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HEART SPEACIALISTS IN BANGALORE Stress echocardiography Ischaemic areas of myocardium are known to have reduced contraction compared with normal areas. This can be demonstrated by high-quality echocardiograms. A number of standard views of the heart are obtained and the wall is divided into regions that are assessed for reduced motion. The echo equipment must be designed to store rest images and to present them next to stress images on a split screen so that direct comparison can be made. The stress can be provided by exercise or dobutamine infusion. Exercise echocardiography is difficult to perform because of movement problems and there is quite high inter-reporter variability, but both techniques can approach the accuracy of sestamibi testing in experienced hands. It is not possible to obtain images of adequate quality in all patients.
CARDIOLOGISTS IN HEBBALA Risk stratification using myocardial perfusion scans A normal perfusion scan is associated with a good prognosis. The annual rate of myocardial infarction of cardiac death is < 1%, at least for some years. Stress echocardiography Ischaemic areas of myocardium are known to have reduced contraction compared with normal areas. This can be demonstrated by high-quality echocardiograms. A number of standard views of the heart are obtained and the wall is divided into regions that are assessed for reduced motion. The echo equipment must be designed to store rest images and to present them next to stress images on a split screen so that direct comparison can be made. The stress can be provided by exercise or dobutamine infusion. Exercise echocardiography is difficult to perform because of movement problems and there is quite high inter-reporter variability, but both techniques can approach the accuracy of sestamibi testing in experienced hands. It is not possible to obtain images of adequate quality in all patients. Coronary angiography (cardiac catheterisation) This procedure enables the cardiologist to visualise the coronary arteries It is the standard against which other less-invasive investigations are assessed. Selective catheterisation of the right and left coronary ostia is performed. Contrast is then injected into the vessels and digital tape or disc storage of the images obtained. In most hospitals the patient is admitted on the morning of the test and allowed to go home that afternoon. The procedure is most often performed through the femoral artery (Judkins technique) . This artery can be punctured through the skin under local anaesthetic. A fine softtipped guide wire is then advanced into the artery and the needle withdrawn (Seldinger method). A short guiding sheath can then be placed over the wire and long cardiac catheters advanced through this sheath along a long guide wire into the femoral artery and up via the aorta to the aortic arch. The catheter and wire are advanced under X-ray control. Usually one catheter with a curved tip (pig-tail catheter;is advanced across the aortic valve into the left ventricle where left ventricular pressures are measured via a pressure transducer connected to the other end of the catheter. Measurement of the left ventricular end-diastolic pressure gives an indication of left ventricular function. Raised end-diastolic pressure (over 15 mmHg) suggests left ventricular dysfunction . The catheter is then connected to a pressure injector. This enables injection of a large volume of contrast over a few seconds; for example, 35 mL at 15 mL/second. X-ray recording during injection produces a left ventriculogram Here left ventricular contraction can be assessed and the ejection fraction (percentage of end-diastolic volume ejected with each systole) estimated. The normal is 60% or more. The figure obtained by this method tends to be higher than that produced by the nuclear imaging method—gated blood pool scanning. The guide wire is reintroduced and the catheter withdrawn to be replaced by one shaped to
Echocardiologist in Kattigenahalli, Bangalore • Stress echocardiography Ischaemic areas of myocardium are known to have reduced contraction compared with normal areas. This can be demonstrated by high-quality echocardiograms. A number of standard views of the heart are obtained and the wall is divided into regions that are assessed for reduced motion. The echo equipment must be designed to store rest images and to present them next to stress images on a split screen so that direct comparison can be made. The stress can be provided by exercise or dobutamine infusion. Exercise echocardiography is difficult to perform because of movement problems and there is quite high inter-reporter variability, but both techniques can approach the accuracy of sestamibi testing in experienced hands. It is not possible to obtain images of adequate quality in all patients.
Echocardiologist in Kattigenahalli, Bangalore • Stress echocardiography Ischaemic areas of myocardium are known to have reduced contraction compared with normal areas. This can be demonstrated by high-quality echocardiograms. A number of standard views of the heart are obtained and the wall is divided into regions that are assessed for reduced motion. The echo equipment must be designed to store rest images and to present them next to stress images on a split screen so that direct comparison can be made. The stress can be provided by exercise or dobutamine infusion. Exercise echocardiography is difficult to perform because of movement problems and there is quite high inter-reporter variability, but both techniques can approach the accuracy of sestamibi testing in experienced hands. It is not possible to obtain images of adequate quality in all patients.
CARDIOLOGY DOCTORS IN HOSUR ROAD Pulmonary embolism This is not quite a cardiac condition and not quite a respiratory condition but it is often managed by cardiologists. Modern CT pulmonary angiography is very sensitive and specific for the diagnosis of PE. A negative scan that is of good quality effectively excludes the diagnosis. The scans are so sensitive that small distal emboli may be detected in patients who do not have convincing symptoms of embolism. This poses a therapeutic problem that may be avoided if scans are not ordered inappropriately. Some patients cannot have a CTPA, usually because of renal impairment that would make the injection of contrast risky. A V/Q nuclear scan is then a reasonable alternative to a CTPA. These scans are less accurate than CT pulmonary angiography but the clinical suspicion of PE and a lung scan reported as intermediate or high probability is an indication for treatment. Patients should be admitted to hospital and treatment begun with intravenous heparin or subcutaneous low molecular weight heparin. The latter has the advantage that the dose is determined by body weight and repeated measurements of clotting times are not required. In some cases it may be possible to treat patients with small pulmonary emboli at home with supervised low molecular weight heparin. Either way, soon after diagnosis patients should be started on oral anticoagulation treatment with warfarin. A stable INR may often be achieved within five days or so, the heparin ceased and the patient discharged. Most patients with dyspnoea as a result of PE begin to feel better within a few days of starting treatment. It is often difficult to know how long to continue treatment with warfarin. The usual recommendation for an uncomplicated first PE is three to six months. Recurrent PE may be an indication for lifelong treatment. It also suggests a need to investigate for clotting abnormalities (e.g. anti-thrombin III deficiency, protein S and protein C deficiency, abnormal Factor V and anti-nuclear antibody). A very large and life-threatening PE which is associated with the sudden onset of severe dyspnoea and hypotension may be an indication for thrombolytic treatment. An echocardiogram may show abnormal right ventricular function in these ill patients and help in the decision. Experience with this is limited and the optimum regimen is not really known. Tissue plasminogen activator (TPA) is now indicated for this purpose and current recommendations are for a 10 mg bolus over two minutes followed by 90 mg over two hours.
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