*All Registry Level candidates must either pass or be granted exemption from the Cardiovascular Science Examination in addition to passing the specific Registry Level Examination before being awarded a registry level credential (RCIS, RCS, or RVS).

Cardiovascular Science Examination: $185 (Click here to be directed to that section)

Self Assessment Booklets can be ordered for all CCI examinations. An order form can be found on the last page of the Application.

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Examination Matrix

CONTENT CATEGORY AND APPROX. PERCENTAGE OF EXAM

Patient Management and Clinical Medicine	11%
Ultrasound Physics and Instrumentation	15%
Pathophysiology of Cardiovascular Disease/ Therapeutic Measures	20%
Two-Dimensional and M-mode Echocardiography	20%
Cardiac Doppler and Color Flow Echocardiography	20%
Advanced Techniques in Echocardiography	10%
Other Non-invasive Modalities	4%
TOTAL	100%

Detailed Outline

A. Patient Management/Clinical Medicine
I. Patient Management
ccccca. Basic patient care
cccccb. Transportation and proper body mechanics
cccccc. Emergency care
cccccd. Medical ethics
II. Clinical Medicine
ccccca. Physical Assessment
cccccccccc1. Inspection and palpation of arterial and venous pulses
cccccccccc2. Auscultation
cccccccccc3. Blood pressure
cccccb. Basic Pharmacology
cccccccccc1. Antihypertensives
cccccccccc2. Antiarrythmics
cccccccccc3. Anticoagulants
cccccccccc4. Calcium channel blockers
cccccccccc5. Chronotropic agents
cccccccccc6. Inotropic agents
cccccccccc7. Nitrates
cccccccccc8. Oxygen
cccccccccc9. Sedatives
cccccccccc10. Vasopressors
cccccccccc11. Vasodilators
cccccccccc12. Diuretics
cccccccccc13. ACE inhibitors
cccccccccc14. Contrast agents
cccccc. Defibrillation/Emergency measures
cccccd. Sterile Technique

B. Ultrasound Physics and Instrumentation
I. Physical properties of ultrasound
ccccca. Definition
cccccb. Terms
cccccccccc1. Cycle
cccccccccc2. Wavelength
cccccccccc3. Velocity
cccccccccc4. Frequency
cccccccccc5. Harmonics
cccccc. Velocity of sound in human tissue
cccccd. Propagation speed in different media
II. Acoustical properties of tissue
ccccca. Impedance
cccccb. Reflection
cccccc. Refraction
cccccd. Specular Echoes
ccccce. Scattered Echoes
cccccf. Resolution
cccccg. Attenuation
III. Principles of Doppler
ccccca. Doppler effect
cccccb. Doppler equation
IV. Doppler Instrumentation
ccccca. Continuous Wave
cccccccccc1. Advantages –high velocity detection
cccccccccc2. Disadvantages –range definition
cccccb. Pulsed Doppler
cccccccccc1. Limitations
cccccccccc2. Aliasing
ccccccccccccccca. Nyquist effect
cccccccccccccccb. Effect on flow and velocity
cccccccccccccccc. PRF
cccccc. High pulsed repetition frequency pulsed Doppler
cccccccccc1. Effect on Nyquist effect
V. Doppler display
VI. Doppler controls
VII. Color flow mapping
ccccca. Sampling methods
cccccb. Artifacts
cccccc. Limitations
VIII. Transducers and sound beams
ccccca. Design
cccccb. Piezoelectric effect
cccccc. Sound beam formation
cccccccccc1. Near field
cccccccccc2. Fairfield
cccccccccc3. Focal zone
cccccd. Beam focusing
ccccce. Resolution
cccccccccc1. Axial
cccccccccc2. Lateral
cccccf. Transducer Types
cccccccccc1. Focused single crystal
cccccccccc2. Phased array
cccccccccc3. Annular array
cccccccccc4. Mechanical
IX. 2-D, Doppler and Color Flow
ccccca. Characteristics
cccccb. Processing and displays
cccccc. Instrumentation
cccccd. Imaging, Doppler and color flow artifacts
ccccce. Storage, displays and recording devices
cccccf. Computer manipulation of data
X. Quality Control, Troubleshooting, and Preventative Maintenance
XI. Biologic Effects and Safety Considerations
ccccca. Mechanisms of bioeffects
cccccb. Epidemiology
cccccc. AIUM statements
cccccd. Electrical and mechanical hazards

