Welcome to our next module, where we are going to discuss cardiovascular diagnostics. My name is Jamie Warren. I am the VP of Care Transformations with Medaxium and very excited to have you with us for this module. These are my disclosures. And for our learning objectives today, we are going to cover three categories. We're going to take a look at the common cardiovascular diagnostic modalities. We're going to understand the clinical applications for these cardiovascular diagnostics and identify the role of nursing in the cardiovascular diagnostic space. You will see a lot of information on each slide that you will be able to come back to and read, but today we will highlight high level your role as a nurse as it is involved in cardiovascular diagnostics. The additional readings for this module, you have your required and your additional resources. So what is diagnostic imaging? You may also hear this as non-invasive imaging, but what does this mean? This is taking a look at a patient's body from the inside to determine if they have any causes of injury or illness and being able to assist in a diagnosis. We also are able to evaluate how well a body is responding to a treatment. And when I say treatment, this could be either a procedure that was done like a cardiac cath, or this could be medication that the patient has started. Diagnostic imaging can be found within multiple locations within a hospital or outpatient center. You may see it in the radiology or even a specific cardiology imaging department. And there is even testing that can be done in the patient's home. Inpatient diagnostic imaging can be performed either bedside where one of our technologists would come to the patient, or the patient may be brought down to the imaging department to complete their procedure. So who can perform a diagnostic imaging procedure? Common titles or professional roles that you will see is a technologist, a sonographer, an allied health professional, a nurse, a diagnostic imaging assistant, exercise physiologist, and these are just a few. The list is many, many more. One of the things that you will notice, though, is that the word technician is not included in common titles. With this, for each of the imaging modalities, your technologist or sonographer or allied health profession has received formal education. So they have attended and graduated from an accredited educational program that leads to a degree or certificate. They are also required to take a board that will certify them in the specific imaging modality. So think of this very much like nursing where you sit for your boards. This also happens in the diagnostic space. The last piece is state dependent, but many states require the allied health professionals to hold state licensure. For today, these are the common cardiovascular imaging modalities that we will talk of. We are going to cover EKG holter and event monitors, stress testing, ultrasound. We will cover both the cardiac and vascular space, nuclear medicine and PET, CT and MRI. Our first category will start with the EKGs, holters and event recorders. An EKG is the most commonly found diagnostic tool that can be performed anywhere. You may see this bedside. You may see this in your office. You may see this within a diagnostic center. And this is where you're going to hook that patient up using those stickers or those electrodes and wires to the patient and be able to measure or record the electrical signals from the heart. The most important thing to remember is that we're going to be hooking the patient up with arm leads and leg leads. So that means we'll have electrode stickers up by the collarbones or lower on their abdominal area or down by their legs. It's very important to make sure that you hook up the left and the right correctly with the orientation of the patient. You do not want to have what is called limb reversal because that will change the results of your EKG. Our next in this category is holter monitor. And the best way to think of a holter monitor is taking that EKG but extending the recording over 24 to 48 hours. The picture at the top right hand is the most common way that a holter monitor would look that's placed on a patient. And so you see several wires and stickers or those electrodes that then attach to a box that is on the patient's waist or can be placed in a pocket or they can even have a little purse that is laced around their neck and then they can read it across their chest. Down at the bottom right is our newer technology that has come out with holter monitors where it is a single sticker that is placed on the patient's chest. What's important to remember is that the patient will not be able to take a shower or a bath or swim while they're wearing this and they will not be able to remove it until the end of the recordings. It is an important reminder to the patient to have them come in with no lotion or anything that's on the chest that would prevent the sticker from sticking to the skin. Our last one in this category is an event monitor. And this is being able to look at the electrical activity of the heart for a much longer period of time and could be up to 30 days. Now because this is a much longer exam the patient is shown how to take this off and put back on and they are given supplies on how to best be able to put this back on after their period of time. Our next category is with