Tests and Procedures

Cardiolite Stress Test

Nuclear exercise myocardial perfusion imaging combines a graded exercise stress test or pharmaceutical stress test with the injection of the radioisotope, Technetium (Tc99") or cardiolite, along with a second study done while at rest. This test helps to determine the extent and severity of coronary artery disease, and assess the success of interventions such as intracoronary balloon angioplasty or stent placement.

When the agent is injected, it is normally distributed throughout the heart muscle. The amount of the agent taken up by the heart muscle is directly related to the blood flow to the heart. If there is narrowing or blockage, in a coronary artery, agent doesn't distribute to the area supplied by this artery. Therefore, when the pictures of the heart are taken a dark area is seen on the film. When pictures are repeated, if the dark spot is no longer seen, this suggests narrowing of an artery. If the dark spot remains, this suggests the presence of damaged heart muscle - old heart attack.

Stress perfusion imaging detects the effects of coronary artery disease, i.e., perfusion, or abnormal blood flow. On the other hand, a coronary arteriography - dye test - provides information about the anatomy and percent of blockage of the coronary arteries.

With the exception of a small sip of water to take your medications, don't eat or drink 12 hours prior to your exercising test time. Wear loose fitting clothes and comfortable walking shoes. This facilitates walking on the treadmill. If you are having a pharmaceutical stress test, please ask for special directions.

After electrodes for the exercise stress test are applied, an EKG and blood pressure are taken. Next, an IV catheter is placed in an arm vein. After the perfusion agent is injected and the stress test completed, the IV is removed.

At peak exercise, the agent is injected. To obtain optimal images, the stress test must continue for an additional minute after the injection. Communicating with the staff is extremely important. Please notify the personnel if you experience dizziness, chest discomfort, undue fatigue, excessive shortness of breath, or any unusual feelings. There are no side effects to the radioisotope agent.

Films are obtained 15-20 minutes following the injection of the agent. This imaging procedure requires lying flat with your arms above your head for approximately 20 minutes. It is important to remain still during the procedure. Therefore, if you do not believe you will be able to maintain this position, please let us know prior to the test.

Upon scheduling the exercising portion of the test, you are also given an appointment for a resting set of pictures. For the resting study you may eat an early breakfast, but not have anything to eat or drink for four hours before your scheduled time. An injection of the agent is administered by the technologist. After a 30-45 minute wait, pictures are taken. The imaging procedure takes approximately 10 minutes. After the second set of images, the procedure is completed.

Dobutamine Stress Echocardiogram

A dobutamine stress echocardiogram combines an ultrasound examination of the heart with medication. Dobutamine takes the place of exercise stress testing - it increases the heart rate and makes the heart pump stronger. This test provides information about the heart muscle's ability to contract, which helps to determine the presence and severity of coronary artery disease. In addition, the ultrasound gives information about the size of the heart chambers, the thickness of the walls of the heart, and abnormalities in the structure or function of the heart valves.

A dobutamine stress echocardiogram consists of several steps. The first step is to obtain ultrasound pictures of your heart. To do this, a small transducer with conductive jelly is placed on your chest. The transducer is moved to various areas of your chest so that different views of the heart can be recorded on video tape. During the procedure, it is important for you to quietly lie on your left side. Please avoid deep breathing.

Next, a small needle will be inserted into an arm vein. This allows the medication to be given. To monitor your hearts rhythm during the procedure, ten electrodes will be placed on your chest and attached to the EKG machine.

Dobutamine will be started and administered until a predetermined heart rate is achieved, or you report bothersome symptoms. Symptoms you may experience include: feeling your heart beat, warmness, tingling or numbness of the arms, headache, chest discomfort, or nausea. If you experience any sensations, please tell the staff. Dobutamine has no lasting effects - it will wear off within 15 minutes after being stopped.

During the test, your EKG and blood pressure are monitored. Ultrasound pictures will be taken at various intervals. To further increase your heart rate. Atropine may need to be given. Side effects of this drug include a flushing sensations and dry mouth. The procedure lasts approximately one hour. After the procedure, you will be able to sit up and have your choice of water or juice.

Avoid eating a large meal immediately before the test; a light meal is suggested. You may continue to have liquids, particularly water til one hour prior to the test. It is not necessary to avoid drinking fluids. In addition, wear comfortable clothes as you will be lying down for approximately one hour.