C. Pathophysiology of Cardiovascular Diseases/ Therapeutic Measures
Identify the etiology, symptoms, pathophysiology, hemodynamic effect and treatment.
I. Congenital Heart Disease
ccccca. Embryology
cccccb. Abnormalities of the left & right aria and systemic veins
cccccc. Anomalies of the right and left ventricular inflow
cccccd. Right and left ventricular outflow tract obstruction
ccccce. Congenital lesions leading to intracardiac shunts
cccccf. Abnormalities of the great vessels
cccccg. VaIvular abnormalities
ccccch. Surgical/palliative procedures
II. Valvular Heart Disease
ccccca. Mitral valve disease
cccccb. Aortic valve disease
cccccc. Tricuspid valve disease
cccccd. Pulmonary valve disease
III. Ischemic Heart Disease
ccccca. Coronary Artery Disease
cccccb. Left ventricular obstruction
cccccc. Wall motion abnormality
cccccd. Associated thrombi
ccccce. Aneurysm
cccccf. Rupture of the papillary muscle, chordae, and interventricular septum
cccccg. Arrhythmia and conduction disturbance
IV. Inflammatory Heart Disease
ccccca. Endocarditis
cccccb. Myocarditis
cccccc. Pericarditis
V. Cardiomyopathy
ccccca. Dilated
cccccb. Constrictive
cccccc. Restrictive
cccccd. Hypertrophic
cccccccccc1. Obstructive
cccccccccc2. Non-obstructive
VI. Pericardial Diseases
ccccca. Effusion
cccccb. Constrictive
cccccc. Tumor
cccccd. Cardiac tamponade
VII. Cardiac Masses
ccccca. Benign
cccccb. Malignant
VIII. Diseases of the Aorta
IX. Systemic and Pulmonary Hypertension
X. Compensatory Mechanisms
XI. Basic Understanding of Interventional Procedures
ccccca. Valvular repair/replacement
cccccb. Coronary arteries
cccccc. Catheterization/intervention

D. Two Dimensional and M-mode Echocardiography
I. Deductive echocardiography and the segmental approach of cardiac anatomy
II. Basic and advanced techniques and imaging planes
III. Normal values and quantitative measurements/calculations
IV. Qualitative evaluation of cardiac chambers and myocardial wall segments
V. Hemodynamic information derived from echocardiography
ccccca. Measurements
cccccb. Normal parameters
cccccc. Equations
VI. Two-dimensional recognition and assessment
ccccca. Congenital heart disease
cccccb. VaIvular heart disease
cccccc. Inflammatory heart disease
cccccd. Ischemic heart disease
ccccce. Cardiomyopathy
cccccf. Pericardial diseases
cccccg. Cardiac masses
ccccch. Diseases of the aorta
ccccci. Systemic and pulmonary hypertension
cccccj. Prosthetic valves
ccccck. Left ventricular function

E. Cardiac Doppler and Color Flow Echocardiography
I. Normal and abnormal flow patterns
II. Normal values and quantitative measurements and calculations
III. Clinical Applications in Acquired and Congenital Heart Disease
ccccca. Left sided lesion
cccccb. Right sided lesion
cccccc. Intracardiac shunt
cccccd. Hemodynamic assessment
ccccce. Prosthetic valves
cccccf. Systolic/diastolic function

F. Advanced Techniques in Echocardiography
I. Pharmacologic application
II. Ultrasound contrast studies
III. Stress echocardiography
IV. Transesophageal echocardiography
V. Harmonic imaging
VI. Physiologic maneuvers

G. Other Non-invasive Modalities
I. Electrocardiography and Holter monitoring
II. Exercise Stress Testing
III. Nuclear Cardiology
IV. Pacemakers
V. Chest X-Ray

2. While performing two-dimensional echocardiography on Ms. Heinz, you discover what appears to be a large thrombus in the left ventricle. Ms. Heinz states that she just can’t wait to talk with her doctor and that any information you could supply concerning what you see would be a big relief to her. You should inform Ms. Heinz that:
a. Her nurse is the only person qualified to discuss the results of her test
b. There is a large thrombus in the main pumping chamber of her heart and that surgery is definitely necessary
c. You do see a small abnormality in her Echocardiogram, but it is not something she should concern herself with
d. You cannot interpret her Echocardiogram, but assure her that her doctor will be reviewing it as soon as possible

3. Mr. Smith is a 90-year-old male scheduled for a Transesophageal Echocardiogram. As a preoperative
measure, his doctor has given him 25mg of Demoral. Upon entry to the laboratory, his breathing is shallow and he is unresponsive. After notifying the physician, which of the following medications would be MOST useful for counteracting the effects of the narcotic given?
a. Versed
b. Narcan
c. Oxygen
d. Valium

