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A USER’S GUIDE OF YOUR HEART: TESTING YOUR HEART
By now you’ve been poked, probed, wired, monitored, measured, tested and analysed until you’re sick of it all. Most of that testing is now in the past, but you’re still in for more of the same in the months and years to come. While I hope that your doctors have informed you about these tests in general, you might still have some questions remaining.
Electrocardiogram (ECG or EKG). Your heart is driven by a mild electrical current; problems can be noted by changes in this activity. To measure your heart’s electrical patterns and to diagnose heart ailments, physicians take an electrocardiogram, abbreviated to ECG or EKG. This produces a detailed graph called a tracing that, with some accuracy, reveals your heart’s condition.
As you no doubt know by now, ECGs are non-invasive and cause no pain. The electrical activity comes from your heart, not from the electrodes which are affixed to your chest and limbs, and is measured by the apparatus to which the wires lead.
To the casual observer, the ECG tracings look like squiggly lines. But each beat of your heart produces a specific series of waves which are designated as the P, Q, R, S and T waves. Ventricular activity, reflecting the power of your heart, is measured by the Q, R and S waves, which make up the spike you see on the graph. The Q begins the spike, the R is its apex, and the S, which descends a little lower than the Q, finishes it. As the ventricles relax, the T wave measures this relaxation. The P wave is the slight rise that occurs just before the spike, triggered by activity in your heart that occurs right before your heart’s chambers contract. Take a look at the sample ECG tracing in Figure 2 on page 96.
Variations from the normal P, Q, R, S and T waves indicate cardiac abnormalities. For instance, a depressed ST segment indicates that insufficient oxygen is getting to the heart’s muscle. Note that the ECG does not measure or examine your arteries, but rather the heart muscle itself. One can indirectly assume that the arteries are not supplying sufficient blood, for example, if one notes the depressed ST segment.
Exercise Stress Test (Treadmill Test). While a resting ECG, taken while you lie back on a table, can give valuable information, there are distinct limits to its diagnostic abilities. Most of us don’t spend our days just lying down. The exercise stress test, then, can measure our heart’s activity during the stress placed on it by increments of exercise, usually on a treadmill. The more the exercise, the more oxygen the heart requires, and the more blood will have to flow through the coronary arteries. On the other hand, the stress of exercise is not always responsible for oxygen deficits. Emotional stress may play a much greater role in some patients’ lives. To measure such stress as it occurs throughout a normal, typical day, one might be asked to wear a Holter monitor which, as noted earlier, is a miniaturised ECG machine.
Your doctor will want you to have regular exercise stress tests following your heart attack or bypass surgery. This will enable both you and your doctor to determine just what level of exercise you can safely reach. Such testing is quite safe. Bear in mind that your heart’s activities are clearly displayed on the monitor or ECG tracing as you walk or run on the treadmill. The odds of having a heart attack at this time are really remote, as your doctor can see how well you’re doing before advancing to the next level of exertion.
The test’s greatest flaw lies in a rather high rate of false positives. That is to say, a patient’s heart may appear to be functioning abnormally when in actuality all is well. If any abnormality shows up on the ECG, you may be asked to have further testing.
You may have had an exercise stress test in the hospital before release following your heart attack or bypass. At that time you were asked to exert yourself to an extent far below your maximum potential. From that test your doctor was able to predict that you would do well at home, and that typical physical activity would do no harm.
Eventually you’re asked to take a more extensive treadmill test to determine your full physical capabilities. It is most likely that your physician will keep your level of exertion below the maximum to be expected for someone your age who has not developed heart disease. From this test he will be able to tell you, for example, that your top exercising heart rate should be in a range between 120 and 130. For you, this is a better guide than the standard heart-rate formulas. We’ll talk in far greater detail about such matters in the chapters on cardiac rehabilitation and exercise.
Echocardiogram. This test, performed in a hospital or doctor’s office, uses ultrasound to determine the internal size of the heart chambers, the thickness of chamber walls, any fluid buildup around the heart, contractibility of the heart muscle, and the condition of the heart valves.
With an echocardiogram, which is non-invasive, high-frequency sound waves are beamed at the heart via a transducer. Those waves are reflected back to the transducer, and are fed into an echocardiograph machine. The apparatus translates the signals to either a picture on a monitor which can be videotaped or to a graph on paper.
The echocardiogram may be performed at the same time you are given a treadmill stress test. It can detect any abnormal muscle contraction during exercise.
