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Overview of Cardiovascular Tests and Procedures. Cardiac catheterization is the passage of a catheter through peripheral arteries or veins into cardiac chambers, the pulmonary artery, and coronary arteries and veins. Procedure, specific tests during cardiac catheterization, contraindications to cardiac catheterization and complications of cardiac catheterization are discussed.

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Cardiac imaging tests can delineate cardiac structure and function. Standard imaging tests include: echocardiography, chest x-ray, computed tomography, magnetic resonance imaging, various radionuclide techniques. Standard CT and MRI have limited application because the heart constantly beats, but faster CT and magnetic resonance techniques can provide useful cardiac images if the rhythm is regular and the heart rate is controlled; sometimes patients are given a drug (eg, a beta-blocker) to slow the heart rate during imaging.

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Coronary artery bypass grafting (CABG) involves bypassing native coronary arteries that have high-grade stenosis or occlusion not amenable to angioplasty with stent insertion. Indications are changing as percutaneous interventions are being increasingly used.

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Echocardiography uses ultrasound waves to produce an image of the heart, the heart valves, and the great vessels. It helps assess heart wall thickness (eg, in hypertrophy or atrophy) and motion and provides information about ischemia and infarction. It can be used to assess systolic function as well as diastolic filling patterns of the left ventricle, which can help in the assessment of left ventricular hypertrophy, hypertrophic or restrictive cardiomyopathy, severe heart failure, and constrictive pericarditis. It also is used to assess the structure and function of the heart valves; detect valvular vegetations and intracardiac thrombus; and provide an estimate of pulmonary arterial pressure and central venous pressure.

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The standard electrocardiography (ECG) provides 12 different vector views of the heart’s electrical activity as reflected by electrical potential differences between positive and negative electrodes placed on the limbs and chest wall. Six of these views are vertical (using frontal leads I, II, and III and limb leads aVR, aVL, and aVF), and 6 are horizontal (using precordial leads V1, V2, V3, V4, V5, and V6). The 12-lead ECG is crucial for establishing many cardiac diagnoses (see table Interpretation of Abnormal ECGs), including: Arrhythmias, Myocardial ischemia, Atrial enlargement,  Ventricular hypertrophy and Conditions that predispose to syncope or sudden death (eg, Wolff-Parkinson-White syndrome, long QT syndrome, Brugada syndrome).

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In electrophysiologic studies (EPS), recording and stimulating electrodes are inserted into all 4 cardiac chambers via right- or left-sided cardiac catheterization. Atria are paced from the right or left atrium, ventricles are paced from the right ventricular apex or right ventricular outflow tract, and cardiac conduction is recorded. Various mapping techniques are available. Programmed stimulation techniques may be used to trigger and terminate a reentrant arrhythmia. Tilt table testing is used to evaluate syncope in Younger, apparently healthy patients and Elderly patients when cardiac and other tests have not provided a diagnosis. Tilt table testing produces maximal venous pooling, which can trigger vasovagal (neurocardiogenic) syncope and reproduce the symptoms and signs that accompany it (nausea, light-headedness, pallor, hypotension, bradycardia).

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00:00 | Percutaneous Coronary Interventions 

13:46 | Radionuclide Imaging

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In stress testing, the heart is monitored by electrocardiography and often imaging studies during an induced episode of increased cardiac demand so that ischemic areas potentially at risk of infarction can be identified. Heart rate is increased to 85% of age-predicted maximum (target heart rate) or until symptoms develop, whichever occurs first.

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The need for treatment of arrhythmias depends on the symptoms and the seriousness of the arrhythmia. Treatment is directed at causes. If necessary, direct antiarrhythmic therapy, including antiarrhythmic drugs, cardioversion-defibrillation, implantable cardioverter-defibrillators (ICDs), pacemakers (and a special form of pacing, cardiac resynchronization therapy), catheter ablation, surgery, or a combination, is used. Most antiarrhythmic drugs are grouped into 4 main classes (Vaughan Williams classification) based on their dominant cellular electrophysiologic effect - Vaughan Williams Classification.

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A transthoracic direct-current (DC) shock of sufficient magnitude depolarizes the entire myocardium, rendering the entire heart momentarily refractory to repeat depolarization. Thereafter, the most rapid intrinsic pacemaker, usually the sinoatrial node, reassumes control of heart rhythm. Thus, DC cardioversion-defibrillation very effectively terminates tachyarrhythmias that result from reentry. However, it is less effective for terminating tachyarrhythmias that result from automaticity because the return rhythm is likely to be the automatic tachyarrhythmia. For tachyarrhythmias other than ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT), the DC shock must be synchronized to the QRS complex (called DC cardioversion) because a shock that falls during the vulnerable period (near the peak of the T wave) can induce VF. In VF, synchronization of a shock to the QRS complex is neither necessary nor possible. A DC shock applied without synchronization to a QRS complex is DC defibrillation.

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