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Course: Medical Surgical Nursing

Topic: Laboratory Tests, Chest X-Ray and Fluoroscopy

The Nurses International Community

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Module Goals

Learners will be able to

Discuss the common blood laboratory tests performed in cardiovascular (CV) disorders.
Discuss diagnostic procedures performed in cardiovascular disorders.
Discuss indications for diagnostic procedures performed in cardiovascular disorders.
Discuss interprofessional interventions, if applicable.

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Blood Tests

A complete cholesterol test checks four types of fats in the blood:

Total cholesterol is the sum of all cholesterol in the blood:

Low-density lipoprotein (LDL) cholesterol is sometimes called “bad” cholesterol.

Too much of it causes fat to build up in your arteries, which reduces blood flow.
This can lead to a heart attack or stroke.

High-density lipoprotein (HDL) cholesterol is sometimes called “good” cholesterol.

It helps carry away LDL cholesterol and clear your arteries.

Healthline, 2023a

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Blood Tests (Continued)

Triglycerides are a type of fat in the blood.

High levels of triglycerides are often associated with diabetes, smoking, and excessive alcohol consumption.

C-reactive protein (CRP) tests: check your body for signs of inflammation.

Results of CRP and cholesterol tests are evaluated to assess the risk of heart disease.

Healthline, 2023a

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Blood Tests (Continued)

Complete blood count (CBC)

Hemoglobin, platelets, white blood cells

Basic metabolic panel (BMP)

Electrolytes, blood urea nitrogen (BUN), creatinine

Glucose
Liver function
Thyroid function

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Blood Tests (Continued)

Troponin
Cholesterol level and lipid profile

Total cholesterol
Low-density lipoprotein (LDL)
High-density lipoprotein (HDL)
Triglycerides

Natriuretic peptides

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Troponin is a protein the heart releases when there is damage to the cardiac muscle. An increased troponin level could indicate a recent heart attack (also known as acute myocardial infarction or AMI).

Total cholesterol measures the entire amount of cholesterol in the blood. LDL is often referred to as the “bad” cholesterol because it leads to atherosclerosis and causes blockages in blood vessels. HDL is often referred to as “good” cholesterol because it carries away LDL and is therefore thought to be protective against cardiovascular disease. Triglycerides are a type of fat present in the bloodstream that may be associated with an increased risk of cardiovascular disease.

Natriuretic peptides, such as the brain natriuretic peptide (BNP), can diagnose the onset of heart failure.

https://www.nhsinform.scot/illnesses-and-conditions/heart-and-blood-vessels/common-tests/tests-for-diagnosing-heart-conditions

https://www.healthline.com/health/heart-disease/tests-diagnosis#physical-exam-and-bloodtests

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Critical Thinking Question

Which blood test is commonly used in cardiology to assess the risk of a heart attack?

Complete blood count (CBC)
Prothrombin time (PT)
Troponin levels
Serum cholesterol levels

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Answer: C) Troponin levels

Rationale: Troponin is a protein released into the bloodstream when heart muscle cells are damaged. It is a highly specific biomarker used in cardiology to detect and evaluate the risk of a heart attack (myocardial infarction). When the heart muscle is injured due to reduced blood flow, such as in a heart attack, troponin levels increase in the bloodstream. Therefore, measuring troponin levels through a blood test helps in diagnosing and assessing the severity of cardiac conditions.

A) Complete blood count (CBC) is a common blood test that provides information about different types of blood cells, including red blood cells, white blood cells, and platelets. While CBC can indirectly indicate some cardiac conditions (e.g., anemia), it is not specific for assessing the risk of a heart attack.

B) Prothrombin time (PT) is a blood test used to measure the time it takes for blood to clot. Although clotting issues can contribute to heart-related problems, PT is not primarily used to assess the risk of a heart attack.

