Cardiology PDF
Cardiology PDF
Cardiology PDF
TABLE OF CONTENTS
1 Scope of cardiology 3
Annexure
Role of
A. Consultant
Annexure No. I B. Cathlab Technician
C. Staff Nurse
D. Nursing Aid
Annexure No. II Organogram
1. SCOPE OF CARDIOLOGY
1.1. Purpose
The department of Cardiology aims at delivering High quality total patient cardiac care
combined with compassion, care and understanding.
1.2. Scope
Patients with known or suspected to have cardio vascular disease.
1.3. Responsibilities & Authority:
Head of the Department
1.4. Quality objectives
The quality objective of department of Cardiology is to diagnose, to medically and
interventionally manage coronary arteries due to heart attacks, angina, and other heart
diseases such as valvular incompentency, septal defects, and electrophysiological
conduction blocks.
1.5. Definitions
Department of cardiology is one of the important unit in Bangalore Baptist Hospital. This
Unit mainly focuses and looks for the warning signals at an early stage of a disease when
there are no symptoms and thereby advice to prevent or reduce the intensity of future
health problems. It helps to avoid serious complications and improve quality of life. A
healthy individual is an asset to the society and to the nation
The theme behind the concept of cardiology “Organizational team- spirit in delivering
highest quality of clinical and nursing care through personalized service in utmost ethical
way” – binds all of us together. It is the spirit that is helping us to create a difference for all
our patients, their relatives and their friends who come to us.
Note* -For all the general nursing procedures refer OP- nursing department
operating manual as mentioned in the Annexure IV
3. CAG PROCEDURE
3.1. The groin area around the skin crease where the lower belly meets the upper thigh is cleaned
and shaved for use as a tiny portal of entry to the femoral artery. Alternatively, sometimes the
arm is used, either near the elbow crease (brachial artery) or near the wrist (radial artery).
3.2. Once in the catheterization laboratory (a.k.a. cath lab), the skin at the selected entry site is
numbed with an injection of local anesthetic. From this point forward, there should be no
pain.
3.3. A sheath (essentially just a small tube with a one-way Hemostatic [acting to stop bleeding]
valve on the back end to prevent blood from escaping as various catheters are sequentially
introduced) is inserted into the artery. The remainder of the procedure is performed through
the sheath. The hole in the skin is typically about half the diameter of a pencil.
3.4. A long thin hollow tube (catheter) is fed into the sheath and advanced to the heart using X-
ray guidance.
3.5. With the tip of the catheter in one of the arteries that supplies the heart muscle (coronary
artery), a special iodine solution (contrast) is injected while an x-ray image of the heart is
recorded. The contrast blocks x-rays and thus provides an outline image of the artery.
Multiple images are recorded from various “camera” perspectives.
3.6. This catheter is removed and the same procedures repeated for any additional arteries or
chambers that require angiography.
3.7. Certain other measurements, such as pressure recordings in various heart chambers are
typically also obtained.
3.8. Once all the required information is gathered, all catheters are removed and the sheath is
removed.
3.9. Bleeding is stopped either by holding firm pressure for a period of time, or by using a closure
device that either plugs, staples, or stitches the small hole in the artery.
3.10. PTCA – Procedure for PTCA will be the same as 3.1 through 3.5 and the following
addition:
3.10.1. Informed Consent is obtained for PCI
3.10.2. A guide catheter is used to cannulate the stenosed coronary artery.
3.10.3. The stenosis is wired and a balloon is passed over this wire and dilated. The balloon then
is removed and a stent is passed through the wire and deployed across the stenosis.
3.10.4. Angiographic views are obtained to check the patency of the vessel and the guide catheter
is removed. The sheath is sutured to the groin and the patient transferred to coronary care
unit.
3.11. PPI – Left Infra clavicular area is prepared and draped under sterile conditions. Local
anesthesia is administered and two inch incision is made. Subclavian vein is punctured
and a sheath introduced. A steroid eluting screw in atrial and ventricular tined lead is
anchored in the atrium and ventricle. The leads are then connected to the pacemaker on
completion of threshold test. The pocket is irrigated with antiboitic solution and the
wound is closed in two layers and the patient is transported to CCU.
