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Chapter02:DiagnosticTestinginCardiology
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Previous:EpidemiologyandRiskFactors

DiagnosticTestinginCardiology

ClinicalHistoryandPhysicalExamination
Theinitialstepinevaluatingforheartdiseaseisathoroughhistoryandphysicalexamination.
Specifically,acarefulexplorationofchangesinfunctionalstatus,associatedsymptoms,andthe
timingandnatureofsymptomswillhelpfocustheassessmentandguideselectionofappropriate
testing,ifindicated.
Cardiovasculartestingprovidesbothdiagnosticandprognosticinformationanditsuseshouldbe
guidedbysymptoms,thelevelofriskforheartdisease,andwhetheroutcomesmaybealteredby
interventionsbasedontestingresults.

DiagnosticTestingforAtheroscleroticCoronaryDisease
CardiacStressTesting
RelatedQuestions
Question19
Question38
Question39
Question57
Question65
Question86
Question91
Patientsarereferredforstresstestingtoestablishthediagnosisofcoronaryarterydisease(CAD)most
oftenbecauseofnewonsetoforachangeinsymptoms.Theutilityofstresstestingshouldbe
interpretedinthecontextofthepretestlikelihoodofdisease.Thosewithlowprobabilityofdisease,
suchasyoungerpatients,haveahigherincidenceoffalsepositivetestsandmayundergounnecessary
testingwithoutchangingpatientoutcomes.Thosewithahighprobabilityofdiseaseshouldproceed
directlytoaninvasivediagnosticstrategy,suchascardiaccatheterization,becausetheriskofafalse
negativeresultandmisseddiagnosisistoohigh.Furthermore,anegativetestinahighriskpatient
wouldnotsignificantlychangetheposttestprobabilityofCAD,andthereforewouldnotchange
management.Stresstestingismostclinicallyappropriateinpatientswithanintermediateriskof
CAD.Itisthesepatientswho,bytheresultoftheirstresstest,canbereclassifiedintohigherorlower
riskcategories.Stresstestingalsohasimportantprognosticvalueforpredictingtheriskofmyocardial
infarctionanddeathinselectedpatients.Forexample,inpatientswithaprevioushistoryofCADand
worseningcardiacsymptoms,stresstestingishelpfultoassessforpossiblerecurrentorprogressive
disease.However,althoughtheleadingcauseofdeathinpatientswithdiabetesmellitusis

