CARDIO INVASIVE DIAGNOSTIC TESTS

INTRODUCTION

 Cardiac diseases are complex in nature

 New and advanced diagnostic tests and tools are constantly being introduced
 Involves tests used both inside and outside of body
 Comprehensive in nature
 Simplified the diagnosis of complex cardiac diseases

TYPES OF CARDIAC TESTS:-

 NON INVASIVE TESTS

 INVASIVE/INTERVENTIONAL TESTS

 Non invasive tests:-

1. Blood Tests
2. Carotid & Extremity Vascular Testing
3. CAT Scans
4. Echocardiography
5. Electrocardiograms (EKG)
6. Holter and Event (Loop) Monitoring
7. Exercise Stress Tests
8. MRIs
9. Nuclear Cardiology Tests
10. VO2 Max Study
11. Blood tests:-
 Antistreptolysin-O test
 Arterial blood gases
 Blood fat profile
 Blood calcium test
 BNP blood test
 C-reactive protein test
 Carbon dioxide content.
 Complete blood count
 Electrolyte panel
 Erythrocyte sedimentation rate (ESR)
 Cardiac enzyme tests
 Glucose test.
 INR/prothrombin time tests
 Serum myoglobin test.
 Total serum protein
 Waste products test
 INVASIVE TESTS:-
1. Cardiac Catheterization
 2. Cardiac Biopsy
3. Electrophysiology Studies (cardiac mapping
4. Hemodynamic monitoring
5. Transesophageal Echocardiography(TEE)
6. Angiography

1. CARDIAC CATHETERIZATION:-

 History:- Coronary catheterization was further explored in 1929 when the German
physician Werner Forssmann inserted a plastic tube in his cubital vein and guided it to the right
chamber of the heart. He took an x-ray to prove his success and published it on November 5 1929
with the title "Über die Sondierung des rechten Herzens" (About probing of the right heart). The
coronarography of the left heart was introduced in 1953 with the report by a Portuguese group,
published in Cardiologia

 INTRODUCTION:-
 Test in which catheters (hollow tubes) are placed into the heart in order to evaluate the
anatomy and function of the heart and surrounding blood vessel.
 Insertion of catheter into heart and surrounding vessels to obtain detailed information
about the structure and performance of heart valves and circulatory system.
 Characteristics
 Performed in cardiac laboratory and special examination table.
 Local anesthesia is given ,and catheter is inserted into blood vessels.
 SITES OF INSERTION

 Groin
 Inner bend of the elbow
 Wrist (palm side)
 Neck

 GOALS

 Confirm the presence of a suspected heart ailment eg.stenosis,congenital heart failure etc.
 Quantify the severity of the disease and its effect on the heart
 Seek out the cause of a symptom such as shortness of breath or signs of cardiac insufficiency
 Make a patient assessment prior to heart surgery.

 INDICATIONS:-
 Confirm a diagnosis of heart disease & determine the extent to which disease has
affected structure & function of the heart.
 Determine congenital abnormalities.
 Obtain a clear picture of cardiac anatomy before heart surgery.
 Measure blood oxygen concentration, tension & saturation within heart chambers.
 To determine cardiac output.
 To perform angiography for better coronary artery visualization
 To obtain endocardial biopsies.
 To allow fibrinolytic agents directly into an occluded coronary artery in the hope that
coronary blood flow may be restored.
 There is continuous monitoring of ECG during procedure.

 RISKS
 Minor bleeding at the site of catheter insertion.
 Temporary heart rhythm disturbances caused by the catheter irritating the heart muscle.
 Temporary changes in the blood pressure.
 Cardiac tamponade, sudden blockage of a coronary artery.
 Stroke
 Clot may formation may be there which can be prevented by administering moderate
amount of anticoagulant (4000 to 5000 units of heparin).
 Patient may feel anginal pain.Pain occurs when contrastt dye replaces the blood flowing
through coronary arteries under study.
 Clients may have an allergic reaction to the iodine based contrast media.symptoms of
allergy include flushing, nausea & vomiting.