D) Serum cholesterol levels measure the amount of cholesterol in the blood, which is a risk factor for heart disease. While high cholesterol levels are associated with an increased risk of heart-related issues, it is not the most specific blood test for assessing the immediate risk of a heart attack. Other tests, such as troponin levels, are more indicative of an ongoing cardiac event.

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Diagnostic Procedures

Echocardiogram
Electrocardiogram
24-hour or ambulatory electrocardiogram
Stress test
Tilt test
Magnetic resonance imaging (MRI)
Cardiac computed tomography (Cardiac CT)
Thallium scan (myocardial perfusion scintigraphy)
Coronary angiogram
Chest X-ray
Fluoroscopic Percutaneous Coronary Interventions

NHSInform, 2023

Contact info: info@nursesinternational.org

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Diagnostic Procedures: Echocardiogram

An echocardiogram - or "echo" - is an ultrasound scan of the heart.
It uses high-frequency sound waves to create an image of the heart.

Features:

Painless procedure that is usually performed in a hospital or an outpatient clinic.
It can check:

the size of the heart
how well the heart muscle is contracting and relaxing
how well the valves are working

NHSInform, 2023

Contact info: info@nursesinternational.org

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Echocardiogram: Indications

The use of echocardiography in asymptomatic clients includes:

screening patients who have first degree relatives with hypertrophic cardiomyopathy (HCM).
aortic aneurysms or dissections.
athletes that have electrocardiographic (ECG) changes.

These clients may not have any immediate complaints, but their strong family history should give the clinician a high pretest probability to order an Echocardiogram.

Omerovic & Jain, 2023

Contact info: info@nursesinternational.org

Second, the initial evaluation of patients with clinical signs or symptoms of heart disease. This includes palpitations, syncope, presyncope, newly diagnosed bundle branch blocks, arrhythmias, ACS, exertional shortness of breath, and evaluation of pulmonary hypertension.

Third, follow-up on previously diagnosed heart failure or valvular disease. In regards to the former, a re-evaluation of the patient's ejection fraction with echocardiography, especially in those with acute heart failure exacerbations, would provide important information to better treat the patient.

Finally, the evaluation of patent foramen ovale in those with cerebrovascular accidents (CVA). One of the common causes of CVA is cardioembolic disease. Echocardiography with "bubble study" is a way to evaluate for a patent foramen ovale (PFO). Agitated saline is injected into the heart chambers, and flow across the atrium is evaluated for a defect. This defect may require surgical closure.

https://www.ncbi.nlm.nih.gov/books/NBK558940/

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Echocardiogram: Interprofessional Care

Assessment of fluid status by physicians or nursing staff.
Interprofessional communication is important when treating any client, including those with a cardiac history.
It is vital to continuously assess a client's fluid status and need for further imaging assessments.
Adequate communication about the specific indication for echocardiography for each specific client will help ensure optimal views and help improve the clinical utility of this test.

Omerovic & Jain, 2023

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Diagnostic Procedures: Electrocardiogram (ECG)

It is a test that records the electrical activity of the heart.

The ECG reflects what’s happening in different areas of the heart and helps identify any problems with the rhythm or rate of the heart.

The ECG is painless and takes around 5-10 minutes to perform.

NHSInform, 2023

Contact info: info@nursesinternational.org

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ECG: Indications

Symptoms:

palpitation
dizziness
cyanosis
chest pain
syncope
seizure
poisoning

Symptoms or signs associated with heart disease, such as tachycardia and bradycardia

Sattar & Chhabra, 2023

To detect myocardial injury, ischemia, and the presence of prior infarction
Clinical conditions including

hypothermia
murmur
shock
hypotension
hypertension

Rheumatic heart disease

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Indications (Continued)