cardiovasculardisease,routinestresstestinginasymptomaticpatientswithdiabeteshasnotbeen
showntoreducemortality.
Themodalitiesabletodetectcardiacischemiaarehighlydependentonthedegreeofimpairmentof
coronarybloodflow.Theearliestchangeswithmildstenosisareperfusionchangesdetectableonly
withhighlysensitivemodalities,suchasnuclearorcardiacmagneticresonance(CMR)imaging.With
progressivecoronaryocclusion,diastolicdysfunctionfollowedbysystolicdysfunctionmaybeseen
byimagingstudiessuchasechocardiography.Onlywhenthereissignificantcoronarystenosiswill
electrocardiographic(ECG)changesbeseenandsymptomsoccur.
ThemanydifferenttypesofteststodiagnoseCADcanbebroadlycategorizedasassessingeither
functionaloranatomicevidenceofischemia.FunctionalstudiesevaluateforobstructiveCADfrom
evidenceofECGchanges,myocardialperfusionabnormalities,orwallmotionabnormalities,usually
understressconditions.Anatomicstudiesassesspercentagestenosisofthecoronaryvesselsatrest,
whichcanbevisualizedbysinglephotonemissionCT(SPECT),PET/CTscan,orCMRimaging
study.Theseimagingmodalitiesmayalsobeusedtoquantifyinfarctionsizeandassessmyocardial
viability.Morespecificsignsofischemiasuchasreducedregionalcontractilitycanbeassessedby
echocardiographyorMRI.
TestingmodalitiesforsuspectedCADaresummarizedinTable3.Inintermediateriskpatientswho
areabletoexerciseandhaveanormalbaselineECG,theinitialtypeofstresstestingshouldbe
exercisestresstesting.Theadditionalprognosticinformationavailablewithexercise,including
functionalcapacityandheartrateandbloodpressureresponse,canbeutilizedinpredictionmodels
suchastheDuketreadmillscore,whichfactorsdevelopmentofsymptoms,degreeofSTsegment
depression,andexercisedurationtoprovideincrementalprognosticinformationfor5yearmortality
risk.Heartraterecoveryisanotherpowerfulpredictorpatientswithaheartratedropoflessthan
12/mininthefirstminuteaftercessationofexercisehaveahighermortalityrate.
Ischemiaisidentifiedonthebasisofthedevelopmentof1mmorgreaterofhorizontalor
downslopingSTdepressionwithexercise(Figure1),butthecoronaryterritoryinvolvedcannotbe
localizedbasedontheECGchangesalone.Ideally,patientsshouldexercisefor6to12minutesto
provideadequatetimefordevelopmentofmaximalmetabolicdemand.Althoughachieving85%of
theagepredictedmaximalheartrate(PMHR)isconsideredadequatefordiagnosisofischemia,as
heartrateandbloodpressurearethemajordeterminantsofmyocardialoxygendemand,patients
shouldcontinuetoexerciseuntillimitedbysymptoms.Achievingaratepressureproduct(heartrate
systolicbloodpressure)ofatleast25,000isalsoconsideredanadequateworkload,asthismeasure
reflectsleftventricularmyocardialperformance.AstandardBruceprotocolincreasesthespeedand
gradeofthetreadmillevery3minutes,andpatientswhohavepoorfunctionalcapacityandcannot
achieveatleastthefirststageoftheBruceprotocol(5metabolicequivalents[METs])have
significantlyhigherallcausemortality.Stresstestsshouldbeterminatedwhenthepatienthasexerted
maximaleffortandachievedatleast85%PMHR,thepatientrequeststostoporexperiences
significantanginalorotherphysicalsymptoms,orwhenotheradversemarkersdevelop,suchas
exertionalhypotension,significanthypertension,STsegmentelevationorsignificantSTsegment
depression,orventricularorsupraventriculararrhythmias.
Thedecisionaboutwhethertokeepapatientoncardiacmedicationsduringstresstestingshouldbe
individualizedbasedontheclinicalquestionbeingaddressed.Ifthestresstestisbeingperformedto
establishthediagnosisofCAD,medicationssuchasblockersandnitratesshouldbewithheldforat
least24hoursbeforethetest.Ifthestresstestisbeingperformedtoevaluatesymptomsortodefine
prognosisinapatientwithknowndisease,thepatientshouldremainoncurrenttherapytodetermine
ifischemiaispresentonthecurrentregimen.
Thereareseveralindicationsforstresstestingwithadditionalimagingwitheitherechocardiography,
CMRimaging,orperfusionimagingwithSPECTorPET/CT.Theseincludeinabilitytoexercise,
baselineECGabnormalities,andconditionsinwhichexerciseiscontraindicated.Patientswith