 How is the Test Performed?

 You will be given a mild sedative before the test to help you relax. An intravenous (IV)
line is inserted into one of the blood vessels in your arm, neck, or groin after the site has
been cleansed and numbed with a local numbing medicine (anesthetic).
 A catheter is then inserted through the IV and into your blood vessel. The catheter is
carefully threaded into the heart using an x-ray machine that produces real-time pictures
(fluoroscopy). Once the catheter is in place, your doctor may:-

 Collect blood samples from the heart

 Measure pressure and blood flow in the heart's chambers and in the large arteries around
the heart
 Measure the oxygen in different parts of your heart
 Examine the arteries of the heart with an x-ray technique called fluoroscopy (which gives
immediate, "real-time" pictures of the x-ray images on a screen and provides a permanent
record of the procedure)
 Perform a biopsy on the heart muscle

 Nursing Assessment& Intervention:-

Before cardiac catheterization , the patient must be physically & emotionally prepared.
Major steps in preparation are as follows………
 Explain the procedure , its purposes & its hazards.
 Take consent from patient after giving information regarding procedure.
 Take history for any allergy ,particularly to iodine containing substances.
 Solid food must be with held for 6 to 8 hours & liquids for at least 4 hours before the
procedure to prevent vomiting & aspiration.
 Record height & weight of patient for calculating the amount of dye to be administered.
 Prescribed medications like sedative should be administered.
 Insertion site is prepared by shaving & cleansing it with an antiseptic solution.
  The peripheral pulses must be marked distal to probable cannulation site with felt tipped
pen.

 Care after cardiac Catheterization:-

 Vital signs must be assessed every 15 minutes for 1 hour, every 30 minutes for 2 hours .
 Extremity in which catheter is inserted must be kept straight for 4 to 6 hours after
procedure.
 The pressure dressing over the puncture site must be checked for intactness & for
evidence of bleeding.
 The pulse , color , warmth and sensation of extremity distal to insertion site must be
checked & documented every 30 minutes during the first hour.
 Cardiac rhythm must be monitored.
 Fluid intake should be encouraged for elimination of contrast medium.
 Observe for signs of hypersenstivity like nausea, vomiting.
 Sometimes cardiac catheterization is an emergency procedure & not an elective. In this
case the procedure ends with cardiac surgery or angioplasty. The nurse must provide
motional support to patient .

2. CARDIAC BIOPSY:-

INTRODUCTION:-

 A cardiac biopsy is a procedure to take samples of heart tissue for evaluation.

 It is a outpatient procedure.

Cardiac biopsy is presently the only reliable means of diagnosing heart rejection. It is performed
at regular intervals after surgery, at occasional times when rejection is suspected, and to assess
the adequacy of anti-rejection therapy.

When a small piece of heart muscle tissue is needed for examination, a heart biopsy can be
performed. A catheter is carefully threaded into an artery or vein to gain access into the heart. A
bioptome (catheter with jaws in its tip) is then introduced. Once the bioptome is in place, three to
five small pieces of tissue from the heart muscle are removed.

INDICATIONS

 After a heart transplant, to check for rejection of your new heart.

 If a patient has a cardio-myopathy,it is done to find the cause
 The test is performed routinely after heart transplantation to detect potential rejection.
 It may also be performed when cardiomyopathy, myocarditis, cardiac amyloidosis, or
other disorders are suspected.

PROCEDURE:-
The procedure is done in the operating room or cardiac cath lab. It is most often done by
inserting the biopsy instrument (called a bioptome) through a small incision in the skin on the
right side of the neck.

Under fluoroscopy, the bioptome will be guided through the jugular vein and into the right
ventricular chamber of the heart. The jaws of the instrument are opened and closed, and a small
piece of tissue is snipped off and removed. Four or five separate pieces are needed for adequate
sampling. The procedure ordinarily takes about 30 minutes and is done with a local anesthetic at
the site where the bioptome is inserted.

