What Is an Exercise Stress Test?
Why do I need a stress test?
What happens during the test?
What is monitored during the test?
What equipment is used?
Is there a risk?
What Types of Stress Tests Are There?
How Should I Prepare for the Exercise Stress Test?
What If I Have Diabetes?
What Should I Wear the Day of the Test?
What Happens During the Exercise Stress Test?
How does a Regular Stress Test work?
How is a Treadmill Stress Test performed?
How safe is it?
What is the reliability of the test?
When is a Regular Stress Test ordered?
How is a Regular Treadmill Stress Test Performed?
How quickly will I get the results and what will it mean?
How important or necessary is this test for diagnosis?
Do any tests need to be done prior to the angiogram?
What type of angiography will be performed?
What will happen during the procedure?
What are the risks?
What should be expected after the procedure?
Will any medication be given?
What are the side effects?
Will any anesthesia be given?
What should I do to prepare for my procedure?
What is my expected recovery time and will I have any activity restrictions?
Will the procedure be painful?
What is conscious sedation?
What are the risks of my procedure?
What happens after I check in at the hospital?
What is an angiogram?
What is an angioplasty?
Why do I need an angiogram, angioplasty and/or stent?
What signs should I watch for, following the procedure, which may indicate a problem?
What is peripheral vascular disease (PVD)?
What are the symptoms of PVD?
What are the risk factors of PVD?
What should I do to prepare for my procedure?
What is my expected recovery time and will I have any activity restrictions?
Will the procedure be painful?
What is conscious sedation?
What are the risks of my procedure?
What happens after I check in at the hospital?
What is an angiogram?
What is an angioplasty?
Why do I need an angiogram, angioplasty and/or stent?
What signs should I watch for, following the procedure, which may indicate a problem?
What is peripheral vascular disease (PVD)?
What are the symptoms of PVD?
What are the risk factors of PVD?
What is Ultrasound?
What is an Echocardiogram?
What is Doppler?
What information does it provide?
How safe is it?
How long does it take?
How quickly do I get the results and what do they mean?
What is a Doppler Examination?
What information does Echocardiography and Doppler provide?
Are you seeing a doctor?
Who is your next of kin?
Are you taking any medication?
Have you ever had this type of pain before?
For example, if the patient presents with chest pain, the physician will inquire about the character, location, severity and duration of the pain. What brought it on? What relieved it? Did it move to the shoulder, arms, jaw, back or other parts of the body? Were there associated symptoms like shortness of breath, sweating, dizziness, weakness, nausea, vomiting, etc.? When did it first start? How often does it occur? If it was initially brought on by exertion, is the pattern changing? Is it brought on by lesser amounts of exertion? Is it becoming more frequent with time? Are the symptoms lasting longer? Do they appear at rest or has it awakened the patient from a sound sleep? Answers to these questions are analyzed by the physician and help him or her determine the cause of the pain and the seriousness of the problem.
Other cardiac chief complaints can consist of shortness of breath, dizziness, blackout spells, palpitations (a sensation of skipped, forceful, or fast heartbeats), weakness, swelling of the legs, etc. Each of these will prompt a series of specific questions that will help the physician arrive at a preliminary single diagnosis, or a group of different diagnoses. The latter is known as a "differential diagnosis" A HISTORY obtained by a physician is similar to a detective interviewing a victim. The goal is to identify the criminal (disease) that is responsible for the victim's (patient's) problem.
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PAST HISTORY:
After obtaining information about the chief complaint, the physician will inquire about the past history. This will include questions about diseases such as diabetes, high blood pressure, elevated cholesterol levels, prior surgery, asthma, stroke, cancer, allergies, etc. This information may also strengthen a suspected diagnosis. For example, the presence of diabetes, high blood pressure and high cholesterol is known to increase the risk of heart disease.
FAMILY HISTORY:
Certain cardiac illnesses such as coronary artery disease and high blood pressure may occur in more than one member of a family. Therefore, the physician will inquire about the health of the patient's parents, brothers, sisters and children. Similarly, risk factors for coronary artery disease, such as diabetes, high cholesterol, etc., may be prevalent in the same family.
SOCIAL HISTORY:
Information about smoking and drinking is sought because of tobacco's undeniable link to coronary artery disease. Similarly alcohol can weaken the heart muscle in susceptible individuals, and caffeine can provoke irregular heartbeats. The physician will also inquire about the patient's work and family if he or she feels that stress is contributing to, or aggravating the patient's illness.
REVIEW OF SYSTEMS:
This is a "laundry list" of symptoms related to various organs of the body. A series of questions are designed to seek out information that the patient may have neglected to provide the physician. A history of asthma during childhood, for example, may be discovered this way and keep the physician from prescribing certain heart medicines that may provoke an asthmatic attack.