Detecting pacemaker or defibrillator device malfunction, evaluating their programming and function, verifying the analysis of arrhythmias, and monitoring for delivery of the appropriate electrical pacing in patients with defibrillators and pacemakers
Evaluation of metabolic disorders
Helpful for the assessment of blunt cardiac trauma
Cardiopulmonary resuscitation
Valuable aid in the study and differential diagnosis of congenital heart diseases
Electrolyte imbalance and rhythm disorders
To monitor the pharmacotherapeutic effects and adverse effects of drug therapy
Perioperative anesthesia monitoring, such as preoperative assessment and intraoperative and postoperative monitoring
Screening tool in a sports physical exam to rule out cardiomyopathy

https://www.ncbi.nlm.nih.gov/books/NBK549803/#:~:text=Symptoms%20are%20the%20foremost%20indication,%2C%20shock%2C%20hypotension%2C%20and%20hypertension

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ECG: Interprofessional Care

Nurses initially:

interpret the EKG
gather data
promptly notify the physician-in-charge to ensure an appropriate management plan

Assess the client's clinical condition and ensure that an excellent quality of care is delivered.
Demonstrate competency in initial EKG interpretation.

Sattar & Chhabra, 2023

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Diagnostic Procedures:

24-hour (Ambulatory ECG)

In this test, electrodes are connected to a small box and attached to a belt.
The client is instructed to wear the belt for 24 hours and perform normal daily activities.
The ECG will be monitored and will be able to record any abnormalities over the day.
The client is asked to record any symptoms.
Then, the electrophysiologist or cardiologist will assess the abnormalities in addition to any recorded symptom.

NHSInform, 2023

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Diagnostic Procedures:

24-hour (Ambulatory ECG) (Continued)

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24-hour (Ambulatory ECG) - Indications

Symptoms of irregular heartbeat, such as:

dizziness
faintness
feeling like your heart is racing or skipping a beat

Abnormal heart rhythms (arrhythmias)

Healthline, 2023b

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Diagnostic Procedures: Stress Test

The stress test - or exercise tolerance test (ETT) or treadmill test - is similar to an ECG but records the activity of the heart as it works harder, for example, while walking on a treadmill.

The "exercise" ECG records how the heart responds to exercise.

https://youtu.be/24UfNoTUzfw

NHSInform, 2023

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Stress Test: Indications

Symptoms suggesting myocardial ischemia
Acute chest pain in patients excluded for acute coronary syndrome (ACS)
Recent ACS treated without coronary angiography or incomplete revascularization
Known CAD with worsening symptoms
Prior coronary revascularization (5 years or longer after coronary artery bypass grafting [CABG] or two years or less after percutaneous coronary intervention [PCI])
Valvular heart disease (to assess exercise capacity and need for surgical intervention)

Vilcant & Zeltser, 2022

Contact info: info@nursesinternational.org

Certain cardiac arrhythmias to assess chronotropic competence
Newly diagnosed heart failure or cardiomyopathy

Absolute Contraindications

Acute myocardial infarction within 2 to 3 days
Unstable angina not previously stabilized by medical therapy
Uncontrolled cardiac arrhythmias causing symptoms or hemodynamic compromise[10]
Symptomatic severe aortic stenosis[11]
Uncontrolled symptomatic heart failure
An acute pulmonary embolus or pulmonary infarction
Severe pulmonary hypertension
Acute myocarditis or pericarditis or endocarditis
Acute aortic dissection

Relative Contraindications (can be overlooked if the benefits of treadmill stress testing outweigh the risks)

High-grade AV blocks
Severe hypertension (systolic greater than 200 mmHg, diastolic greater than 110 mmHg, or both)
Inability to exercise given extreme obesity or other physical/mental impairment
Left main coronary stenosis
Moderate stenotic valvular heart disease
Electrolyte abnormalities
Tachyarrhythmias or bradyarrhythmias
Hypertrophic cardiomyopathy and any other forms of outflow tract obstruction
Mental or physical impairment leading to an inability to exercise adequately

https://www.ncbi.nlm.nih.gov/books/NBK499903/

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Stress Test: Interprofessional Care

Treadmill stress testing requires the coordinated efforts of an interprofessional healthcare team that includes:

cardiologists
family clinicians (MDs, DOs, NPs, PAs)
nurses

All team members must know the parameters of stress testing, contraindications, interpretation, and signs that the test may need to be terminated earlier.
Any concerns noted by any team member should be documented in the patient's health record and communicated to other interprofessional team members.

