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Diagnostic Investigations in the remote contextALEX KAETHNER – NT CARDIAC
Cardiac Care in the NT Annual Workshop
2017 is proudly supported by:
Diagnostic Investigations
▪ Overview
▪ Range of Investigations
▪ In clinic services
▪ Visiting services
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsSnapshot of tests
▪ Local tests
▪ ECG
▪ Holter monitor
▪ Exercise stress test
▪ Visiting tests
▪ Echocardiogram (TTE)
▪ Exercise Stress Echocardiogram
▪ Dobutamine Stress Echocardiogram
▪ 6 minute walk test
▪ Event monitor
▪ Pacemaker/device interrogation
▪ Trans-oesophageal Echocardiogram (TOE)*
▪ Loop Recorder Implantation*
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsECG
▪ Local tests▪ ECG
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsECG
▪ ACS (acute coronary syndromes) pathway
▪ ECGs performed in remote clinic sighted
by a Cardiologist within seconds/minutes
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsHolter monitor
▪ Holter monitor
▪ What is it?
▪ 24hr/48hr ECG monitoring
▪ Why perform it?
▪ Pts with palpitations, syncope etc
▪ Arrhythmias/pauses etc
▪ Who performs it?
▪ Monitors fitted in community clinic
by nursing staff (cardiac physiologists at NTC)
▪ Data transferred to NT Cardiac Darwin
for analysis and reporting.
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsHolter monitor
▪ Remote Holter monitor numbers
▪ 2012 – approx. 100 Holters fitted in remote locations
▪ 2016 – approx. 635 Holters fitted in remote locations
▪ Remote sites-▪ ASH, TCH, KDH, GDH, Angurugu, Gapuwiyak, Gunbalanya, Maningrida, Nguiu, Numbulwar, Ramingining,
Wadeye, Ali Curung, Borroloola, Elliott, Hermannsburg, Papunya, Yuendumu
▪ Lajamanu, Kalkarindji, Ngukurr, Galiwinku, Yirrkala, Milingimbi
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsExercise Stress Test
▪ Exercise Stress Test▪ What is it?
▪ Treadmill test for functional
capacity with continuous ECG
recording
▪ Why perform it?▪ Performed mainly for the
assessment of coronary artery disease
▪ Also dyspnoea, arrhythmias etc
(eg chronotropic incompetence)
▪ Who performs it?▪ Cardiac Tech, Nurse
▪ Cardiologist, or doctor with
cardiologist supervision.
▪ Performed at NTC, RDH, ASH, TCH, KDH, GDH
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic Investigations
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsEchocardiogram
▪ Echocardiogram
▪ What is it?
▪ Diagnostic ultrasound imaging of the heart
▪ Why perform it?
▪ Used to assess cardiac structure and function.
▪ Most commonly –
▪ ventricular size and function assessment (LV function)
▪ valvular assessment (valve leakage or blockages)
▪ Who performs it?
▪ Cardiac sonographers
▪ Cardiologists and other doctors do perform limited, focused scans with the correct basic training
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic Investigations Echocardiogram
Cardiac Care in the NT Annual Workshop - June 2017
1998/1999 2017
Diagnostic InvestigationsEchocardiogram
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsEchocardiogram
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsExercise Stress Echocardiogram (treadmill)
▪ What is it?
▪ Treadmill test for functional capacity with continuous ECG
recording, and echocardiographic images (pre and post treadmill)
▪ Why perform it?
▪ Performed mainly for the assessment of coronary artery disease
▪ Echo component allows for extra assessment of valves and pulmonary artery pressure
▪ Also dyspnoea, arrhythmias etc (eg chronotropic incompetence)
▪ Who performs it?
▪ Cardiac Sonographer, Cardiologist and generally a nurse.
▪ Performed at NTC, ASH, TCH, KDH, GDH
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsExercise Stress Echocardiogram (treadmill)
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsDobutamine Stress Echocardiogram
▪ What is it?
▪ Pharmaceutical (dobutamine) stress test with continuous ECG recording, andechocardiographic images (at intervals during dobutamine infusion)
▪ Why perform it?
▪ Performed mainly for the assessment of coronary artery disease
▪ Echo component allows for extra assessment of valves and pulmonary artery pressure
▪ Also dyspnoea, arrhythmias etc
(eg chronotropic incompetence)
▪ Performed when pt unable to walk on t/mill
▪ Who performs it?
▪ Cardiac Sonographer and Cardiologist
▪ Performed at NTC, ASH, TCH, KDH, GDH
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsDobutamine Stress Echocardiogram
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsSix minute walk test
Cardiac Care in the NT Annual Workshop - June 2017
▪ Six minute walk test
▪ What is it?▪ Simple functional test
▪ Patient walks for 6 minutes
on a measured course (eg 25m corridor)
▪ HR, BP, oxygen sats, resp. rate,
and levels of exertion measured
▪ Why perform it?▪ Functional capacity in cardiac
and respiratory disease
▪ Used to guide therapeutic treatment
(eg pulm. HT medications)
▪ Who performs it?▪ Cardiac Tech, Nurse or
other health worker
Diagnostic InvestigationsPacemaker/device Interrogation
▪ What is it?
▪ Interrogation of pacemaker, ICD (internal defibrillator) or loop recorder
▪ Why perform it?
▪ To check for any dangerous rhythms, pauses and battery life of device
▪ Who performs it?
▪ Appropriately trained Cardiac Tech, Cardiologist
▪ (Some devices now have function for home monitoring)
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsTrans-oesophageal Echocardiogram (TOE)
▪ What is it?
▪ Specialist cardiac ultrasound from inside the oesophagus, behind the heart.
▪ Why perform it?
▪ For better assessment of cardiac structures when TTE results unclear
▪ Common referrals for endocarditis, mitral valve assessment, LAA clot presence
▪ Who performs it?
▪ Cardiologist (sometimes ICU, anaesthetics)
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsEvent monitor
▪ What is it?
▪ A small device to capture ECG readings during symptomatic episodes
▪ Patient activates the recording as symptoms occur
▪ Worn for up to 4 weeks
▪ Why perform it?
▪ Used when symptoms not captured
on 24hr/48hr Holter monitor
▪ Fills the gap between Holter monitor and
loop recorder
▪ Who performs it?
▪ Cardiac tech/nurse to fit the device
▪ Patient downloads readings as events occur
Cardiac Care in the NT Annual Workshop - June 2017
Diagnostic InvestigationsLoop recorder Implantation
▪ What is it?
▪ A small device implanted under the skin
▪ Why perform it?
▪ To record suspected arrhythmias not detected on Holter/event monitoring
▪ Who performs it?
▪ Specialist Cardiologist
Cardiac Care in the NT Annual Workshop - June 2017
Summary
▪ Access to cardiac diagnostic services in the remote setting has come a long way
▪ Provision of diagnostic services is a collaboration between all parties involved (NTC, Community Clinics, Hospitals, CNCs, SONT, IT services, HF, RHD etc)
Cardiac Care in the NT Annual Workshop - June 2017
Thank you!
PRESENTATION AT THE CARDIAC CARE IN THE NT ANNUAL WORKSHOP
DARWIN, JUNE 2017