The history dictates whether or not the patient needs further work-up or testing, and the urgency with which they should be carried out. Should the patient be hospitalized because there is a threat of an impending heart attack? Is the likelihood of disease low enough that testing can be obtained at a more leisurely pace? Subsequent testing helps to identify the patient's problem, or exclude different parts of the differential diagnosis.
Physical Exam Next Page
After obtaining a history, the physician proceeds to perform a physical examination. Depending upon the patient's condition and suspected medical problem, a physician may include one or more of the following four phases of the physical examination:
Inspection
Palpation or "hands-on" examination
Percussion or "tapping" examination
Auscultation or use of stethoscope
Inspectgion Inspection: During this portion of the examination, the physician inspects or looks at different parts of the patient's body. For example, while inspecting the eyes, the physician could obtain a clue about an overactive thyroid that could be responsible for the patient's rapid heart beat. A characteristic growth on the eyelids could point to a high cholesterol level that is a risk factor for coronary artery disease.
Inspection of the neck veins and its prominence could be indicative of heart failure and an excessive load on the right side of the heart. A bluish discoloration of the tongue and nail beds could point to a low oxygen level in the blood, while pallor or a pale appearance could indicate a low level of hemoglobin. Additionally, inspection of the chest may provide information about enlargement of the heart. Thus, a physician obtains an enormous amount of information even before touching the patient.
Palpation or "hands-on examination": During palpation, the physician uses his or hands to examine the patient. During this phase, the physician can feel the heart beat and diagnose enlargement. Loud heart murmurs may also be felt without the use of a stethoscope. This is known as a "thrill." Palpation of the belly could help diagnose liver enlargement, find the tenderness of an active ulcer, or help uncover an aneurysm.
The patient's pulses are also felt to help determine if there is disease of the blood vessel accounting for calf pain when the patient walks. Pressing the legs and feet with the fingertip can diagnose the presence of edema or excess fluid.
Percussion
Percussion or Tapping: During percussion, the patient places one hand on the patient and then taps a finger with the index finger of the other hand. Since hollow and solid areas generate different vibrations, the physician uses this technique to measure the size of various organs (heart, liver, etc.). Percussion is also used to diagnose fluid in the abdominal and chest cavities or make one suspect the presence of pneumonia.
Auscultation or listening with a stethoscope: During auscultation, the physician listens to the patient's heart beat, lungs and blood vessels of the neck and groin. Abnormal heart sounds, known as gallops, are a clue to heart disease. Also, the location, character and timing of a heart murmur (this is a prolonged sound that is created by turbulent blood flow across heart valves) are used to diagnose various valve diseases. However, it should be recognized that murmurs may also be heard in many normal individuals.
Certain characteristics of the murmur and other portions of the examination help the physician diagnose specific forms of heart diseases. Similarly, blockages in the arteries of the neck and those that supply the legs may also produce a turbulent flow. This can be heard with a stethoscope and is known as a "bruit" (pronounced broo-ee). Listening to the lungs, when integrated with the history and other portions of the physical examination, can diagnose such conditions as heart failure, accumulation of fluid, asthma, bronchitis, pneumonia, collapsed lungs, etc.
Electrocardiogram, EKG or ECG: An EKG is an important part of the initial evaluation of a patient who is suspected to have a heart related problem. Small sticky electrodes are applied to the patient's chest, arms and legs. However, with some systems, the electrodes may be applied to the chest, shoulders and the sides of the lower chest, or hips . Wires are used to connect the patient to an EKG machine. You will be asked to remain very still while a nurse or technician records the EKG. The electrical activity created by the patient's heart is processed by the EKG machine and then printed on a special graph paper. This is then interpreted by your physician. It takes a few minutes to apply the EKG electrodes, and one minute to make the actual recording.
EKG test
The EKG is extremely safe and there is no risk involved. In rare cases, some people may develop skin irritation from the electrode adhesive, but no serious allergic reactions have been reported.
The only preparation for an EKG to wear clothes that allow easy access to your chest. Thus, a blouse or shirt with buttons down the front is a lot more practical than a pantsuit or dress. Once you arrive in your doctor's office or in the hospital, your chest may be cleansed with alcohol to ensure good electrical contact with the EKG electrode. In men with hairy chest, small areas may have to be shaved to allow adequate skin contact with the electrode. This avoids interfering artifacts from being recorded on the EKG and produces a technically satisfactory study.
The EKG can provide important information about the patient's heart rhythm, a previous heart attack, increased thickness of heart muscle, signs of decreased oxygen delivery to the heart, and problems with conduction of the electrical current from one portion of the heart to another. For example, the EKG tracing shown above demonstrates an acute or ongoing heart attack involving the bottom (or inferior portion of the heart). An example of an EKG of a patient with a heart attack is shown below.
EKG
It is important to remember that EKGs are not 100% accurate. Normal recordings can be obtained in patients with significant heart disease, or some "abnormalities" may exist in the presence of a normal heart.
