In-Office Cardiovascular Services
Exercise Stress Testing
To determine the presence of significant coronary artery disease (blockages in heart arteries) stress testing is routinely performed. Electrodes are applied to the chest wall and EKG leads are connected. The patient is then instructed to walk on a treadmill using a standard protocol. If the patient has a significant blockage inside one or more arteries, he or she may experience chest discomfort. There may also be a change in the EKG during the test. Besides determining the presence or absence of coronary artery disease, stress testing is also used to assess a patient’s exercise capacity and to evaluate for exercise-induced arrhythmia.
Nuclear Cardiac Stress Imaging
In addition to exercise stress testing, nuclear stress testing can be used to evaluate a patient for the presence of coronary artery disease. In general, nuclear stress testing is more accurate than regular exercise stress testing. In addition to walking on a treadmill, isotopes such as Thallium, Cardiolite or Myoview are given to the patient intravenously. These agents are taken up by the heart muscle via heart arteries. After the isotope is given, a blood-flow picture of heart is obtained before the heart is stressed. Another isotope is injected while the heart is stressed and a second blood-flow picture is obtained. If there is a significant blockage in an artery, the territory of heart muscle supplied by that vessel will show reduced uptake of the isotope. This difference in blood flow allows the cardiologist to determine the presence and severity of coronary artery disease.
For patients who are unable to exercise, a chemical stress test is performed. Agents such as adenosine, regadenoson, and dobutamine are used to chemically stress the heart. Patients are instructed not to eat or drink anything for at least several hours prior to the test. They are also instructed to avoid caffeine products for at least 24 hours prior to the test to improve accuracy. Similar to exercise nuclear stress testing, isotopes are injected and images are obtained at rest and with stress. Comparisons are made between the two sets of images to determine to presence of coronary artery disease. These tests are very safe and serious complications are very rare. Pregnant patients cannot receive nuclear stress testing. The entire test can take 45 minutes up to 3 hours to allow for adequate heart imaging.
To improve patient comfort and lessen radiation exposure, a number of locations use Wide Beam Reconstruction (UltraSpect) which is hardware that enhances our existing cameras performance by reducing both the standard injected dose and imaging time by 50 percent. For availability, please speak with your Physician.
An echocardiogram is an ultrasound examination of the heart. Using an ultrasound transducer on the chest, a real time image of the heart is obtained. In addition, Doppler echo and a single-dimension image known as M-mode echo can help obtain further information about heart. Electrodes are applied for EKG recording and gel is applied on the chest to improve image quality. An echocardiographer will obtain images of your heart and store them on a CD for the cardiologist to review. The test typically takes about 30 minutes and there is no preparation involved. An echocardiogram is a very powerful diagnostic tool and can give very accurate information regarding heart size, structure and function.
This is another testing modality used to diagnose the presence and extent of coronary artery disease using ultrasound technology. The patient is stressed either with exercise or chemically with Dobutamine. Ultrasound pictures of the heart are obtained prior to and at the peak of the exercise. Patients with significant coronary artery disease show worsening of the heart’s ability to pump with exercise. Often, part of the heart wall will not be contracting normally compared to the rest of the heart wall. This test is useful for patients who cannot tolerate a nuclear stress test.
Holter Monitors and Event Recorders
Cardiac monitoring devices are available to evaluate patients for occult heart rhythm disturbances which may manifest as palpitations, heart “pounding” or “racing”, dizziness, fainting, shortness of breath, fatigue, or no symptoms at all. These devices consist of a small “box” unit which is linked to several electrode leads that are attached to the chest. They are small, worn underneath one’s clothing and can be carried or attached to a belt or waistband. A Holter Monitor is worn by the patient for 24 to 48 hours and allows continuous monitoring of the patient’s heart rhythm. It is useful for detecting unsuspected abnormal heart rhythms in patients lacking symptoms, or in patients who have symptoms frequently throughout the day. An Event Recorder is worn for 30 days but only records when it is triggered by the patient (i.e. a button is pressed to trigger the device to record). It is most useful in identifying the cause of symptoms in patients that only experience them infrequently.
Loop Recorder ( ILR) Implant
If you suffer from episodes of passing out ( syncope) then an implantable loop recorder can help identify the exact cause. Also, ILR can help patients who have had stroke to evaluate whether they have atrial fibrillation – an arrhythmia which is a major cause of clots and strokes. It can also help your doctor diagnose the cause of your palpitations and heart racings.
Loop recorder is a small wireless monitor than is injected under the skin and can record your heart rhythm for up to about 4 years. It regularly sends the data to your cardiologist through a wireless transmitter.
Once it has served its purpose, or when its battery is depleted it can easily be removed in the office.
The implant and explant is performed in the office and under local anesthesia.
There are a variety of diagnostic vascular ultrasound examinations, which include carotid duplex ultrasonography, peripheral arterial duplex ultrasonography, and lower extremity venous duplex ultrasonography. Vascular ultrasound is a noninvasive way to detect and assess the severity of circulatory problems. Ultrasonography of the carotid arteries is used locate areas of obstructed blood flow in the major arteries leading to the brain that could eventually lead to a stroke. Arterial duplex ultrasound is used to assess blood flow in the legs, especially in patients with known circulatory problems or prior vascular surgery. Venous duplex ultrasonography is used in patients with pain and swelling in a lower limb to exclude the presence of a venous blood clot.
Ankle-Brachial Index (ABI)
This is a simple test used to screen for the presence of peripheral arterial disease (PAD), or impaired arterial circulation. This test uses four blood pressure cuffs to compare the pressures in the arms and legs. A lower blood pressure in either leg compared to those in the arms may suggest the presence of PAD. Patients with PAD often have pain, burning, or cramping in the calf, thighs, or buttocks that limits their ability to walk or exercise. The presence of PAD is an important predictor of an increased risk for heart attack and stroke. Therefore, the ABI test is a fast, simple, noninvasive way to screen for cardiovascular disease, especially in patients with symptoms of leg pain with activity.
Pacemaker / Defibrillator Interrogation
Patients with implanted permanent pacemakers or defibrillators require an interrogation of their device at least twice a year to assess battery life, to ensure that the device is functioning properly, and to make appropriate adjustments in the settings. Newer devices also have heart monitoring capabilities. Information recorded can be elicited by pacer interrogation. Device testing and analysis is simple and involves placing an interrogator “wand” over the site of the implanted pacemaker or defibrillator. A full computerized report is then obtained and any necessary adjustments are made under the supervision of the cardiologist.
A comprehensive array of laboratory testing, including cholesterol/lipid analysis, urine testing, thyroid and glucose monitoring, and cardiac biomarker analysis are all performed within the office.
Coumadin (Warfarin) Clinic
Coumadin (Generic name: warfarin) is a blood thinner that is used for the treatment or prevention of blood clots. Monitoring at regular intervals is required to ensure that the blood does not become too thin, but is adequately thin for effective treatment. A blood test, reported as an INR (International Normalized Ratio), is obtained in our office through a simple fingerstick. The Coumadin clinic is staffed by technicians trained in Coumadin management. Each visit requires only a minor fingerstick, and results are available almost immediately. Depending on the INR levels, the coumadin dose may require adjustment. INR levels should be checked every 1-4 weeks once a therapeutic level is achieved.