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What is a heart attack?
Every 34 seconds, someone dies from heart and blood vessel diseases, America’s No. 1 killer. Since most of those deaths are from coronary heart disease — about 500,000 each year — it’s important to learn all you can about heart attack. Don’t ignore heart problems. It’s a matter of life and death! For example, you should know the warning signs so you can get help right away, either for yourself or someone close to you. Many lives have been saved by acting quickly. Get help quickly if you feel any of these signs:

• Uncomfortable heavy feeling, pressure, pain or squeezing in the center of your chest that lasts more than a few minutes.
• Pain that goes to your shoulder, neck or arms.
• Discomfort in your chest along with a light head, fainting, sweating, nausea or shortness of breath.

What causes heart attacks?
Another name for a heart attack is myocardial infraction (pronounced my-o-KAR-dee-ul in-FARK- shun) – "M.I" for short. It occurs when the blood flow to a part of the heart is blocked (often by a blood clot). This happens because coronary arteries that supply the heart with blood slowly become clogged from a build up of cells, fat and cholesterol (ko-LES-ter-ol) called plaque(plak).  Blood that tries to flow through these clogged arteries can form a clot. If this clot cuts off the blood flow completely, the part of the heart muscle supplies by that artery begins to die.

Resting and Stress Echocardiography

Heart Failure:  Echocardiogram Test (ECHO) An echocardiogram (often called "echo") is a graphic outline of the heart's movement. During this test, high-frequency sound waves, called ultrasound, provide pictures of the heart's valves and chambers. This allows the technician, called a sonographer, to evaluate the pumping action of the heart. Echo is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart's valves.

What Are the Types of Echocardiograms?

• Transthoracic echocardiogram. This is the standard echocardiogram. It is a painless test similar to X-ray, but without the radiation. The procedure uses the same technology used to evaluate a baby's health before birth. High frequency sound waves (ultrasound) are bounced off the heart structures (using a device called a transducer) producing images and sounds that can be used by the doctor to detect heart damage and disease.
• Transesophageal echocardiogram (TEE). This test requires that the transducer be inserted down the throat into the esophagus (the swallowing tube that connects the mouth to the stomach.) Because the esophagus is located close to the heart, clear images of the heart structures can be obtained without the interference of the lungs and chest.
• Stress echocardiogram. This is an echocardiogram that is performed while the person exercises on a treadmill or stationary bicycle. This test can accurately visualize the motion of the hearts walls and pumping action when the heart is stressed; it may reveal a lack of blood flow that isn’t always apparent on other heart tests. The echocardiogram is performed just prior and just after the exercise.
• Dobutamine or adenosine stress echocardiogram. This is another form of stress echocardiogram. However, instead of exercising to stress the heart, the stress is obtained by giving a drug that stimulates the heart and makes it "think" it is exercising. The test is used to evaluate your heart and valve function when you are unable to exercise on a treadmill or stationary bike. The test is also used to determine how well your heart tolerates activity, determine your likelihood of having coronary artery disease (blocked heart arteries) and evaluate the effectiveness of your cardiac treatment plan.
• Intravascular ultrasound. This is a form of echocardiography performed during cardiac catheterization (a procedure done to visualize the heart arteries). During this procedure, the transducer is threaded into the heart blood vessels via a catheter in the groin. It is often used to provide detailed information about the atherosclerosis (blockage) inside the blood vessels.

Exercise Treadmill Testing

What is an exercise Stress Test? The exercise stress test - also called a stress test, exercise electrocardiogram, treadmill test, graded exercise test or stress ECG –is a test used to provide information about how the heart responds to exertion. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while your electrocardiogram , heart rate and blood pressure are monitored.