In some patients the jugular vein is not accessible, and the bioptome must be inserted from the
femoral vein in the groin area, instead of the neck.
Following the biopsy, you will be asked to keep your head upright to avoid increased pressure in
the jugular vein which could result in bleeding at the site of biopsy. After the biopsy, your neck
area will be observed for bleeding and gentle pressure applied. You should notify the nurses or
physician if you experience either bleeding or swelling. This rarely occurs and is usually
controlled readily with additional light pressure.

Shortness of breath or unusual chest pain immediately after a biopsy may be signs of a
complication and should be reported promptly. If the femoral approach is used, you will be asked
to lie on your back with your leg straight for an hour after the procedure.

Biopsy specimens are examined under the microscope for signs of rejection and take one day to
process. You will receive the results of the biopsy the next day and be advised about the need for
any changes in your medication regimen based on the results. An echocardiogram is done with
each heart biopsy to assess ventricular function and is used in conjunction with the heart biopsy
to determine a treatment regimen.

3. ELECTROPHYSIOLOGY STUDY:-
A test in which insulated electric catheters are placed inside the heart to study the heart's
electrical system.

An electrophysiology study (EPS) of the heart is a test performed to analyze the electrical
activity of the heart. The test uses cardiac catheters and sophisticated computers to generate
electrocardiogram (EKG) tracings and electrical measurements with exquisite precision from
within the heart chambers.
Purpose

An EPS can be performed solely for diagnostic purposes or to pinpoint the exact location of
electrical signals (cardiac mapping) in conjunction with a therapeutic procedure called catheter
ablation (tissue removal). A cardiologist may recommend an EPS when the standard EKG,
Holter monitor, event recorder, stress test , echocardiogram, or angiogram cannot provide
enough information to evaluate an abnormal heart rhythm (arrhythmia).

An EPS offers more detailed information about the heart's electrical activity than many other
noninvasive tests because electrodes are placed directly on heart tissue. This placement allows
the electrophysiologist to determine the specific location of an arrhythmia and, often, to correct it
during the same procedure. This corrective treatment is considered a permanent cure; in many
cases, the patient may not need to take heart medications.

EPS may be helpful in assessing:

 certain tachycardias (fast hearbeats) or bradycardias (slow heartbeats) of unknown cause

 patients who have been resuscitated after experiencing sudden cardiac arrest
 various symptoms of unknown cause, such as chest pain, shortness of breath, fatigue, or
syncope (dizziness/fainting)
 response to anti-arrhythmic therapy

Indications

 Heart rhythm disorders.

 Patient at a risk of sudden cardiac death.
 Evaluate the effectiveness of certain medications.
 Predict the risk of a future cardiac event.
 Assess the need for an implantable device (pacemakers) or treatment procedures

Precautions

 Pregnant patients should not undergo EPS because the study requires exposure to
radiation, which may harm the growing baby.
  Patients who have coronary artery disease may need to be treated prior to EPS. EPS is
contraindicated in patients with an acute myocardial infarction, as the infarct may be
extended with rapid pacing.

 The test is also contraindicated for patients who are uncooperative.

PROCEDURE:-

To undergo EPS, the patient is placed on a table in the EPS lab and connected to various
monitors. Sterile technique is maintained. A minimum of two catheters are inserted into the right
femoral (thigh) vein in the groin area. Depending on the type of arrhythmia, the number of
catheters used and their route to the heart may vary. For certain tachycardias, two additional
catheters may be inserted in the left groin and one in the internal jugular (neck) vein or in the
subclavian (below the clavicle) vein. The catheters are about 0.08 in (2 mm) in diameter, about
the size of a spaghetti noodle. The catheters used in catheter ablation are slightly larger.