abnormalbaselineECGsthatinterferewiththeinterpretationoftheexerciseECG(forexample,left
bundlebranchblock[LBBB],leftventricularhypertrophywithSTsegmentabnormalities,orapaced
rhythm)shouldundergostressimagingtoidentifyobstructiveCAD.Inaddition,stresstestingwith
imagingmaybehelpfultoelucidateadiagnosisinpatientswithindeterminateresultsontreadmill
testing.Patientswithrightbundlebranchblock(RBBB),bifascicularblock,orwhoareondigoxin
canundergoexercisestresstesting,butSTsegmentsmaybemoredifficulttointerpretormay
producefalsepositiveresults.Patientswithsevereaorticstenosis,abdominalaorticaneurysm,severe
hypertension,oruncontrolledarrhythmiasshouldnotexerciserather,thesepatientsshouldundergo
pharmacologicstresstestingwithvasodilators.Patientswhoareunabletoexerciseshouldundergo
pharmacologicstresstestingwithimaging.Inaddition,inpatientswithLBBBundergoingnuclear
stresstesting,apharmacologicstressorshouldbeusedevenifthepatientisabletoexercisebecause
ofthepotentialforafalsepositivetestowingtoaseptalperfusionabnormalitythatmayoccurwith
exercise.Thechoiceofimagingmodalityshouldbebasedonlocalexpertiseandpatient
characteristics.
Instresstestingwithadjunctiveimaging,baselineimagesareobtainedandcomparedwithimages
obtainedaftereitherexerciseorpharmacologicstress(Table4).Exerciseinvokesischemiaasthe
epicardialvesselsbecomeunabletomaintainadequateflowrelatedtomyocardialoxygendemandvia
autoregulation,andischemiadevelopsdistaltotheobstruction.Dobutamine,likeexercise,increases
myocardialoxygendemandandelicitsischemiabecauseofinsufficientperfusiontotheaffected
myocardium.Vasodilators,suchasregadenosonoradenosine,producehyperemiaandaflow
disparitybetweenmyocardiumsuppliedbythestenoticvessel(inwhichthedistalvasculatureis
alreadymaximallydilated)ascomparedwiththemyocardiumsuppliedbyunobstructedvessels.In
additiontoidentifyingthepresenceofdisease,perfusionimagingcandefinethelocationandextentof
reducedperfusionandprovideadditionalprognosticinformationcomparedwithECGstresstesting
alone.Theseimagingmodalitiesmayalsobeusedtoquantifyinfarctionandassessmyocardial
viability.Theadditionalinformationandimpactonpatientcareobtainedwithimagingmustbe
balancedwiththeadditionalcosts,time,andexposuretoradiationorcontrastagentsincurred.
Exercisestressechocardiographyisperformedwitheithersupineergometryortreadmilltesting.
Supineergometryallowsforcontinuousimagingduringexercise,whereaswithtreadmilltesting,
imagesneedtobeobtainedimmediatelyafterexercise,andanydelaycanreducetheaccuracyofthe
informationobtained.Newregionalwallmotionabnormalitiesseenontheechocardiogramfollowing
exerciseindicateareasofischemia(seeTable4).Wallmotionabnormalitiesatrestthatdonotchange
withexerciseusuallyindicateinfarction.Improvementinregionalwallmotionwithlowdoseexercise
ordobutaminethatworsensathigherlevelssuggestsviablebuthibernatingmyocardium.Aswith
perfusionimaging,theextentofwallmotionabnormalitiesprovidesprognosticinformationregarding
riskoffuturecardiovascularevents.
Thesensitivityofstressechocardiographyisreducedwithsinglevesseldiseaseandisdependenton
timelyimaging.Inaddition,interpretationcanbemoresubjectivethanwithothermodalities,
particularlywithbaselinewallmotionabnormalitiesorsystolicdysfunction.Amajoradvantageof
stressechocardiographyistheabilitytoobtainadditionalinformation,suchaschangesinpulmonary
pressuresorchangesinvalvularfunctionwithexercise.Atminimum,stressechocardiographyallows
assessmentofwallmotionatrestandatpeakorimmediatelyfollowingimagingtoassessfor
obstructiveCAD.Iftheexaminationisperformedtoassessdyspneaonexertionorvalvularfunction
withexercise,theseshouldbespecificallyrequestedinordertobesurethatadequate
echocardiographicinformationisobtained.Routinetransthoracicechocardiography(TTE)evaluates
leftandrightventricularsize,thickness,andfunctionvalvularmorphologyandfunctiondiastolic
functionandthepericardium.Thesearenotnecessarilyroutinelyperformedinastress
echocardiogramsoifthisinformationisclinicallyimportant,itmaybenecessarytoobtainbotha
TTEandastressechocardiogram.Dobutaminestressechocardiographyisusedforpatientswho
cannotexerciseandcanbeparticularlyusefulforevaluationofmyocardialviability(Table5)andto
evaluateaorticstenosisinpatientswithalowejectionfraction.

