Presentations
- Abnormal ECG patterns suspicious for the presence of ischaemia
- Symptoms suspicious for myocardial ischaemia, such as chest pain, dyspnoea, or palpitations, for quantification of left ventricular systolic function
Conditions
- Cardiac failure:
- cardiac rhythm disorders:
- atrial arrhythmias, such as atrial ectopics, atrial flutter, supraventricular tachycardia (SVT)
- congenital conduction abnormalities, such as Wolf–Parkinson–White syndrome, that may effect method of stress testing
- fibriliation
- ischaemic and non-ischaemic conditions of heart failure
- Coronary artery disease:
- ECG abnormalities:
- atrial arrhythmias
- bundle branch block
- changes of ischaemia at rest
- heart block
- left ventricular hypertrophy
- myocardial infarction
- myocardial ischaemia
- pericarditis and left ventricular aneurysm
- QT interval abnormalities
- ventricular arrhythmias
- Wolff–Parkinson–White syndrome
- Ischaemic heart disease
PCH
Conditions
- Acquired paediatric abnormalities:
- Congenital cardiac disease:
- anomalous coronary artery disease
- transposition of the great arteries
- Trainees will be aware there are complex congenital cardiac conditions, as well as acquired diseases and the associated cardiac sequelae
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Presentations
- Known or suspected:
- cardiac infiltrative disorder
- cardiac manifestation of systemic disorder
- congenital heart disease
- disorder of sympathetic innervation
Conditions
- Cardiac amyloidosis and sarcoidosis
- Congenital heart disease:
- atrial septal defect (ASD)
- Eisenmenger syndrome
- patent ductus arteriosus (PDA)
- septal defects:
- ventricular septal defect (VSD)
- tetralogy of Fallot
- transposition of the great arteries
Cardiac anatomy and physiology
- Cardiac and coronary artery anatomy, including variants:
- identify territories of coronary arteries and how this relates to the myocardial perfusion image interpretation in all three axes
- importance of coronary artery anatomy to confidently exclude imaging artefacts
- Effect of different modes of stress on coronary blood flow and tracer uptake into cardiac myocytes
- Effect of previous coronary bypass surgery on perfusion territories
- Left ventricle (LV) and right ventricle (RV) function, both regionally and globally, with rest and exercise
- Myocardial flow reserve
- Myocardial oxygen consumption, and the factors affecting coronary blood flow and flow reserve
- Normal and abnormal LV regional wall motion
- Radiation exposure relating to the different radioisotopes
- Relationship between coronary stenoses and blood flow, both at rest and during stress
Cardiac disease
- Basic pathogenesis of atherosclerosis, with reference to coronary artery disease and its consequences
- Impact of microvascular disease on cardiac tracer uptake and on differences between coronary angiographic findings and myocardial perfusion scans (MPS)
- Myocardial substrate utilisation, energy production, and contraction
Procedural information
- Absolute myocardial blood flow (MBF) quantification during dynamic cardiac PET and SPECT (using solid state detectors)
- Clinical / ECG and pathological features of cardiomyopathy, endocarditis, myocarditis, and valvular heart disease
- Concepts of reversibly dysfunctional myocardium in coronary artery disease (ischaemic stunning), and myocardial hibernation and infarction, and how to confidently diagnose those conditions on MPS with and without thallium / FDG
- Patient preparation needed for nuclear medicine diagnostic studies with respect to imaging indication, modality (e.g. CTCA acquisition, PET, and SPECT), and pharmacological protocols that may be required
- Role of stress-only imaging, including diagnostic performance, long-term follow-up, and radiation safety considerations
- Starling’s Law and relate this to preload, afterload, myocardial contractility, and mechanisms of cardiac reserve
- The significance of a change in ejection fraction, including potential sources of error
- Normal and abnormal patterns of lymphatic drainage
- CAD using SPECT radiopharmaceuticals:
- assess ventricular function using planar and gated SPECT
- radionuclide ventriculography and gated SPECT using MPS agents
- CT coronary angiography and calcium scoring
- ECG
- LV and/or RV ejection fractions planar and SPECT with labelled red cells
- Cardiac shunt function studies
- I-123 MIBG adrenergic cardiac imaging studies in the evaluation of heart failure and movement disorders (Parkinsonian syndromes)
- Cardiac F-18 FDG
- Perfusion PET tracer imaging techniques
- Cardiac amyloid imaging with bone-seeking radiopharmaceuticals and/or PET agents
- Lymphoscintigraphy (assessment of lymphatic drainage)
PCH
- Myocardial perfusion studies
Cardiac failure
- Bisphophonate and FDG PET imaging in the diagnosis of ATTR cardiac amyloidosis and cardiac sarcoidosis, and guideline recommendations for test performance and reporting
- Decompensated heart failure as a contraindication to stress testing
- Ischaemic and non-ischaemic causes of heart failure
Cardiac rhythm disorders
- Complete heart block and bundle branch block patterns, including tri-fascicular and hemi-blocks
- Identify the following conditions on ECG:
- left ventricular hypertrophy and strain pattern
- previous myocardial infarction
- typical transient ischaemic ECG changes
- Potential lethal arrhythmias – ventricular tachycardia (non-sustained / sustained) and VF ECG abnormalities
- The potential impact of irregular heart rhythms on left ventricular ejection fraction assessment
Cardiac stress testing
- Limitations and requirements of common treadmill and cycle ergometer protocols
- Manage arrythmias and other cardiac events that may by caused by stress tests
- Patient demographics, including geographic location, socioeconomic status, ethnicity, and cultural background, and how these might affect choice of specific protocol
- Perform cardiopulmonary resuscitation if required
- Provide a safe environment for cardiac stress testing
- Radiation protection and patient safety
- Stress testing using pharmacological agents:
- infusion protocols used for pharmacological agents, including reversal agents
- which agents to use in specific situations, including patient preparation required for use, such as caffeine withdrawal
- The Duke treadmill score
Coronary artery disease
- ECG abnormalities commonly associated with ischaemia / infarction
- Ischaemic ECG changes during stress tests
- Know when to cease / modify stress tests when concerning ECG changes occur
- Normal chronotropic and BP response during stress procedures, and significance of abnormal responses during testing
Electrocardiograms
- Bruce treadmill exercise test or other standard protocols:
- criteria for positive, negative, non-diagnostic, and uninterpretable exercise ECGs
- terminate exercise stress tests at the appropriate endpoint
Myocardial perfusion stress testing
- Determine the most appropriate method to stress test patients to answer clinical questions
- Evaluate baseline ECG studies
- Know the difference between requests for:
- ischaemia imaging
- myocardial function assessment (gated cardiac blood pool scan)
- myocardial viability imaging (thallium / FDG)
- Patient and environmental safety
- Pre-test probability of myocardial ischaemia and potential contribution of non-ischaemic cardiac conditions and non-cardiac conditions to symptomatology
- Resting wall motion abnormality, post-stress wall motion abnormality, and changes in left ventricular function at rest and post-stress, and significance of post stress LV dilation
- Risks and current management guidelines for performing tests on / off anti-angina medications, such as ischaemia directed management on optimal medical therapy
- Ventricular function as part of myocardial perfusion imaging
PET
- PET tracers and use in assessment of cardiac perfusion
- The utility of FDG PET in:
- cardiac sarcoidosis
- endocarditis (including Duke criteria)
- infection of cardiac pacemakers / leads, LVADs, and prosthetic valves
- myocarditis
