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108 Cards in this Set
- Front
- Back
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Narrowing of a coronary artery, which prevent adequate blood supply to the myocardium.
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Ischemia.
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Coronary artery narrowing to the point that heart muscle is damaged.
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Infarction.
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Etiology of ischemic heart disease. (4)
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Atherosclerosis
Coronary artery spasm Embolus Dissection |
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What is the most common indication for echo?
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Ischemic heart disease.
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What does echo look at in evaluating ischemic heart disease?
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Systolic wall thickening
Endocardial motion Global and regional function |
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Which coronary arteries can be seen with TTE and TEE?
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Proximal Left and Right main coronaries.
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What is the gold standard in for coronary anatomy?
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Cath.
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How can you see infarcted myocardium?
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There will be wall abnormalities at rest.
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Wall thickness of acute MI?
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Normal
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Acute MI on echo?
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Normal wall thickness.
Systolic thickening and endocardial motion reduced or absent. |
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At what point of coronary artery stenosis is ischemia present?
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70%
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What is ischemia?
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A reversable imbalance in oxygen supply vs. demand ratio. Due to narrowing in the coronary arteries.
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In ischemia, what's going on with wall motion at rest?
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Normal. Unless there was a previous MI.
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Sequence of events with Ischemia.
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1. Perfusion defect.
2. Diastolic function abnormality. 3. Segmental wall motion abnormality. 4. Ischemic ST changes on ECG 5. Clinical angina. |
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What is the most challenging task in echo?
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Regional wall motion analysis.
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What needs to be adjusted to view all the wall segments?
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Gain
Harmonics Contrast |
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Wall Motion Score Index.
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1 -- Normal
2 -- Hypokinetic 3 -- Akinetic 4 -- Dyskinetic 5 -- Aneurysmal |
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What is an abnormal score on the WMSI?
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Anything above 2.
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Formula for WMSI?
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Sum of segments scored/# visualized.
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Which views do you use for the WMSI?
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Long, Short, 4, and 2.
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Irreversible injury to the myocardium due to ischemia?
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Myocardial Infarction.
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Order of events in Myocardial Infarction.
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1. Hypokinnesis, akinesis, dyskinesis of the affected wall segment
2. Thinning and increased echogenicity. Hyperkinesis of the opposing wall segments. |
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What kind of infarct will result in the most thinning of a wall segment?
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Transmural infarct, meaning all layers.
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How can a WMA be fixed and what's the window of time?
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WMA may persist for 72 hours, and is reversed when perfusion resupplies it.
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What exhibits prolonged dysfunction after perfusion?
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Stunned myocardium.
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What is the story with hibernating myocardium?
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It is receiving enough blood to stay alive, but not enough to move. Motion can come back.
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What exhibits prolonged dysfunction after perfusion?
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Stunned myocardium.
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Prolonged ischemia may result in what that can be regained?
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Hibernating myocardium.
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A myocardial infarction is usually due to what?
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An acute thrombotic occlusion from a ruptured plaque.
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2 to 7 days post MI, mechanical complications may occur due to softening of the myocardial tissue. What are these complications?
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Free wall rupture.
VSD Papillary muscle rupture Aneurysm MR LVE LV thrombus |
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Which papillary muscle is more likely to rupture?
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Posteromedial, because it is supplied by a single coronary artery.
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How much more likely is a posteromedial pap muscle rupture likely than a anterolateral pap muscle rupture?
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6 to 10, because it has single artery supply, while the anterolateral has 2.
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What are the complications of MI, not due to myocardial softening?
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Arrhythmias
Heart block LV systolic dysfunction Cardiogenic shock. |
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What is the treatment for a ruptured papillary muscle?
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Valve replacement.
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How does a ruptured papillary muscle look on echo?
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Flail leaflet with attached mass, prolapses into the LA.
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Why does a free wall rupture occur?
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Due to necrosis, within one week of MI.
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What is the prognosis of a ruptured free wall?
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Usually fatal due to tamponade or electrical mechanical disassociation.
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Symptoms of free wall rupture?
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Acute hypotension
Severe heart failure Loud, harsh systolic murmur. |
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What should you look for to see a free wall rupture?
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A thin wall, a jet, effusion.
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What is the only way to treat a ruptured free wall?
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Surgical repair.
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What can happen in a ruptured free wall, making the patient very lucky?
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Psuedoaneurysm.
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How long after an MI is a pericardial effusion likely?
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2-4 days.
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What happens due to an immune response 1-12 weeks post MI?
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Dressler's syndrome.
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How many infarct patients have a septal rupture?
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1 to 3%
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Post MI, when does a septal rupture occur?
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Usually within the first week.
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Who is likely to have a septal rupture?
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Elderly women without previous MI
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What is an indicator of a septal rupture?
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A new systolic murmur.
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What type of shunt can be expected with a septal rupture?
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L to R, In a thinned, dyskinetic area.
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What is a psuedoaneurysm?
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Essentially a hematoma.
Narrow neck. Partial filling with thrombus. Wall is pericardium |
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What motion is seen in a true aneurysm?
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Dyskinetic.
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Where is an aneurysm likely?
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Apex.
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What likely is seen with an aneurysm?
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Thrombus.
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What would a thrombus from MI look like?
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Laminated or mural, concave contour
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Treatment for MI?
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Thrombolysis, 4 hours.
Anticoagulation Percutaneous transluminal coronary angioplasty Coronary Artery Bypass Graft Intra-Aortic Balloon Pump |
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What does IABP stand for?
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Intra-aortic balloon pump.
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How does IABP work?
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Increases perfusion by inflating during diastole, increasing perfusion pressures in the coronary arteries. Deflates prior to systole, thus decreasing afterload.
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How big is the balloon used in IABP?
