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TESTS OFTEN PERFORMED ON PATIENTS WITH HEART DISEASE
Patients with heart disease may undergo a variety of X simple and not-so-simple tests. Their purpose and what patients can expect are detailed below.
Cardiac catheterization and coronary angiography: “Cardiac catheterization” is a general term that refers to the placement of tubes inside blood vessels going to the heart, in order to study the heart function. “Coronary angiography” means that a dye is injected into the arteries that supply the heart with blood, and X-ray pictures are taken of these arteries when they are filled with dye. This test produces the most accurate image of the blood vessels that are prone to hardening or narrowing, and allows fairly precise identification of the extent, location, pattern and severity of narrowings or blockages in the blood vessels to the heart. Alter local anesthetic is injected into the groin area or the arm, a cardiac catheter, a long flexible tube, is inserted into the artery and threaded into the heart’s chambers, usually the left and sometimes the right ventricle. The pressure in this chamber is measured, and then a small amount of dye is injected, after which the cine angiogram, or “movie camera,” is turned on for a few seconds, to record the image of the dye, which is not transparent to the X-ray beam, as it is ejected from the heart. This is necessary since the heart muscle and the blood are transparent to the X-ray beam and thus the heart is normally invisible with ordinary X rays and the naked eye. This left ventricular angiogram gives an accurate image of the strength of pumping action of the heart and of valvular regurgitation, or “leaky valves,” if present. The catheters are then exchanged for other catheters, which are specially shaped to allow injection of dye directly into the coronary arteries, which are the arteries that supply the heart muscle itself and are branches of the aorta (the largest blood vessel in the body, which leads from the heart to the rest of the body. Dye is then injected into the left and the right coronary arteries (the two main trunks from which branches lead), and several different images are taken of each artery, each time after injecting a small amount of dye, and moving the camera so that the arteries may be viewed from several different angles. These images are also stored on film or on computer disk, and can be later reviewed to see the presence and exact appearance of narrowings or blockages. Decisions about the technical suitability of the patient for angioplasty or bypass surgery are made on the basis of these images.
The entire procedure usually takes about forty-five minutes, and generally is associated with some mild discomfort in the groin area but is not terribly painful. The most unpleasant part of the procedure is the requirement to lie flat on a hard X-ray table; the need to lie still, which can result in some back stiffness; and the understandable anxiety that goes along with having a procedure in an unfamiliar and rather forbidding environment.
Patients are asked to lie flat for four to six hours following the procedure, and are generally up and around and may be discharged either the same day or the next day. Complications of angiograms are relatively rare, the most common being bleeding or bruising where the tubes are inserted. More serious complications such as clot formation in the blood vessels, a heart attack or a stroke are very rare, far less than 1 in 100, usually about 1 in 500. The risk of death from this procedure is extremely small, less than 1 in 1,000.
Echocardiogram (ultrasound): An echocardiogram is much like a “radar” of the heart, and provides an image of the heart using high-frequency sound beams (which cannot be heard) emitted from a probe placed on the chest wall. These sound beams travel through the skin to the heart and bounce back to a detector that allows an image of the heart to be displayed on a TV screen. This is a very accurate test, which can allow measurement of the strength of the heart’s beating, the size of the heart and its chambers, localized weakness of the muscles in the heart, problems with the heart valves, and any other structural problem with the heart. The test is often repeated at intervals or after any major events, and provides an accurate measurement of changes in the heart over time. The test takes about half an hour, and requires that you lie still while the probe is placed over various parts of the chest. It involves virtually no discomfort, risk or inconvenience.
Electrocardiogram: This is a test to examine the electrical activity of the heart, and can pick up heart rhythm disturbances, signs of a heart attack or a prior heart attack, and can give important clues about the nature of heart disease, especially in the case of coronary artery disease or electrical disturbances. It is extremely simple, lakes five to ten minutes, and simply involves placing electrodes (a kind of a sticky button) on the arms, legs and chest, and recording the electrical signals into a computer.
Electrophysiologic study: This test is somewhat less frequently performed in patients with a recent heart attack, but is used to assess the electrical functioning of the heart, and is particularly useful when patients have had a history of heart rhythm disturbances or fainting. During the test, the doctors try to deliberately bring on a rapid or irregular heart rhythm by means of an electrode wire placed inside the heart from veins in the leg or neck, using a temporary pacemaker connected to the wires inside the heart. The risk of complications from this test is low, but it can occasionally result in rapid palpitations or even loss of consciousness.
Exercise tests: An exercise test is usually used to diagnose the presence and severity of myocardial ischemia, i.e., lack of blood flow to the heart muscle. It can also provide important information about physical conditioning, and the response of the heart rate to exercise stress, and is important to establish safe levels of physical exercise for patients about to begin rehabilitation. It involves being connected to an ECG machine, and walking on a treadmill at an increasingly rapid rate and with an increasing incline (i.e., up an increasingly steeper hill), such that by the end of it some patients may be jogging uphill. The exercise can also be performed on a stationary bicycle. Although the test can be uncomfortable, since it does involve hard physical work, and will lead to breathlessness, and may lead to chest pain, it is quite safe since it is done under close supervision.
Holter monitoring: This test is primarily used to diagnose heart rhythm disturbances, particularly to discover the cause of palpitations or dizziness. The state of the blood supply to the heart can also be examined with this test. It involves measuring the electrocardiogram for twenty-four or more hours, by means of a device something like a cassette recorder attached to the body by wires and several electrodes, much like an ECG. Patients wear this device for one or several days, and the heart’s electrical signals are continuously transmitted to a cassette tape, which is subsequently played back into a computer, and all of the beats are analyzed. The test involves a few minutes of hookup, and patients then go about their normal everyday activities until the device is returned. A diary is provided so that patients may write down any symptoms that they have, in order that the heartbeat at the moment symptoms occur can be analyzed.
MUGA scan: “MUGA” stands for a multi-gated nuclear angiogram, and is a way of studying the pumping action of the heart by injecting a small amount of radioactive material and taking a picture of the heart muscle as it contracts. A very accurate calculation of the strength of contraction or beating of various portions of the heart muscle can be made, using a computer that records many heartbeats and averages the result. This test allows a precise measurement of the severity of heart damage after a heart attack. It involves minimal discomfort and virtually no risk.
Nuclear imaging: These are tests that assess blood flow to the heart muscle by injecting a small amount of a radioactive substance (thallium or Cardiolite?) intravenously, and then taking a picture using a special camera (gamma counter) to accurately measure blood flow to the heart. This imaging is often combined with either exercise stress (on a treadmill or an exercise bicycle) or stress using an infusion of a medication that can “stress” the heart, bringing out subtle abnormalities of blood flow. These tests are positive if there are areas in the heart that receive no blood flow (because they are scarred from a previous heart attack), or receive normal blood flow at rest but insufficient blood flow during stress, thus indicating narrowing of the arteries to the heart. These important tests can estimate accurately the amount of heart muscle that is threatened with damage due to insufficient blood supply, and can help doctors decide if medication, angioplasty or bypass surgery is likely to be helpful. This test involves minimal discomfort because of the need for an intravenous, but is very safe.
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