A Chest x-ray is obtained either in a physician's office or in the hospital. To obtain a standard PA or postero-anterior view (it is called postero-anterior because the x-ray beam comes from the posterior or back and moves through the chest to the anterior or front). The patient is positioned so that his or her chest touches the container of the x-ray film. The x-ray machine sends a beam from the back and records an image on the film, as shown below. Frequently, a "lateral" film is obtained by having the patient stand sideways in front of the film. This allows the physician to examine the chest from the side. This may help pickup, confirm, or rule out an abnormality suspected in the other view.
A Chest x-ray is very valuable in answering the following questions:
Is the heart enlarged or normal? Are there signs of heart failure and fluid overload? Does the patient have pneumonia or a collapsed lung? Is there evidence of emphysema? Are there findings of an aneurysm involving the aorta (the major blood vessel that arises from the heart and supplies oxygenated blood to the body)? Is there fluid in the sac that surrounds the lung? Is there free air under the diaphragm (the partition that separates the chest from the abdomen) to suggest a hole in the bowel wall? Is there a tumor in the lung that could represent cancer? Are there changes of bronchitis or emphysema.
Thus, one can easily see the cost-effectiveness of this relatively simple test. In patient's with lung or heart disease, chest x-rays obtained at yearly, or longer, intervals may provide information about the progression, stability or improvement of disease.
Shown below is a panoramic view of a patient getting a chest x-ray
What Is an Exercise Stress Test?
The exercise stress test -- also called a stress test, exercise electrocardiogram, treadmill test, graded exercise test, or stress ECG -- is a test used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while your electrocardiogram, heart rate, and blood pressure are monitored.
Why do I need a stress test?
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Your doctor uses the stress test to:
* Determine if there is adequate blood flow to your heart during increasing levels of activity.
* Evaluate the effectiveness of your heart medications to control angina and ischemia.
* Determine the likelihood of having coronary heart disease and the need for further evaluation.
* Check the effectiveness of procedures done to improve blood flow within the heart vessels in people with coronary heart disease.
* Identify abnormal heart rhythms.
* Help you develop a safe exercise program.
What happens during the test?
*
What is monitored during the test?
*
What equipment is used?
*
Is there a risk?
A stress test can be used to test for heart disease. Stress tests are tests performed by a doctor and/or trained technician to determine the amount of stress that your heart can manage before developing either an abnormal rhythm or evidence of ischemia (not enough blood flow to the heart muscle). The most commonly performed stress test is the exercise stress test.
What Types of Stress Tests Are There?
There are many different types of stress tests, including:
* Dobutamine or Adenosine Stress Test: This test is used in people who are unable to exercise. A drug is given to make the heart respond as if the person were exercising. This way the doctor can still determine how the heart responds to stress, but no exercise is required.
* Stress echocardiogram: An echocardiogram (often called "echo") is a graphic outline of the heart's movement. A stress echo can accurately visualize the motion of the heart's walls and pumping action when the heart is stressed; it may reveal a lack of blood flow that isn't always apparent on other heart tests.
* Nuclear stress test: This test helps to determine which parts of the heart are healthy and function normally and which are not. A very small and harmless amount of radioactive substance is injected into the patient. Then the doctor uses a special camera to identify the rays emitted from the substance within the body; this produces clear pictures of the heart tissue on a monitor. These pictures are done both at rest and after exercise. Using this technique, a less than normal amount of thallium will be seen in those areas of the heart that have a decreased blood supply.
Preparation for these types of stress tests will vary from preparation for the exercise stress test. Ask your doctor about any specific instructions.
How Should I Prepare for the Exercise Stress Test?
Before your stress test:
* Do not eat or drink anything except water for four hours before the test.
* Do not drink or eat foods containing caffeine for 12 hours before the test. Caffeine will interfere with the results of your test.
* Do not take the following heart medications on the day of your test unless your doctor tells you otherwise, or if the medication is needed to treat chest discomfort the day of the test: Isosorbide dinitrate (for example, Isordil, Dilatrate SR); Isosorbide mononitrate (for example, ISMO, Imdur, Monoket); Nitroglycerin (for example, Deponit, Nitrostat, Nitro-bid). Your doctor may also ask you to stop taking other heart medications on the day of your test. If you have any questions about your medications, ask your doctor. Do not discontinue any medication without first talking with your doctor.
* If you use an inhaler for your breathing, please bring it to the test.
What If I Have Diabetes?
If you have diabetes:
* If you take insulin to control your blood sugar, ask your doctor what amount of your medication you should take the day of the test. Often, you will take only half of your usual morning dose and eat a light meal 4 hours before the test.
* If you take pills to control your blood sugar, do not take your medication until after the test is complete.
* Do not take your diabetes medication and skip a meal before the test.
* If you own a glucose monitor, bring it with you to check your blood sugar levels before and after your exercise stress test. If you think that your blood sugar is low, tell the lab personnel immediately.