Vilcant & Zeltser, 2022

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Critical Thinking Question

During a stress test, which of the following physiological responses is expected?

Increased heart rate
Decreased blood pressure
Decreased respiratory rate
Decreased muscle tension

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Answer:

A) Increased heart rate

Rationale:

A stress test is a medical examination that assesses how well the cardiovascular system responds to physical stress. It typically involves exercising on a treadmill or stationary bicycle while the heart rate, blood pressure, and other vital signs are monitored. During a stress test, the body's sympathetic nervous system is activated in response to the physical exertion and stress, leading to several physiological changes.

Increased heart rate is one of the expected responses during a stress test. The sympathetic nervous system releases stress hormones, such as adrenaline, which stimulates the heart to beat faster. This increased heart rate helps supply more oxygen-rich blood to the muscles and other organs, supporting the increased demand for energy during exercise.

The other options provided in the question are incorrect:

B) Decreased blood pressure: During a stress test, blood pressure may increase or remain relatively stable. A decrease in blood pressure is not a typical response and could indicate an abnormality.

C) Decreased respiratory rate: During a stress test, the respiratory rate typically increases to meet the increased oxygen demand of the muscles. A decrease in respiratory rate is not expected.

D) Decreased muscle tension: During a stress test, muscle tension may increase as the muscles work harder during exercise. A decrease in muscle tension is not a typical response.

Therefore, the correct answer is A) Increased heart rate.

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Diagnostic Procedures: Tilt Test

A tilt test allows the doctor to monitor blood pressure and heart rate when the client is lying down and standing up.
The test is designed to assess symptoms the client may have been experiencing, like light-headedness or dizziness, and to see if the symptoms are related to blood pressure or heart rate.
The test will normally be done as an outpatient appointment in an electrophysiology department.
https://youtu.be/0zYwKl-YBtQ
https://youtu.be/24UfNoTUzfw

NHSInform, 2023

Contact info: info@nursesinternational.org

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Tilt Test: Indications

Recurrent syncope of unknown origin.
Syncope of unknown origin with traumatic injury.
Even one syncopal event of unknown origin without a prodrome.
Suspicion of pseudo syncope or psychogenic syncope.
Jerking movements during the loss of consciousness to differentiate them from epilepsy.
A fall, which may mask syncope.

Zysko et al., 2023

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Diagnostic Procedures:

Magnetic Resonance Imaging (MRI)

This painless scan uses a magnetic field inside a scanning machine to produce images of the heart and blood vessels.

It’s useful for checking problems with the structure of the heart and blood supply.

It’s very helpful in getting images from people whose vessels and heart anatomy are difficult to see using angiography.

NHSInform, 2023

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Diagnostic Procedures: MRI (Continued)

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MRI: Indications

Ischemia
Tumour
Infiltrative diseases
Congenital malformation
Cardiomyopathy
Stress cardiac MRIs may also be performed, which provide structural information and serve as an ischemic evaluation and myocardial viability study.

Ashby et al., 2023

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Diagnostic Procedures:

Cardiac Computed Tomography (Cardiac CT)

It is an imaging method that uses x-rays to create detailed pictures of the heart and its blood vessels.
This test is called a coronary calcium scan when it is done to see if the individual has a buildup of calcium in the heart arteries.
It is called CT angiography if it is done to look at the arteries that bring blood to the heart and evaluates if there is narrowing or a blockage in those arteries.
The test is sometimes done in combination with scans of the aorta or pulmonary arteries to look for problems with those structures.

