GE Healthcare

TiP-EdSM Online Program

Supplement and Test for
Healthcare Professionals

Patient Preparation for

Cardiac CT Angiography

Publication Date: June 6, 2017

0.25 ASRT-Approved Category A CE Credit
GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Table of Contents
TABLE OF CONTENTS .........................................................................................................................................................................2
INTRODUCTION .................................................................................................................................................................................3
PROGRAM DESCRIPTION .............................................................................................................................................................................. 3
TARGET AUDIENCE ..................................................................................................................................................................................... 3
CONTINUING EDUCATION CREDIT .....................................................................................................................................................3
CONTINUING EDUCATION CREDIT .................................................................................................................................................................. 3
ONLINE PROCESS FOR CE CREDIT (HLS.GEHEALTHCARE.COM) ............................................................................................................................. 3
CONTINUING EDUCATION CREDIT ELIGIBILITY – IMPORTANT NOTICE!................................................................................................................... 4
PROGRAM OBJECTIVES ......................................................................................................................................................................5
MODULE 1: INTRODUCTION TO PATIENT PREPARATION IN CCTA ......................................................................................................6
MODULE 2: BEFORE THE SCAN ..........................................................................................................................................................8
BETA AND ALPHA BLOCKERS......................................................................................................................................................................... 8
CALCIUM CHANNEL BLOCKER ....................................................................................................................................................................... 9
MODULE 3: ADMINISTERING BETA BLOCKERS TO DIABETIC PATIENTS ............................................................................................ 10
MODULE 4: ON THE DAY ................................................................................................................................................................. 10
SUMMARY ....................................................................................................................................................................................... 14
APPENDIX A: PRESENTERS ............................................................................................................................................................... 15
APPENDIX B: POST-TEST .................................................................................................................................................................. 16

© 2017 General Electric Company. All rights reserved. 2 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Introduction

Program Description
Hello and welcome to TIP-Ed online. I am Dr. Karen Dobeli. I am a lecturer for the Faculty of Health Sciences at the
University of Sydney. I am also a radiographer team leader in CT at the Royal Brisbane and Women's hospital, which
is the largest tertiary hospital in Queensland, Australia. In this presentation, we are going to be looking at preparing
patients for Cardiac CT Angiography, or CCTA.

Target Audience
This program specifically targets radiologists, technologists and healthcare workers. Other medical personnel also
may benefit from this material.

Continuing Education Credit

Continuing Education Credit
0.25 ASRT-Approved Category A CE Credit

NOTE: While the technical content is most effective for the target audience, other healthcare professionals may also benefit
from viewing this course. Regardless of your specialty, you may apply for continuing education credit.

Online Process for CE Credit (hls.gehealthcare.com)

In order to receive continuing education credit, you must log into the GE Healthcare Learning Systems (HLS) and
complete all of the required steps.

1. View the entire program video online. This supplement is not intended to replace watching the video.

© 2017 General Electric Company. All rights reserved. 3 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

2. Go to the GE HLS website at hls.gehealthcare.com and complete the feedback form.

 NOTE: The Feedback Form link is not activated until the View Video Now module has been completed.
 Feedback provides valuable information regarding your thoughts on the program’s quality and effectiveness.
3. Complete the program post-test without aids or assistance of any kind; this is an individual effort.
 You have up to three attempts to successfully complete the test with a minimum passing score of 75% (ASRT
and CBRN approved programs) or 80% (SNMMI-approved programs).
 The post-test measures knowledge gained and/or provides a self-assessment on a specific topic.
4. Upon successful completion of the online CE information, you can instantly print a certificate.

Continuing Education Credit Eligibility – Important Notice!

A GE Healthcare TiP-Ed Online course may be available in several different formats, such as an online web course or
CD/DVD. You may be able to receive CE credit only once for a particular course during your biennium, regardless of
the format in which it was viewed. If you have already received credit for a course, you are encouraged to contact
your CE certification organization (ARRT, NMTCB, ARDMS, CBRN, etc.) to determine if you can repeat this course for CE
credit.

