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Cardiology

 

Cardiology is the field of medicine that deals with diseases and abnormalities of the heart and vessels. Whether the cardiologist sees you in the office or in the hospital, he or she will review your medical history and perform a physical examination which may include checking your blood pressure, weight, heart, lungs, and blood vessels. Some problems may be diagnosed by your symptoms and the doctor’s findings when you are examined. For other symptoms you may need additional tests such as an ECG, echo, stress test, or blood test. Other problems may require even more specialized testing. Your cardiologist may recommend lifestyle changes or medicine. Each patient’s case is unique.
A cardiologist usually serves as a consultant to other doctors. Your physician may recommend a cardiologist or you may choose one yourself. As your cardiac care proceeds, your cardiologist will guide your cardiac care and plan tests and treatment with your other doctors. Once your diagnosis is confirmed, appropriate treatment will be started.

Learn about commonly ordered cardiology testing below.
         • 12 Lead EKG
         Cardiac table tilt test
         Holter Monitoring
         Cardiac Echo
         Cardiac Exercise Stress test
         Cardiac Echo Exercise Stress test
         Cardiac Echo Dobutamine Stress test

Please access the PATIENT CORNER tab then Cardiology submenu to find many cardiology study preparatory forms and instructions to help you prepare for your tests.
Other related procedures that may be used to assess the heart include signal-averaged ECG, cardiac catheterization, chest X-ray, computed tomography (CT scan) of the chest, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and cardiac CT scan.

 

12 LEAD EKG

INTRODUCTION
Electrocardiography (ECG or EKG from Greek: kardia, meaning heart) is the process of recording the electrical activity of the heart over a period of time using electrodes placed on a patient's body. These electrodes detect the tiny electrical changes on the skin that arise from the heart muscle depolarizing during each heartbeat.
In a conventional 12 lead ECG, ten electrodes are placed on the patient's limbs and on the surface of the chest. The overall magnitude of the heart's electrical potential is then measured from twelve different angles ("leads") and is recorded over a period of time (usually 10 seconds). In this way, the overall magnitude and direction of the heart's electrical depolarization is captured at each moment throughout the cardiac cycle. The graph of voltage versus time produced by this noninvasive medical procedure is referred to as an electrocardiogram (abbreviated 12 Lead ECG or EKG).


WHAT TO EXPECT
The test takes 5 to 10 minutes. You will be asked to lie down on a table or stretcher. Once data is entered into the computer and the leads are placed onto your body you are ready for the test. During the test it is very important to be still, movement can cause artifact. If there is too much artifact the test is repeated till an artifact free 12 lead EKG is obtained. The electrocardiogram is then reviewed by a cardiologist and the results given to the ordering doctor. Your doctor will then review the findings and implement any necessary treatment or potentially more diagnostic testing.

 

CARDIAC TABLE TILT TEST

INTRODUCTION
A tilt table test, occasionally called upright tilt testing, is a medical procedure often used to diagnose dysautonomia or syncope. Patients with symptoms of dizziness or lightheadedness, with or without a loss of consciousness (fainting), suspected to be associated with a drop in blood pressure or positional tachycardia are good candidates for this test.


WHAT TO EXPECT
The procedure tests for causes of syncope by attempting to cause syncope by having the patient lie flat on a special table or bed and then be monitored with ECG and a blood pressure monitor which measure continuous, beat to beat, non-invasively. The table then creates a change in posture from lying to standing.
A tilt table test can be done in different ways and be modified for individual circumstances. In some cases, the patient will be strapped to a tilt table lying flat and then tilted or suspended completely or almost completely upright (as if standing). Most of the time, the patient is suspended at an angle of 60 to 80 degrees. Sometimes, the patient will be given a drug, such as Glyceryl trinitrate (nitroglycerin) or isoproterenol, to create further susceptibility to the test. In all cases, the patient is instructed not to move. Symptoms, blood pressure, pulse, electrocardiogram, and sometimes blood oxygen saturation are recorded. The test either ends when the patient faints or develops other significant symptoms, or after a set period, usually from 20 to 45 minutes, depending on the individual patient.