* Plan to eat and take your blood sugar medication following your stress test.
What Should I Wear the Day of the Test?
On the day of your stress test, wear soft-soled shoes suitable for walking and comfortable clothes. Do not bring valuables.
What Happens During the Exercise Stress Test?
First, during a stress test, a technician will gently clean 10 small areas on your chest and place electrodes (small, flat, sticky patches) on these areas. The electrodes are attached to an electrocardiograph monitor (ECG or EKG) that charts your heart's electrical activity during the test.
Before you start exercising, the technician will perform an EKG, to measure your heart rate at rest and will take your blood pressure.
You will begin to exercise by walking on a treadmill or pedaling a stationary bicycle. The rate of exercise, or degree of difficulty will gradually increase. You will be asked to exercise until you feel exhausted.
At regular intervals, the lab personnel will ask how you are feeling. Please tell them if you feel chest, arm or jaw pain or discomfort, short of breath, dizzy, lightheaded, or any other unusual symptoms. It is normal for your heart rate, blood pressure, breathing rate, and perspiration to increase during the test. The lab personnel will watch for any symptoms or changes on the ECG monitor that suggest the test should be stopped.
What Happens During the Exercise Stress Test?
After the test you will walk or pedal slowly for a couple of minutes to cool down. Your heart rate, blood pressure and ECG will continue to be monitored until the levels begin returning to normal.
Although the appointment lasts about 60 minutes, the actual exercise time is usually between seven and 12 minutes.
Ask your doctor if you have any questions about the exercise stress test.
How does a Regular Stress Test work?
When is a Regular Stress Test ordered?
How is a Treadmill Stress Test performed?
Preparing for the test?
How safe is it?
What is the reliability of the test?
How quickly will I get the results?
How does a Regular Stress Test Work? Patients with coronary artery blockages may have minimal symptoms and an unremarkable or unchanged EKG while at rest. However, symptoms and signs of heart disease may become unmasked by exposing the heart to the stress of exercise. During exercise, healthy coronary arteries dilate (develop a more open channel) than an artery that has a blockage. This unequal dilation causes more blood to be delivered to heart muscle supplied by the normal artery. In contrast, narrowed arteries end up supplying reduced flow to it's area of distribution. This reduced flow causes the involved muscle to "starve" during exercise. The "starvation" may produce symptoms (like chest discomfort or inappropriate shortness of breath), and the EKG may produce characteristic abnormalities. Most commonly, a motorized treadmill is used for exercise, while a stationary bicycle is used in some exercise laboratories.
When is a Regular Stress Test ordered? A regular stress test is considered in the following circumstances:
* Patients with symptoms or signs that are suggestive of coronary artery diseases (CAD).
* Patients with significant risk factors for CAD.
* To evaluate exercise tolerance when patients have unexplained fatigue and shortness of breath.
* To evaluate blood pressure response to exercise in patients with borderline hypertension.
* To look for exercise-induced serious irregular heart beats.
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Please remember that the regular stress test is heavily dependent upon interpretation of EKG changes produced by exercise. Therefore, the reliability drops drastically if there are significant EKG changes at rest (for example in patients with long standing high blood pressure, an artificial cardiac pacemaker, use of medications like digitalis, or presence of a bundle branch block pattern, etc.). In all such cases, the physician will usually order an Echo Stress Test or a Nuclear Stress Test, particularly if he or she is suspecting coronary artery disease. However, a regular stress may be sufficient in stable patients or those with a low suspicion of coronary artery disease who are being assessed for exercise tolerance (for example, prior to undergoing a structured exercise or rehab program).
How is a Regular Treadmill Stress Test Performed? The patient is brought to the exercise laboratory where the heart rate and blood pressure are recorded at rest. Sticky electrodes are attached to the chest, shoulders and hips and connected to the EKG portion of the Stress test machine. A 12-lead EKG is recorded on paper. Each lead of the EKG represents a different portion of the heart, with adjacent leads representing a single wall. For example:
* Leads 2, 3, and aVF = bottom or inferior portion of the heart.
* Leads V1 and V2 = septum or partition of the heart.
* Leads V3, V4, V5 and V6 = anterior or front portion of the heart.
* Leads 1 and aVL = superior or top and outer left portion of the heart.
* Lead aVR looks at the cavity of the heart and has almost no clinical value in identifying coronary disease.
Three of the EKG leads are also constantly displayed on the treadmill monitor. Each lead representing a different wall. The physician has the option of selecting different combinations of three.
The treadmill is then started at a relatively slow "warm-up" speed. The treadmill speed and it's slope or inclination are increased every three minutes according to a preprogrammed protocol (Bruce is the commonest protocol in the USA, but several other protocols are perfectly acceptable). The protocol dictates the precise speed and slope. Each three minute interval is known as a Stage (Stage 1, Stage 2, Stage 3, etc. Thus a patient completing Stage 3 has exercised for 3 x 3 = 9 minutes). The patient's blood pressure is usually recorded during the second minute of each Stage. However, it may be recorded more frequently if the readings are too high or too low.