Thank you for choosing GE Healthcare as your continuing education partner. We hope you will join us for other TiP-
Ed Online programs in the future. For more details and program information, please visit our education web site
(www.gehealthcare.com/education). Please forward any questions or comments to: geeducation@ge.com

The materials, presentations, and content therein are the opinions and experiences, and represent the views of the
specific authors and presenters and are not statements of advice, opinion, or information of GE Healthcare.

Not all charts, graphics, or images are included in this supplement. Refer to the online presentation to see items not
included in this supplement.

© 2017 General Electric Company. All rights reserved. 4 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Program Objectives

Please keep a copy of the Program Objectives and the Table of Contents with your continuing education certificate. It is
also recommended that you provide a copy of this information to your manager as a record of your educational
achievement.

By the end of this course, the participant should be able to:

 Describe how to prepare patients for Cardiac CT Angiography (CCTA).
 Identify how to reduce motion artifacts, reduce irregularities in the heart rate, and provide good contrast
enhancement when performing a CCTA.

© 2017 General Electric Company. All rights reserved. 5 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Module 1: Introduction to Patient Preparation in CCTA

One of the main aspects of preparing patients for CCTA is managing the patient's heart rate and rhythm to reduce
artifacts. Motion artifacts are a major concern for Coronary CT angiography because the coronary arteries are so
small that even a tiny amount of movement artifact can completely obscure the vessels.

To reduce artifacts, we need the patient's heart rate to be low. Scanners these days are very fast. But, even with
current temporal resolution, the scanners may not be fast enough to completely freeze frame cardiac motion;
particularly with high heart rates. So, we often must employ strategies to reduce the patient's heart rate and this
might include medications. It is not only the heart rate that we are worried about, but also the rhythm that can have
an influence on image quality.

If we are performing prospective gated or step-and-shoot protocols, the scanner looks at the patient's heart rate
before it takes the main acquisition to make an educated guess as to when to turn the X-rays on and off during the
scan.

If the patient's heart rate changes, or if there is an ectopic beat during the scan, then the scanner can take the data
at the wrong part of the heart cycle, where there might be motion. Also, many scanners need to take several steps to
acquire the entire heart.

If the patient has regular heart motion, then the heart will follow the same pattern of motion for each heartbeat. So,
when we stitch the steps together, we will have little or no miss-registration of the vessels across those steps. But, if
the patient is in arrhythmia, the heart will have very different motion between each of the heartbeats. So, when
those step data sets are stitched together, we can have miss-registration across the vessels.

© 2017 General Electric Company. All rights reserved. 6 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Reducing cardiac motion is a high priority for CCTA, but other types of motion, namely respiratory motion and
patient movement, are also important to consider because that type of movement is quite gross in relationship to
the size of the coronary vessels. So, it is important to limit this type of motion as well.

Another goal of patient preparation for CCTA is to obtain venous access that will provide good contrast
enhancement. This is because the coronary arteries are very small, so they are prone to partial volume artifacts,
more so than larger vessels like the aorta. So, we need to have higher levels of contrast density within those
coronary arteries to be able to get enough enhancement for diagnosis. We need venous access that will be able to
provide high flow rates.

In summary, the main aspects of patient preparation for cardiac CT angiography are to reduce motion artifacts, to
reduce irregularities in the heart rate, and to provide good contrast enhancement. We are now going to look at each
of these aspects in detail.

© 2017 General Electric Company. All rights reserved. 7 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Module 2: Before the Scan

For Cardiac CT, patient preparation may need to start a few days before the scan. If the patient is taking Viagra or
Cialis or other similar erectile dysfunction medication, that needs to be ceased two days before the scan because it
is a contrary indication for GTN, which we will talk about a little later in this presentation. Apart from those erectile
dysfunction medications, we want the patient to continue with all their regular medications, particularly their heart
medications because if they suddenly go off their treatment, that could have unwanted side effects; particularly for
their heart rate or their blood pressure.