With the help of fluoroscopy (x rays on a television screen), all catheters are guided to several
specific locations in the heart. Typically, four to 10 electrodes are located on the end of the
catheters, which have the ability to send electrical signals to stimulate the heart (called pacing)
and to receive electrical signals from the heart, but not at the same time (just as a walkie-talkie
cannot send and receive messages at the same time).

First, the electrodes are positioned to receive signals from inside the heart chambers, which
allows the doctor to measure how fast the electrical impulses travel in the patient's heart at that
time. These measurements are called the patient's baseline measurements. Next, the electrodes
are positioned to pace. That is, the EPS team tries to induce (sometimes in combination with
various heart drugs) the arrhythmia that the patient has previously experienced so the team can
observe it in a controlled environment, compare it to the patient's clinical or spontaneous
arrhythmia, and decide how to treat it.

Once the arrhythmia is induced and the team determines that it can be treated with catheter
ablation, cardiac mapping is performed to locate the precise origin and route of the abnormal
pathway. When this is accomplished, the ablating electrode catheter is positioned directly against
the abnormal pathway, and high radio-frequency energy is delivered through the electrode to
destroy (burn) the tissue in this area.

Diagnosis/Preparation:-

The following preparations are made for an EPS:

 Blood tests usually are ordered one week prior to the test.
 The patient may be advised to stop taking certain medications, especially cardiac
medications, that may interfere with the test results.
 The patient fasts for six to eight hours prior to the procedure. Fluids may be permitted
until three hours before the test.
 The patient undergoes conscious sedation (awake but relaxed) during the test.
 A local anesthetic is injected at the site of catheter insertion.
 Peripheral pulses are marked with a pen prior to catheterization. This permits rapid
assessment of pulses after the procedure.

Aftercare:-

The patient needs to rest flat in bed for several hours after the procedure to allow healing at the
catheter insertion sites.

The patient often returns home either the same day or the next day. Someone should drive the
patient home.

To minimize bleeding and pain, the patient is advised to keep the extremity in which the catheter
was placed immobilized and straight for several hours after the test.

Risks:-

EPS and catheter ablation are considered low-risk procedures. There is a risk of

 bleeding and/or infection at the site of catheter insertion.

 Blood clot formation may occur and is minimized with anticoagulant medications
administered during the procedure.
  Vascular injuries causing hemorrhage or thrombophlebitis are possible.

 Cardiac perforations are also possible.

 If the right internal jugular vein is accessed, the potential for puncturing the lung with
the catheter exists and could lead to a collapsed lung.

Because ventricular tachycardia or fibrillation (lethal arrhythmias) may be induced in the patient,
the EPS lab personnel must be prepared to defibrillate the patient as necessary.

Patients should notify their health care provider if they develop any of these symptoms:

 numbness or tingling in the extremities

 heavy bleeding
 change in color and/or temperature of extremities
 loss of function in extremities

Normal results

Normal EPS results show that the heart initiates and conducts electrical impulses within normal
limits.

Abnormal results include confirmation of arrhythmias, such as:

 supraventricular tachycardias
 ventricular arrhythmias
 accessory pathways
 bradycardias

4. TRANSESOPHAGEAL ECHOCARDIOGRAPHY:-

TEE is an invasive test that gives a higher quality of picture than does a regular echocardiogram.
It is especially useful in clients who have thickened lung tissue or thick chest walls or who are
obese.

Procedure:-
The client lies on bed with ECG leads attached.ECG and BP are monitored. The throat is
anesthetized and sedation is given. An esophageal scope is inserted through the mouth and
passed into esophagus by physician. Because the probe is placed behind the heart , it allows the
left atrium to be viewed. TEE allows clear visibility of heart and its structures and is most useful
inn diagnosis of cardiac masses, prosthetic valve function and aneurusm.