 

HOLTER MONITORING

INTRODUCTION

In medicine, a Holter monitor (often simply "Holter" or occasionally ambulatory electrocardiography device) is a portable device for continuously monitoring various electrical activity of the cardiovascular system for at least 24 hours (often for two weeks at a time).

The Holter's most common use is for monitoring heart activity (electrocardiography or ECG). Its extended recording period is sometimes useful for observing cardiac arrhythmias which would be difficult to identify in a shorter period of time. For patients having more transient symptoms, a cardiac event monitor which can be worn for a month or more can be used.


WHAT TO EXPECT
When used for the heart, (much like standard electrocardiography) the Holter monitor records electrical signals from the heart via a series of electrodes attached to the chest. Electrodes are placed over bones to minimize artifacts from muscular activity. The number and position of electrodes varies by model, but most Holter monitors employ between three and eight.
These electrodes are connected to a small piece of equipment that is attached to the patient's belt or hung around the neck, and is responsible for keeping a log of the heart's electrical activity throughout the recording period.
Although some patients may feel uncomfortable about a Holter examination, there is nothing to worry about. No hazards are involved, and it should have little effect on one's normal daily life. The recording device can be worn in a case on a belt or on a strap across the chest. The device may be visible under light clothing, and those wearing a Holter monitor may wish to avoid shirts with a low neckline.
Persons being monitored should not limit normal daily activities since its purpose is to record how a heart works under various actual conditions over an extended period. It is an electrical device, however, and should be kept dry; showering or swimming should probably be avoided. Monitors can be removed for a few minutes without invalidating collected data, but proper reattachment is critical to avoid degradation of its signals. Beyond changing batteries, one should leave its handling to trained personnel.
Once the time collection period is complete, the monitor is removed. A cardiologist will review the collected data and communicate findings to the ordering doctor. Your doctor will then implement appropriate treatment or schedule more testing.

 

CARDIAC ECHO

INTRODUCTION

An echocardiogram (also called an echo) is a type of ultrasound test that uses high-pitched sound waves that are sent through a device called a transducer. Echo is a noninvasive procedure used to assess the heart's function and structures. During the procedure, a transducer sends out ultrasonic sound waves at a frequency too high to be heard. The waves echo off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer interprets the echoes into an image of the heart walls and valves.
The different types of echocardiograms are:
       • Transthoracic echocardiogram (TTE). This is the most common type. Views of the heart are obtained by moving the transducer to different locations on your chest or abdominal wall.
         • Stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine (ex. dobutamine) that makes your heart beat harder and faster. A stress echocardiogram is usually done to find out if you might have decreased blood flow to your heart (coronary artery disease).
         • Doppler echocardiogram. This test is used to look at how blood flows through the heart chambers, heart valves, and blood vessels. The movement of the blood reflects sound waves to a transducer. The ultrasound computer then measures the direction and speed of the blood flowing through your heart and blood vessels. Doppler measurements may be displayed in black and white or in color.

 