For the best chance of a low heart rate, it is advisable to have the patient refrain from stimulants for 4-24 hours
before the scan. This includes smoking, strenuous exercise, and caffeine such as coffee, tea, chocolate and
caffeinated sodas. We would also want the patient to stop eating for a little while before the scan because after we
eat a meal our heart rate increases, but we want them to continue drinking, apart from those caffeinated drinks,
because dehydration can cause tachycardia. We do not want the patient fasting for too long though because that
can cause irregular heart beat and low blood pressure. So, a couple of hours is usually enough. The recommended
upper threshold for heart rate for Cardiac CT varies across the literature from about 55-75 beats per minute. The
variations are due to the differences in scanner types and the way that the data is acquired, but nevertheless, if the
heart rate is higher than what you would like for your scanner, then you might consider using a beta blocker.

Beta and Alpha Blockers

Beta blockers block norepinephrine and epinephrine or adrenaline from binding to receptors or nerves. When they
are not blocked, they act as neurotransmitters to allow nerves to talk to one another. There are three types of beta
receptors, which are found in different parts of the body.

© 2017 General Electric Company. All rights reserved. 8 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Beta blockers can be selective or nonselective. The nonselective beta blockers act on the beta one and beta two
receptors. This reduces the heart rate and dilates the blood vessels, which in turn reduces blood pressure. Blocking
off the beta two receptors can also stimulate the muscles around the air passages, which can constrict them, and
for this reason, some beta blockers are contraindicated in asthmatics. Some beta blockers also block alpha
receptors. The alpha receptors work on smooth muscle and they also have some function in inhibiting
neurotransmission. Typically, the beta blockers that also block the alpha receptors have a greater effect on blood
vessel dilation. But, whatever type of beta blocker is used, the usual effect is to reduce the heart rate variation and to
suppress ectopic beats.

Calcium Channel Blocker

As I mentioned earlier, caution may be required when administering beta blockers to asthmatics because of that risk
of air passage restriction. So, in these patients, a calcium channel blocker may be considered instead.

Calcium channel blocker block calcium from entering the cells of the heart and the blood vessel walls, which reduces
blood pressure. But a side effect is to also reduce the heart rate and to reduce arrhythmias.

© 2017 General Electric Company. All rights reserved. 9 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Module 3: Administering Beta Blockers to Diabetic Patients

We also must be careful when administering beta blockers to diabetic patients. A rapid heartbeat is a sign of low
blood sugar, so if we give a beta blocker to a diabetic patient it can mask the fact that they are hypoglycemic. So, if a
diabetic patient is given beta blockers we need to monitor their blood sugar closely. One of the main uses of beta
blockers in the clinical environment is to reduce blood pressure. But in CT, we are after the effect they have on the
heart rate and rhythm. Many of our patients will not have high blood pressure and some may even have low blood
pressure. Giving beta blockers to a patient with low blood pressure can cause significant hypotension. So, before
giving a patient beta blocker, we need to make sure that they have enough reserve blood pressure to cope. This
simply means taking their blood pressure.

Beta blockers can be administered orally or intravenously. The oral medication takes about an hour to fully settle in.
So, the patient needs to be in the department early, or they can be given their medication to take home with them
before they come in. But, if the scan is required urgently or the patient's heart rate is still high after having oral beta
blockers, IV beta blockers may be administered. These are fast acting, so they are usually given in small doses and
the heart rate and blood pressure are monitored before giving further doses. Sometimes, a patient's heart rate
is still too high even after having beta blockers. In these cases, it may be prudent to send the patient home to have
oral beta blockers for a few days before coming back in for their scan.

Module 4: On the Day

Anxiety is a cause for a patient's heart rate to rise, so keeping the patient calm and comfortable is a priority. A clear
explanation of what they will see, hear, and feel during the procedure will usually be welcomed by the patient and
help to alleviate any concerns they might have. It is recommended that the right arm be preferentially cannulated
for a CCTA, and this is for several reasons.
 Firstly, because the left brachiocephalic vein has a smaller space to go through behind the sternum so it is
more prone to compression.
 Secondly, the contrast has further to travel from the left elbow through to the SVC, so the contrast has more
chance of being diluted.
 Thirdly, because dense contrast in the left brachiocephalic vein can cause artifact, which can obscure the
origin of the left internal mammary artery, which could be important for a patient who has had a bypass.

