1. BY DR : RAMY A. SAMY

2. CARDIAC BIOMARKERS RADIOLOGY ECG AND STRESS ECG ECHO

3. Cardiac biomarkers CK (CPK) CK-MB Troponin-I/T LD (LDH) Myoglobin ALT/AST Others

4. Creatine Kinase an enzyme expressed in a number of tissues. Function: it catalyses the conversion of creatine to phosphocreatine degrading ATP to ADP  The CK enzyme consists of two subunits, B (brain type) or M (muscle type), Making three different isoenzymes: CK-MM, CK- BB and CK-MB

5. ck

7. CK-MB

9. Troponin Troponin is a complex of three regulatory proteins that is integral to non-smooth muscle contraction in skeletal as well as cardiac muscle Troponin has three subunits, TnC, TnT, and TnI Troponin is a complex of three regulatory proteins that is integral to non-smooth muscle contraction in skeletal as well as cardiac muscle Troponin has three subunits, TnC, TnT, and TnI

10. – Troponin-C binds to calcium ions to produce a conformational change in TnI – Troponin-T binds to tropomyosin, interlocking them to form a troponin- tropomyosin complex – Troponin-I binds to actin in thin myofilaments to hold the troponin- tropomyosin complex in place

11. Thus far, studies have failed to find a source of Troponin-I outside the heart, but have found some Troponin-T in skeletal muscle Because of it’s increased specificity, our lab uses Troponin-I

13. LD (LDH) – Used in the past along with aminotransferases to diagnose AMI. LD is non-specific for cardiac tissue, which contains LD-1. – However, pancreas, kidney, stomach tissue and red cells also contain LD-1. – In the setting of AMI, LD rises at about 10 hours, peaks at 24-48 hours, and remains elevated for up to 8 days LD (LDH) – Used in the past along with aminotransferases to diagnose AMI. LD is non-specific for cardiac tissue, which contains LD-1. – However, pancreas, kidney, stomach tissue and red cells also contain LD-1. – In the setting of AMI, LD rises at about 10 hours, peaks at 24-48 hours, and remains elevated for up to 8 days

14. Myoglobin – small-size heme protein released from all damaged tissues. Increases often occur more rapidly than TI and CK. – Not utilized often for AMI/cardiac damage assessment because of its very rapid metabolism (short plasma half-life) causing short burst increases that are difficult to assess clinically, as well as its lack of specificity for cardiac tissue. Myoglobin – small-size heme protein released from all damaged tissues. Increases often occur more rapidly than TI and CK. – Not utilized often for AMI/cardiac damage assessment because of its very rapid metabolism (short plasma half-life) causing short burst increases that are difficult to assess clinically, as well as its lack of specificity for cardiac tissue.

15. ALT/AST – not used for assessment of myocardial damage any longer H-FABP – Heart-type fatty acid binding protein – Kinetically similar to myoglobin but more specific to cardiac tissue which contains a greater percentage of this protein than skeletal muscle – May also have role in prediction- prognosis in patients with NSTEMI – Current studies ongoing to further evaluate its utility

16. Radiology

19. CARDIAC CATHETERIZATION DESCRIPTION

20. These procedures involve insertion of a specialized catheter into the systemic circulation and advancement into individual coronary arteries or retrograde advancement across the aortic valve and into the LV. Following placement of the catheter in the desired location, hemodynamic data can be acquired, and angiography can be performed by injection of radiocontrast dye and fluoroscopic image acquisition. Catheterization is primarily used to diagnose obstructive coronary artery disease, assess its severity, and design the optimal medical and/or surgical treatment.

21. NUCLEAR IMAGING

22. Nuclear myocardial perfusion imaging is occasionally obtained in conjunction with stress testing to further aid diagnostic accuracy. This is especially useful in patients with baseline ECG abnormalities. Nuclear myocardial perfusion imaging is occasionally obtained in conjunction with stress testing to further aid diagnostic accuracy. This is especially useful in patients with baseline ECG abnormalities.

23. The technique involves injection of a radioactive isotope that is extracted from plasma by viable myocardium. (technetium 99m [99mTc] sestamibi or 99mTc tetrofosmin), The images are acquired with a special camera that captures radioactive emissions. The intensity of the image is proportional to the perfusion of the myocardium The technique involves injection of a radioactive isotope that is extracted from plasma by viable myocardium. (technetium 99m [99mTc] sestamibi or 99mTc tetrofosmin), The images are acquired with a special camera that captures radioactive emissions. The intensity of the image is proportional to the perfusion of the myocardium

24. Images are acquired both at rest and after peak- exercise or vasodilator infusion. The images are then compared, and stress- induced perfusion defects identified. The defects correlate with the presence of epicardial coronary artery disease. The use of myocardial perfusion imaging increases the accuracy of stress testing for diagnosing coronary artery disease.

25. Gamma Camera

29. ELECTROCARDIOGRAM

32. CHAMBER ENLARGEMENT  LEFT ATRIAL ENLARGEMENT CRITERIA  RIGHT ATRIAL ENLARGEMENT CRITERIA  ECG CRITERIA FOR LEFT VENTRICULAR HYPERTROPHY  ECG CRITERIA FOR RIGHT VENTRICULAR HYPERTROPHY

35.  ECG CRITERIA FOR ACUTE MYOCARDIAL INFARCTION

37. EXERCISE STRESS TESTING

38. DESCRIPTION : The exercise stress test (EST) is most commonly used to diagnose coronary artery disease in low- to intermediate-risk patients.