WHAT TOO EXPECT
Before Your Echo Test
         o Your physician may instruct you to stop or taper certain medications (heart and lung meds usually) before your echo test. Please check with your physician if any medications should be stopped before this test.
         o Generally, no prior preparation, such as fasting or sedation, is required
         o Notify your physician if you have a pacemaker.
         o If you are pregnant or suspect that you may be pregnant, you should notify your physician before the test.
        o Women should wear a separate top, preferably that fastens in the front for ease of attaching the ECG electrodes to the chest.
         o Please be aware, the areas where the electrodes will need to be placed may be shaved.
         o You may wear your glasses, dentures, or hearing aids if you use any of these.
         o For some patients, having to lie still on the examination table for the length of the procedure may cause some discomfort or pain. Be sure to discuss any concerns with the technician or doctor prior to the procedure.
During The Procedure
         o You will be asked to remove any jewelry or other objects that may interfere with the procedure.
         o You will be asked to open your blouse or shirt in the front (men may be asked to remove their shirts), or you may be asked to wear a hospital gown.
         o If your chest, arms, or legs are very hairy, the technician may shave small patches of hairs needed so that the electrodes will stick to skin. Electrodes will then be attached to your chest, arms, and legs.
         o A blood pressure cuff will be attached to your arm while you are sitting down. Initial, or baseline, ECG and blood pressure readings will be taken while you are lying or sitting down and standing up.
         o You will lie on a table or bed, positioned on your left side. A pillow or wedge may be placed behind your back for support.
        o You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. The ECG tracings that record the electrical activity of the heart will be compared to the images displayed on the echocardiogram monitor.
         o The room will be darkened so that the images on the echo monitor can be viewed by the technologist.
        o The technologist will place warmed gel on your chest and then place the transducer probe on the gel. You will feel a slight pressure as the technologist positions the transducer to get the desired image of your heart.
         o During the test, the technologist will move the transducer probe around and apply varying amounts of pressure to obtain images of different locations and structures of your heart. The amount of pressure behind the probe should not be uncomfortable. If it does make you uncomfortable, however, let the technologist know.
         o After the procedure has been completed, the technologist will wipe the gel from your chest and remove the ECG electrode pads. You may then put on your clothes.
After the Procedure
         o You should be able to resume your normal diet and activities, unless your physician instructs you differently.
         o Generally, there is no special care following an echo
        o Notify your physician if you develop any signs or symptoms you had prior to the test (e.g., chest pain, shortness of breath, dizziness, or fainting).

 

CARDIAC EXERCISE STRESS TEST

INTRODUCTION

An exercise stress test is one of the simplest and fastest procedures used to evaluate the heart and its response to stress or exercise. The electrical activity of the heart is measured, interpreted, and monitored. The ECG is monitored while a person is exercising on a treadmill.


WHAT TO EXPECT
Before Your Exercise Stress Test:
         • Your physician may instruct you to stop or taper certain medications (heart and lung meds usually) before your stress test. Please check with your physician if any medications should be stopped before this test.


IMPORTANT
         • You are usually asked to:
         • stop eating for 4 hours before the procedure.
         • stop smoking for 4 hours before the procedure
         • stop caffeine for 4 hours before the procedure
         • If you are pregnant or suspect that you may be pregnant, you should notify your physician before the test.
         • Wear flat shoes with rubber soles or sneakers that are comfortable for walking and loose-fitting pants or shorts.
         • Women should wear a short-sleeved top that fastens in the front for ease of attaching the ECG electrodes to the chest.
         • Please be aware, the areas where the electrodes will need to be placed may be shaved.
During the test:
         • You will be asked to remove any jewelry or other objects that may interfere with the procedure.
         • You will be asked to open your blouse or shirt in the front (men may be asked to remove their shirts), or you may be asked to wear a hospital gown.
        • If your chest, arms, or legs are very hairy, the technician may shave small patches of hairs needed so that the electrodes will stick to skin. Electrodes will then be attached to your chest, arms, and legs.
        • A blood pressure cuff will be attached to your arm while you are sitting down. Initial, or baseline, ECG and blood pressure readings will be taken while you are lying or sitting down and standing up.
        • You will be instructed on how to walk on the treadmill. You will be told to let the technician, or physician know if you begin to have any chest pain, dizziness, lightheadedness, extreme shortness of breath, nausea, headache, leg pains, or other symptoms during exercise.
       • You will begin to exercise at a minimal level. The intensity of the exercise will be gradually increased on the treadmill by increasing the incline and speed of the treadmill every few minutes.
         • ECG, blood pressure and oxygenation readings will be taken periodically during the exercise to measure how well your heart and body are responding to the exercise.
      • The exercise will end once you have reached a target heart rate. The test may also be stopped if you develop severe symptoms such as chest pain, dizziness, nausea, severe shortness of breath, severe fatigue, or an abnormally elevated blood pressure or for abnormal findings on the ECG.
         • Once you have reached your target heart rate, the rate of exercise will be slowed for a "cool down" period to help avoid any nausea or cramping from sudden stopping of exercise.
         • You will sit in a chair and your ECG and blood pressure will be monitored until they return to normal or near-normal. This may take 10 to 20 minutes.
After the test:
         • You should be able to resume your normal diet and activities, unless your physician instructs you differently.
         • Generally, there is no special care following an exercise ECG.
        • Notify your physician if you develop any signs or symptoms you had prior to the test (e.g., chest pain, shortness of breath, dizziness, or fainting).

