Key investigations for cardiovascular disease are the electrocardiogram (ECG; see Chapter 14), chest X-ray and echocardiogram. Others include exercise ECG testing, ambulatory blood pressure monitoring, lipid profile, cardiac enzyme assays and catheterization with coronary or pulmonary angiography.

X-Rays (Chest Radiography)

The chest X-ray (CXR) is an essential diagnostic tool. The initial CXR is taken in the postero-anterior (PA) direction, with the patient upright and at full inspiration. Figure 33a shows the major structures in which gross abnormalities can be detected, such as enlargement of the heart chambers and major vessels, and a normal PA CXR. Heart size and cardiothoracic ratio (size of heart relative to thoracic cavity) can also be estimated. This ratio is normally <50%, except in neonates, infants and athletes, but may be greatly increased in heart failure (see Chapter 46). Calcification due to tissue damage and necrosis may be detected by CXR if significant (Figure 33c). Enlargement of the main pulmonary arteries coupled with pruning of the peripheral arteries suggests pulmonary hypertension, whereas haziness of the lung fields is indicative of pulmonary venous hypertension and fluid accumulation in the tissues.

Echocardiography and Doppler Ultrasound

Echocardiography

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