39. The EST is also used to assess exercise capacity and functional reserve in patients with known coronary artery disease. The test employs physical exercise (treadmill, stationary bicycle, or arm crank) in a controlled environment coupled with continuous telemetry monitoring and serial electrocardiographs (ECGs) to evaluate for evidence of myocardial ischemia. Serial hemodynamic measurements are also obtained to determine the physiologic response to exercise.

40. Stress testing is often performed in conjunction with an imaging modality to increase the sensitivity for detecting coronary artery disease.

41. INDICATIONS  To diagnose coronary artery disease (CAD) in adult patients  To risk stratify  To assess the efficacy of medical treatment  To evaluate exercise capacity and functional status in patients with valvular heart disease.  To diagnose coronary artery disease (CAD) in adult patients  To risk stratify  To assess the efficacy of medical treatment  To evaluate exercise capacity and functional status in patients with valvular heart disease.

42. CONTRAINDICATIONS Absolute contraindications to stress testing include the following:  Acute MI (within 2 days)  High-risk unstable angina  Uncontrolled cardiac arrhythmias  Symptomatic severe aortic stenosis  Decompensated heart failure  Acute pulmonary embolus  Acute myocarditis or pericarditis  Acute aortic dissection Absolute contraindications to stress testing include the following:  Acute MI (within 2 days)  High-risk unstable angina  Uncontrolled cardiac arrhythmias  Symptomatic severe aortic stenosis  Decompensated heart failure  Acute pulmonary embolus  Acute myocarditis or pericarditis  Acute aortic dissection

43. Relative contraindications to stress testing include:  Known left main coronary artery stenosis  Moderate stenotic valvular heart disease  Electrolyte abnormalities  Severe arterial hypertension (systolic blood pressure [SBP] >200 or diastolic blood pressure [DBP] >100)  Tachyarrhythmias or bradyarrhythmias  Hypertrophic cardiomyopathy  High-grade atrioventricular (AV) block  Exercise intolerance Relative contraindications to stress testing include:  Known left main coronary artery stenosis  Moderate stenotic valvular heart disease  Electrolyte abnormalities  Severe arterial hypertension (systolic blood pressure [SBP] >200 or diastolic blood pressure [DBP] >100)  Tachyarrhythmias or bradyarrhythmias  Hypertrophic cardiomyopathy  High-grade atrioventricular (AV) block  Exercise intolerance

44. DISCONTINUING A TEST Absolute indications for discontinuing an exercise test include the following:  Decrease in SBP >10 mm Hg from baseline  Moderate to severe angina  Development of central nervous system abnormalities (ie, ataxia, dizziness)  cyanosis or pallor  difficulty in monitoring the ECG or blood pressure  Sustained ventricular tachycardia  ST elevation >1 mm in any lead without significant Q waves Absolute indications for discontinuing an exercise test include the following:  Decrease in SBP >10 mm Hg from baseline  Moderate to severe angina  Development of central nervous system abnormalities (ie, ataxia, dizziness)  cyanosis or pallor  difficulty in monitoring the ECG or blood pressure  Sustained ventricular tachycardia  ST elevation >1 mm in any lead without significant Q waves

45. ECHOCARDIOGRAPHY DESCRIPTION Echocardiography is a noninvasive modality that utilizes reflected sound waves to image the heart and define both its structure and function. Two-dimensional echocardiography is used to assess cardiac structure, left ventricular function, valvular integrity and function, and the pericardium. It also permits calculation of chamber dimensions, areas, and volumes.

46. Color flow imaging assigns different colors to blood that is moving toward the transducer (red) and away from the transducer (blue). It is used to detect abnormal flow such as valvular regurgitation, intraventricular shunts, and obstruction of flow within or between the cardiac chambers

47. Contrast echocardiography Agitated saline

48. INDICATIONS

49. Evaluation of murmurs and valvular heart disease. Evalution of patients with established valvular heart disease. Evaluation of prosthetic heart valves. Chest pain and suspected ischemic heart disease. Left ventricular function, pericardial disease, and miscellaneous. Pulmonary disease. Arrhythmias, palpitations and syncope. Evaluation of murmurs and valvular heart disease. Evalution of patients with established valvular heart disease. Evaluation of prosthetic heart valves. Chest pain and suspected ischemic heart disease. Left ventricular function, pericardial disease, and miscellaneous. Pulmonary disease. Arrhythmias, palpitations and syncope.

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51. TRANSESOPHAGEAL ECHOCARDIOGRAPHY A similar study to a surface echocardiogram, however, the ultrasound probe is passed into the esophagus to examine the cardiac structures in close proximity. Transesophageal echocardiography offers superior assessment of cardiac anatomy and physiology because of the proximity of the probe.

53. STRESS ECHOCARDIOGRAPHY Echocardiography is often used as an imaging modality to increase the sensitivity and specificity of exercise stress tests for the detection of CAD. Stress echocardiography also assesses myocardial viability in patients with known CAD and in whom revascularization is being considered.