As noted earlier, the EKG is constantly displayed on the monitor. It is also recorded on paper at one minute intervals. The physician pays particular attention to the heart rate, blood pressure, changes in the EKG pattern, irregular heart rhythm, and the patient's appearance and symptoms. The treadmill is stopped when the patient achieves a target heart rate (this is 85% of the maximal heart rate predicted for the patient's age). However, if the patient is doing extremely well at peak exercise, the treadmill test may be continued further. The test may be stopped prior to achievement of the target heart rate if the patient develops significant chest discomfort, shortness of breath, dizziness, unsteady gait, etc., or if the EKG shows alarming changes or serious irregular heart beats. It may also be stopped if the blood pressure (BP) rises or falls beyond acceptable limits. Please note that the systolic BP (upper number) may normally rise to 200 at peak exercise. At the same time, the diastolic BP (lower number) remains unchanged or falls to a slight degree. In contrast, the BP of patients with hypertension or high BP will show a rise of both systolic and diastolic readings. The latter may rise above 90 - 100.
Preparing for the Regular Stress Test:
The following recommendations are "generic" for all types of cardiac stress tests:
* Do not eat or drink for three hours prior to the procedure. This reduces the likelihood of nausea that may accompany strenuous exercise after a heavy meal. Diabetics, particularly those who use insulin, will need special instructions from the physician's office.
* Specific heart medicines may need to be stopped one or two days prior to the test. Such instructions are generally provided when the test is scheduled.
* Wear comfortable clothing and shoes that are suitable for exercise.
* An explanation of the test is provided and the patient is asked to sign a consent form.
* How long does the entire test take? A patient should allow approximately one hour for the entire test, including the preparation.
How safe is a Regular Treadmill Stress Test? The risk of the stress portion of the test is very small and similar to what you would expect from any strenuous form of exercise (jogging in your neighborhood, running up a flight of stairs, etc.). As noted earlier, experienced medical staff is in attendance to manage the rare complications like sustained irregular heart beats, unrelieved chest pain or even a heart attack.
What is the reliability of a Regular Stress Test? If a patient is able to achieve the target heart rate, a regular treadmill stress test is capable of diagnosing important disease in approximately 67% or 2/3 rd of patients with coronary artery disease. The accuracy is lower (about 50%) when patients have narrowing in a single coronary artery or higher (greater than 80%) when all three major arteries are involved. Approximately 10% of patients may have a "false-positive" test (when the result is falsely abnormal in a patient without coronary artery disease).
How quickly will I get the results and what will it mean?
Computed tomography (CT)
Q. Is exploring the coronary arteries using computed tomography (CT) almost as good as exploring them directly with a catheter?
Q. Have you tried this method?
Q. Isn't this the better method?
Q. What are the merits and demerits of this method?
What Is a Coronary Angiogram?
A coronary angiogram is a special X-ray test. It’s done to find out if your coronary arteries are clogged, where and by how much. This information sheet provides answers to the following questions regarding having a coronary angiogram:
Why do I need this test?
What happens in the test?
What might I feel?
What happens after the test?
Echocardiogram
Described below is a regular transthrocic echocardiogram. To review two other types of echo, click one one of the links below:
Transesophageal Echo or TEE
Stress Echocardiogram or Stress Echo
What is Ultrasound?
What is an Echocardiogram?
What is Doppler?
What information does it provide?
How safe is it?
How long does it take?
How quickly do I get the results and what do they mean?
What is Ultrasound: Sound is made up of several different frequency waves. The very high frequency range is inaudible to the human ear and is known as ultrasound. Ultrasound was used by the Navy during World War II to detect submarines, and is widely used by fisherman to help find schools of fish.
In each case, an ultrasound machine is used. With the help of a microphone-shaped device (known as a transducer) ultrasound waves are created and beamed through water. When the beam encounters a boundary or interface between liquid (water) and a solid (submarine or fish) with a different density or compactness, part of the beam is reflected back to the transducer. The remaining waves move through the object and reach the back boundary between solid and water. Here, some more of the ultrasound waves are reflected back to the transducer. In other words, the transducer transmits ultrasound and constantly receives waves that are reflected back every time the beam travels from one density to another.
The reflected ultrasound waves are collected and analyzed by the machine. Knowing the amount of time it took for the beam to travel from and to the transducer, the ultrasound machine can determine the shape, size, density and movement of all objects that lay in the path of the ultrasound beam. The information is presented on a monitor screen and can also be printed on paper. That is how ships detected submarines during World War II, fishermen identify choice fishing spots, an obstetrician can evaluate the fetus of a pregnant woman, and a cardiologist can examine the heart of a patient.