3.12. IABP – Procedure for IABP will be the same as 3.1 through 3.5 and the following
addition:
3.12.1. Intraaortic balloon is advanced through the sheath and placed in the descending aorta
with the distal balloon placement being above the renal arteries. The pressure tubings are
connected to the arotic balloon and the pressure and ECG are monitored. The helium
tubing of the arotic balloon is connected to the helium port of the intraarotic balloon
pump. The balloon pump is then switched on in the auto ECG trigger mode in ratio of 1:1.
3.13. PTRA – Procedure for PTRA will be the same as 3.1 through 3.5 and the following
addition:
3.13.1. A renal guide catheter is advanced into the renal artery and angiographic views
obtained. The renal artery is then wired and a balloon is passed over the wire across the
stenosis and dilated. The balloon is removed and a stent is passed over the wire and the
lesion is stented. The catheters are removed and the sheath is sutured to the groin and
transported back to ICU.
3.14. PTPA/PTLICA/PTRICA/PTCCA-Procedure for all these are the same as 3.1 through 3.5.
3.15. IVCFI – The right femoral vein is punctured and a sheath is introduced. Contrast is
injected and a venogram is obtained. The renal veins are visualized. IVC filter is advanced
through the sheath and placed above the renal veins and deployed. Venogram is once again
obtained to check the position of IVC filter. The sheaths are removed and the patient is
transported back to medical ICU.
3.16. EQUIPMENT NECESSARY:
3.16.1. Guide wires
3.16.2. Sheaths
3.16.3. Manifolds
3.16.4. Pressure Tubings
3.16.5. Inflation devices.
3.16.6. Balloons
3.16.7. Angioplasty wires
3.16.8. Puncture needles
3.16.9. Y connectors
3.16.10.Injector Syringes
3.16.11.Diagnostic guiding catheter
3.16.12.IV Set
3.16.13.Betadine solution
3.16.14.Puncture needle
3.16.15.Blade No. 10 & 11
To protect the patient from overall radiation exposure, efforts are made for adequate
coning on the patients body.
4.6. Personnel shielding
Radiation exposure to occupational workers can be optimized by judicious applications of
time, distance, and shielding:
4.6.1. Personnel should remain in the radiation environment only when necessary.
4.6.2. The distance between the personnel and the patient should be maximized when
practical and while not interfering with work efficiency as the intensity of radiation
decreases as the square of distance (inverse square law).
4.6.3. Shielding apparel should be used as and when necessary which comprise of lead
aprons and thyroid shields.
4.6.4. The occupational workers must use monitoring devices such as Thermo luminescent
Dosimeter (TLD) and pocket dosimeters to record the exposure to radiations.
4.7. Lead aprons: Lead Aprons are shielding apparel for radiation workers. These aprons
protect an individual from radiation and should be worn by the employees as and when
required during the course of their work.
4.8. Thermoluminescent dosimeters (TLD’s): It is used to estimate the personal dose
equivalent for external occupationally exposed workers during their course of work. TLD’s
policies need to be in place for all occupationally exposed individuals. It is responsibility of
the employer to see that these rules are followed. The TLD’s should be worn over the
clothing.
4.9. Personnel Dosimetry: Personnel dosimetry refers to the monitoring of individuals who are
exposed to radiation during the course of their work. Personnel dosimetry policies need to
be in place for all occupationally exposed individuals. It is up to the employer to see that
these rules are followed. The data from the dosimeter are reliable only when the dosimeters
are properly worn, receive proper care, and are returned on time. Proper care includes not
irradiating the dosimeter except during occupational exposure and ensuring proper
environmental conditions.
levels and monitoring of the radiation protection program and regular educational activities
form an integral part of the responsibilities of the HOD and other administrative authorities
of the department/ hospital.
