E. Cardiovascular System

E. Cardiovascular System

CLINICAL PROBLEM		INVESTIGATION	RECOMMENDATION {GRADE}		COMMENT
Acute central chest pain : myocardial infarction	E01	CXR	Indicated	[B]	CXR must not delay admission to a specialised unit. CXR can assess heart size, pulmonary oedema, etc. and can exclude other causes. Department film preferable.
Chronic ischaemic heart disease and assessment after myocardial infarction	E02	CXR	Indicated only in specific circumstances	[B]	May be helpful only if signs or symptoms have changed, when comparison with the CXR obtained at presentation.
		NM (myocardial perfusion imaging)	Indicated	[B]	Appropriate method of determining prognosis / diagnosis, ischaemic burden and specific ischaemic zone. Either pharmaceutical or exercise stress can be used in conjunction with isotopes. TI-201 imparts a higher radiation burden but may be a better prognostic / viability agent. Tc-99m has a higher energy and allows contaminant assessment of LV contraction to be made via gated imaging. Particular uses are: Prognostic assessment Diagnosis in atypical or asymptomatic individuals Assessing patients for revascularisation strategies Risk stratification prior to non-cardiac surgery
		Angiography	Indicated	[B]	Only technique currently available for detailed assessment of coronary artery anatomy. Essential prerequisite for interventional strategies and sometimes to establish diagnosis
		MRI	Specialised Investigation	[B]	The role of MRI perfusion is still to be evaluated.
		NM (radionuclide angiography: MUGA or ERNVG)	Specialised Investigation	[B]	Can assess both LV and RV function after myocardial infarction. Echocardiography is the preferred technique for assessment of LV contraction, etc.
		US echo-cardiography	Indicated	[A]	Allows assessment of residual LV contraction, valves and complications such as myocardial rupture. Can easily be used sequentially, particularly if haemodynamic clinical deterioration is noted.
Chest pain: ?aortic dissection	E03	CXR	Indicated	[B]	Mainly to exclude other causes; rarely diagnostic.
		CT	Indicated	[B]	CT with IV contrast is the most reliable and practical technique.
		US Trans-oesophageal echo-cardiography (TOE)	Indicated	[B]	TOE is a useful and accurate bedside technique, but not as good as CT for aortic arch
		MRI	Specialised Investigation	[B]	MRI is accurate and assesses any change in longitudinal extent, but practical difficulties can limit imaging potential. Useful for a sequential follow-up.
Pulmonary embolism (see also N03, E13)	E04	CXR	Indicated	[B]	CXR should be preliminary investigation to demonstrate consolidation and pleural effusion, but a normal CXR does not exclude a pulmonary embolus
		NM (perfusion scintigraphy / ventilation)	Indicated	[B]	Ventilation / perfusion (V/Q) scintigraphy can be diagnostic if used selectively in patients without COPD or consolidation on CXR, or less often if used non-selectively. a normal perfusion scintigram excludes clinically significant pulmonary emboli.
		CT	Specialised investigation	[B]	Spiral CT is the investigation of choice , is as accurate as pulmonary angiography in the detection of pulmonary emboli, and reliably excludes clinically important pulmonary embolism. It is the investigation of choice for patients with COPD or an abnormal CXR and may be used following a non-diagnostic V/Q scintigram.
?Pericarditis ?pericardial effusion	E05	CXR	Indicated	[B]	May reveal concomitant pathology (e.g. tumour) or calcification in pericardium.
?Pericarditis ?pericardial effusion	E05	US echo-cardiography	Indicated	[B]	useful for assessment of concomitant pathology (e.g. effusion) can make assessment of size of pericardial effusion, suitability for drainage, development of tamponade etc. Best for sequential follow-up
Suspected valvular cardiac disease	E06	CXR	Indicated	[B]	Used for initial assessment and when there is a change in the clinical picture.
		US echo-cardiography	Indicated	[B]	Best method of sequential follow-up. TOE may be needed for prosthetic valves