Thallium Stress Test. Sometimes a doctor will want to confirm a diagnosis obtained by way of a treadmill test, or he needs more precise information. Perhaps he doubts the positive treadmill results. He may, at such times, call for this type of testing, which is performed in a specially equipped hospital or outpatient facility. The thallium stress test, or scan as it is sometimes called, is highly accurate, easy to administer, and does not require a stay in the hospital. Moreover, this is a noninvasive procedure, as compared with the angiogram. In addition to ECG electrodes, the patient receives an intravenous line in the arm. When the subject reaches peak heart rate, a small amount of the radioactive isotope thallium is injected through the IV line. At this point the patient lies down on an examining table and a scanning camera moves across him. Portions of the heart that receive inadequate blood flow and oxygen will show decreased thallium absorption. The patient and the doctor are able to look at a picture formed of the heart and actually see affected areas.
There is no need to be concerned about the radioactivity since so very little is involved. The test is extremely safe. It is far more accurate than the standard treadmill test, and very often will be reassuring to both the doctor and patient in proving that the positive result from the treadmill was false.
Angiography: Cardiac Catheterisation. The most informative test available is, unfortunately, invasive. That is to say, the doctor makes a direct examination of the health of the heart and its arteries. At this time, cardiac catheterisation remains the gold standard in testing. When a surgeon needs to plot and plan an upcoming bypass operation, it is mandatory to have an accurate map of the blockage of the coronary arteries and of the health of the heart. At other times it is necessary to provide a definitive diagnosis of conditions indicated by ECGs and other tests.
The term cardiac catheterisation refers to the fact that a catheter, a long, flexible tube, is inserted through a needle in either the groin or the inside of the elbow and threaded through the arterial system on into the heart itself. Doctors view the progress of the catheter by way of a fluoroscope which provides a picture on a TV monitor. The patient remains awake and conscious throughout the procedure, though sedated.
Once in the heart, the catheter lets the doctor, usually a cardiologist, take blood samples and pressure readings. The former are analysed for oxygen content and can point to problems such as leaks or defects in the heart walls. The latter may indicate scarred or narrowed valves as well as help to gauge the heart’s ability to pump blood. The picture of the heart obtained is called the cardiogram.
To examine the left ventricle, the catheter is inserted into the chamber, dye is released, and a ventriculogram is taken. This helps determine the heart’s ejection fraction, which is the percentage of blood the left ventricle pumps out with each beat. The normal fraction is about 60 per cent; a diseased heart may pump 30 per cent or less.
In some cases, pulmonary angiography is performed. The catheter is threaded to the right side of the heart into the pulmonary arteries. Dye is injected and X-rays are taken. The resulting pictures show any abnormalities in those arteries, perhaps detecting a pulmonary embolism or blockage.
The next step is angiography, taking pictures of the coronary arteries called angiograms. The doctor threads the catheter into one artery at a time and injects a bit of dye. Blockages are immediately spotted, and the percentages of blockage can be measured very accurately.
After the catheterisation has been completed, the patient is taken to a recovery area for 6 to 8 hours. If entry was through the groin, pressure is applied to the site until potential bleeding has ceased. In the case of entry through the crook of the arm, the area is sutured. Groin entry requires only a puncture. Both procedures have their distinct advantages, and your doctor will determine which is best in your case.
While in the recovery area, you’ll be asked to drink a lot of water to allow your kidneys to flush the dye out of your system.
On the one hand, catheterisation is quite safe; on the other hand, as with all invasive procedures, there is a degree of risk. About one in 1000 patients suffers a heart attack during or within 24 hours of catheterisation. The procedure may also produce arrhythmias or haemorrhaging. On rare occasions the patient could be allergic to the dye used. But, despite all that, the general consensus in the medical community is that the benefits far outweigh the risk when catheterisation is indicated. The bottom line here is that while this method of testing should not be undertaken frivolously, just out of curiosity to take a closer look, it need not be feared.
I’ve had three catheterisations, two through the arm and one through the groin. While I must admit a degree of anxiety beforehand, the procedure isn’t painful or difficult. Of course, the latest angiogram gave me the wonderful results indicating that my program has kept my bypass grafts and native arteries free and flowing, and that was worth any degree of anxiety. I have another scheduled in 1993, and I have no trepidation whatever.
Of course, by that time we may have other, non-invasive methods at our disposal. A new technique, magnetic resonance angiography, may eventually replace the conventional approach. Early results are extremely promising.
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