What is an Echocardiogram: An echocardiogram is a test in which ultrasound is used to examine the heart. The equipment is far superior to that used by fishermen. In addition to providing single-dimension images, known as M-mode echo that allows accurate measurement of the heart chambers, the echocardiogram also offers far more sophisticated and advanced imaging. This is known as two- dimensional (2-D) Echo and is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle
An echocardiogram can be obtained in a physician's office or in the hospital. For a resting echocardiogram (in contrast to a stress echo or TEE, discussed elsewhere) no special preparation is necessary. Clothing from the upper body is removed and covered by a gown or sheet to keep you comfortable and maintain the privacy of females. The patient then lies on an examination table or a hospital bed
Sticky patches or electrodes are attached to the chest and shoulders and connected to electrodes or wires. These help to record the electrocardiogram (EKG or ECG) during the echocardiography test. The EKG helps in the timing of various cardiac events (filling and emptying of chambers). A colorless gel is then applied to the chest and the echo transducer is placed on top of it. The echo technologist then makes recordings from different parts of the chest to obtain several views of the heart. You may be asked to move form your back and to the side. Instructions may also be given for you to breathe slowly or to hold your breath. This helps in obtaining higher quality pictures. The images are constantly viewed on the monitor. It is also recorded on photographic paper and on videotape. The tape offers a permanent record of the examination and is reviewed by the physician prior to completion of the final report.
What is a Doppler Examination? Doppler is a special part of the ultrasound examination that assess blood flow (direction and velocity). In contrast, the M-mode and 2-D Echo evaluates the size, thickness and movement of heart structures (chambers, valves, etc.). During the Doppler examination, the ultrasound beams will evaluate the flow of blood as it makes it way though and out of the heart. This information is presented visually on the monitor (as color images or grayscale tracings and also as a series of audible signals with a swishing or pulsating sound)..
What information does Echocardiography and Doppler provide?
Echocardiography is an invaluable tool in providing the doctor with important information about the following:
Size of the chambers of the heart, including the dimension or volume of the cavity and the thickness of the walls. The appearance of the walls may also help identify certain types of heart disease that predominantly involve the heart muscle. In patients with long standing hypertension or high blood pressure, the test can determine the thickness and "stiffness" of the LV walls. When the LV pump function is reduced in patients with heart failure, the LV and RV tends to dilate or enlarge. Echocardiography can measure the severity of this enlargement. Serial studies performed on an annual basis can gauge the response of treatment.
Pumping function of the heart can be assessed by echocardiography. One can tell if the pumping power of the heart is normal or reduced to a mild or severe degree. This measure is known as an ejection fraction or EF. A normal EF is around 55 to 65%. Numbers below 45% usually represent some decrease in the pumping strength of the heart, while numbers below 30 to 35% are representative of an important decrease.
Echocardiography can also identify if the heart is pumping poorly due to a condition known as cardiomyopathy (pronounced cardio-myo-puth-e), or if one or more isolated areas have depressed movement (due to prior heart attacks). Thus, echocardiography can assess the pumping ability of each chamber of the heart and also the movement of each visualized wall. The decreased movement, in turn, can be graded from mild to severe. In extreme cases, an area affected by a heart attack may have no movement (akinesia, pronounced a-kine-neez-ya), or may even bulge in the opposite direction (dyskinesia, pronounced dis-kine-neez-ya). The latter is seen in patients with aneurysm (pronounced an-new-riz-um ) of the left ventricle or LV. It must be remembered that LV aneurysm due to an old heart attack does not usually rupture or "burst."
How important or necessary is this test for diagnosis?
Do any tests need to be done prior to the angiogram?
What type of angiography will be performed?
What will happen during the procedure?
What are the risks?
What should be expected after the procedure?
Will any medication be given?
What are the side effects?
Will any anesthesia be given?
What should I do to prepare for my procedure?
What is my expected recovery time and will I have any activity restrictions?
Will the procedure be painful?
What is conscious sedation?
What are the risks of my procedure?
What happens after I check in at the hospital?
What is an angiogram?
What is an angioplasty?
Why do I need an angiogram, angioplasty and/or stent?
What signs should I watch for, following the procedure, which may indicate a problem?
What is peripheral vascular disease (PVD)?
What are the symptoms of PVD?
What are the risk factors of PVD?
What should I do to prepare for my procedure?
Your doctor needs to know if you have had an allergic reaction to contrast (Xray Dye or IVP Dye) or iodine. (If you have, you may need to take special medication, (prednisone), 24 hours prior to your scheduled exam.
If you are diabetic and on insulin: Since you will not be eating your usual diet, your doctor should inform you to adjust your insulin dose the morning/day of the exam. You should not have solid food 6 hours prior to your procedure and clear liquids only, 2 hours prior to the procedure.
