coronary artery
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| 2-D ADVANTAGES IN CAD EVALUATION | Performed immediately
Determines location and extent of LV wall motion abnormalities
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| Estimates systolic and diastolic function Serial studies | Assess LV function changes after infarct or reperfusion therapy
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| Complications identified ACUTE MYOCARDIAL ISCHEMIA | Ischemia is a reversible imbalance in the myocardial oxygen demand-to-supply ratio
Obstructed coronaries can usually still compensate for demands at rest
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| When narrowing exceeds 70% of cross sectional area blood flow can’t keep up with demands from: | Exercise
Pharmacologic interventions
mental stress
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| ACUTE MYOCARDIAL ISCHEMIA Consequences I | Coronary artery occlusion/obstruction
Diastolic dysfunction
Impaired relaxation and decreased compliance
Increased LVEDP
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| ACUTE MYOCARDIAL ISCHEMIA Consequences II | Decreased left ventricular ejection fraction
Impaired systolic thickening
Reduction of endocardial motion
Dysynchronous contrac
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| ACUTE MYOCARDIAL ISCHEMIA Consequences III | Consequences
Possible LV dilatation
Large infarctions
More increase in LVEDP
CHF develops
Increased heart rate to compensate and maintain adequate cardiac output
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| WALL MOTION ABNORMALITIES Describing abnormality: | Hypokinesis – an increase in systolic wall thickening <40%
Akinesis – systolic wall thickening <10%
Dyskinesis – present when wall moves outward during ventricular systole and has wall thinning
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| CLASSIFICATIONS MI’s divided into 3 categories: | Subendocardial – involving only the inner layer of the myocardium
Subepicardial – involving both inner and middle layers
Transmural – extending through all three layers of the myocardial walls
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| EKG FINDINGS | T wave inversion suggests ischemia
Elevated ST segment represent acute MI
Prominent peaked T waves show acute MI
Pathologic Q waves show “old” MI
May also see ventricular arrhythmias or other conduction defects
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| SYMPTOMS | Physical examination
May be normal if MI is uncomplicated
Symptoms are usually the last thing to occur
Chest pain
SOB
Nausea
Vomiting
May not occur at all
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| MYOCARDIAL INFARCTION LAB VALUES CK I | AKA Total CK, creatine phosphokinase, CPK, creatine kinase
Levels rise when muscle or heart cells are injured
Levels begin to rise 4-6 hrs after MI
Highest levels are 18-24hrs after
Will return to normal 2-3 days
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| MYOCARDIAL INFARCTION LAB VALUES CK II | Can also be seen w/ skeletal muscle damage
If CK is high, a more specific test is needed
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| LAB VALUES I CK-MB | AKA CK MB, CPK MB, creatine kinase-MB
CK-MB helps differentiate between heart damage or damage to other muscles
CK-MB can also tell Dr. if clot dissolving drugs are working
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| LAB VALUES CK-MB II | Ck-MB to total CK index higher than 2.5-3 indicates high likelihood of heart muscle damage
Some skeletal muscle injury can be severe enough to raise CK-MB levels
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| LAB VALUES Troponin | AKA Tn1, TnT, Cardiac specific Troponin I and T
Usually ordered along with other cardiac markers
Troponin is starting to replace CK & CK-MB because it is more specific for heart injury
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| Troponin | Troponin is elevated for longer period of time, 1-2 weeks after a heart attack
Levels are not affected by damage to other muscles
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| 2D DOPPLER EXAM Sonographer needs: | Clinical history
Prior cardiac events
Cardiac murmurs
Evidence of CHF
Systolic BP
Pulmonary artery cath info in CCU
Hemodynamic info
12 lead EKG for presumed infarct location
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| IMPORTANT ECHO INFORMATION | LV and RV size and function
Wall motion abnormalities
Valve integrity and regurgitation
LV diastolic filling parameters
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| ECHO FINDINGS | 2D evidence of wall motion abnormalities is always seen in transmural infarction
Wall motion abnormalities may or may not be seen where ischemia occurs in the subendocardial myocardium
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| COMPLICATION OF MI | Pericarditis
Pericardial inflammation
May or may not see effusion
Dressler’s syndrome
Delayed form of pericarditis 1-12 weeks post MI
Recurrence is common
Tamponade is rare
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| Symptoms of Dressler’s | Fever
Pleuropericardial pain
Malaise
Pericarditis
Pleuritis
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| RV infarction | Frequent complication of inferior MI
Hemodynamic signs of RV infarction resemble those of cardiac tamponade
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| Mitral regurgitation | Common complication of acute or recent MI
papillary muscle rupture can occur and cause MR
Flail leaflet seen
Papillary muscle dysfunction may occur due to localized ischemia with underlying wall motion abnormality
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| LV aneurysm:I | May form at the site of infarction
Most commonly involved are anterior wall and apex
Distortion of LV contour at end diastole and end systole
Thrombus frequently forms
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| LV aneurysm:II | “hinge point” demarcates the infarct zone and aneurysm formation from normal myocardium
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| LV thrombus after MI: | Higher incidence with aneurysm formation
Thrombus can spontaneously resolve, or resolve after anticoagulant therapy
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| LV pseudoaneurysm I | Myocardial rupture contained by parietal pericardium
True aneurysm involves myocardium
Usually seen post recent MI
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| LV pseudoaneurysm II Can also be seen in the following cases: | Cardiac trauma
Myocarditis
Infective endocarditis
Cardiac surgery
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| LV PSEUDOANEURYSM III | There is a likelihood of rupture common in these patients
Small communicating neck creates a gradient
Thrombus may extend into neck and increase the size
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| Differential diagnosis of LV PSEUDOANEURYSM | Loculated pericardial effusion
Pericardial cyst
LV diverticulum
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| LV DIVERTICULOSIS | A rare congenital cardiac malformation which may be confused w/ aneurysm
Small circular echo free space arising from LV w/ all 3 layers intact
Doppler may demonstrate low velocity, systolic-diastolic flow w/in the chamber
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| Ventricular septal rupture or VSD post MI: | New systolic murmur accompanied by signs of hypoperfusion after acute MI
Could be rupture or severe MR
2D, color flow, and Doppler are used together to detect rupture
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| LV free wall rupture: | Predisposing factors
Large MI
Lateral or posterolateral
Elderly patient
Post MI hypertension
No prior CAD
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| LV FREE WALL RUPTURE | Seen within 48 hours of acute MI
Rupture site is between the zone of necrotic and normal myocardial tissue
Cardiac tamponade can develop
This causes hypotension and bradycardia
Survival is rare
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