4. Splitting of S2 is best heard at the
a. Apex
b. Third left intercostal space
c. Fourth left intercostal space
d. Second right intercostal space

5. During the holding phase of the Valsalva Maneuver, which of the following occurs?
a. increased cardiac output
b. decreased intrathoracic pressure
c. increased venous return to the heart
d. decreased venous return to the heart

6. Mr. Kline reported to the non-invasive laboratory for an exercise stress test. While preparing Mr. Kline for his examination, he complains of chest pain radiating down his left arm. The resting 12 lead ECG indicates ST segment elevation is present in leads V1 through V6, and the T wave is inverted. Before the physician can be notified, Mr. Kline converts to ventricular tachycardia, lapses to an unconscious state, and has no palpable pulse. According to ACLS guidelines, the technologist should:
a. Begin CPR
b. Administer intracardiac epinephrine
c. Defibrillate the patient at 360 watts/second
d. Prepare an external pacemaker for immediate use

7. Sound travels through tissue at approximately:
a. 154.0 m/sec
b. 1,540.0 m/sec
c. 15,400 m/sec
d. 154,000 m/sec

8. Which of the following is most influenced by distance from the face of the transducer?
a. Frequency
b. Wavelength
c. Axial resolution
d. Lateral resolution

9. If the relative output of an ultrasound instrument is calibrated in decibels and the technologist increases the output by 50 dB, how many times will the beam intensity increase?
a. 2
b. 100
c. 100,000
d. 1,000,000

10. A ventricular wall motion abnormality that is reversible with nitroglycerine is associated with:
a. Pericarditis
b. Myocardial fibrosis
c. Myocardial ischemia
d. Myocardial infarction

11.  Difficulty in determining echocardiographic signs of tamponade may occur in the presence of:
a. Right pleural effusion
b. Systemic hypertension
c. Left ventricular dysfunction
d. Right ventricular hypertrophy

12.  While performing a 2-D Echocardiogram on Ms. Cane for assessment of her left ventricular function, you discover regional wall motion abnormalities and a dilated hypokinetic left ventricle. The pericardium contains no fluid, valvular pathology and function are normal. The patients chart indicates a history of rheumatic heart fever, and a recent history of fever, fatigue and precordial pain. Her 12 lead EKG exhibits a LBBB and nonspecific ST-T wave changes and a prolonged QT interval. Pulmonary congestion and a moderate cardiomegaly are evidenced by chest X-ray. Correlating these data you would suspect a
diagnosis of:
a. Myocarditis
b. Cardiac tamponade
c. Pericardial effusion
d. Congestive heart failure

13.  According to the American Society of Echocardiography, the left ventricle should be measured at the region of the:
a. Papillary muscles
b. Chordae tendineae above the papillary muscles
c. Mitral valve where only the anterior leaflet is seen
d. Mitral valve where both the anterior and posterior leaflets are visualized

14.  Your patient’s history shows recent cardiac catheterization data indicating elevated right heart pressures and an IV end-diastolic pressure less then the left atrial mean pressure. The EKG demonstrates atrial fibrillation. A holosystolic murmur can be auscultated. Which of the following imaging methods would be useful during two dimensional echocardiography of this patient?
a. Continuous wave Doppler and m-mode echocardiography
b. Two-dimensional echocardiography for the measurement of aortic valve orifice size
c. Two-dimensional echocardiography in combination with Doppler for the measurement and determination of the mitral orifice size
d. Color flow imaging in combination with two-dimensional echocardiography for the evaluation of flow disturbance across the aortic valve

15.  In the performance of echocardiography, which of the following methods requires invasive introduction of the transducer?
a. Stress echocardiography
b. Contrast echocardiography
c. Assisted pericardiocentesis
d. Transesophageal echocardiography

16.  Which of the following conditions would be a contraindication to the performance of contrast Echocardiography?
a. VaIvular regurgitation
b. Left ventricular dysfunction
c. Complex congenital heart disease
d. A large right-to-left intracardiac shunt

17. How many colors can be displayed in a single pixel of color flow image?
a. 1
b. 2
c. 3
d. 4

18.Which of the following Doppler frequencies would result in the shallowest penetration depth?
a. 2 MHz
b. 8 MHz
c. 10 MHz
d. 20 MHz

19.Which of the following frequency shifts would produce aliasing, when using a 5 MHz pulsed Doppler transducer, with a pulse repetition frequency of 15 kHz?
a. 3 kHz
b. 5 kHz
c. 6 kHz
d. 8 kHz