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40cc
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In MI, why is MR seen?
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Not due to LVE, but rather aortic root dilation or valve disease.
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What Echo looks for.
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Segmental pattern of LV function
EF for overall function LV thickness LVID MR PAP AR reduced function - look for thrombus. |
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When not to use modified Simpsons?
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When difference of lengths is greater than 20%
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Methods of measuring global LV systolic function?
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LV end diastolic and end systolic dimensions and volumes
FS EF SV CO CI |
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What is an important predictor of mortality after MI?
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Global LV systolic function
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What gives a percentage change in the LV cavity with systole?
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Fractional Shortening.
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Fractional Shortening formula?
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LVEDD-LVESD/LVEDD x100
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Normal fractional shortening?
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25-45%
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What gives a percentage of LV diastolic volume that is ejected with systole?
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Ejection Fraction
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Ejection Fraction formula.
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LVEDV-LVESV/LVEDV x100
or LVEDD2-LVESD2/LVEDD2 x100 |
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Normal ejection fraction?
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55%-75%
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What is the procedure to coordinate pumping action of the ventricles?
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CRT - Cardiac Resynchronization Therapy.
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What echo test can help identify candidates of CRT?
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Tissue doppler.
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Outcomes with CRT?
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Reduce symptoms
Increase SV |
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How does CRT increase SV?
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Increasing the mechanical sequence of contraction.
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In stress echo, images are acquired in a cine loop during what EKG phase?
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R wave to just past T wave
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Why is stress echo helpful in diagnosing coronary artery disease?
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Patient could have normal function at rest.
Increase workload increases myocardial oxygen demand Ischemia impairs function |
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What does TMET stand for?
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Treadmill exercise test, the EKG test. Echo stress test is better in all ways.
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What are the indications for a stress echo?
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Diagnosed CAD
RX adjustment for those with CAD Guide post MI rehab Pre-op risk stratification Screen high risk professionals Assess MV in patients who are symptomatic Chest pain of unknown origin Shortness of breath |
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What are contraindications for stress echo?
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Unstable angina
Acute MI 2 days prior Severe AS Severe pulmonary hypertension Significant arrhythmia Uncontrolled hypertension Aneurysm Mobile thrombus IHSS - due to arrhythmias Syncope or seizures |
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How can abnormal wall motion be independent of inducible ischemia?
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Conduction abnormalities, like LBBB
Ventricular pacemakers Right sided pressure/volume overload |
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What are potential pitfalls of stress echo?
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AWM independent of ischemia
Operator dependent Technical difficult images - obesity, pectus, COPD Getting patient to goal |
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How do you achieve an increased cardiac workload?
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Exercise
Dobutamine |
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What are the key elements in stress echo interpretation?
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Duration of exercise
Maximum workload Symptoms BP response Arrhythmias ST segment changes on ekg (ELEVATION OR DEPRESSION) |
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What is important in image acquisition in stress echo?
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Ensure segments are visualized in at least one view
Use comparable views at rest and stress Record in cine loop Optimize endocardium Do it fast - at max workload. |
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How do you optimize the myocardium?
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Harmonics, contrast, TGC
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How many peak images need to be obtained?
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5 or more
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When the images are side by side on quad screen, what do you look for?
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systolic thickening and wall motion
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What is a normal stress response?
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Hyperdynamic walls
Systolic thickening Decreased systolic cavity Normal diastolic dimensions |
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How should a patient be prepped?
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NPO for 3 hours
Explain procedure Rate and rise of treadmill Patient will be pushed to a goal HR Patient needs to convey symptoms |
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Why is dobutamine used in stress echo?
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Increases HR and contractility
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What is the half-life of dobutamine?
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2 min.
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How is dobutamine administered?
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5mcg/kg/min increased incrementally every 3 to 5 min up to 40mcg/kg/min
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What may be added on top of dobutamine to increase heart rate above the 85% goal?
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Atropine
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What is the normal dobutamine response?
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Wall thickening and increased endocardial motion.
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What are positive indicators for ischemia with dobutamine?
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Areas of hypokinesis or akinesis in a region that had normal function.
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If the coronary artery is stenosed proximally, WMA will be present where?
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base of the heart.
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If the coronary artery is stenosed distally, WMA will be present where?
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Toward the apex.
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Dobutamine and hibernating/stunned myocardium?
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Improvement has been shown with low dose dobutamine (10mcg/kg/min) but then worsening at higher doses.
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When to terminate a stress test?
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Angina
Wall change (new, worsening of existing) Significant arrhythmias Hypotensive response Hypertensive response Max dose Max HR Intolerable symptoms |
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At rest, normal wall motion. What should happen in SE for a normal interpretation?
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Increased EF, decreased vol, hyperdynamic.
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At rest, normal wall motion. What should happen for an ischemia interpretation?
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New RWMA, lack of hyperdynamic response.
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At rest, RWMA. What should happen for an ischemia interpretation?
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Worsening RWMA
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At rest, RWMA. What should happen for an infarct interpretation?
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Unchanged
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What are the advantages of dobutamine SE?
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Alternative if they cant exercise
Contrast evaluation The test ends immediately when you see RWMA Test for viable myocardium |
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What are disadvantages to dobutamine?
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Functional capacity not assessed.
Operator dependent Subjective interpretation |
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Advantages of stress echo?
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Low cost (1/2 to 3/4 of nuclear studies)
No irradiation Portable Brief Immediate answers Ability to see wall thickening |
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Disadvantages of stress echo?
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Operator dependent
Subjective interpretation. |
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In SE, when do you use contrast?
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If less than 80% of the segments can be seen.
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How is contrast administered?
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Injected into a vein in the arm. Runs through pulmonary system into LV.
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What views do you use in SE?
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PLAX, PSAX, 4, 2.
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