In many places, cannulation is done outside of the CT room. But, if in your institution, you usually perform
cannulations on the CT table, it is advisable to take anxious patients outside the room and cannulate them; and give
them plenty of time to recover and relax before bringing them in for their scan.

© 2017 General Electric Company. All rights reserved. 10 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

A vital element when performing a CCTA is knowing exactly when the R-peaks will occur. So, it is a good idea to take
your time when placing the ECG dots on the patient’s skin. This might involve clipping the hair around the placement
site, or using an abrasive surface like the back of the ECG dot or a gauze pad to take away the dead skin cells. If the
skin is oily, use an alcohol wipe, but just give it enough time to dry before placing the dots. We need good conduction
between the dot and the skin, this means we need a good amount of gel on the back of the ECG dot.

Check the dots before placing them and if they look dry, then throw them away. If using snap electrodes, attach
them to the dot before placing them on the patient's skin, because if you press on to the dot you can dislodge the gel
from the back of the pad.

© 2017 General Electric Company. All rights reserved. 11 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

In normal clinical practice, the arm leads are usually placed on the pectoral muscles, but in CT we may get less
interference by placing those arm dots at the back of the sides of the neck on the trapezius muscles. This is because
we will be asking the patients to place their arms above their head. It is common for patients to use their pectoral
muscles to hold their arms above their heads. This movement of the pectoral muscles can generate an electrical
impulse, which appears as noise on the ECG trace. All the dots should be placed within the frame of the ribcage
but the leads and particularly the junction should be placed away from the heart to avoid artifacts. Secure the leads
with tape so they do not move or touch the gantry during the scan can reduce interference.

Once the dots are in position, check whether the R-peak is obvious within the ECG trace; and that the scanner is
accurately and consistently picking that R-peak. If the scanner is not able to pick that R-peak or if the trace is noisy,
check that there is good communication between the dots and the patient's skin. Check that all the leads are
attached firmly, and that the leads are not touching a conductive surface like a metal drip pole. If you still have noise
within the trace, you may need to reposition one or more of the leads or dots.

© 2017 General Electric Company. All rights reserved. 12 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

It is a good idea to have the patient practice holding their breath before doing this scan, and this is for several
reasons.
 Firstly, so the patient is aware of how long they need to hold their breath for, and so they can see any lights
or hear any sounds that will occur during the scan.
 Secondly, so that you can make sure they are not going to perform a Valsalva maneuver as they are holding
their breath because this can cause poor contrast enhancement. It is a phenomenon that is well known for
CT pulmonary angiography, but it also occurs for CCTA.
 Thirdly, we want to see what happens to the patient's heart rate as they hold their breath. Often, the patient's
heart rate will rise and then slowly drop off and stabilize. So, with these patients we can use the breath
holding practice to plan when to get the patient to hold their breath during the scan.
 Lastly, we want to observe the patient's heart rate as they are holding their breath. For some patients, the
heart rate will remain stable, but for others the heart rate may initially rise and then slowly drop off. We can
use this to plan when to get the patient to hold their breath during the scan. If the heart rate does rise before
dropping, we can ask those patients to hold their breath slightly earlier before triggering the scan.

As I mentioned earlier, movement of the arms can cause electrical activity, which appears as noise on the ECG trace.
So, it is a good idea to make sure that the patients are comfortable with their arms above their head. You may need
to use pillows or strapping so that the patient can hold their arms in place, without having to strain. Before the main
CCTA scan is acquired, Sublingual Nitroglycerin, commonly known as GTN, may be administered. It acts on the
smooth muscle and dilates blood vessels, and we use this to try and make the coronary arteries as large as they can
to help improve detection and diagnosis.