stress testing and we're going to talk about exercise and pharmacological. Treadmill testing, you may also hear this as stress test or even an ETT is going to refer to the patient doing physical activity and this could be with them walking on the treadmill or even riding a stationary bike. The patient is going to be hooked up just like they would if they were hooked up to have an EKG and they will have a blood pressure cuff placed on their arm. The treadmill will start out very slowly. It will increase in speed and the angle or the incline of the treadmill until the patient is able to reach a certain heart rate. There will be multiple people in the room supervising while the patient is having the stress test to identify if there's any changes in their EKGs. This test usually takes about 20 minutes and can be performed by itself without any additional testing with it, but it may also be in conjunction with imaging like you would with a nuclear spec study or an echo. So what do you do with a patient that's not able to walk on a treadmill? There is the option to have a pharmacological stress test and this is having a pharmacological agent administered through an IV line. This is going to mimic the response that the patient would have if they were able to exercise on the treadmill. Common pharmacological stress agents that you may hear your provider ordering are regadenosine or also known as lexiscan, dipertamol also known as persantene, adenosine or dobutamine. Now depending on which stress pharmacological agent is used, the patient may experience some side effects and common side effects are shortness of breath. They may have a headache or some minor chest pain. All of this will be covered and discussed with the patient prior to starting the test by the allied health professional. Now it's important to note with a pharmacological stress test, this is not a standalone test. This will have to be performed in conjunction with imaging. So if you see one of your providers order, we'll use adenosine for example, an adenosine stress test only. It is important to go back to that provider and get clarification on your order on if they want it to do a treadmill test or a pharmacological stress test with imaging. So a couple of things to consider when you see orders for stress test. Patient prep is extremely important. Patients will be asked to hold some of their medications and hold caffeine 12 to 24 hours prior to testing. I would recommend that you check with your ordering cardiology provider for specific instructions that they would like to see the patient have while they're doing their stress test. Also one other point to be aware of is that if you see an order for a regular treadmill stress test so that the patient will be walking on a treadmill, it's important to evaluate your patient to ensure that they are able to walk on a treadmill comfortably. If you have a patient that you're unsure of their GANT or being able to walk at a fast speed, please check with your ordering provider to see if an alternative test should be ordered. Our next category is echocardiography and this is taking a look of as an ultrasound of the heart. So with this we are going to start with our echo. You will also hear this as an echocardiogram or cardiac ultrasound and this is where you have your sonographer, your cardiac sonographer or echo technologist who is going to do images of the patient's heart to assist with evaluating the structure and the function of the heart muscle. They're going to use a handheld probe and that ultrasound machine to take pictures. With an echo study the patient may have an IV placed and have the administration of an echo enhancement agent to assist with the images. Side effects are discussed with the patient prior to starting the IV administration. These agents do not contain any contrast and therefore there is not a need to do pre-medication from a contrast allergy that would be needed if the patient was having a CT. There's no special prep for a patient having an echo and this usually takes about 40 to 60 minutes to complete. The next test in this category is a stress echo and this is taking that echo and combining it with a stress test. This could be done on a treadmill or a bike or pharmacologically using the stress agent dobutamine. It's important that your patients follow the prep so this may be medications that need to be held prior to the test and do recommend that you check with your cardiology provider for specific instructions. The last test in this category that we will discuss is a transesophageal echocardiogram or a TEE and this is where we're going to take images from the inside. So you will have a cardiology provider in the room that will guide a very thin flexible tube that is the ultrasound probe down the patient's esophagus. So for the patient they will be given IV sedation and they will have numbing placed into the back of their throat. They will have several allied health professionals, so your cardiac sonographer, a nurse, and your cardiology provider will all be in the room during the procedure. Now while the TEE piece of it where they're taking the images takes approximately 15 minutes, the entire test from getting the patient ready to when they're done with their recovery takes approximately 90 minutes. There is patient prep since the patient will be sedated and they will be asked to eat to not eat or