SPECTimagingtakesadvantageoftherelativedifferencesinbloodflowwithstress.Radioactive
tracerisinjectedandtakenupbythemyocardiumwithbloodflow.Imagesareobtainedatrest.Then,
withexerciseorvasodilatorstress,asecondinjectionisgiven.Tracerisagaindistributedwithblood
flowand,therefore,lesstraceristakenupintheleftventricularregionsuppliedbyastenoticvessel.
Thisrelativedifferenceinflowbetweenstressandresttomographicimagesisseenasaperfusion
defectandisindicativeofCAD(Figure2).Mostcommonly,technetiumbasedradiotracersareused.
Thesehaveahigherenergyandprovidegoodimagequality.Thisisparticularlyusefulwhenthereis
potentialforsofttissueattenuationthatcaninterferewithinterpretation,suchaswithbreast
attenuationinwomen.Thalliumisapotassiumanalogueandcanonlybetakenupbyactivemyocytes.
Liketechnetium,thalliumcanbeusedformyocardialperfusionimaging,butbecauseitrequires
activemetabolism,thalliumalsocanbeusedtoassessviability.Myocytesthatoninitialstresstesting
appeartobeinfarctedmayslowlytakeupthalliumtracer,identifyingthemasviable.Thebenefitsof
thalliumarebalancedagainsthigherradiationexposurebecauseofitslonghalflife.
Myocardialperfusionimagingcanquantifytheextentandseverityofdiseaseandhelpdirect
treatmentstrategies.Highriskfeaturesthatmaybeseenonmyocardialperfusionimaginginclude
lackofaugmentationofpoststressejectionfraction,cavitydilatation,andnewwallmotion
abnormalities.Unlikestressechocardiography,imagesarenotobtainedimmediatelypoststressand
areoftendelayed.Ifthereisevidenceofanewwallmotionabnormalityinthesedelayedimages,it
signifiesahighdegreeofstenosis.
LikeSPECTimaging,cardiacPETcanbeusedtodetectischemia.PETimagingprovidesimproved
diagnosticaccuracycomparedwithSPECTandcanbeparticularlyusefulinpatientswith
nondiagnosticimagingstresstests,obesepatients,andpatientswithdiabetesmellitus.CardiacPET
alsoallowsforassessmentofpeakstressejectionfraction,quantitationofmyocardialbloodflow,and
evaluationofmyocardialmetabolism.BecausesomePETradiotracersidentifymetabolicallyactive
myocytes,itisanexcellenttooltoevaluateforviability.BecausecardiacPETusesCTforattenuation
correction,limitedanatomicinformationaboutcoronarycalcificationisalsoobtained.Becauseofthe
shorthalflifeofPETradiotracers,allstudiesmustbeperformedwithvasodilators.Theutilityof
PET/CTscanningislimitedbyitsavailability.
CMRimagingcanbeusedforevaluationofmyocardialandpericardialdiseaseprocessesandcanbe
particularlyusefulforevaluationofinfiltrativeandinflammatorydiseases.Itcanbeutilizedtodetect
theextentandseverityofmyocardialinfarctionandviability.BecauseCMRimagingcanbegated,
measuresofrightandleftventricularfunctioncanbeobtained.Althoughnotwidelyperformed,stress
testingwithdobutaminetoassesswallmotionandvasodilatorssuchasadenosinetoassessperfusion
canbeusedwithCMRimagingtodetectischemia.LimitationsoftheuseofCMRimaginginclude
thelengthoftimeneededtoacquireimagesandmagneticinterferencewithcardiacimplanted
electronicdevices.

KeyPoints
Stresstestingismostefficaciousinpatientswithanintermediatepretestprobabilityofcoronary
arterydisease,becauseitisthesepatientswho,bytheresultoftheirstresstest,canbe
reclassifiedintohigherorlowerriskcategories.
Inpatientswhoareabletoexerciseandhaveanormalbaselineelectrocardiogram,theinitial
typeofstresstestingshouldbeexercisestresstesting.
Patientswithabnormalbaselineelectrocardiograms(ECGs)thatinterferewiththeinterpretation
oftheexerciseECG(forexample,leftbundlebranchblock,leftventricularhypertrophywith
STsegmentabnormalities,orapacedrhythm)shouldundergostressimagingtoidentify
obstructivecoronaryarterydisease.

