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Evaluation and Treatment of Coronary Artery Disease
Cardiac Catheterization / Coronary Angiography
Cardiac catheterization is an invasive technique used to evaluate for blockages of the coronary arteries. Valve function and heart function can also be assessed using this technique. The procedure involves passing a small hollow tube through an artery in the leg or wrist to the heart where a dye is injected and xray pictures are taken. This allows for very accurate assessment of any blockages that may be present.

The procedure generally takes 20-30 minutes and is often performed as an oupatient. Light sedation and a local anesthetic are usually administered for patient comfort. Risks are generally small, although serious complications occur in approximately 1 out of 1000 patients.

Please notify your physician of any previous allergic reactions to iodine containing contrast as this is used during the procedure.
Coronary Stent Placement / Balloon Angioplasty
Blockages found at the time of cardiac catheterization can frequently be treated using less invasive methods such as coronary stenting. Once a blockage is identified, a balloon is used to stretch open the narrowed artery. A stent (a tiny metal tube used to scaffold the artery) is frequently implanted following balloon angioplasty to keep the artery from collapsing. Two basic types of stents are used, bare metal and drug-coated. Drug-coated stents are often preferred as they are 50% less likely to re-narrow. Drug-coated stents require you to take a special blood thinner (Plavix or Effient) for at least a year following the procedure to make sure that no blood clots form inside the stent.

Other techniques such as rotablation (a high speed diamond tipped drill) are also used to remove plaque from coronary arteries. Patients are generally hospitalized overnight following a stent procedure. Complications such as vessel perforation or tearing are rare (1 out of 500) in which case an emergency open heart surgery may be required.

Please notify your physician if you have an allergy to aspirin or Plavix, or are prone to excessive bleeding when taking blood thinners.
Echocardiogram
An echocardiogram referred to in the medical community as a CARDIAC ECHO or simply an ECHO. This is a sonogram of the heart and uses standard ultrasound techniques to image two-demensional slices of the heart. In addition to creating two-dementional pictures of the heart an echocardiogram can also produce accurate pictures of the blood velocity using Doppler ultrasound. This allows assessment of cardiac valve areas and function, and abnormal communications between the left and right side of the heart, any leaking of blood through the valves, and calculation of heart function.

Echocardiography is used to diagnose cardiovascular disease. It produces a wealth of helpful information including the size and shape of the heart, its pumping capacity and the location and extent of any damage to its tissue. It can detect abnormalities in the pattern of blood flow through heart valves. This includes backward flow of blood through partly closed heart valves, known as regurgitation. By assessing the motion of the heart wall echocardiography can help determine whether any chest pain or associated symptoms are related to coronary artery disease. The biggest advantage to echocardiography is that it is noninvasive (doesn't involve breaking the skin or entering the body cavities) and has no known risk or side effects. This is a non-invasive and highly accurate and quick assessment of the overall health of the heart.
Transesophogeal Echocardiogram
This is an alternative way to perform an echocardiogram. A specialized probe containing an ultrasound transducer at the tip is passed into the patient esophagus while the patient is sedated. This is known as transesophageal echocardiogram or (TEE). TEE is most often utilized when transthoracic images are suboptimal and when a more clear and precise image is needed for diagnosing disease. This technique is performed in the hospital with a cardiologist, anesthesiologist, registered nurse, and ultrasound technichian.
Carotid Ultrasound

A carotid ultrasound is a safe, painless procedure that uses ultrasound waves from a machine to examine the structure and function of the arteries in the neck. You have two carotid arteries, one from each side of the neck that delivers blood from the heart to your brain.

Carotid ultrasound may be used by your doctor to screen for blockages that increase your risk of a stroke. A build up of fats, cholesterol, and calcium in the blood stream may cause narrowing in the arteries. Early detection of narrowing of the carotid arteries enables your doctor to begin treatments that improve blood flow to the brain and decrease the risk of a stroke.

A carotid ultrasound may be recommended by your doctor of you have any of the following risk factors that increase your risk of stroke.

  • High blood pressure
  • Diabetes
  • High cholesterol
  • Family history of stroke or heart disease

A carotid ultrasound to screen for stroke may be used in combination with other tests.

  • Abdominal ultrasound, to screen for potential abdominal aortic aneurysm, a ballooning of the large artery that supplies blood to the abdomen, pelvis and legs.
  • Ankle-brachial index test, this is a comparison of the blood pressure measured at the ankle and your blood pressure measured at the arm. This can indicate a blockage of blood flow to the legs.

You can prepare for the appointment, call the day before to confirm the time and location of the exam. Wear a comfortable shirt with no collar or an open collar. Do not wear any necklaces of dangling earrings. Other than that you should not need any special preparations.