5.6.2. Application forms for TLD badges for staff identified by the RSO/ Dept
Head/Supervisor after completion will be sent to Avanttec Laboratories. A copy of the
application form will be filed with the RSO for reference.
5.6.3. Once the badges with name of the staff and TLD badge number are received from
Avanttec Laboratories, the same will be handed over to the respective staff and an
acknowledgment of the same will be documented in the application copy.
5.6.4. At the end of every quarter of a calendar year the badge shall be returned to the RSO
who in turn will send the badges to Avanttec laboratories for periodic dosage reports.
5.7. Over exposure:
5.7.1. As per the AERB regulatory limits, the effective dose for an individual staff shall not
exceed 20 mSv averaged over 5 consecutive years and any single year shall not exceed
30mSv. In case a staff receives a dosage reading of more than 10mSv in one quarter, it
will be considered as over exposure. In case of high dosage readings the RSO shall
inform the respective staff and head of the department/ supervisor. The staff is referred
for medical checkup followed by blood tests. In case of high blood counts the staff is
advised rest/transferred to an non radiation work area
5.7.2. The RSO shall examine the working conditions and the circumstances that might have
resulted in the above excessive exposure and report the details to RPAD,BARC within
15 days from the date of receipt of the dosage report.
5.7.3. A written statement from the staff, explaining the cause for the reported exposure shall
also be forwarded along with the RSO’s investigation report. This is to take preventive
steps to avoid such exposure in future.
5.8. Guidelines for using TLD badge
5.8.1. The TLD badges are to be worn at all times during working hours
5.8.2. TLD badges should be always worn at chest level.
5.8.3. If lead apron is used, TLD badge should be worn under the lead apron
5.8.4. After work hours the badges should be kept in the cupboards within the department. As
the badges measures occupational radiation exposure thus they should not be taken
home after work hours.
5.8.5. Ensure that the badge are not left in the radiation field or near hot plates, ovens,
furnaces, burners etc
5.8.6. Effectively use Time-Distance-Shielding principles (TDS)
5.8.7. TLD badges should not be exchanged amongst staff
5.9. Maintenance of Records
5.9.1. The dose records of all the staff is maintained by the RSO and a copy of the same is
distributed to each department supervisors every quarter.
5.9.2. A copy of the dosage report is issued to the staff leaving the organization and the TLD
number is also informed to the staff, if requested.
6.7. Preparation
6.7.1. Informed consent
6.7.2. Stop the betablocker prior to the TMT
6.7.3. Overnight fasting or 4 hour fasting prior to test.
6.7.4. Shaving of the chest with prior discussion with the patient.
6.8. Medications
6.8.1. All rate lowering drugs are stopped 48 hours prior to the test.
6.8.2. Other medications to be continued as usual.
6.9. Procedure
6.9.1. Explanation & demonstration to walk on tread mill.
6.9.2. The test is started as per desired protocol, commonly Bruce protocol will be used.
6.9.3. B.P. is checked in every stage & documented.
6.9.4. Chest is examined for rates.
6.9.5. CVS is examined for any murmur or third heart sound.
6.9.6. End point is achievement of age predicted target heart rate or reaching certain end
points.
6.10. Termination Of The Test
6.10.1. Severe fatigue or dyspnoea.
6.10.2. Ataxia.
6.10.3. Grade III/IV chest pain.
6.10.4. Ischemic ST depression >3.0mm
6.10.5. Ischemic ST elevation >1.0mm in Non Q leads.
6.10.6. Unsuspected appearance of VT.
6.10.7. Ectopic SVT.
6.10.8. Progressive reproducible decreased in SBP.
6.10.9. Abnormal high BP >250/120.
6.10.10.Decreasing heart rate.