VisualizationoftheCoronaryAnatomy

CoronaryangiographyandcoronaryCTangiography(CTA)provideanatomicinformationregarding
thecoronaryvessels(Figure3).Bothproceduresrequireiodinatedcontrastandexposethepatientto
radiation.Coronaryangiographyprovidesatwodimensionalimageofthelumenofthevesselfilled
withcontrast.Assessmentofthestenoticlesionsismadefrommultipleviewsofthevessel.Coronary
CTAcanprovideadditionalinformationaboutsomeofthecharacteristicsoftheplaque.If,however,
culpritlesionsarevisualizedoncoronaryCTA,thepatienttypicallyrequirescoronaryangiography
forbetterdefinitionofthedegreeofcoronarystenosis.Coronaryangiographyisalsorequiredif
coronaryrevascularizationistobeperformed.Ifpercutaneouscoronaryinterventionisindicated,it
maybeperformedatthetimeofapatient'sdiagnosticcatheterization.Coronaryangiographymaybe
usefulasadiagnostictestinpatientswho,despitemaximalmedicaltherapy,haveintolerableischemic
symptomsaslongastheyarecandidatesforcoronaryrevascularization.CoronaryCTAmaybeused
toruleoutCADinsymptomaticpatientswithanintermediateriskofcoronarydisease.Other
limitationsofcoronaryCTAincludepoorvisualizationofdistalvesselsandartifactfromcalcification
thatmaylimitinterpretation.
Suspectedcoronaryanomalies,suchasanomalouscoronaryorigins,canbeevaluatedbycoronary
CTA,CMRimaging,orcoronaryangiography.Theseimagingmodalitiescanhelpidentifythose
abnormalitiesthatareassociatedwithahigherriskofsuddencardiacdeath.

CoronaryArteryCalciumScoring
Coronaryarterycalcium(CAC)scoringprovidesinformationregardingtheburdenofatherosclerotic
diseasebutdoesnotprovideinformationregardingthedegreeofobstructionitmaybecausing.CAC
scoringcanbeperformedwitheitherelectronbeamormultidetectorCT,andnewertechnologic
advanceslimitradiationexposuretothepatient.Itdetectsthepresenceofcalcificationinthewallsof
thecoronaryarteries,whichisdirectlyproportionaltothedegreeofplaqueburdenpresent.CAC
scoresarecategorizedasfollows:0,nodisease199,milddisease100399,moderatediseaseand
above400,severedisease.Coronarycalciumscoresgreaterthan400areassociatedwithahigher
incidenceofabnormalperfusiononSPECTimaging.Becauseofitscostandassociatedradiation
exposure,measurementofcoronaryarterycalciumshouldbelimitedtoaselectgroupof
asymptomaticpatientswithanintermediateFraminghamriskscore(10%20%)inwhomresultswill
influencetreatmentstrategy.CACscoringmaybeusefulparticularlyiftheresultswillinfluence
treatmentstrategy,suchasinitiationoflipidloweringtherapy.

KeyPoint
Measurementofcoronaryarterycalciumshouldbelimitedtoaselectgroupofasymptomatic
patientswithanintermediateFraminghamriskscore(10%20%)inwhomresultswillinfluence
treatmentstrategybecauseofitsassociatedcostandradiationexposure.

RisksofCoronaryDiagnosticTesting
Inadditiontothephysicalandsocietalcostsofdownstreamtestingthatresultfrominappropriate
testing,eachofthemodalitiesusedfordiagnosisandriskstratificationcarryspecificrisks.Itis
importanttodeterminethepretestprobabilityofdiseaseandtofocusadditionaltestingappropriately.
Forexample,orderinganexercisestresstestinapatientwithalowpretestprobabilityofdiseasemay
resultinafalsepositivestresstestandadditionaldownstreamtesting.ObtainingaCACscoreina
lowriskpatientmayleadtoadditionaltestsorproceduresforanincidentalfindingonCT.
Exercisetestingisassociatedwithasmallriskofmyocardialinfarctionordeath(1/2500tests).
Exercisestresstestingiscontraindicatedinpatientswithunstablecardiacconditions,suchas
uncontrolledcardiacarrhythmias,severesymptomaticaorticstenosis,uncontrolledheartfailure,and
unstableangina.Pharmacologicstressagents,includingdipyridamole,adenosine,andregadenoson,