drink six hours prior to the study and they may be asked to hold their medications. One important note with this test is that due to the patient being sedated they will have to have a driver to take them back home. Our next category is still ultrasound but we're going to flip this time to look at the veins and the arteries. So this is our vascular testing. Your allied health professional that will perform this test, they are either a vascular sonographer, they may also be called a non-invasive ultrasound technologist. The first one we will discuss is the carotid ultrasound and this is still taking that ultrasound probe and placing it on the neck of the patient for them to look at the blood flow through the carotid artery. From a patient perspective this is a very easy test. They just lay down on a bed and then they have some gel placed on the skin and the probe will have some slight pressure as they take those images. There's no special prep but it is important to express to your patient that they would need to wear a shirt that they can have access to the neck area and if they're wearing any necklaces or large earrings they will be asked to remove those and if they could leave those at home that is the best practice. Abdominal vascular ultrasound is now moving down to the stomach or the abdominal area and the main indication for this test is to rule out an abdominal aortic aneurysm. Again this is a very easy test from a patient perspective. They will lay down on a stretcher, have gel placed on their skin and the probe will take images. They may feel some slight pressure from the probe and they will be asked to not eat or drink six hours prior to the exam. Venous Doppler ultrasound is one of the most commonly ordered scans when it comes to vascular ultrasound and this is looking for blood clots that could be either in the arms or the legs. So the patient will be asked to change into a gown. They will lay down onto the table or the stretcher and the sonographer will use gel and that probe to take images. One important note, this test is looking for a critical finding or a critical value of that deep vein thrombus. So when this test is ordered it is important to include contact information so that the department can call back with any critical findings. We just talked about looking at the veins but let's flip to talking to the arteries. This is also an exam that can be done with looking at both the arms and the legs of the patient. In conjunction with using the ultrasound machine they will also put blood pressure cuffs on the patient's arms and legs to check the pressure between these areas. Depending on which parts of the body that need to be done in this test, so if they're doing both arms or both legs or both arms and legs together, that will change the duration of how long this test will take. The last piece in this category is an ankle brachial index, also known as an ABI. In this, there is a special machine that is used within the vascular department that looks like a series of blood pressure cuffs that are placed on the arms and the legs of the patient. These are each squeezed and then the pressure is taken from each of those specific spots on the patient. They may also be asked to do this with or without exercise where the patient would walk slowly on a treadmill or perform toe ups. And think about toe ups like you're pressing a gas pedal and then releasing your toe back up. There's no special prep for this exam and it takes about 30 to 45 minutes to complete. Moving on to nuclear cardiology, we're going to talk about SPECT and PET imaging. Some important notes or considerations with the nuclear medicine procedures is that patient prep is extremely important with these tests. Patients not following the patient prep is the number one reason why this test would be canceled and rescheduled. It is important that the patient follows holding their medications and no caffeine 12 to 24 hours prior to the test. We recommend that you check with your ordering cardiology provider for specific instructions. For a nuclear medicine or PET procedure, the patient will be administered a small amount of a radioactive tracer or radioisotope through an IV. If your patient is pregnant or breastfeeding, there does need to be discussions with your ordering provider to see if an alternative test should be ordered. With nuclear medicine and PET, iodine contrast is not given and it is not where a patient would need to be pre-medicated for an allergy. One of the most common tests that are ordered within this nuclear medicine or nuclear cardiology space is called a myocardial perfusion SPECT study. This test has lots of names, so you may hear this as a stress cardiolite, a stress test with images. You may even hear it called a stress valium. It's all the same piece and it's more most commonly known as that SPECT study. So SPECT stands for single photon emission computed tomography and this is the method or technique that the nuclear medicine technologist is going to use to evaluate the blood supply to the heart. The patient can expect to be in the department for about four hours as multiple images are taken and a stress test where the patient either walks on the treadmill or can have this with the pharmacological stress agent. An IV will be started and the patient will be given a radiopharmaceutical. Also in the nuclear medicine department, the