6.11. Interpretation Of Test (Selzer’s)
6.11.1. Mildly Positive
6.11.2. HZ ST depression 1-1.5mm
6.11.3. J depression with slowly upslopping ST slope that remain depressed foe 1.5mm at J 60.
6.11.4. Moderately Positive
6.11.5. HZ ST depression 1.5-2mm
6.11.6. US ST depression >2.5mm at J 80
6.11.7. VPCs 15-20% of QRS over 1 sec at HR <130 bpm with ST ↓
6.11.8. DS ST depression with J ↓1-2mm.
6.11.9. Strongly Positive
6.11.10. DS ST depression with J ↓> 2mm.
6.11.11. HZ ST depression >2.5mm
6.11.12. DS or HZ ST depression in stage 1 or persisting beyond 8 min of recovery
6.11.13. Complex VPCs, Salvos, Runs of VT or VF.
6.11.14. Duke Score
6.11.15. EX Time – 5 x ST depression (max) – 4 x Angina Score
6.12. ANGINA INDEX
6.12.1. No Angina - 0
6.12.2. Typical Angina - 1
6.12.3. Angina requiring test termination - 2
6.12.4. Score 5 years survival
6.12.5. <-11 72%
6.12.6. >5 97%
8.6.4. Patient’s resting heart rate and blood pressures are being monitored.
8.6.5. Two dimensional echocardiographic cine views are obtained in the parasternal long
axis/short axis and four chambers views.
8.6.6. Dobutamine IV is started at 4mcg/kg/min for 3 minutes and two dimensional
echocardiographic views are obtained. Increase dobutamine drip every 3 minutes by
4mcg/kg/min until the patient reaches THR.
8.6.7. Vitals signs are monitored at the end of every stage. Every stage is consisted of 3
minutes.
8.6.8. When the patient reaches THR, the dobutamine drip is stopped. Patient is monitored
for 5 minutes until recovery.
8.7. Equipment necessary:
Echo Machine, IV cannula
8.8. Medications
Dobutamine IV, Atropine IV
abnormalities in the pattern of blood flow such as showing the backward flow of blood
through heart valves.
9.5. Definitions and Abbreviations:
Echocardiogram–(Echo): Echocardiography is a diagnostic test that uses ultrasound
waves to produce an image of the heart muscle and the heart's valves.
Procedure
9.5.1. Patient is positioned on the table (lies on his/her left side)
9.5.2. Transthoracic probe with ultrasound jelly is placed on the patient’s chest and two
dimensional views are obtained in the parasternal long axis/short axis and four
chambers views.
9.5.3. Measurements are made of the heart’s structure in the M mode.
9.5.4. The valves leakages and blood velocities are measured by color and pulse/continuous
doppler. Ejection fraction of the heart is calculated.
9.5.5. The various technical assessments made are .
a. M-mode assessment.
b. 2D assessment.
c. Doppler assessment.
d. Color Doppler assessment.
e. Contrast ECHO in selected cases.
f. Tissue Doppler assessment.
9.6. Equipment necessary:
Echo Machine
10.6. Procedure:
10.6.1. Prepare patient by making sure that he/she has a patent IV line, assist patient into a
supine position
10.6.2. Apply the EKG leads to the patient and turn on the defibrillator monitor.
10.6.3. Keep defibrillator paddle on the patient’s chest, one on the right chest wall and the
other on the apex.
10.6.4. Turn the monitor machine onto synchronize mode then print an initial strip
10.6.5. Administer proprofol medication or drug of choice per physician’s instruction when
ready and have patient count backward starting from 100 after administration of
sedation medication.
10.6.6. Shock patient with 200J once the patient loses conscious and everyone is clear and
deliver the shock to the patient.
10.6.7. Print EKG strip if patient converted; If patient is not converted after the initial shock,
may deliver the second shock per Physician’s order.
10.7. Equipment necessary: Biphasic Defibrillator
10.8. Medication such as : Propofol
tilt table. It is then tilted upright to a 60-80 degree vertical angle for approximately 45
minutes.
13.5.4. Patient is instructed to limit the movement of his/her legs and not to shift his/her
weight during the test. Patient will also be asked to describe any symptoms he/she
may be experiencing during the test.
13.5.5. If after 45 minutes if patient has not experienced syncope, a medication, usually
Isoproterenol/ Isuprel or sublingual nitroglycerin is administered while he/she is
tilted again, for up to another 45 minutes while patient’s heart rate and blood
pressure continue to be monitored.