Why do I need a stress Test?
Your doctor uses the stress test to:

• Determine if there is adequate blood flow to your heart during increasing levels of activity.
• Evaluate the effectiveness of your heart medications to control angina and ischemia.
• Determine the likelihood of having coronary heart disease and the need of further evaluation.
• Identify abnormal heart rhythms.
• Help you develop a safe exercise program

What types of Stress Tests Are There?
There are different types of stress tests, including:

• Dobutamine or Adenosine Stress Tests: this test is used for people who are unable to exercise. A drug is given to make the heart respond as if the person were exercising. This way the doctor can still determine how the heart responds to stress, but no exercise is required.
• Stress echocardiogram: an echocardiogram ( often called "echo") is a graphic outline of the heart’s movement. A stress echo can accurately visualize the motion of the heart’s movement. A stress echo can accurately visualize the motion of the heart’s walls and pumping action when the heart is stressed: it can reveal a lack of blood flow which is not always present on other heart tests.
• Thallium(nuclear) stress test : this test helps to determine which parts of the heart are normal and function properly. Before exercising, a small amount of radioactive substance is injected into the patient. Then the doctor uses a special camera to identify the rays emitted from the substance within the body; this produces clear pictures of the heart tissue on the monitor. Using this technique, the heart has "hot" and "cold" spots that indicate the areas of the heart muscle damage present before, during and after exercise.

Radionuclide SPECT Tomographic Imaging

Nuclear Cardiology Nuclear cardiology studies use small doses of radioactive material to assess myocardial blood flow, evaluate the pumping function of the heart as well as visualize the size and location of a heart attack. Among the types of nuclear cardiology studies, myocardial perfusion imaging is the most widely used.

Nuclear Cardiology: Types of Studies
Myocardial Perfusion Imaging

1. Exercise Stress Test
2. Pharmacologic or Chemical Stress Test: Dipyridamole/ Adenosine
3. Pharmacologic or Chemical Stress Test: Dobutamine

Test Overview
Cardiac catheterization is a test to evaluate your heart and coronary arteries. During a cardiac catheterization, a dye (contrast material) is injected into the coronary arteries to trace the movement of blood through the arteries. The portion of the test involving the injection of contrast material and the tracing of blood is called coronary angiography.

To perform cardiac catheterization, a thin flexible tube called a catheter is threaded through a blood vessel in your arm or groin and into your heart. Through the catheter, your doctor can measure pressures, take blood samples, and inject contrast material into the coronary arteries or chambers of the heart. The doctor watches movement of the dye through your heart's chambers and blood vessels to see whether the coronary arteries are narrowed or blocked. Arteries can become narrowed when plaque builds up inside the lining of the vessels.

The purpose of cardiac catheterization is to determine whether you have disease in your coronary arteries, and if so, pinpoint the size and location of plaque that may have built up in your coronary arteries from atherosclerosis. This is generally done to determine whether you may need bypass surgery or angioplasty.

If your coronary arteries are blocked, your doctor can use the catheter to open them and restore normal blood flow to your heart. This is called percutaneous coronary intervention (PCI). The three common types of PCI are angioplasty, coronary stenting, and coronary atherectomy. These procedures can be done separately or in combination.

• Angioplasty may be done by attaching a small balloon to the catheter. Once the catheter has been guided to the proper location in a coronary artery, the balloon is inflated. The pressure from the inflated balloon presses the plaque against the wall of the artery to improve blood flow.
• Stenting usually is done along with angioplasty. Once the plaque is compressed using angioplasty, a small expandable wire tube called a stent is inserted into the artery to hold it open. Reclosure of the artery is less likely to occur after angioplasty followed by stenting than after angioplasty alone. This is the most common procedure performed.
• Atherectomy may be done during cardiac catheterization to open a partially blocked coronary artery. Once the catheter reaches the narrowed portion of the artery, a cutting device, a whirling blade (such as a rotoblade), or a laser beam is used to remove the plaque.

Cardiac catheterization and coronary artery disease The primary purpose of cardiac catheterization (cardiac cath) is to determine whether you have coronary artery disease (CAD), and if so, whether surgery or another type of procedure is needed to open the blocked blood vessels. Cardiac cath also can be used to treat CAD by opening the blocked vessels.