patient may have a test order to evaluate if they have amyloid. This is also known as a PYP scan. This is a fairly easy exam for our patients. There is no prep that's associated with it. They will come in, an IV will be started, a small amount of a radioactive tracer will be administered, and then the patient will be given instructions on when to return to the department to have images. The picture in the top right hand corner is a picture of a camera you would commonly see in a nuclear medicine or nuclear cardiology department. The patient will lay down on their back, their arms will go above their head, they will slide in, and then images will be taken. This is a great camera, especially with patients that are claustrophobic because their head is out and it's a little bit more open than what they would experience with their CT or MRI. A myocardial perfusion PET study. So now we're flipping over to a different type of camera. This camera, a positron emission tomography method, is used. And again, this is looking at the blood supply to the heart. This camera is usually found in an outpatient setting. With this, the patient will have an IV started and they will be administered with a radiopharmaceutical. They will have multiple sets of images acquired and they will also have a stress test, a pharmacological stress test, while they're laying on the table. This takes approximately 45 to 60 minutes. Now you may be asking yourself, okay, well what's the difference between this and a spec study? So a PET scan is usually ordered if a patient has had a spec study in the past where it produced a false positive or if the patient's BMI is over 35. In the top left-hand corner, this is taking what we call a fused image. So everything that's in the black and white is a CT and everything that is in the color portion is the PET. And they overlay or put those two pictures directly over top of them so that they can evaluate the function or the physiology and the anatomy of the patient. In the PET department, they can also do a sarcoidosis PET study. And this is looking for that granuloma or inflammation specifically in the heart tissue. Same thing with this as the other tests, the patients will have an IV started and be administered with a radiopharmaceutical. They will have multiple sets of images that are performed and they can plan on being with the department for about two to three hours. The patient prep is extremely important with this test and has to be followed at 100%. This includes a low carb, high fat dietary prep prior. And this is the number one reason why the study is canceled and rescheduled. Our last test that we will talk about in the PET department is a cardiac viability study. And this is taking a look at the viability of the heart tissue that may have been damaged by a heart attack or heart disease. And this is often taking a look to determine if the patient needs to go on for additional procedures that may even include bypass surgery or heart transplant. The patient will be administered with a radiopharmaceutical through an IV and multiple images will be taken. So now we're going to move to CT procedures. In CT, when a doctor or a provider wants to order a CT, there are four buckets that this could fall into. We're going to talk about each one of these and what the differences are. But please note, when we start talking about CT, it is important to ask your patient if they have a history of iodine related allergies and ensure if the patient needs to be evaluated to be pre-medicated because the patient may be administered with contrast. So for our first one, calcium scoring CT. This is probably the fastest and easiest out of all the four that we're going to talk about. There is no special prep that the patient needs to do. They will come in, they will lay down on their back, arms above their head. They may be asked to hold their breath in several different sections of the test. It takes about 15 minutes. The important note for a calcium scoring is that this is considered a screening tool. It may not be covered underneath the patient's insurance policy. The patient may be expected to pay out of pocket for this particular study. The next category is a cardiac CT, but this we're looking at anatomy. This is really taking a look at the anatomy or structure of the heart. This is often used post-cardiac surgery or structural heart procedure and can also be used to review for congenital heart disease. The patient will lay flat on the CT camera. They will have an IV started and will be administered with that iodine contrast. Again, they will be asked to hold their breath during parts, several parts of the scan. There is patient prep associated with this with no food or drink four hours prior, and they may be asked to hold their medications. Our next one is a cardiac computed tomography or CCTA. This one today is probably the most commonly one ordered by our cardiology providers. This is the exam that's going to review the patient's coronary arteries for blockages. With this exam, the most important piece is heart rate management, and that may start prior to the patient coming to the department with an oral beta blocker. Once they reach the department, they will have an IV placed and given IV medications to also handle the heart rate. With this exam, the heart rate does have to be within a certain range before they can start the