13.5.6. If patient faints during the test, the table will be returned to a flat (horizontal)
position and vital signs are being monitored at regular intervals. Recovery is usually
immediate.
13.6. Typical symptoms of vasovagal or neurocardiogenic syncope includes:
13.6.1. Nausea
13.6.2. Sweatiness
13.6.3. Pallor
13.6.4. Light headedness
13.6.5. Sensation of palpitations
13.6.6. Near-fainting
13.6.7. Fainting
13.7. Equipment necessary:
13.7.1. Tilt Table
13.7.2. IV Cannula
13.7.3. Arterial line
13.7.4. Bedside Monitor
14.1. Imaging Results for various procedures are available within a definite Time Frame
14.2. Coronary Angiogram / Angioplasty Reports /CD : The turnaround time for patients
undergoing Catheterization procedures is 5 hours, which includes from the time the
patient arrives to the Catheterization laboratory till the Angiographic reports / CD are
dispatched to the patient..
14.3. Echocardiographic / TMT Reports – 10 Minutes from the completion of the procedure.
14.4. Holter Monitoring : 24 hours from the time of disconnection of Holter monitor.
15.1. All used catheterization hardware are washed with water, flushed with hydrogen peroxide
and immersed in hydrogen peroxide for 30 minutes.
15.2. After 30 minutes all hardware are once again washed with running water.
15.3. Compressed air is used to clear the water particles.
15.4. Hardware are then packed and sealed in steribag and sent for Ethylene oxide sterilization.
15.5. The labeling of single use and second use marked on the catheter hub.
15.6. The date is marked on the steribag in for six months.
15.7. Hardwares are then packed and sealed in covers and sent for Ethylene Oxide sterilization.
15.8. Documentation of reuse catheters done.
16.5.3. During the transportation of unstable cardiac patients, the family members shall be
appropriately informed of risks involved and their consent shall be sought.
16.5.4. During transportation of unstable cardiac patients, appropriately qualified and trained
staff as follows shall accompany the patient.
a. A qualified Physician with BCLS/ACLS training.
b. A qualified nurse with BCLS.
16.6. Inter facility transfer of cardiac patients:
16.6.1. Patients may be referred to other hospital when the patient needs a diagnostic or
therapeutic service not available in the hospital.
16.6.2. The treating doctor shall be responsible for making decisions regarding patient
referral to outside facilities.
16.6.3. The summary of the patient’s condition and the treatment under taken in the hospital
shall be documented in the specified form form.
16.6.4. While shifting the patient to the outside facility, the procedure for transfer of stable
and unstable patients shall be complied with.
16.6.5. All preventive measures and necessary precautions shall be taken to avoid risks/
complications during shifting.
16.6.6. When the patient is refereed to another hospital, the medical record shall contain the
date & time of referral, the reason for the referral and the name of the receiving
hospital.
16.6.7. The duplicate copy of the inter facility transfer form or referral letter shall be pasted
in the patient’s medical record for future reference.
16.6.8. The treating doctor shall decide the type of ambulance; the equipments needed en-
route & personnel who should accompany the patient based on the patient’s
condition.
16.7. Intra hospital transfer of patients:
16.7.1. Patients shall be transferred from one department or unit to another as appropriate to
meet patient needs. Patient transfer shall be considered when there is a change in the
condition of the patient which might require a different setting (i.e. Intensive
18.1. Purpose: To define the process for ECHO procedure for IP and OP patients
18.2. Scope: All IP and OP patients advised for ECHO test
18.3. Responsibility: Doctor/ Nurses/Nursing Aides
18.4. Procedure
18.4.1. Out patient:
a. Any patient advised for ECHO test should have the requisition slip duly filled by
the treating Doctor with patient details (Name, Hosp. Number and/or Barcode) and
the clinical data.
b. The patient /attendant is instructed to take appointment from ECHO room in
cardiology OPD ( second floor) .
c. The staff in ECHO room shall gives appointment date and time.
