Phys · cardiovascular
Cardiac Investigations
Also known as echocardiography · transthoracic echo · transoesophageal echo · stress testing · exercise ECG · exercise tolerance test · myocardial perfusion imaging · CT coronary angiography · coronary angiography · cardiac MRI · cardiac CT · calcium score · electrophysiology study · high-sensitivity troponin · NT-proBNP
Consultant-physician-depth guide to cardiac investigations — echocardiography, stress testing, CT coronary angiography, coronary angiography, cardiac MRI, electrophysiology, implantable devices, and biomarkers — structured for FRACP DWE and DCE preparation.
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Target exams
Red flags
- Positive stress test in a high-risk patient with typical angina — proceed to invasive coronary angiography
- ST-elevation on ECG with ongoing chest pain — this is STEMI; do NOT wait for biomarkers, go straight to primary PCI
- Echocardiographic features of tamponade (RV diastolic collapse, IVC plethora) — emergency pericardiocentesis
- Cardiac MRI showing subendocardial LGE in a coronary territory — this is established infarction, not viable myocardium
- High-sensitivity troponin rising with chest pain — this is acute myocardial injury; differentiate type 1 MI from type 2
Cardiac Investigations
Meet the patient
A 58-year-old woman presents to the clinic with three months of exertional central chest tightness, relieved by rest, on a background of hypertension. Her ECG shows left bundle branch block. The registrar reaches for an exercise tolerance test — the wrong test for the wrong patient, because LBBB makes the exercise ECG uninterpretable.[1]
The question her stem plants is the question every investigations viva turns on: what is the right test for this patient, and what will the result let me do next? Hold that, and the three decisions below slot into place.[1]
References7ShowHide
- [1]Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes Eur Heart J, 2020.PMID 31504439
- [2]Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease N Engl J Med, 2015.PMID 25773919
- [3]Newby DE, Adamson PD, Berry C, et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction N Engl J Med, 2018.PMID 30145934
- [4]SCOT-HEART Investigators CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial Lancet, 2015.PMID 25788230
- [5]Ferreira VM, Schulz-Menger J, Holmvang G, et al. Cardiovascular Magnetic Resonance in Nonischemic Myocardial Inflammation: Expert Recommendations J Am Coll Cardiol, 2018.PMID 30545455
- [6]McDonagh TA, Metra M, Adamo M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure Eur Heart J, 2021.PMID 34447992
- [7]Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease N Engl J Med, 2020.PMID 32227755