areassociatedwithdevelopmentofhighdegreeatrioventricularblockandbronchospasm.
Nuclearstresstesting,CACscoring,coronaryCTA,andcoronaryangiographyexposethepatientto
radiation.Theamountofexposureisdependentonfactorssuchastheradiotracerused,equipment,
operatortechnique,complexityofprocedureperformed,andpatientcharacteristics(suchasbody
size).
VariouscontrastagentsareusedforCMRimaging(gadolinium),echocardiography(microbubble
contrastagentsusedforenhancementofendocardialborders),coronaryCTA,andcoronary
angiography(nonioniccontrast).Nonioniccontrastmaybeassociatedwithhypersensitivityreactions
andacutekidneyinjurywhereasgadoliniumisassociatedwiththedevelopmentofnephrogenic
fibrosingdermatopathyinpatientswithchronickidneydisease.
Cardiaccatheterizationcanresultincomplicationsfromvascularaccess,injurytothecoronary
arteries,dissectionoftheaorta,ordisruptionofplaqueresultinginperipheralemboliandpossible
stroke.Vascularaccesscomplicationsincluderetroperitonealhematomafrombleedingatthegroin
accesssiteaswellaspseudoaneurysmatthearterialpuncturesite.Bothofthesecomplicationsrequire
promptrecognitionandtreatment.

DiagnosticTestingforStructuralHeartDisease
RelatedQuestions
Question74
Question107
Diagnostictestingforstructuralheartdiseaseshouldbebasedonathoroughhistoryandphysical
examination.Newmurmursorachangeinexaminationfindingsorsymptomsinapatientwithknown
structuralheartdiseaseshouldpromptfurtherevaluation.Routineyearlyimagingevaluationof
structuralheartdiseaseinasymptomaticpatientsisusuallynotindicated.Benignmurmurs,suchas
grade1/6or2/6midsystolicmurmurs,arecommonwithpregnancy,anemia,andotherhighflow
states,anddonotroutinelyneedechocardiographicevaluation.
ImagingmodalitiesusedtoevaluatestructuralheartdiseasearelistedinTable6.Evaluationof
structuralheartdiseasetypicallybeginswithaTTE.TTEprovidesinformationaboutleftandright
ventricularcavitysize,thickness,andfunction,aswellasquantitativeinformationregardingvalvular
function,diastolicfunction,andfillingpressures.TTEcanbeusedwithintravenousagitatedsaline
contrast,normallyclearedbythepulmonarycirculation,todocumentthepresenceofanintracardiac
shuntorapatentforamenovale.Atrialseptaldefectissuggestedbyshuntingofmicrobubblesfrom
therightatriumtotheleftatrium.TTEisanoninvasiveprocedureandisthepreferredimaging
modalityforevaluatinganteriorstructuresoftheheart,suchastheaorticvalve.
Transesophagealechocardiography(TEE)takesadvantageoftheproximityofthehearttothe
esophagusforbetterimagequality.Theprocedurerequiressedationandiscontraindicatedinpatients
withesophagealstricturesoractiveesophagealvaricesorbleeding.Complicationsincludeesophageal
injuryandbleeding.TEEiscommonlyusedtoevaluateforendocarditisinpatientswithahighpretest
probabilitytoassessfordiagnosticfindingsorcomplicationsofendocarditis(suchasabscess)to
bettervisualizevalvularpathology,particularlywhenplanningrepairtoevaluatespecificstructures
thatcannotbewellvisualizedonTTE(suchasprostheticheartvalves)toevaluateacuteaortic
pathologiesandtoruleoutleftatrialthrombuspriortocardioversion(Figure4).

KeyPoints

Routineyearlyimagingevaluationofstructuralheartdiseaseinasymptomaticpatientsis
usuallynotindicatedbenignmurmurs,suchasgrade1/6or2/6midsystolicmurmurs,are
commonwithpregnancy,anemia,andotherhighflowstatesanddonotroutinelyneed
echocardiographicevaluation.
Evaluationofstructuralheartdiseasetypicallybeginswithtransthoracicechocardiography,
whichprovidesinformationaboutventricularcavitysize,thickness,andfunction,aswellas
quantitativeinformationregardingvalvularfunction,diastolicfunction,andfillingpressures.