d. On the day of the procedure, patient shall make payment and report to ECHO room
with the paid receipt.
e. Prior to the procedure the staff in ECHO room shall receive the paid receipt from
the patient, confirm the identity by calling out the patient name written on the
requisition slip and shall confirm the name and hospital number against the
requisition slip with the FOB/Shepherd Card which the patient holds.
f. After confirming the identity of the patient, the patient is called inside the ECHO
room and the nurse shall explain the procedure to the patient & provide privacy.
g. Incase of a female patient, the nurse shall inform that the procedure will be
performed by the male doctor.
h. Name of the patient, hospital number and gender will be entered in the computer by
the doctor performing the procedure. The doctor shall confirm the patient name and
hospital number match with the details on the requisition form prior to printing of
the report.
i. The ECHO room staff shall confirm that the patient name and hospital number match
with the details on the requisition slip.
j. At the time of dispatch the staff shall confirm the patient identity as mentioned in
point No.5.
k. The date, time and name of the staff dispatching and the date, time and name of
person receiving the report is entered in the register for ECHO procedure.
18.4.2. Inpatient:
a. The ECHO request is filled by treating doctor in the ward.
b. The assigned nurse from the ward shall send the requisition slip duly filled in by the
treating doctor to the ECHO room.
c. The staff in the ECHO room shall call the respective ward for the procedure
according to the appointment time.
d. Incase of requiring emergency ECHO, it will be written on the requisition slip and
the patient will be called in immediately.
e. The patient shall be shifted to ECHO room in a trolley / wheelchair only.
f. The ECHO staff shall confirm the name and hospital number on the requisition slip
match with the details on identification band and the summary sheet in the patient
file.
g. After confirming the identity of the patient, the patient is called inside the ECHO
room and the nurse shall explain the procedure to the patient & provide privacy.
h. Incase of a female patient, the nurse shall inform that the procedure will be
performed by the male doctor.
i. Name of the patient, hospital number and gender will be entered in the computer by
the doctor performing the procedure. The doctor shall confirm the patient name and
hospital number match with the details on the requisition form prior to printing of the
report.
j. The ECHO room staff shall confirm that the patient name and hospital number match
with the details on the requisition slip.
k. At the time of dispatch the staff shall confirm the patient identity as mentioned in
point No.5.
l. The date, time and name of the staff dispatching and the date, time and name of
person receiving the report is entered in the register for ECHO procedure.
19.2. Forms
19.2.1. Electro Cardio Graph Requisition & Report (cardiology) F/CAR/01
Signature: Signature:
Annexure I
A. Role of Consultant
Cardiologist – responsibilities include: explaining risks of procedure, obtaining, performing
catheterization procedure safely
B. Role of Cath Lab Technician
1. Switching on the x-ray equipments
2. Ensuring that the radiation safety norms are followed by all the personnels such as wearing
of lead aprons/thyroid shields, Dosimeters and ensuring that all personnels stay clear of x-ray
tubes.
3. Entering patient’s details into the archiving systems.
4. Angulating the cath machine and panning the cath table for obtaining angiographic views
from different angles.
5. Performing QCA (measuring the stenosis length and diameter digitally) analysis.
6. Interrogating pacemakers telemetrically
7. Archiving the digital angiographic imagines and transfer of angiographic data into CDs in
Dicom format/laser prints.
C. Role of Nurse
1. Placing patient on cath table, monitoring ECG and vital signs.
2. Reassuring the patient such as teaching patient to take deep breath and hold and cough when
necessary.
3. Ensuring that the patient has a patent IV line and administering medications as and when
needed.
4. Preparing patient for cath procedure such as exposing, prepping patient’s groin or brachial
site.
5. Flushing all catheter tubes and other angiographic hardwares with heparinized saline, and
setting trolley for angiographic procedure.
6. Removing of sheath/obtaining hemostasis, and ensuring pedal pulses and monitoring vital
signs.
Annexure II
Organogram
Director
CCU Consultant
Incharge Nurse
Team leader