© 2017 General Electric Company. All rights reserved. 13 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Sublingual Nitroglycerin or GTN is rapidly absorbed by the buccal and sublingual mucosa, so it is usually
administered under the tongue. It can be administered orally or via a spray. The spray is said to be more stable than
the tablets and give a greater effect per dose. The effects of GTN are maximal at around four minutes, so it is
common to administer it just prior to performing the scan or topograms. Patients often get a headache after GTN, so
it is advisable to let them know that this can happen. Paracetamol is a recommended treatment if they do get a
headache.

There are several contrary indications for GTN.

 For patients having CCTA, we are concerned about low blood pressure, aortic stenosis, and concurrent use of
erectile dysfunction medication, and this is because the GTN can cause a lowering of blood pressure
(hypotension), which requires an increase in cardiac output to maintain perfusion to the vital organs.
 The second main contraindication is aortic stenosis. When GTN dilates the blood vessels, the heart needs to
pump blood through to the body faster to be able to keep up perfusion to the organs. In patients with aortic
stenosis, the heart may not be able to increase its capacity enough because of the narrowing of the aorta.
 In patients with aortic stenosis, there is a limit to the amount of blood flow that can pass through the
stenosis, and this again can cause ischemic injury to important organs.
 Erectile dysfunction medication also lowers blood pressure, so in these patients and in patients with existing
hypotension, the cumulative effect of the GTN can exacerbate the hypotension to the point where ischemic
injury occurs in vital organs, like the heart, the liver, and the kidneys.

Summary

In summary, the main goal of patient preparation in CCTA is to obtain a slow, steady heart rate and to minimize all
other motion. A clear ECG trace is also needed, so we acquire the data or reconstruct at the right part of the heart
cycle. And we also need good venous access to be able to get sufficient contrast enhancement. A comprehensive
approach is required to obtain all three goals. This means adequate preparation before the patient arrives in the
department, keeping the patient calm and comfortable, taking care in placement of the ECG dots, and the use of
GTN and beta blockers when required and not contraindicated.

Thank you for participating today. For a summary of the information presented, please download the supplement
that accompanies this program. Please complete the survey. Your input is vital for future programs and topics.
Remember to complete and pass the post-test for continuing education credits. Join us again soon for another
program of TiP-Ed Online.

© 2017 General Electric Company. All rights reserved. 14 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Appendix A: Presenters
Dr. Karen Dobeli
Faculty of Health Sciences, University of Sydney
Radiographer Team Leader in CT at the Royal Brisbane and Women's Hospital

Program Developer
Poornima Krishnan
TIP-Ed Online
GE Healthcare, Global Customer Education

© 2017 General Electric Company. All rights reserved. 15 of 16

GE Healthcare Patient Preparation for Cardiac CT Angiography

REV 0 Program Supplement and Test

Appendix B: Post-Test
To be eligible for CE credit, you MUST view the video presentation first. Then complete the post-test on the GE
Healthcare Learning System (hls.gehealthcare.com) by the due date listed online.

HLS Course: #9059

1. The main aspects of patient preparation for Cardiac CT angiography are to _______.
a. Reduce motion artifacts
b. Reduce irregularities in the heart rate
c. Provide good contrast enhancement
d. ALL of the above

2. If the patient is taking Viagra or Cialis or other similar erectile dysfunction medication, that needs to be
ceased _____ days before the scan because it is a contrary indication for GTN?
a. Two
b. Three
c. Four
d. Five

3. Giving beta blockers to a patient with low blood pressure can cause significant ______.
a. Hypotension
b. Hypertension
c. Cardiac block
d. Coronary occlusion

4. Which of the following is NOT TRUE about CCTA?

a. A vital element when performing a CCTA is knowing exactly when the R-peaks will occur. So, it is a
good idea to take your time when placing the ECG dots on the patient’s skin.
b. It is recommended that the right arm be preferentially cannulated for a CCTA.
c. It is a good idea to have the patient practice holding their breath before doing this scan.
d. In CT, we may get more interference and artifacts by placing the arm dots at the back of the sides of
the neck on the trapezius muscles.

© 2017 General Electric Company. All rights reserved. 16 of 16