MedlinePlus, 2023

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Cardiac CT: Indications

Coronary artery disease
Measuring the hemodynamics in the right and left side of the heart
Evaluate the left ventricular function
Evaluation and treatment of cardiac arrhythmias
Evaluation and treatment of valvular heart disease
Assessment of pericardial and myocardial diseases
Assessment of congenital heart diseases
Evaluation of heart failure

Manda & Baradhi, 2023

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Diagnostic Procedures:

Thallium Scan (Myocardial Perfusion Scintigraphy)

The scan shows how well blood is reaching the heart muscle through the coronary arteries.
A small amount of thallium (radioactive substance) is injected into a vein, and a special camera moves around your heart.
The camera picks up traces of thallium and produces pictures.
As thallium doesn’t travel well to areas where there’s a poor blood supply.
This is done at rest and during exercise.
The very low levels of radiation used are considered to be safe.

NHSInform, 2023

Contact info: info@nursesinternational.org

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Thallium Scan: Indications

Diagnosis of symptomatic and asymptomatic coronary artery disease.
Screening of non-specific results on the exercise EKG test.
Determination of risk before non-cardiac surgery.
Determination of risk after an event of myocardial infarction.
Determination of risk before and after revascularization procedures.

Poudyal et al., 2023

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Diagnostic Procedures: Coronary Angiogram

A type of X-ray used to examine the coronary arteries supplying blood to the heart muscle.
It's considered to be the best method of diagnosing coronary artery disease - conditions that affect the arteries surrounding the heart.
During the test, a long, flexible tube called a catheter will be inserted into a blood vessel in either the groin or arm.
The tip of the catheter will then be fed up to the heart and coronary arteries.

NHSInform, 2023

Contact info: info@nursesinternational.org

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Coronary Angiogram: Indications

Thoracic and abdominal aortic aneurysm and dissection.
Diagnosis and treatment of coronary artery disease.
Coronary artery aneurysms.
Peripheral vascular disease, including intermittent claudication and limb-threatening ischemia.
Vascular malformations.

Omeh & Shlofmitz, 2023

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Diagnostic Procedures:

Coronary Angiogram (Continued)

Special dye will then be injected through the fine catheter into the coronary arteries, and X-ray images will be taken.

The images created during angiography are called angiograms.

The images will be used to identify narrowing or blockage of the arteries that may be responsible for your symptoms.

NHSInform, 2023

Contact info: info@nursesinternational.org

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Diagnostic Procedures: Chest X-ray

A chest X-ray is useful for showing the size and shape of the heart and detecting chest disorders.

This can provide doctors additional information about your symptoms (which can often relate to both chest and heart conditions) and can also show any fluid in the lungs, which may be caused by heart disease.

NHSInform, 2023

Contact info: info@nursesinternational.org

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Chest X-ray: Indications

Quantification of ventricular and atrial size.
Measurement of left and right ventricular ejection fraction.
Detection of left ventricular hypertrophy.
Detection of features of diastolic dysfunction.
Estimation of left atrial pressure.
Estimation of pulmonary artery systolic pressure.
Detection of regional wall motion abnormalities (which may indicate underlying ischaemic heart disease).
Assessment of valvular lesions (including their mechanism and severity).
Detection and quantification of intra-cardiac shunts.

Stokes & Roberts-Thomson, 2023

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Diagnostic Procedures:

Fluoroscopic Percutaneous Coronary Interventions

Nearly all percutaneous coronary intervention (PIC) were carried out under fluoroscopic guidance by utilizing ionizing radiation.
It is essential to take appropriate fluoroscopic views according to vessel anatomy during percutaneous coronary intervention so that the diseased segment should not be missed.
The views for percutaneous coronary intervention help cover the diseased segment of the artery and reduce radiation exposure to both clients and healthcare workers by decreasing fluoroscopic time and radiation dose.