If you take glucophage/glucovance, you can take this the day of the exam, but you will be instructed not to take it for 2 days following the exam at which time you will be asked to get a blood test, (creatinine level). After your physician has seen these results he/she will inform you as whether to resume your medication.
If you are a chronic renal failure patient on dialysis, you will need to have your potassium, P.T., and INR drawn minimally 1-4 hours before some procedures.
Prior to the examination, the physician requesting the procedure will order blood tests to assess your kidney function and to check your blood's ability to form a clot, (creatinine, PT/INR and platelets).
You will need to have someone to drive you home.
Your doctor needs to know if you are on any blood thinning medicine(e.g. coumadin, warfarin, plavix, aspirin.).
Your doctor will advise you as whether to stop taking this medicine for a certain time period prior to your procedure. Do not stop a medication on your own! Your doctor needs to advise you when to stop taking them, if this is unclear please call your doctor.
You will be asked for a current list of all your over the counter and prescription medicine. Better yet, bring all the prescription medicines with you. It is much less expensive to take your own medication if your regularly scheduled dose comes up while you are still at the hospital.
Do not eat any solid foods for six hours before your procedure.
You may have clear water, black coffee or tea, white grape juice, or ginger ale until two hours before your procedure.
You may take all of your routine medications with a sip of water. If you are a diabetic, please consult with your doctor about the amount of insulin during the time you are not eating.
You must have a responsible adult available to drive/escort you home from the hospital.
If conscious sedation has already been planned for you, you can expect a phone call from one of our radiology nurses. They will review these instructions and answer any questions that you may have about the sedation or the procedure itself. They will also ask you some important health related questions as they develop an individualized plan of care for you.
What is my expected recovery time and will I have any activity restrictions?
Recovery will vary with the type of procedure. In general we require a minimum of 2 hours of observation following IV sedation.
Following an arteriogram patients will be at bed rest for at least 4-6 hours while keeping the extremity that was punctured straight. Patients are then be allowed to walk and observed for an additional hour. If there are no signs of bleeding at that time patients are discharged home. For the next 48 hours patients should not lift more than 5-10 lbs., minimize use of stairs and bending at the hip such as in picking things up from the floor. Any straining such as vomiting, coughing, forced bowel movements, could dislodge the clot that forms to seal the artery and cause bleeding.
It is usually safe to resume any blood-thinning medications within 24 hours, however you should ask the physician performing the procedure.
Will the procedure be painful?
The doctor will give you local anesthesia in the skin at the site of entry into the blood vessel. A small nick, (about the size of a pencil tip,) will be made in the skin, through which the procedure will be done. The radiology nurse will also give you some medication, (usually a Valium-like medication: “Versed®” and a morphine-like medication: “Fentanyl”,) through your IV to help you relax, (“Conscious Sedation,”) You will not be put to sleep, but we will make you comfortable and relaxed while you maintain breathing on your own.
What is conscious sedation?
Conscious sedation is a type of anesthesia in which the patient is given medication to produce a sleepy & relaxed dreamlike state. It is safer than general anesthesia. The most frequently used drugs are a Valium-like medication: “Midazolam (Versed®)” and a morphine-like medication: “Fentanyl.”
This conscious sedation will be administered through an intravenous, (IV,) line by a specially trained radiology nurse. Its purpose is to relax you during your procedure and to reduce perception of any discomfort that you may experience. If you have an allergy to either of these medications, please let your doctor know.
You will be drowsy, but will remain conscious and able to speak and follow directions throughout your procedure. Your blood pressure, blood oxygen level, heart rhythm and breathing rate will be continually monitored throughout the procedure.
What are the risks of my procedure?
Any medical procedure has inherent risks. The decision to perform a given procedure is based upon consideration of the risks and the benefits. In almost all instances and certainly all elective procedures, the potential benefits should far outweigh the risks. The relative risks may vary between patients depending on general health, underlying diseases and medications being taken.
Most common general risks include:
Any procedure which breaks the skin carries the risk of infection. This may manifest as local wound infection to severe life-threatening internal infection. Great care is taken to avoid infections as procedures are performed under sterile conditions.
In general the pain experienced varies with the type of procedure. Individual patients may also have different expectations and responses to pain. Nearly all procedures utilize Lidocaine local anesthetic which, once injected, blocks perception of sharp pain and temperature. Patients can expect to continue to feel pressure such as pulling and pushing.
Inherent in any procedure which breaks the skin is the potential to cause bleeding. Bleeding can range from oozing of the incision or under the skin, (“hematoma”), to massive life-threatening hemorrhage. Again, relative risks vary with the type of procedure and underlying medical conditions and medications being taken
What happens after I check in at the hospital?
You will be directed to McClure 1 Radiology Department.
Your family members will be asked to wait in the waiting room while the nurse prepares you for your exam. You will be able to see your family member before the start of the procedure.
