Cholesterol/Lipids Test
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.

Pericardiocentesis
Also called a pericardial tap -- means using a needle to get a sample of the fluid in the sac surrounding the heart.

Heart MRI
A heart MRI is a great way for doctors to get a look -- from the outside -- at how your heart is working.
Other tests
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?
P-R INTERVAL
The P-R interval - 0.12-2.0 sec
Are they consistent throughout the ECG?
A prolonged P-R interval -
heart block
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
P wave
- atrial contraction,
pumping blood into the ventricles. 
QRS complex
- ventricular contraction-
ventricular ejection
PR interval
- transit time for the electrical signal
to travel from the sinus node to the ventricles.
T wave
- 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.

A.TRUE
B. FALSE
The medical term for chest pain is...

C. Angina
B. Flutter
A. Stroke
If you are thin, eat right and exercise, you wont get heart disease.

A. True
B. False
"Broken heart syndrome" is a medical condition, and its symptoms are similar to those of a heart attack.

A. True
B. False
Heart Disease kills more men than women.

A. True
B. False
During heart attack, the heart stop beating.

A. True
B. False
The most common risk factor for heart disease

A. Inactivity
B. Obesity
C. High cholesterol
D. Alcohol

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 ?
[A] S1

[B] S2

[C] S3

[D] S4
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

ECHOCARDIOGRAM




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

Risk factors,

Physical examination

Clinical examination (Lab tests & imaging)

Coordination of these findings
ST segment
An isoelectric line (neither elevated or depressed)
Abnormalities of the ST segment – pathological

ST Elevation
> 1mm (1 small square) in relation to the baseline
Cause: Acute myocardial infarction

ST Depression
< 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 Tachycardia
Sinus rhythm with a rate >100 beats per minute
With fast rates, 'P waves' may merge with preceding 'T waves' and be indistinct

Sinus Bradycardia
Sinus rhythm with a rate <60 beats per minute

SA Block
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.

Heart auscultation
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
3. Echocardiography
4. Bio markers of myocardial damage
Relevant plasma chemistry

http://www.bem.fi/book/19/19.htm
From “P wave”
Key notes
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?
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