The sonographer will apply a warm gel to your skin above the site of each carotid artery. The gel helps eliminate the formation of air pockets between you skin and the transducer. The sonographer then gently presses the transducer against the side of your neck in order for the instrument to send and receive sound waves. You should not feel any discomfort during the procedure.

Your cardiologist will review and interpret the results of your carotid ultrasound. The cardiologist will then explain the results of the carotid ultrasound and how it affects your medical care. If the test was ordered to screen for stroke risk, your cardiologist may recommend the following treatments, depending on the severity of the blockage: Change in your diet and routine exercise, medication to lower blood cholesterol, medication to prevent clots, surgical procedure to remove the plaques. Additional tests may be ordered of the results are unclear. These include Computerized tomography (CT) or Magnetic resonance imaging (MRI).

Holter Monitor

A holter monitor is a device that records your heart rhythm. You may be asked to wear the monitor which will record your heart beat. The holter monitor is used by your physician if the electrocardiogram does not give your doctor enough information about your heart rhythm. Your cardiologist uses the information from the holter monitor to figure out if you have a heart rhythm problem.

A Holter monitor is performed if you have problems such as a irregular heart beat or arrhythmia. The holter monitor may be able to detect irregularities in your heart rhythm that an electrocardiogram could not, since an electrocardiogram only takes a few seconds of your heart rhythm.

Before your holter monitor test you should take a bath. Since ounce your monitoring begins you will not be able to get the monitor wet or remove it. A technician will place the electrodes that sense your heart beat on your chest. For men a small amount of hair may have to be shaved, to make sure the electrodes stick. The technician will then connect some wires to the leads and to a recording device and will instruct you on how to properly wear the recording device, so it can transmit data transmitted from the electrode. You will also be instructed to keep a diary of all activities you do while wearing the monitor. It is particularly important to record any palpitations, skipped beats, shortness of breath, chest pain or lightheadedness you feel.

Holter monitoring is painless and noninvasive. You can hide the electrodes and wires under your clothes, and can wear the recording device on your belt or attached to a strap. Once your monitoring begins, don't take the holter monitor off -- you must wear it at all times, event while you sleep.

Once the monitoring period is over you will return the monitor to your cardiologist office. A technician will remove the electrodes from your chest. You will turn in the diary and a doctor will go over the monitor and the diary. Make sure you record all abnormal symptoms, if you have an abnormal rhythm this will be important information for your doctor to know. The information from the monitor may reveal that you have a heart condition or your doctor may need to order more tests. In some cases the results of the holter monitor may lead to a diagnosis or it may show a normal heart rhythm that requires no treatment.

Consultative Cardiology
Arrhythmia & Pacemaker Surveillance
Exercise Stress Testing
Cardiac Nuclear Medicine
What is cardiac nuclear medicine?

Nuclear medicine is a type of medical imaging that uses small amounts of radioactive material to diagnose and treat a variety of diseases, including cancers, heart disease and other abnormalities within the body. Nuclear medicine is unique because it documents function as well as structure.

Nuclear medicine or radionuclide imaging procedures are noninvasive, and except the intravenous injections, are usually painless medical tests to help physicians diagnose medical conditions. These imaging scans use radioactive materials called radiopharmaceuticals or radiotracers.


What are common uses of the procedure?

Physicians use cardiac nuclear medicine studies to help diagnose cardiac disease in patients with these symptoms:

  • unexplained chest pain
  • chest pain brought on by exercise (angina)

Cardiac nuclear medicine imaging is also performed:

  • to visualize blood flow patterns to the heart walls, called a myocardial perfusion scan.
  • to evaluate the existence of suspected or known coronary artery disease.
  • to determine the extent of heart injury following a heart attack, or myocardial infarction.
  • to evaluate bypass surgery results or other revascularization procedures designed to restore blood supply to the heart.
  • in conjunction with an electrocardiogram (ECG), to evaluate heart-wall movement and overall heart function.

Preparations for your Procedure

You may be asked to wear a gown during the exam or you may be allowed to wear your own clothing.

Women should always inform their physician or technologist if there is any possibility that they are pregnant or if they are breastfeeding.

You should inform your physician and the technologist performing your exam of any medications you are taking, including vitamins and herbal supplements. You should also inform them if you have any allergies and about recent illnesses or other medical conditions.

You should inform your physician if you have asthma, a chronic lung disease or have problems with your knees, hips or maintaining your balance, which may limit your ability to perform the exercise needed for this procedure.

Jewelry and other metallic accessories should be left at home or removed prior to the exam because they may interfere with the procedure.

You should avoid caffeine and smoking for 48 hours prior examination. Please review the list of caffeine containing products and medications.