The nurse that is working in the Pre-Procedure Holding room will escort you to where you will change into a hospital gown and an intravenous(IV) line will be placed in one of your veins. This will be used to give you fluids and medications during the procedure. The IV will stay in place until after your procedure is completed.
They also will take a brief Medical History to include any past medical problems/surgeries. Write down a complete list of medications. A member of the Interventional team, (physician or Nurse Practitioner,) will talk to you about the procedure, explaining the benefits and risks and give you the opportunity to answer any questions you may have.
What is an angiogram?
A small needle is used to access the blood vessel. A wire is placed through the needle and the needle is removed so there is nothing sharp in the body. A small catheter, (tube,) is inserted into the artery through a small incision and used to inject contrast, (dye,) into your blood vessels to make them visible on X-ray. The contrast may make you feel warmth and heat in the area in which the contrast dye is injected. The contrast dye allows the radiologist to see narrowings/blockages in your blood vessels. If a narrowing is identified you may be benefit from a balloon angioplasty to re-open thevessel. If not, at the very least your surgeon will have a road map of your vessels which can be used to guide bypass surgery.
What is an angioplasty?
An angioplasty is a procedure that opens up blocked blood vessels without surgery. A specially trained physician, known as an interventional radiologist, can perform this procedure in the radiology department. During the procedure, the interventional radiologist places a catheter, (a small tube,) into a narrowed artery. There is a balloon on the end of the catheter. When the balloon is in the area of narrowing, the balloon is inflated. Inflating the balloon stretches the artery to a more normal size, thereby improving blood flow to the area supplied by the blood vessel. Fluoroscopy, (low energy x-rays,) and contrast, (X-ray dye,) are used to help guide the catheter into the correct area for the angioplasty.
The doctor may also be need to place a stent, (wire mesh tube,) to help keep the blood vessel open.
Why do I need an angiogram, angioplasty and/or stent?
The most common reason for an angioplasty is to open a narrowed artery caused by atherosclerosis (“hardening of the arteries”). Atherosclerosis causes fatty/cholesterol deposits, (plaque,) to build up on the inside of your arteries. These plaques often calcify (collect calcium deposits,) and become firm.
Arteries carry blood and oxygen to all the tissues of your body. When an artery becomes narrowed, the tissues supplied by that artery do not get enough oxygen. The symptoms you feel depend on which artery is blocked. For example, a blocked artery in the legs may cause persistent ulcers, pain when you walk a certain distance or even when you are resting in bed. A blocked artery to a kidney may cause high blood pressure. Some blockages are better treated with surgery and others are better treated with angioplasty and/or stent placement. In many cases, angioplasty or stents can open up the artery that is blocked. This can relieve your symptoms as more oxygen will be delivered to your tissues.
What signs should I watch for, following the procedure, which may indicate a problem?
The amount of discomfort will vary with the type of procedure you have. In most cases, it is normal to have a soreness at the point of entry into the body. Often this is relieved by non-prescription medication such as Tylenol or Motrin. Discomfort is usually worse within the first 48 hours following the procedure. Some signs to watch for include progressively worsening pain, bleeding at the point of entry or fever/chills.
What is peripheral vascular disease (PVD)?
Peripheral vascular disease, or PVD, is a condition in which the arteries that carry blood to the arms or legs become narrowed or clogged. This interferes with the normal flow of blood, sometimes causing pain, especially with exercise of the arm or leg, but often causing no symptoms at all. If you have PVD, you are more likely to have heart disease and stroke.
The most common cause of PVD is atherosclerosis (“hardening of the arteries”). This disease of the blood vessels causes formation of deposits called "plaque" that narrow the blood vessels. These plaques are the result slowly progressive blood vessel injury caused by cholesterol deposits and scar formation. Interventional radiologists may treat blockages with techniques called angioplasty and thrombolysis.
For information about how to reduce your risk of vascular disease visit this link to the American Heart Association.
What are the symptoms of PVD?
The most common symptom of PVD is painful cramping in the leg or hip, especially while walking. This phenomenon is called "claudication." Claudication occurs when there is not enough blood flow to muscles to meet their metabolic demands. The shorter the distance you can walk before developing pain, the more severe the vascular disease. Typically the pain will subside with rest.
PVD is often not recognized because patients attribute the symptoms to signs of normal aging or they do not tax their muscles enough to cause symptoms until the disease if far advanced.
If you are experiencing any of these symptoms please contact your physician:
PVD Symptoms
Leg or hip pain during walking and relieved at rest
Numbness, tingling or weakness in the legs (may also be caused by vertebral disk disease)
Burning or aching pain in your feet or toes when restingNon-healing ulcer on your leg or foot
Cold legs or feet
Color change in skin of legs or feet
Loss of hair on legs
What are the risk factors of PVD?
Important risk factors for PVD:
Age over 50 yrs
Smoking
Diabetes
Obesity
Lack of exercise
High cholesterol
High blood pressure
Family history of PVD / heart disease
