E
E. Cardiovascular system

CLINICAL/DIAGNOSTIC

PROBLEM

INVESTIGATION

RECOMMENDATION

(GRADE) 

COMMENT

DOSE

Acute central chest pain: myocardial infarction

CXR

Indicated (B)

CXR must not delay admission to a specialised unit.  CXR can assess heart size, pulmonary oedema, tumour, etc., and can exclude other causes.

Departmental radiograph preferable.

I
 
Chronic ischaemic heart disease and assessment after myocardial infarction 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. I
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 concomitant assessment of IV 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
 II
Angiography Indicated (B) Only technique currently available for detailed assessment of coronary artery anatomy.  Essential prerequisite for interventional strategies and sometimes to establish diagnosis. III
MRI Specialised investigation (B)

The role of MRI perfusion is still to be evaluated.

0
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 IV contraction, etc. III
  US echocardiography 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. 0
 
Chest pain: aortic dissection CXR Indicated (B) Mainly to exclude other causes; rarely diagnostic. I
US transoesophageal echo-cardiography (TOE) Indicated (B) TOE is a useful and accurate bedside technique, but not as good as CT for aortic arch 0
  CT Indicated (B) CT with IV contrast is the most reliable and practical technique. III
  MRI Specialised investigation (B) MRI is accurate and assesses any change in longitudinal extent, but practical difficulties can limit imaging potential. Useful for sequential follow-up. 0
 
Pulmonary embolism CXR Indicated (B) CXR should be the preliminary investigation to demonstrate consolidation and pleural effusion, but a normal CXR does not exclude a pulmonary embolus. I
NM (ventilation/perfusion scintigraphy) 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. II
Spiral CT Indicated (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 and abnormal CXR, and may be used following a non-diagnostic V:Q scintigram. III
 
Pericarditis, pericardial effusion US echocardiography 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. 0
CXR (including left lateral) Indicated (B) May reveal concomitant pathology (e.g. tumour) or calcification in pericardium. I
 
Suspected valvular cardiac disease CXR Indicated (B) Used for initial assessment and when there is a change in the clinical picture I
US echo-cardiography Indicated (B) Best method of sequential follow-up. TOE may be needed for prosthetic valves 0
MRI Indicated (B) Can be useful but generally impracticable. Contraindicated for many prosthetic valves. Useful in the context of congenital heart disease. 0
 
Clinical deterioration following myocardial infarction US echo-cardiography Indicated (B) US may show remediable complications (ventriculoseptal defect, papillary rupture, aneurysm, etc.). 0
CXR Indicated (B)   I
 
Hypertension CXR Indicated (B) Assesses cardiac size and possible associated pathology such as coarctation or rib erosion from collaterals. I
US echo-cardiography Indicated (B) Most practical method of assessing LV hypertrophy 0
MRI Specialised investigation (B) Most accurate method of assessing LV hypertrophy. 0
 
Suspected cardiomyopathy, myocarditis CXR Indicated (B) Globular cardiac silhouette suggestive of dilated cardiomyopathy I
US echocardiography Indicated (A) Allows clear assessment of dilated, hypertrophic, and constrictive/restrictive cardiomyopathy and associated cardiac abnormalities. Not so useful for arrhythmogenic RV dysplasia. Toe can distinguish constrictive from restrictive cardiomyopathy. 0
NM (radionuclide angiography) 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 patients receiving chemotherapy with doxorubicin. Myocardial perfusion imaging may help to differentiate ischaemic and dilated cardiomyopathy and to assess myocardial ischaemic in hypertrophic cardiomyopathy. III
 
Congenital heart disease US echo-cardiography/US transoesophageal echo-cardiography (TOE) Indicated (B) Provides diagnostic and functional data. Facilitates follow-up. Specialist area.

TOE can provide additional useful information to transthoracic echocardiography.

 0/0
MRI Indicated (B) Best assessment/follow-up tool. Contraindicated for many prosthetic valves. 0
 
Unstable angina NM Specialised investigation (B) Tc-99m or Tl-201 scintigraphy in diagnosis, prognosis, and assessment of therapy in patients with unstable angina is indicated in the:
  • Identification of ischaemia in the distribution of the culprit lesion or in remote areas
  • Measurement of baseline LV function
  • Identification of the extent and the severity of disease in patients with ongoing ischaemia or myocardial hibernation
 III
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. III
 
Abdominal aortic aneurysm US Indicated (A) Useful in diagnosis, determination of maximal diameter, and follow-up. CT preferable for suspected leak but should not delay urgent surgery.  
CT/MRI Indicated (A) CT (especially spiral) and MRI for relationship to renal and iliac vessels. There is increasing demand for detailed anatomical information because of increasing consideration of percutaneous stenting. III/0
 
Deep vein thrombosis US Indicated (A) More sensitive with colour flow Doppler. Most clinically significant thrombi are detected. There is increasing experience with US for calf vein thrombi. May show other lesions. 0
Venography Indicated only in specific circumstances (B) Extensive variation according to US expertise and local therapeutic strategy. II
 
Ischaemic leg 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. III
CTA/MRA Specialised investigation (B) Local policy needs to be determined in agreement with vascular surgeons, especially with regard to therapeutic intervention. III
Back to contents

Next