 

CARDIAC ECHO EXERCISE STRESS TEST

INTRODUCTION

An exercise stress echocardiogram is performed to learn about the size, shape, and motion of the heart and heart valves, and whether the heart receives enough blood during exercise or when it is stressed. During the test, exercise increases the heart rate and the amount of blood and oxygen the heart needs to function. Sound waves are used to make pictures of the heart before and after the exercise.


WHAT TO EXPECT
Before the Exercise Stress Echocardiogram:
• Notify the physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
• Your physician may instruct you to stop or taper certain medications before your stress test. You should check with your physician if any medications should be stopped before this test.


IMPORTANT.
         • You are asked to:
         • fast for 4 hours before the procedure.
         • stop smoking for 4 hours before the procedure
         • stop caffeine for 4 hours before the procedure
         • If you are pregnant or suspect that you may be pregnant, you should notify your physician.
         • Notify the physician if you have a pacemaker or defibrillator.
         • Wear flat shoes with rubber soles or sneakers that are comfortable for walking and loose-fitting pants or shorts.
         • Women should wear a short-sleeved top that fastens in the front for ease of attaching the ECG electrodes to the chest.
         • The area(s) where the electrodes are to be placed may be shaved.
         • If you take insulin, check to find out what amount of insulin to take on the day of the exam.


During the test:
The first part of the test is usually performed in a darkened room. You will be asked to lie on your back, your left side and/or sit up. A lubricating gel will be applied to your skin over the heart area. A small smooth instrument (called a transducer) will be moved and/or tilted gently across your chest in various positions during the exam. The echo transducer picks up the sound waves from your heart and a live image of your heart is displayed on a TV monitor.
         • You will be asked to remove any jewelry or other objects that may interfere with the procedure.
         • You will be asked to open your blouse or shirt in the front (men may be asked to remove their shirts).
        • If your chest, arms, or legs are very hairy, the technician may shave small patches of hairs needed so that the electrodes will stick to skin. Electrodes will then be attached to your chest, arms, and legs.
        • A blood pressure cuff will be attached to your arm while you are sitting down. Initial, or baseline, ECG and blood pressure readings will be taken while you are lying or sitting down and standing up.
         • If you begin to have any chest pain, dizziness, lightheadedness, extreme shortness of breath, nausea, headache, leg pains, or other symptoms during exercise notify the nurse or physician.
      • The exercise will end once you have reached a target heart rate. The test may also be stopped if you develop severe symptoms such as chest pain, dizziness, nausea, severe shortness of breath, severe fatigue, or an abnormally elevated blood pressure or for abnormal findings on the ECG.
At times during the exam you will hear a "swishing" sound (called Doppler) coming from the machine. This is the blood flow as it moves through the heart valves. After the echo is completed, you will be asked to walk on a motorized treadmill. The speed and incline of the treadmill will be gradually increased. Once your maximum heart rate is achieved you will lie down again and repeat images will be taken with the echo machine. There is no pain or discomfort during the test. Test time is approximately 45-60 minutes.