Echocardiogram

An echocardiogram (ultrasound) is an ultrasound examination of the heart using sound waves. It will give information about the size of the heart chambers, the thickness of the walls of the heart, how the heart is contracting and detect abnormalities in the structure or function of the heart valves. An echocardiogram can also be done using color flow and/or doppler. This gives information about blood flow in the heart.

The test is done by placing a small transducer on your chest. The test is painless and takes less than a half-hour to complete. Before the test is done, you will be asked to undress to the waist and put on a gown so that it opens in the front. Then you will be asked to lie comfortably on the bed on your left side.

First, three paper disks (electrodes) will be placed on your chest; these are then attached to a cable and are used to give a picture of the electrical activity of your heart. Next the transducer, which has conductive jelly applied to it, will be placed on your chest. The transducer is moved to various areas so different views of the heart can be recorded. The echocardiogram is recorded on paper and on video tape.

It is important to lie quietly during the procedure. The technician will inform you when the test has been completed. Diagnostic cardiac ultrasound is a safe examination with no known side effects. Since sound waves are used, there is no danger from exposure to x-rays.

Elective Cardioversion

For people with arrhythmias - disturbances in their heart rhythms - cardioversion attempts to restore the heart's normal electrical activity. Elective cardioversion is commonly done to convert atrial fibrillation, atrial flutter, or atrial tachycardia to a normal sinus rhythm.

Normally, each heartbeat begins in the right atrium. Here, a specialized group of cells called the sinus node - your natural pacemaker - sets the pace for the heart's rhythm. From the sinus node, the electrical impulse spreads across the atria - the top part of the heart. This activity registers on the EKG in the form of a blip, called the P wave. As the electrical impulse travels down the specialized conduction system to the ventricles - lower part of heart, a QRS complex is generated. As the signal travels through the heart, the heart contracts or beats.

Should atrial fibrillation occur, the normal sinus rhythm is replaced by chaotic electrical activity in the atria. Instead of the sinus node initiating 60 to 90 regular waves of electrical activity per minute, many different cells in the atria fire on their own. Only a fraction of these electrical impulses make their way down to the ventricles. They do so in an irregular manner, and cause an irregular pulse rate.

Synchronized cardioversion attempts to suppress atrial fibrillation and restore sinus rhythm by delivering an electrical current to the heart through paddles applied to the chest wall. This procedure uses low energy levels. The burst of electricity is precisely timed, or synchronized.

Do not eat or drink anything other than a small sip of water with medications after midnight, 12:01 A.M., on the day of the procedure.

Upon arrival, a staff member will direct you to the proper room. Following an electrocardiogram and a blood pressure reading, a nurse will place a small needle in an arm vein and begin an intravenous infusion. She may also give a blood thinner or antiarrhythmic medication. She will place a small, dip-like device on your forefinger to monitor your blood-oxygen level.

When the cardiologist arrives, you will be given medication to put you to sleep for a short period of time - five to ten minutes. Although most people say they have no memory of the procedure, some say they briefly felt a sharp, stabbing sensation.

If an oxygen mask is placed on your face after the electrical current is delivered, try to take in deep - not shallow breaths as you awaken. Special jelly pads are placed on the chest to prevent skin bums. Should you notice any reddish areas similar to a sunburn, however, use an anesthetic lotion such as Aloe Vera. Do not use petroleum-based products such as Vaseline because they hold in heat.

During recovery, a nurse monitors your pulse rate, oxygen level, blood pressure, and level of consciousness. No fluids are permitted until you are fully recovered. The entire procedure usually takes about two hours. CAUTION: Be certain you have someone to drive you home. Do not attempt to drive yourself. Before leaving, you receive information regarding any changes in medication.

Stress Echocardiogram

A stress echocardiogram combines an ultrasound examination of the heart with an exercise test. This test helps to determine the presence of coronary artery disease. A stress echocardiogram provides information about the heart muscles ability to contract, the size of the heart chambers, the thickness of the walls of the heart, and detects abnormalities in the structure or function of the heart valves.

A stress echocardiogram consists of several steps. The first step is to obtain ultrasound pictures of your heart. This is done before you walk on the treadmill. To do this, a small transducer with conductive jelly is placed on your chest. The transducer is moved to various areas of your chest so that different views of the heart can be recorded on video tape. During the procedure, it is important for you to quietly lie on your left side. Please avoid deep breathing.