20.Why are patients requested to record the time of bowel movements when wearing a Holter monitor?
a. Valsalva Maneuver will cause a heart rate change
b. To correlate the motion artifact on the recording
c. For the systematic recording of all patient activity
d. Breathing rate will delay conduction through AV node

21.Dr. Hager has ordered an echocardiogram of Mr. Finney for evaluation of left ventricular function. The patient’s history indicates that the left ventricle is enlarged. When reviewing the 12 lead ECG, you observe that the T wave is inverted in leads 1, AVL, V5 and V6. The ST segment is depressed. You realize that this finding is MOST consistent with:
a. Pericarditis
b. An old myocardial infarction
c. Left ventricular hypertrophy
d. Right ventricular hypertrophy

22.Which of the following is NOT an effect of exercise in the patient with a healthy heart? Increased:
a. Stroke volume
b. Ejection fraction
c. End-systolic volume
d. End-diastolic volume

23.Which of the following is NOT considered an indicator of coronary artery disease, during the performance of exercise stress testing?
a. Sinus tachycardia
b. ST segment elevation
c. ST segment depression
d. Increased in R wave amplitude

24.The first heart sound is associated with:
a. preload
b. afterload
c. semilunar valve closure
b. atrioventricular valve closure

25. The patient’s ECG indicates the presence of atrioventricular disassociation, without heart block. This condition may cause a significant drop in blood pressure and cardiac output. Which of the following would be the MOST effective treatment choice to control and increase heart rate?
a. Atropine sulfate intravenously
b. Temporary atrial or ventricular pacing
c. Administration of approximately 500cc of normal saline
d. Implantation of a permanent atrioventricular pacemaker

Answers
 1. d   2. d   3. b   4. b   5. d  6. a   7. b
 8. d   9. c 10. c  11. d 12. a 13. b 14. c
15. d 16. b 17. a  18. d 19. a 20. a 21. c
22. c 23. a 24. d  25. b

References

1. Any general text on nursing management and care of the cardiac patient.
2. Publications and Reports of the American Society of Echocardiography (ASE), Raleigh, NC.
A. American Society of Echocardiography –Educational Outline for Echocardiography, 4th Edition, 1993.
B. Report of the American Society of Echocardiography (ASE), 1980, Committee on Nomenclature and Standards in 2D Echocardiography.
C. Report of the ASE Committee on Nomenclature and Standards; 1982, on the Identification of Myocardial Wall Segments.
D. Report of the ASE Committee: Stress Echocardiography.
E. Report of the ASE Committee, 1984, on Contrast Echocardiography.
F. Report of the ASE Doppler Standards and Nomenclature Committee, 1984, on Recommendations for terminology and display of Doppler Echocardiography.
G. Publication: Digital Signal and Image Processing in Echocardiography.
H. Publication: Transesophageal Echocardiography. Journal of the American Society of Echocardiography, September/October, 1989.
I. Publication: Recommendations for Quantitation of the Left Ventricle by Two-Dimensional Echocardiography. ASE Committee on Standards, subcommittee on Quantitation of Two-Dimensional Echocardiograms, 1989, Journal of the American Society of Echocardiography, September/October.
3. Heart Disease, 5th Edition, Braunwald, Eugene, 1996, W. B. Saunders, Philadelphia, PA.
4. Congenital Heart Disease in Infants, Children, and Adolescents, 5th Edition, Part II, Congenital Defects. Fink, B. W., 1991, The Williams and Wilkins, Co., Baltimore, MD.
5. Echocardiography, 5th Edition, Feigenbaum, H.,1994, Mosby Yearbook, St. Louis, Missouri.
6. Diagnostic Ultrasound: Physical Principles and Exercises, 4th Edition, Kremkau, E.W., 1993, W.B. Saunders, Philadelphia, PA.
7. The Echo Manual, Oh, Jae, et al, 1998, The Williams and Wilkins, Co., Baltimore, MD.
8. Otto, Catherine M., 1997, The Practice of Clinical Echocardiography, Otto, Catherine M., 1997, W. B. Saunders Company, Philadelphia, PA.
9. The Echocardiographer’s Pocket Reference, Reynolds, Terry, 1993, Arizona Heart Institute Foundation, Phoenix, Arizona.
10. Ultrasound Physics and Instrumentation, 4th Edition, Miele, Frank, 2007 Pegasus Lectures or Essentials of Ultrasound Physics:  The Board Review Book, Miele, Frank, 2008 Pegasus Lectures