DiagnosticTestingforCardiacArrhythmias
RelatedQuestions
Question50
Question98
Inadditiontoacarefulhistoryandphysicalexamination,theevaluationofapatientwithahistoryof
palpitations,presyncope,orsyncopeinwhichanarrhythmiaissuspectedbeginswitha12leadresting
ECG.Evidenceofpreexcitation,ectopicrhythms,atrioventricularblock,orintraventricular
conductiondelaymaygiveinsightintotheetiologyofthesymptoms.Inpatientsinwhomthe
presenceofstructuralheartdiseaseissuspected,echocardiographymayalsobeindicated.Becauseof
theintermittentnatureofarrhythmias,theirdiagnosisanddocumentationcanbechallenging.
Monitoringanddiagnosticstrategiesarebasedonthefrequencyofthepatient'sepisodes(Table7).
Patientswithdailysymptomscanbeevaluatedwitha24or48hourambulatoryECGmonitor
(Holtermonitor),whereaspatientswithlessfrequentepisodesrequireothermonitoringstrategies.For
infrequentsymptomaticevents,anexternalpatienttriggeredeventrecordercancapturethe
arrhythmia,providedtheeventlastslongenoughforthepatienttorecordit.Aloopingeventrecorder
capturesseveralsecondsoftheECGsignalpriortothedevicebeingtriggeredandisusefulwhen
episodesareaccompaniedbysyncopeorpresyncope.Forveryinfrequentevents,animplantedloop
recordermaybewarranted.
Exercisetestingisalsofrequentlyemployedinpatientswithasuspectedorknownarrhythmia.
Treadmillexercisetestingisanimportanttoolforevaluatingchronotropicresponse,ischemia,and
exerciseinducedoradrenergicallyinducedarrhythmia.
Onceapatientisdiagnosedwithanarrhythmiaorarrhythmiapronecardiovascularcondition,
diagnosticelectrophysiologytestingcanbehelpfulforbothriskstratificationandtreatment(suchas
catheterablation).Selectionofthesediagnostictestsisdependentupontheparticularpatientandthe
diagnosticconcerns,andmostpatientswitharrhythmiasdonotrequireanelectrophysiologystudy.

KeyPoint
Patientswithasuspectedarrhythmiawhoexperiencedailysymptomscanbeevaluatedwitha
24or48hourambulatoryelectrocardiographicmonitor(Holtermonitor),whereaspatients
withlessfrequentepisodesrequireothermonitoringstrategies,includingvarioustypesof
longertermeventrecorders.

Bibliography
AmericanCollegeofCardiologyFoundationTaskForceonExpertConsensusDocuments,
HundleyWG,BluemkeDA,FinnJP,etal.ACCF/ACR/AHA/NASCI/SCMR2010expert
consensusdocumentoncardiovascularmagneticresonance:areportoftheAmericanCollegeof
CardiologyFoundationTaskForceonExpertConsensusDocuments.JAmCollCardiol.2010