5. HEMODYNAMIC MONITORING:-
Introduction:-
 Swan-Ganz catheter has been in use for almost 30 years
 Initially developed for the management of acute myocardial infarction
 Now, widespread use in the management of a variety of critical illnesses and surgical
procedures

PURPOSES OF INVASIVE HEMODYNAMIC MONITORING:-

 Early detection, identification, and treatment of life-threatening conditions such as heart

failure and cardiac tampanade
 Evaluate the patient’s immediate response to treatment such as drugs and mechanical
support
 Evaluate the effectiveness of cardiovascular function such as cardiac output and index

INDICATIONS FOR HEMODYNAMIC MONITORING:-

 Any deficit or loss of cardiac function: such as AMI,CHF,Cardiomyopathy

 All types of shock;cardiogenic,neurogenic,or anaphylactic
 Decreased urine output from dehydration, hemorrhage,G.I. bleed,burns,or surgery

COMPONENTS OF A PULMONARY ARTERY CATHETER:-

 Normally has four[4] ports

 Proximal port – [Blue] used to measure central venous pressure/RAP and injectate port
for measurement of cardiac output
 Distal port – [Yellow] used to measure pulmonary artery pressure
 Balloon port – [Red] used to determine pulmonary wedge pressure;1.5 special syringe is
connected
  Infusion port – [White] used for fluid infusion

COMPONENTS OF THE MONITORING SYSTEM:-

 Bedside monitor – amplifier is located inside. The amplifier increases the size of signal
 Transducer – changes the mechanical energy or pressures of pulse into electrical energy;
should be level with the phlebostatic axis[ you can estimate this by intersecting lines from
the 4th ICS,mid axillary line
 Recorder – please record information

POSSIBLE COMPLICATIONS:-

 Increased risk of infections – same as with any central venous lines—use occlusive
dressing and Biopatch to prevent
 Thrombosis and emboli-- air embolism may occur when the balloon ruptures, clot on
end of catheter can result in pulmonary embolism
 Catheter wedges permanently—considered an emergency, notify MD immediately, can
occur when balloon is left inflated or catheter migrates too far into pulmonary artery (flat
PA waveform)…can cause pulmonary infarct after only a few minutes!
 Ventricular irritation – occurs when catheter migrates back into RV or is looped
through the ventricle, notify MD immediately…can cause VT

TROUBLESHOOTING:-

 Dampened waveform –can occur with physical defects of the heart or catheter; can be
caused by kinks, air bubbles in the system, or clots

Solution: Check your line for kinks & air bubbles, aspirate (not flush) for clots,
straighten out tubing or patient as much as possible

 No waveform – can occur with non-perfusing arrhythmias or line disconnection

Solution: Check your line for disconnection, check your patient for pulse, could also
be wet transducer or broken cable or box

EQUIPMENT NEEDED:-
SET-UP FOR HEMODYNAMIC PRESSURE MONITORING
1. Obtain Barrier Kit, sterile gloves, Cordis Kit and correct swan catheter. Also need extra IV
pole, transducer holder, boxes and cables.
2. Check to make sure signed consent is in chart, and that patient and/or family understand
procedure.
3. Everyone in the room should be wearing a mask!
4. Position patient supine and flat if tolerated.
5. On the monitor, press “Change Screen” button, then select “Swan Ganz” to allow physician
to view catheter waveforms while inserting.
6. Assist physician (s) in sterile draping and sterile setup for cordis and swan insertion.
7.Set up pressure lines and transducers. Please level pressure flush monitoring system and
transducers to the phlebostastic axis. Zero the transducers. Also check to make sure all
connections are secure.
8. Connect tubings to patient [PA port and CVP port] when physician is ready to flush the
swann. Flush all ports of swann before inserting.
9. While floating the swann, observe for ventricular ectopy on the monitor, and make physician
aware of frequent PVC’s or runs of VT !
10. After swann is in place, assist with cleanup and let patient know procedure is complete.
11. Obtain your RA [CVP], PAS/D, PAM, and wedge. For Cardiac Outputs, inject 10 mLs of
D5W after pushing the start button, repeat X 3. Delete outputs not within 1 point of the mean
value. Can use .9NS instead, but affects the accuracy of the output reading.
12. Before obtaining the cardiac output, please check the computation constant [should read
0.692 for regular yellow swans; 0.692 for SVO2 or blue swanns]
13. Perform hemocalculations (enter today’s height and weight).
14. Document findings on the ICU flowsheet.