Adnan & Rahman, 2023

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Fluoroscopic PIC: Indications

Unprotected left main artery with:

ST-elevation myocardial infarction
unstable angina
stable ischemic heart disease

Triple vessel coronary artery disease with or without proximal LAD.
Two-vessel disease with and without proximal LAD.
One-vessel disease with proximal LAD.
Patients who survived sudden cardiac death with presumed ischemia-mediated ventricular tachycardia.

Adnan & Rahman, 2023

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Fluoroscopic PIC: Contraindications

Absolute Contraindication

Intolerance to dual antiplatelets.
Severe illness which reduces the lifespan to less than one year.

Relative Contraindication

Coronary artery vessel diameter < 2.5 mm.
Anatomy not feasible for coronary intervention.
Diffusely disease saphenous vein graft.

Adnan & Rahman, 2023

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Fluoroscopic PIC: Interprofessional Care

The nursing staff gives medications and monitors vitals during the procedure.

The radiographic technician sets views on the fluoroscopy machine for the procedure and supports performing procedures such as intravascular imaging and invasive physiological assessment.

The cath lab technician prepares equipment such as a coronary balloon and coronary stent and guides catheters for the procedure.

Adnan & Rahman, 2023

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Critical Thinking Question

Which of the following is an appropriate indication for obtaining a chest X-ray for a client with a cardiac condition?

Routine screening in asymptomatic individuals
Suspected acute myocardial infarction (heart attack)
Assessment of heart rhythm abnormalities
Monitoring response to heart failure medication

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Answer: B) Suspected acute myocardial infarction (heart attack)

Rationale: A chest X-ray is not routinely performed as a screening tool in cardiology, as it does not provide specific information about cardiac function or coronary artery disease. However, it is useful in certain clinical scenarios. In the case of suspected acute myocardial infarction (heart attack), a chest X-ray may be performed to evaluate the heart and lungs for any signs of acute changes or complications such as pulmonary edema or cardiomegaly. The X-ray can provide valuable information to aid in the diagnosis and management of the patient with suspected myocardial infarction. Options C and D may involve other diagnostic modalities, such as electrocardiography (ECG) or echocardiography for heart rhythm abnormalities and monitoring response to heart failure medication, respectively.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures, talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures, family members play a large role in healthcare decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting and following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health-seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be okay in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Adnan, G., & Rahman, M. N. (2023). Fluoroscopic Percutaneous Coronary Interventions, Assessment, Protocols, and Interpretation. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK570602/

Ashby, K., Adams, B. N., & Shetty, M. (2023). Appropriate Magnetic Resonance Imaging Ordering. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK565857

Healthline. (2023a). Heart Disease: Tests & Diagnosis. https://www.healthline.com/health/heart-disease/tests-diagnosis#invasive-tests

Healthline. (2023b). Holter Monitor: 24-Hour Heart Monitoring. https://www.healthline.com/health/holter-monitor-24h

Contact info: info@nursesinternational.org

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References

Manda, Y. R., & Baradhi, K. M. (2023). Cardiac Catheterization Risks and Complications. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK531461

NHS Inform. (2023). Tests for Diagnosing Heart Conditions. https://www.nhsinform.scot/illnesses-and-conditions/heart-and-blood-vessels/common-tests/tests-for-diagnosing-heart-conditions

Omeh, D. J., & Shlofmitz, E. (2023). Angiography. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557477/

Omerovic, S., & Jain, A. (2023). Echocardiogram. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK558940/

Contact info: info@nursesinternational.org

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References

Poudyal, B., Shrestha, P., & Chowdhury, Y. S. (2023). Thallium-201. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560586/

Sattar, Y., & Chhabra, L. (2023). Electrocardiogram. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549803/

Stokes, M. B., & Roberts-Thomson, R. (2017). The Role of Cardiac Imaging in Clinical Practice. Aust Prescr, 40(4), 151-155. doi: 10.18773/austprescr.2017.045

Vilcant, V., & Zeltser, R. (2023). Treadmill Stress Testing. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499903/

Contact info: info@nursesinternational.org

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