Next, you will be prepared for the exercise portion of the test. Ten electrodes will be placed on your chest. To obtain a clear EKG trancing, excess hair is shaved, your skin cleansed with alcohol and then roughened with the abrasive edge of the electrode.

To begin the treadmill test, place both feet on either side of the brown conveyor belt. Start by placing one foot on the belt and then the other. Stand straight and take long strides. During the test, your EKG is continuously monitored; blood pressure measurements are done prior to, during and after the test.

The speed and the grade (height) of the treadmill will increase every two to three minutes until you reach a predetermined target heart rate, or you develop symptoms. It is important, however, to notify the personnel if you experience any unusual dizziness, chest discomfort, undue fatigue, shortness of breath, or any unusual feelings.

When you achieve your target heart rate, or when you feel that the workload is very hard and you can no longer continue, the treadmill will be abruptly stopped. Do not jump off the treadmill. As soon as the treadmill stops, turn and lie on the table on your left side with your left arm under your head. Avoid deep breathing. It is normal to experience lightheadedness, dizziness and a forceful heart beat.

After the pictures are taken, you will be able to sit up and have your choice of water or juice. Your physician will review the results with you. This may be done immediately after the procedure, or you may need to schedule an appointment with your physician.

In order to facilitate walking on the treadmill, wear loose fitting clothes and comfortable walking shoes. Avoid eating a large meal immediately before the test; a light meal is suggested.

Treadmill Stress Test

A graded exercise stress test (GXT) is the observation and recording of an individual physiological response during a measured exercise challenge. A GXT provides an objective measure of an individual's level of cardiovascular fitness, and a basis for an exercise prescription. It can provide useful diagnostic information, and is used as a means of follow-up after coronary artery balloon angioplasty (PTCA) and stenting, open heart bypass surgery (CABG), and a heart attack.

The test gives information about the presence and type of arrhythmia (disturbances in the heart's rhythm), can be used to determine the effectiveness of various drug therapy, i.e., medication that is given for high blood pressure, arrhythmias, or angina. A person's blood pressure or EKGs can be normal at rest. With exercise, the blood pressure may rise inappropriately, or changes may be noted on the EKG which are not seen at rest. The test can also be used to note improvements in cardiovascular fitness after an exercise program.

In order to facilitate walking on the treadmill, it is recommended that you wear loose fitting clothes and comfortable walking shoes. Also, it is preferable to avoid eating a large meal immediately before the test; a light meal is suggested.

To monitor your electrocardiogram (EKG) during the procedure, ten electrodes will be placed on your chest. A clear EKG tracing is facilitated by good contact between the skin and the electrode. Therefore, before applying the electrode, excess hair will be shaved, the skin cleansed with alcohol, and the skin roughened with the abrasive edge of the electrode.

During the test, your EKG is continually monitored. Blood pressure measurements are done prior to, during, and after the test. You will be asked to read and sign the informed consent for the procedure. Also, you will be asked to list your current medications. Please be sure to bring a list of your medications with you.

You will be shown the proper way to walk on the treadmill. First straddle the conveyor belt and hold onto the handrail. When the treadmill starts, get the feel of the speed by placing one foot on the belt. Start walking; take as long a step as possible. Stay close to the bar and stand erect.

A target heart rate and length of time to reach this heart rate is computed according to your age. These numbers determine how long you should be on the treadmill. Every three minutes/the speed and grade (height) of the treadmill increases. The actual time on the treadmill will depend on your physical condition and whether or not you develop any symptoms, a marked increase in blood pressure, or abnormalities on your EKG.

It is important that you notify the personnel if you experience any unusual shortness of breath, chest discomfort, undue fatigue, dizziness or any unusual feelings. The test can be terminated at any time. Therefore, if at any point you need to stop walking notify the personnel and the treadmill will be stopped. Do not jump off the treadmill.

At the end of the procedure, the speed and grade of the treadmill will be gradually decreased and stopped. You will then lie back down on the exam table. Your EKG and blood pressure will be monitored for a period of time after the procedure.

After stopping the test, it is not unusual to feel as if you are still walking, feel your heart pounding or to experience some light headedness and dizziness.

Tilt Table Test

Recurrent unexplained passing out spells, known as syncope, is a common problem in all age groups. A frequent cause of passing out, or almost passing out is the vasovagal reaction. During a vasovagal reaction, the heart rate slows and the blood pressure decreases to a point where the person passes out or almost passes out. The head-up tilt table test is done to detect a person's susceptibility to this reaction. The tilt table test is one method of reproducing your symptoms in a controlled environment.