Central Venous Pressure (CVP)

 Zero transducer to the patient’s phlebostatic axis

 Always read CVP at end expiration
 CVP is a direct measurement of right ventricular end diastolic pressure

Right Ventricular Waveform

  If the swan falls or gets pulled back into the RV it is considered a swan emergency.
 If you see an RV waveform (looks like VT) pull the swan immediately.
 If the swan remains in the RV it may cause the patient to go into VT.

Pulmonary Capillary Wedge Pressure (PCWP)

 Zero the transducer to the patient’s phlebostatic axis.

 Measure the PCWP at end expiration
 PCWP should not be higher than PA diastolic
 PCWP is an indirect measurement of left ventricular end diastolic pressure.

Cardiac Output

 It is the amount of blood pumped by the heart in one minute.

 Calculated by multiplying heart rate times stroke volume.
 Cardiac Index is the cardiac output adjusted for body surface area.

How to read a PA waveform

 Measured at end expiration!

 Dicrotic notch (closure of PulmonicValve) should always be on

Right side of wave (if notch on Left side find out if the tip in the RV)

 Measure PAS at the top of the wave upslope (at end of QRS);

PAD is measured at the trough preceding the systolic peak

(be careful not to measure whip in the wave)

How to read a PCWP (aka wedge)

 Measured at end expiration!

 After balloon is inflated, compare waveform to respiratory waveform to determine
measurement at the end of expiration. (last clear wave before patient inspires)
  Tip: if waveform is difficult to read, try resting hand on pt’s chest as you wedge;
determine where the end of expiration occurs on the wedge waveform, then measure
across several waves for consistency

Documentation

 Document PAS, PAD, and PCWP on nursing flowsheet under Hemodynamic Parameters
 PCWP will rarely be > PAD (if so, means blood is flowing backwards) If PCWP =
PAD, look for tamponade
 Under circumstances where the catheter will not wedge (or should not be), do not
document any values in the PCWP column on the flowsheet
 If you use the PAD measurement for calculations, it is acceptable to write ONLY

“PAD value used for calculations” at the top of your numbers .

6. ANGIOGRAPHY:-
Angiography or arteriography is a medical imaging technique used to visualize the
inside, or lumen, of blood vessels and organs of the body, with particular interest in
the arteries, veins and the heart chambers. This is traditionally done by injecting a radio-
opaque contrast agent into the blood vessel and imaging using X-ray based techniques such
as fluoroscopy. 

History:-
 The word itself comes from the Greek wordsangeion, "vessel", and graphein, "to write or
record". The film or image of the blood vessels is called an angiograph, or more commonly,
an angiogram. The technique was first developed in 1927 by the Portuguese physician and
neurologist Egas Moniz at the University of Lisbon to provide contrasted x-ray cerebral
angiography in order to diagnose several kinds of nervous diseases, such as tumors, coronary
heart disease and arteriovenous malformations. He is usually recognized as one of the pioneers in
this field. Moniz performed the first cerebral angiogram in Lisbon in 1927, and Reynaldo Cid
dos Santos performed the first aortogram in the same city in 1929. With the introduction of
the Seldinger technique in 1953, the procedure became markedly safer as no sharp introductory
devices needed to remain inside the vascular lumen.
 Procedure:-
This procedure involves intravenous injection of contrast medium into the heart during cardiac
catheterization . immediately after the injection , a series of X-ray film are taken that reveal the
course of contrast medium as it circulated through the heart, lungs, great vessels.
Coronary angiography involves injecting contrast medium into coronary arteries directly during
cardiac catheterization.