pictures. Once they have reached that heart rate range, the patient is placed underneath the camera laying flat with their arms above their head, and they will have images taken. So for this, the image piece of it only takes about 15 minutes, but the patient may be in the department for up to one to three hours as they get that heart rate where it needs to be for the images and then also post-evaluating the patient. From a patient prep perspective, no food or drink for four hours, and they will be administered with iodine contrast, so it is important to check for allergies. Our last test in this category is peripheral, and this is looking at the arteries and veins or your blood vessels of both the arms and the legs. The patient will have an IV started. They will be administered with contrast in the same prep as what we've seen with the other tests for no food or drink for four hours, and it is important to check for that allergy contrast. MRI procedures, we're only going to talk about one particular test with the cardiac MRI, and this is looking at the radio waves and magnets to create an image that's going to look at the heart's chambers, valves, and muscles, and it's going to provide information on how that blood is moving through the heart. An IV will be started, and they will lay flat on the MRI camera. Now, while a contrast will be administered, this is a different contrast than what is used in CT. For this, there is no special prep, but you do need to ensure that the patient does not have any metal or devices inside their body, and you will need to ask if the patient is pregnant. For our claustrophobic patients, they may need to be premedicated, and then if that's the case, they will need a driver to bring them and then take them back home. Cath procedures is our next category. So with our diagnostic procedures, we call those non-invasive, but if we find a finding that we need to go on and get a closer look at the heart, the next procedure is an invasive procedure or a diagnostic cardiac cath. So this is where the cardiologist will use a thin, flexible tube or catheter that is guided through a blood vessel, and this can be placed either in the groin or wrist area of the patient, and this is going to look at the heart muscle, the valves, and the blood vessels to the heart. So when that patient first arrives to the department, they will come into the pre-area, changed into a gown, an IV started, labs drawn, and then they will be asked questions about their medical history. Once ready, they will move into the cath lab, where the patient will be administered sedation, and the area where the catheter will be placed will be numbed. Once the procedure is completed, the catheter will be removed, but the patient will be required to lay flat for several hours to avoid bleeding. There is patient prep associated with this, nothing to eat six hours prior to the procedure, and the patient may be asked to hold their medications. It is important to check with your cardiology provider for specific instructions. For this, the catheter area where it was placed may be sore for a few days. If that patient experiences any bleeding or increase in pain or swelling, they will need to contact their cardiac provider. If the patient has any iodine-related allergies, they will need to notify that ordering provider prior to the procedure beginning. So in your cardiac cath, if they find that there is a narrowed coronary artery, the patient may move on to an intervention, a PCI or a coronary angioplasty. This can be done at the same time that their diagnostic cath is being performed, or may be scheduled at a different date. So with angioplasty, they're going to use a tiny balloon catheter that is inserted into the blocked vessel to widen it and improve the blood flow to the heart. And then to keep that opening, they're going to use a stent to prop the artery open, which is going to decrease the chances of the patient narrowing that artery again. Most of these stents are coated with medication that keeps the artery open. You may hear that as a drug eluding stent. The patient's medications may also be changed post-procedure and may include the addition of blood thinners. So your patient has had their diagnostic study done, and you get a report in the EMR, or electronic medical records. The best way to walk through this report is to start at the top and then look for the conclusion or summary section. It is important to wait for the final interpretation and note that this needs to come from the reading provider. Each report, again, will have that final impression or summary finding section, and they may also provide recommendations for follow-up or further testing. What you will see in that summary area is if the test was normal, abnormal, or you may see where the test results are equivocal, where additional testing may be required. If a patient has critical findings, the diagnostic department will contact the reading physician before the patient leaves to have this test read and then determine if the patient needs to immediately go on for an additional intervention or additional diagnostic testing. So that will complete our section for diagnostic testing. If you have any questions for this section, please email academy at medaxiom.com. Thank you.

cardiovascular diagnostics

diagnostic imaging

EKGs

stress testing

nuclear medicine

patient preparations