Jun855(23):261462.PMID:20513610
AmericanCollegeofCardiologyFoundationTaskForceonExpertConsensusDocuments,
MarkDB,BermanDS,BudoffMJ,etal.ACCF/ACR/AHA/NASCI/SAIP/SCAI/SCCT2010
expertconsensusdocumentoncoronarycomputedtomographicangiography:areportofthe
AmericanCollegeofCardiologyFoundationTaskForceonExpertConsensusDocuments.J
AmCollCardiol.2010Jun855(23):266399.PMID:20513611
AmericanCollegeofCardiologyFoundationAppropriateUseCriteriaTaskForceAmerican
SocietyofEchocardiographyAmericanHeartAssociationAmericanSocietyofNuclear
CardiologyHeartFailureSocietyofAmericaHeartRhythmSocietySocietyfor
CardiovascularAngiographyandInterventionsSocietyofCriticalCareMedicineSocietyof
CardiovascularComputedTomographySocietyforCardiovascularMagneticResonance,
DouglasPS,GarciaMJ,HainesDE,etal.
ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR2011AppropriateUse
CriteriaforEchocardiography.AReportoftheAmericanCollegeofCardiologyFoundation
AppropriateUseCriteriaTaskForce,AmericanSocietyofEchocardiography,AmericanHeart
Association,AmericanSocietyofNuclearCardiology,HeartFailureSocietyofAmerica,Heart
RhythmSociety,SocietyforCardiovascularAngiographyandInterventions,SocietyofCritical
CareMedicine,SocietyofCardiovascularComputedTomography,andSocietyfor
CardiovascularMagneticResonanceEndorsedbytheAmericanCollegeofChestPhysicians.J
AmCollCardiol.2011Mar157(9):112666.PMID:21349406
FihnSD,BlankenshipJC,AlexanderKP,etal.2014ACC/AHA/AATS/PCNA/SCAI/STS
FocusedUpdateoftheGuidelinefortheDiagnosisandManagementofPatientsWithStable
IschemicHeartDisease:AReportoftheAmericanCollegeofCardiology/AmericanHeart
AssociationTaskForceonPracticeGuidelines,andtheAmericanAssociationforThoracic
Surgery,PreventiveCardiovascularNursesAssociation,SocietyforCardiovascular
AngiographyandInterventions,andSocietyofThoracicSurgeons.Circulation.2014Nov
4130(19):174967.PMID:25070666
GreenlandP,AlpertJS,BellerGA,etalAmericanCollegeofCardiologyFoundation
AmericanHeartAssociation.2010ACCF/AHAguidelineforassessmentofcardiovascularrisk
inasymptomaticadults:areportoftheAmericanCollegeofCardiologyFoundation/American
HeartAssociationTaskForceonPracticeGuidelines.JAmCollCardiol.2010Dec
1456(25):e50103.PMID:21144964
GreenlandP,BonowRO,BrundageBH,etalAmericanCollegeofCardiologyFoundation
ClinicalExpertConsensusTaskForce(ACCF/AHAWritingCommitteetoUpdatethe2000
ExpertConsensusDocumentonElectronBeamComputedTomography)Societyof
AtherosclerosisImagingandPreventionSocietyofCardiovascularComputedTomography.
ACCF/AHA2007clinicalexpertconsensusdocumentoncoronaryarterycalciumscoringby
computedtomographyinglobalcardiovascularriskassessmentandinevaluationofpatients
withchestpain:areportoftheAmericanCollegeofCardiologyFoundationClinicalExpert
ConsensusTaskForce(ACCF/AHAWritingCommitteetoUpdatethe2000ExpertConsensus
DocumentonElectronBeamComputedTomography)developedincollaborationwiththe
SocietyofAtherosclerosisImagingandPreventionandtheSocietyofCardiovascular
ComputedTomography.JAmCollCardiol.2007Jan2349(3):378402.PMID:17239724
HendelRC,BermanDS,DiCarliMF,etalAmericanCollegeofCardiologyFoundation
AppropriateUseCriteriaTaskForceAmericanSocietyofNuclearCardiologyAmerican
CollegeofRadiologyAmericanHeartAssociationAmericanSocietyofEchocardiology
SocietyofCardiovascularComputedTomographySocietyforCardiovascularMagnetic
ResonanceSocietyofNuclearMedicine.ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM
2009AppropriateUseCriteriaforCardiacRadionuclideImaging:AReportoftheAmerican
CollegeofCardiologyFoundationAppropriateUseCriteriaTaskForce,theAmericanSociety
ofNuclearCardiology,theAmericanCollegeofRadiology,theAmericanHeartAssociation,
theAmericanSocietyofEchocardiography,theSocietyofCardiovascularComputed
Tomography,theSocietyforCardiovascularMagneticResonance,andtheSocietyofNuclear
Medicine.JAmCollCardiol.2009Jun953(23):220129.PMID:19497454

Next:CoronaryArteryDisease
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Chapter02
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DiagnosticTestinginCardiology
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