USES:-
1. Coronary angiogram:-
One of most common angiograms performed is to visualize the blood in the coronary arteries. A
long, thin, flexible tube called a catheteris used to administer the x-ray contrast agent at the
desired area to be visualized. The catheter is threaded into an artery in the forearm, and the tip is
advanced through the arterial system into the major coronary artery. X-ray images of the
transient radiocontrast distribution within the blood flowing within the coronary arteries allows
visualization of the size of the artery openings. Presence or absence
ofatherosclerosis or atheroma within the walls of the arteries cannot be clearly determined.
2. Microangiography
Microangiography is commonly used to visualize tiny blood vessels.
3. Neuro-vascular angiography
Another increasingly common angiographic procedure is neuro-vascular digital subtraction
angiography in order to visualise the arterial and venous supply to the brain. Intervention work
such as coil-embolisation of aneurysms and AVM gluing can also be performed.
4. Peripheral angiography
Angiography is also commonly performed to identify vessel narrowing in patients with leg
claudication or cramps, caused by reduced blood flow down the legs and to the feet; in patients
with renal stenosis (which commonly causes high blood pressure) and can be used in the head to
find and repair stroke. These are all done routinely through the femoral artery, but can also be
performed through the brachial or axillary (arm) artery. Any stenoses found may be treated by
the use of atherectomy.
5. Other
Other angiographic uses include the diagnosis of retinal vascular disorders, such as diabetic
retinopathy and macular degeneration.
COMPLICATIONS:-
1. Coronary angiography
Coronary angiographies are common and major complications are rare. These include Cardiac
arrhythmias, kidney damage, blood clots (which can cause heart attack or
 stroke),hypotension and pericardial effusion. Minor complications can
include bleeding or bruising at the site where the contrast is injected, blood vessel damage on the
route to the heart from the catheter (rare) and allergic reaction to the contrast.
2. Cerebral angiography
Major complications in Cerebral Angiography are also rare but include stroke,
an allergic reaction to the anaesthetic other medication or the contrast medium, blockage or
damage to one of the access veins in the leg
or thrombosis and embolism formation. Bleeding or bruising at the site where the contrast is
injected are minor complications, delayed bleeding can also occur but is rare.
BIBLIOGRAPHY:-

1. Grubb, Blair P., and Brian Olshansky. Syncope: Mechanisms and Management. Armonk, NY: Futura
Publishing, 1997.

2. Hummel, J. D., S. J. Kalbfleisch, and J. M. Dillon. Pocket Guide for Cardiac

Electrophysiology. Philadelphia: W. B. Saunders Co., 1999.

3. Josephson, M. E. Clinical Cardiac Electrophysiology: Techniques and Interpretations. Philadelphia:

Lippincott Williams & Wilkins Publishers, 2001.

4. Pagana, Kathleen D., and Timothy J. Pagana. Diagnostic Testing and Nursing Implications. 5th ed. St.
Louis: Mosby, 1999.
5. Joyace M.Black, medical –surgical nursing. 2009

PERIODICALS
1. asirvatham, s. j., c. j. bruce, and p. a. friedman. "advances in imaging for cardiac electrophysiology."
coronary artery disease 14 (february 2003): 3–13.
2. binah, o. "cytotoxic lymphocytes and cardiac electrophysiology." journal of molecular and cellular
cardiology 34 (september 2002): 1147–1161.

NET:-
 New York Times
 Familydoctor.org
 emedicine.medscape.com
 Currentnursing.com
SEMINAR
ON
CARDIAC
INVASIVE
 DIAGNOSTIC
TESTS

Submitted to: Submitted

by:
Mr.Jeba Dev Singh M.Sc.(N) Ms.
Rajwant Kaur
Lecturer M.Sc. (N) 2nd
Year
CIMS, CON CIMS, CON