An ECG can provide us with important information on the condition of a patient’s heart. Cases of normal ECG results that do not reflect an existing problem are rare.
Cardiac Triplex Ultrasound Imaging
Technological developments have led to a great improvement in image quality and in the diagnostic prospects offered by this greater quality. We can use an ultrasound to determine if someone has had a heart attack, we can assess how well the heart is functioning and can also check for valve malfunction, fluid around the heart and a number of other pathological conditions. (2 avi files: 1. Triplex – 2. Ultrasound)
Cardiac stress test
The stress test is very important, since it provides significant information on how the heart functions when it is tired and consequently under strain. The patient is monitored using an ECG while walking on a treadmill. When there is a stenosis (a narrowing, or blockage) in one of the heart’s arteries, the ECG will pick up changes that are sometimes also accompanied by symptoms (tightness in the chest, discomfort, dizziness).
Holter Monitor for Heart Rhythm Monitoring
We use the Holter heart rhythm monitor for patients complaining of sudden dizzy spells, loss of balance or loss of consciousness (syncope). The Holter monitor essentially records the heart’s rhythm continually for as long as the patient is wearing it (usually 24 or 48 hours).
Holter Monitor for Blood Pressure Monitoring
This device is similar to the Holter heart rhythm monitor. It is essentially an electronic blood pressure meter that usually takes the patient’s pressure every thirty minutes and has the advantage that all its measurements are automatically stored in a special recorder, so that they may be later analysed by the physician.
This is a detailed ultrasound of the heart, which is carried out by carefully inserting a small tube similar to that used in gastroscopies in the patient’s oesophagus. The test necessarily takes place in a hospital environment. The patient is usually mildly sedated to avoid discomfort and must necessarily be fasted. This test is chosen when we need more detailed images than the ones an ordinary ultrasound can provide, such as when looking for blood clots in the heart, when we suspect valve infection, when we want to take a closer look at a valve insufficiency, and so on.
Lastly, there is also the three-dimensional transoesophageal echocardiography, which (in some cases) provides drastically enhanced information on the anatomy and function of the heart (3D bicuspid video). In the last few years it has been used successfully in daily clinical practice.
Implantable Holter Monitor for Heart Rhythm Monitoring
To increase our chances of detecting an arrhythmia, we need a device that will monitor the heart’s rhythm. Such a device is the implantable Holter, which is a small metal monitor inserted under the skin on the chest to record the heart’s rhythm for as long as it is considered necessary (weeks or months).
The tilt test also takes place in a clinic environment. We mainly conduct a tilt test if a patient mentions sudden fainting spells. In most cases, patients report feeling dizzy or nauseous or that they perspire before losing consciousness. The test aims to recreate the conditions that led to the loss of consciousness (syncope) and thus generate the patient’s symptoms.
However, the ultimate and most precise test yielding the most reliable information on any stenosis, or narrowing, of the heart’s arteries is the coronary angiography. In this test, a contrast medium, or dye, is used to show the insides of the arteries and to precisely determine the existence and extent of any stenoses. The test is performed in a special room in the hospital called the haemodynamic lab. A coronary angiography is normally performed under local anaesthetic and rarely needs general anaesthesia. (http://www.webmd.com/heart-disease/video/cardiac-catheterization)
In previous years coronary angiographies were performed via the leg. Although coronary angiography is a relatively painless technique, when the leg is used as the point of entry the patient is strictly required to stay in bed for at least six hours after the angiography to prevent bleeding. In some cases there may also be other complications at the insertion site, such as haematomas or a ruptured vessel where the tube was inserted (see photograph).
Haematoma where tube was inserted in patient’s leg
What we have been providing over the last three years, with particular success, is the alternative of performing a coronary angiography via the arm. This has the advantage that the patient is able to get up immediately after the procedure and in most cases can even go home a few hours later.
Coronary angiography via the arm. Tube inserted in radial artery.
Special wristband placed on the wrist after the coronary angiography
The procedure lasts 20 to 30 minutes and is painless, since the patient does not even feel the special catheters that we use to reach the heart’s arteries and release the necessary dye. Practically speaking, there is only a risk in 1 in 3000 cases.
Our team’s success rate in performing coronary angiographies and angioplasties (balloons) via the arm is 97% and is comparable with international standards. In a small number of cases (3%) when the arm cannot be used for technical reasons, we perform the angiography via the leg.
Cardiac CT Angiography
This high-resolution cardiac tomography seems to be gaining more and more ground in recent years. It can provide highly detailed images of the coronary arteries and yield information on possible stenoses in place of the classic coronary angiography. This is the method’s main advantage, together with the fact that it only lasts 5 minutes. Its drawbacks include high radiation exposure and limited image clarity with some patients. We currently only use CT angiography in special cases, usually with young high-risk patients mainly as a preventative measure.
Other specialized diagnostic tests
The purpose of right heart catheterization, which is performed in the haemodynamic lab where coronary angiographies take place, is to measure the pressures in the heart. It is performed in certain situations where such information is vital either to diagnose a disease (e.g. pulmonary hypertension) or to decide on how to tackle and treat certain cases.
A myocardial biopsy is another diagnostic test that is performed in the haemodynamic lab under local anaesthetic. Its purpose is to obtain small pieces of heart muscle tissue that are examined under the microscope in order to diagnose rare diseases.
Pericardiocentesis and thoracentesis are two more procedures which are performed when we want a detailed analysis of a quantity of fluid that accumulates either around the heart in the pericardium or around the lung in the pleural space. Both tests are done under local anaesthetic using a particular technique and usually with the aid of an ultrasound.