 

CARDIAC ECHO DOBUTAMINE STRESS TEST

INTRODUCTION

A dobutamine stress echocardiogram is a diagnostic procedure that may be used when a doctor wants to assess the heart muscle under stress but exercise on a treadmill is not an option. The dobutamine stress echo test involves the injection of a medication called dobutamine while you are closely monitored. Dobutamine causes the heart to beat faster and will mimic the effects of exercise on the heart. Once dobutamine is injected the remainder of the study is like a regular echo test.
An echocardiogram is a noninvasive procedure used to assess the heart's function and structures. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves at a frequency too high to be heard. When the transducer is placed on the chest at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves bounce or "echo" off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer displays the echoes as images of the heart walls and valves.
A dobutamine stress echocardiogram may utilize one or more of four special types of echocardiography, as listed below:
         • M-mode echocardiography. This, the simplest type of echocardiography, produces an image that is similar to a tracing rather than an actual picture of heart structures. M-mode echo is useful for measuring heart structures, such as the heart's pumping chambers, the size of the heart itself, and the thickness of the heart walls.
         • Doppler echocardiography. This Doppler technique is used to measure and assess the flow of blood through the heart's chambers and valves. The amount of blood pumped out with each beat is an indication of the heart's functioning. Also, Doppler can detect abnormal blood flow within the heart, which can indicate a problem with one or more of the heart's four valves or with the heart's walls.
         • Color Doppler. Color Doppler is an enhanced form of Doppler echocardiography. With color Doppler, different colors are used to designate the direction of blood flow. This simplifies the interpretation of the Doppler technique.
         • 2-D (two-dimensional) echocardiography. This technique is used to visualize the actual structures and motion of the heart structures. A 2-D echo view appears cone-shaped on the monitor, and the real-time motion of the heart's structures can be observed. This enables the doctor to see the various heart structures at work and evaluate them.


WHAT TO EXPECT
The appointment will take about one hour. The actual infusion time is about 15 minutes. You should plan to stay in the waiting room for at least 30 minutes after completing the procedure, or until all of the symptoms you experienced have resolved.
A dobutamine stress echocardiogram may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices. Generally, a dobutamine stress echocardiogram follows this process:
         • You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your glasses, dentures, or hearing aids if you use any of these.
         • You will be asked to remove clothing from the waist up and will be given a gown to wear.
         • You will be asked to empty your bladder prior to the procedure.
         • An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed.
         • You will lie on your left side on a table or bed, but may be asked to change position during the procedure.
         • You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure. The ECG tracing that will record the electrical activity of the heart will be compared to the images displayed on the echocardiogram monitor.
         • The room will be darkened so that the images on the echo monitor can be viewed by the technologist.
         • The technologist will place warmed gel on your chest and then place the transducer probe on the gel. You will feel a slight pressure as the technologist positions the transducer to get the desired image of your heart.
         • The dobutamine infusion will begin at a rate determined by your weight. The rate of the infusion will be increased every few minutes until you have reached your target heart rate (determined by the physician based on your age and physical condition), or until the maximum dose of dobutamine has been reached.
         • After the dobutamine is started and after each increase in the dobutamine rate, your blood pressure will be checked, an ECG tracing will be performed, and echocardiogram images will be obtained.
         • The technologist will move the transducer probe around on your chest so that all areas and structures of your heart can be observed. The different echocardiogram techniques described above (M-mode, 2-D, Doppler, and color Doppler) may be used. You will not be aware of the different techniques except that during the Doppler or color Doppler, you may hear a "whoosh-whoosh" sound, which is the sound of the blood moving through the heart.
         • Once you have reached your target heart rate or the maximum amount of the dobutamine, the medication will be stopped. Your heart rate, blood pressure, ECG, and echo will continue to be monitored for 10 to 15 minutes until they have returned to the baseline state.
         • You should notify the technologist if you feel any chest pain, breathing difficulties, sweating, or heart palpitations.
         • Once all the images have been taken, the technologist will wipe the gel from your chest, remove the ECG electrode pads, and remove the IV line. You may then put on your clothes.
After the test you may resume your usual diet and activities unless your doctor advises you differently.
Generally, there is no special type of care following a dobutamine stress echocardiogram. However, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

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