1. TMT, HOLTER, HUTT: WHAT SHOULD I KNOW? DR. AMEYA UDYAVAR MADRAS MEDICAL MISSION www.anaesthesia.co.in anaesthesia.co.in@gmail.com

2. 1. TMT

3. TMT Is a means of evaluating the circulatory response to physical stress [exercise] Heart rate Blood pressure ST changes Arrhythmias [heart rhythm]

4. INDICATIONS Evaluate patients with chest pain Assess severity of CAD and prognosis For rehabilitation of patients with MI To assess efficacy of Rx in CAD To screen high risk asymptomatic individuals

5. CONTRAINDICATIONS Acute MI/ ACS Uncontrolled arrhythmias Uncontrolled valvular heart disease CHF Uncontrolled HTN Myocarditis, endocarditis

6. PRECAUTIONS Carried out in the presence of physician Explain the procedure Informed written consent NBM at least 3-4 hours No coffee, tea Medications to be noted

7. PRECAUTIONS Wear loose comfortable shoes Have their chest saved ALWAYS ASK FOR HISTORY OF RECENT/ WORSENING ANGINA Always demonstrate to the patient. Reassure and clear all his doubts

8. treadmill

9. CPU with the monitor

10. Test being conducted

11. Electrodes attachment

12. precautions Oxygen provision Emergency drugs Easy access to the CCU Physician available

13. Things to observe Heart rate Blood pressure Chest pain, dyspnea Arrhythmias ST changes

14. TMT PROTOCOLS

15. ST CHANGES- post J 80 msec

16. ST CHANGES

18. REASONS FOR DISCONTINUING THE TEST CLINICAL: chest pain, severe dyspnea, syncope, fatigue, leg claudication, fall in BP or HR, pts desire to stop ECG DETERMINANTS: ST depression 1 mm or more, ST elevation 1 mm or more, VT, Heart blocks, other arrhythmias

19. POST TEST Help to sit on the chair Monitor HR and BP for 10 min Avoid heavy exertion immediately after the test Report preparation

20. REPORT PREPARATION Patients identity TMT protocol and stages HR response BP response ST changes Arrhythmias METS achieved

21. 2. HOLTER TEST

22. HOLTER MONITORING 24 hours ambulatory ECG monitoring provides a record of patients heart rate and rhythm while the patient is engaged in the activities of daily living

23. INDICATIONS Identify and record cardiac arrhythmias Correlate these arrhythmias with symptoms Assess efficacy of medications Evaluate pacemaker malfunction Detect ST segment changes

24. COMPONENTS Chest electrodes Patients diary Recoding apparatus Holter monitor scanner

25. Recording apparatus

26. Electrode position

27. Belt or vest

28. PROCEDURE Explain the procedure, prepare the chest Apply jelly and then the electrodes Fix the connecting wires with a stress loop Recorder fastened to the waist, note time tell patient to record all activities and symptoms Do not meddle with electrodes or wet them

29. ANALYSIS

30. EXAMPLES

32. 3. HUTT

33. INDICATIONS to study the heart rate and blood pressure adaptations to changes in position as a technique for evaluation of orthostatic hypotension as a method to study hemodynamic and neuroendocrine responses in congestive heart failure, autonomic dysfunction and hypertension

34. SYNCOPE 80%- vasovagal/ neurocardiogenic Orthosatic hypotension Cardiac causes arrhythmias

35. Tilt table

36. NECESSARY EQUIPMENT

37. PROCEDURE Laboratory- Quiet, dim lighting, comfortable temperature 20–45-min supine equilibration period Fasting overnight or for several hours before procedure Recordings with minimum of three ECG leads continuously recording Beat-to-beat blood pressure recordings using the least intrusive means (may not be feasible in children) Table with Foot-board support Smooth, rapid transitions (up and down)

38. PROCEDURE Tilt angle: 60 to 80 degree acceptable 70 degree becoming most common Tilt duration [a] Initial drug-free tilt 30–45 min, [b] Pharmacologic provocation—depends on agent Pharmacologic with Isoproterenol (infusion preferred), Nitroglycerin, Edrophonium Supervision with Nurse or laboratory technician experienced in tilt table technique with Physician in attendance or in proximity and immediately available

39. Cardio-inhibitory response

40. Vaso-depressor response

41. CONCLUSIONS THESE ARE IMPORTANT NONINVASIVE DIAGNOSTIC TESTS IF CONDUCTED WITHOUT FOLLOWING THE NECESSARY INSTRUCTIONS AND PRECAUTIONS, THE PURPOSE OF THE TEST MAY BE NULLIFIED.

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