With the exception of water, you must fast a minimum of four hours prior to the test. With the exception of beta blockers, such as Inderal, Tenormin, Lopressor, Corgard, and calcium channel blockers, such as Verapamil, Isoptin, Cardizem, Procardia, continue to take your prescribed medications. Beta blockers and calcium channel blockers need to be discontinued at least 24 hours prior to the procedure. If you are unsure of what medication to stop, please call us at 745-9800.

Also, it is recommended that before the test you avoid tobacco products for eight hours, alcohol and caffeine for 12 hours, over the counter medicines for eight hours and vigorous exercise for 24 hours. It is preferable to wear comfortable fitting clothes and shoes. For women, slacks, or a loose fitting skirt are advisable.

You will be assisted onto the tilt table. Be certain your feet are touching the foot rest. If you have any orthopedic problems, such as low back pain, please let us know. Every attempt will be made to make you as comfortable as possible.

After you have been connected to the electro-cardiogram (EKG), three safety straps will be placedaround you. The purpose of these straps is to keep you secure as the table is being tilted up. Before the start of the test, you will be given the opportunity to experience a head-up tilt.

After a rest period of lying flat and measurement of blood pressure, the table will be raised to a standing position. Your EKG will be monitored throughout the duration of the test, and blood pressure taken at frequent intervals. You will remain standing for 30-45 minutes or until you experience symptoms you may have experienced in the past. It is important to tell the staff if you experience any symptoms.

If at any time, you begin to feel uncomfortable and wish to stop the test, the table will be lowered and the test discontinued. If after a 30 minute head-up tilt you remain symptom free, the table will be lowered. A small needle will be placed in an arm vein. This will stay in place until the completion of the test. A medication called Isoproterenol (Isuprel) will be administered through the needle. This medication may increase your heart rate and give you a sensation that your heart is pounding. Also, it may make you feel slightly nervous or jittery. These sensations will go away once the medication is stopped.

The table will be raised once again to a standing position. Every 10 minutes, while in a standing position, the dosage of the medication will be increased up to a preset limit. If at any time you experience symptoms, the medication will be discontinued and the table lowered to the flat position. If after 40-60 minutes you do not experience any symptoms, the table will be placed flat and the test will be completed. After an observation period, you will be discharged.

Transesophageal Echocardiogram (TEE)

A transesophageal echocardiogram (TEE) is a special ultrasound examination of the heart. TEE is used to obtain information about the heart and its structures such as the heart valves. TEE is used in situations that require more information that can be obtained from a 2D echocardiogram (transducer placed on the person's chest).

TEE involves the insertion of a flexible tube into the esophagus (food tube) by a skilled cardiologist. The test lasts approximately 20 minutes and is done as an outpatient.

You must not eat or drink anything six hours prior to the test. You may take your medication with a sip of water. Unless otherwise instructed, if you are on a blood thinner such as Coumadin or Aspirin, it is NOT necessary to stop the medication. Because you will be given sedation, alcoholic beverages should be avoided the day of the test.

Before the TEE, a small needle will be placed in an arm vein. A mild sedative will be given through this needle to help you relax during the test. You will be asked to remove any dentures, partial plates or bridges. Before the tube is inserted, an anesthetic throat spray will be given. The Purpose of this spray is to numb your throat. It may taste bitter and may cause your tongue and throat to feel swollen.

You will be asked to lie on your left side with your head flat or slightly elevated. A flexible tube will be lubricated and inserted into your esophagus. To help place the tube, you will be asked to open your mouth, flex your neck forward and swallow. After the tube is inserted, a soft piece of plastic (biteguard) will be placed between your teeth. This is to prevent biting on the tube.

As the tube is advanced, videotape recordings will be made of your heart. During the procedure, your heart's rhythm (EKG), blood pressure and blood oxygen level will be monitored.

After the procedure is completed, you should not eat or drink for approximately two hours, or until you can swallow without difficulty. Start with sips of water. When you can drink water without any problems, resume your regular diet. Since you will feel drowsy after the sedation, you will need to have someone drive you home.

It is important that you report any unusual discomfort, fever, chills, shortness of breath, or persistent bleeding. If you experience a sore throat you may use a salt water gargle or throat lozenges.