		MRI	Indicated	[B]	Can be useful but is generally impracticable. Contraindicated for many prosthetic valves. Useful in the context of congenital heart disease.
Clinical deterioration following myocardial infarction	E07	US echo-cardiography	Indicated	[B]	US may show remediable complications (VSD, papillary rupture, aneurysm, etc.).
Clinical deterioration following myocardial infarction	E07	CXR	Indicated	[B]
Hypertension	E08	CXR	Indicated	[B]	Assess cardiac size and possible associated pathology such as coarctation or rib erosion from collaterals
		US Echo-cardiography	Indicated	[B]	Most practical method of assessing LV hypertrophy
		MRI	Specialised Investigation	[B]	Most accurate method of assessing LV hypertrophy
Suspected cardiomyopathy, myocarditis	E09	CXR	Indicated	[B]	Globular cardiac silhouette suggestive of dilated cardiomyopathy.
		US echo-cardiography	Indicated	[A]	Allows clear assessment of dilated, hypertrophic and constrictive /restrictive cardiomyopathy and associated cardiac abnormalities. Not so useful for arrhythmic RV dysplasia . TOE can distinguish constrictive from restrictive cardiomyopathy.
		NM	Specialised Investigation	[B]	Rest radionuclide angiography is indicated in the determination of initial and serial LV and RV performance in patients with myocarditis or dilated, hypertrophic and restrictive cardiomyopathy and in patient receiving chemotherapy with doxorubicin. Myocardial perfusion imaging may help to differentiate ischaemic and dilated cardiomyopathy and to assess myocardial ischemia in hypertrophic cardiomegaly.
Congenital heart disease	E10	US echo-cardiography / US Trans-oesophageal-echocardiography	Indicated	[B]	Provides diagnostic and functional data. Facilitates follow-up. Specialist area. TOE can provide additional useful information to transthoracic echocardiography
Congenital heart disease	E10	MRI	Indicated	[B]	Best assessment / follow-up tool. Contraindicated for many prosthetic valves.
Unstable Angina	E11	NM	Specialised Investigation	[B]	Tc-99m to TI-201 scintigraphy in diagnosis, prognosis and assessment of therapy in patients with unstable angina is indicated in the : identification of ischemia in the distribution of the culprit lesion or in remote areas measurement of the baseline LV function Identification of the extent and the severity of disease in patients with ongoing ischemia or myocardial hibernation
Unstable Angina	E11	Coronary angiography	Specialised Investigation	[B]	only tool currently available for assessment of coronary artery anatomy. Essential prerequisite for interventional strategies and sometimes to establish diagnosis.
?Abdominal aortic aneurysm	E12	US	Indicated	[A]	Useful in diagnosis, determination of maximal diameter and follow-up. CT preferable for suspected leak but should not delay urgent surgery.
?Abdominal aortic aneurysm	E12	CT or MRI	Indicated	[A]	CT (especially spiral) and MRI for relationship to renal vessels and iliacs. Increasing demand for detailed anatomical information because of increasing consideration for percutaneous stenting.
?Deep vein thrombosis	E13	US	Indicated	[A]	More sensitive with colour flow Doppler. Most clinically significant thrombi are detected. Increasing experience with US for calf vein thrombi. May show other lesions.
?Deep vein thrombosis	E13	Venography	Indicated only in specific circumstances	[B]	Extensive variation according to US expertise and local therapeutic strategy.
Ischaemic leg	E14	Angiography	Specialised investigation	[A]	Local policy needs to be determined in agreement with vascular surgeons, especially with regard to therapeutic interventions. US used in some centres as first investigation.
Ischaemic leg	E14	CTA/MRA	Specialised Investigation	[C]	CTA and MRA are increasing used for diagnosis
Ischaemic upper limb	E15	Angiography	Specialised Investigation	[B]	Local policy needs to be determined in agreement with vascular surgeons, especially with regard to therapeutic interventions.

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