Coffee Regular or decaffeinated
Tea Regular or decaffeinated
Soft Drinks Regular or decaffeinated including Cola, Dr. Pepper, Mellow Yellow, Mountain Dew, Mr. Pibbv, Tab, Ginger Ale, Sprite, etc.
Foods Chocolate or cocoa containing products
Over-the-counter medications Anacin, Excedrin, NoDoz
Presdcribed medications Cafegot, Darvon, Fiorinal, Synalog DC, Wigraine

If you are having a Adenosine (pharmaceutical) Stress Test, the following medications should be discontinued 48 hours prior to your test date. Please call the prescribing physician for permission to withhold these medications.

Aerolate Pletal Theodur Theo-X
Dyphylinne Slobid Theolair Unidur
Marax Slophyllin Theophylline Unihyl

You should not eat or drink anything 4 hours prior to your procedure, but you may continue taking medications with small amounts of water unless your physician says otherwise. If you take beta-blocker medication (Inderal, metoprolol, etc.) you need to ask your physician about temporary discontinuation.


What is the equipment like?

Nuclear medicine procedures are usually performed using a specialized gamma camera encased in metal that is capable of detecting radiation and taking pictures from different angles. This camera is located within a large, doughnut-shaped scanner similar in appearance to a CT scanner and rotates around your body to produce more detailed images, referred to as Single Photon Emission Computed Tomography (SPECT).

The images are created from the data obtained by the camera or scanner aided by a computer.


How does procedure work?

Ordinary x-ray examinations are images made by passing x-rays through your body from an outside source. In contrast, nuclear medicine procedures use radioactive material called radiopharmaceutical or radiotracer, which is injected into your bloodstream. This radioactive material accumulates in the organ or examination area of your body, where it gives off a small amount of energy in the form of gamma rays. A gamma camera, PET scanner, or probe detects this energy and creates pictures offering details on the structure and function of organs and tissues in your body with the help of a computer.

In order to evaluate the coronary arteries, heart scans are often performed immediately after a stress test where patients have engaged in physical exercise so the blood flow throughout your heart is maximized, making any blockages of the coronary arteries easier to detect. These images of the heart are compared with heart images taken while the patient is at rest. Patients who are unable to exercise are given adenosine which increases blood flow to the heart.


How is procedure performed?

To obtain the best results possible, the study should be performed over 2 days.

On Day 1, you will receive an injection of the radiotracer into a vein. Approximately 20-40 minutes after the tracer injection, you will lie on a moveable imaging table with your arms over your head for about 15-20 minutes while images are recorded.

On Day 2, a nurse or technologist will insert an IV line into a vein in your hand or arm. You will then undergo a stress test which requires you to exercise by walking on a treadmill. While you exercise, the electrical activity of your heart will be monitored by ECG and your blood pressure is measured frequently. If you are unable to use a treadmill, you will be given the drug adenosine to increase blood flow to your heart. When blood flow to the heart has reached its peak, the radiotracer will be given through your IV. After you complete the stress test, you may be asked to drink some water. Approximately 20-40 minutes later you’ll be placed on the imaging table a second time so another series of images can be recorded.

Actual scanning time for each heart scan is approximately 15 minutes. Total time in the nuclear medicine department is estimated to be 45-60 minutes each day. Your IV line will be removed prior to going home.


What will I experience during and after procedure?

Most nuclear medicine procedures are painless, except the intravenous injections, and you rarely experience significant discomfort or side effects.

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line when the radiotracer is given intravenously. You may feel a cold sensation moving up your arm, when the radioactive material is injected into your arm, but there are generally no other side effects.

You will be asked to exercise until you are either too tired to continue, short of breath, or experiencing chest pain, leg pain, or other discomfort that makes you to want to stop.

If you are given Adenosine to increase blood flow because you are unable to exercise, the medication may induce a brief period of nausea, anxiety, dizziness, shaky, or short of breath. Mild chest discomfort may also occur. Any symptoms that develop typically resolve as soon as the infusion is complete. If the side effects of the medication are severe or make you too uncomfortable, other drugs can be given to stop side effects.

It is important that you remain still while images are recorded. Though nuclear imaging itself causes no pain, there may be some discomfort from remaining still or staying in one particular position during imaging. Unless your physician tells you otherwise, you may resume normal activities after your nuclear medicine scan. If any special instructions are necessary, you will be informed by a technologist, nurse or physician before you leave the nuclear medicine department.

Through the natural process of radioactive decay, the small amount of radiotracer in your body will lose its radioactivity over time. It may pass out of your body through your urine or stool during a few hours or days following the test. You may be instructed to take special precautions after urinating such as flushing the toilet twice and washing your hands thoroughly. You need to drink plenty of water to help flush the radioactive material out of your body.


Who interprets the results?

A nuclear-trained cardiologist will interpret the images and forward a report to your referring physician.

Cardiovascular Risk Assessment & Management
Preventative Cardiology
Lipid Management
Evaluation & Diagnosis of Peripheral Vascular Disease (PVD)