Cardiac cath is generally done only when you have symptoms of blockage or CAD or when your doctor has reason to believe there is a blockage and you may need treatment, such as bypass surgery or angioplasty (and stenting).

After the test
After all the necessary pictures and measurements have been taken, the catheter will be removed. If the catheter insertion site was in your elbow, a few stitches will be used to close the wound. If the insertion site was in your wrist or groin, firm pressure will be applied to the area for about 10 minutes to stop the bleeding. Then a pressure dressing will be placed over the area.

The entire procedure usually takes 1 to 2 hours, but it may take longer if additional tests are required. The length of the test is not an indication of the seriousness of your condition. After the test, you will be taken to an observation room and a health professional will periodically monitor your heart rate, blood pressure, and temperature and check for signs of bleeding at the insertion site. The pulse, color, and temperature of the arm or leg in which the catheter was inserted will also be checked periodically.

If your procedure was performed using your leg, you will be asked to lie in bed with your leg extended for 4 to 12 hours, depending on the exact procedure used and your medical condition. After that, you can move about freely, but you should avoid strenuous activity for at least 1 to 2 days. A child who has had cardiac catheterization may need to be held by a parent for several hours after the test to prevent the child from moving his or her leg.

You should drink plenty of liquids for several hours after the test, because the contrast material may cause you to urinate frequently. Drinking liquids will prevent dehydration and help flush the contrast material out of your body.

How It Feels
You will feel a sharp sting when the local anesthetic is injected to numb your skin over the catheter insertion site. When the catheter is inserted, you may feel a brief, sharp pain. The movement of the catheter through your blood vessel may cause a feeling of pressure, but it is not usually considered painful. People commonly experience skipped heartbeats for a few seconds when the catheter touches the walls of the heart.

If a contrast material is injected, you may feel a flushed sensation spread through your body for about 20 to 30 seconds, ranging from mild warmth to searing heat. You may also experience some nausea, lightheadedness, chest pain, irregular heartbeat, an urge to cough, a headache, mild itching, or hives from the contrast material. If these symptoms occur, tell your doctor. Some people also report a metallic or salty taste from the contrast material.

The temperature in the cath lab is kept cool so that the equipment does not overheat. For many people, the most difficult aspect of the test is having to lie still for an hour or more on the hard table. You may feel some stiffness or cramping.

If you experience chest pain, extreme shortness of breath, dizziness, trouble speaking or swallowing, or paralysis in any part of your body during or after the test, notify a health professional immediately.

You may experience some soreness and bruising at the insertion site. This is temporary and should disappear within 2 weeks. It is normal for the site to feel tender for about a week. Contact your doctor immediately if:

• Your arm or leg becomes pale, cold, painful, or numb. These signs could indicate a blockage of blood flow to your arm or leg.
• Redness, swelling, or discharge from the catheter insertion site develops.
• You have a fever higher than 100.4 °F (38 °C).

Risks
Cardiac catheterization provides important information about your heart. However, it involves greater risks than other diagnostic tests used to study the heart. Complications of cardiac catheterization are rare, but they can be life-threatening. As with any test, the possible benefits of the test have to be weighed against the risks. You should discuss the risks in your case thoroughly with your doctor before having this test.

Serious complications are rare and are more likely to occur in people who are critically ill or elderly. Serious complications may include:

• Heart attack or stroke. Rarely, the catheter tip can dislodge a blood clot or some debris from the inside wall of the artery. The clot or debris can travel through the bloodstream until it lodges in a smaller artery, blocking the blood flow. If this occurs in an artery supplying the heart, it can cause a heart attack. If it occurs in an artery feeding the brain, it can cause a stroke. A blood clot can also occur at the area where the catheter was inserted, causing a blockage of blood flow to the arm or leg and requiring surgery to restore the blood circulation.
• Irregular heartbeats (arrhythmias). Rarely, this procedure may produce a persistent abnormal heart rhythm. The abnormal rhythm usually corrects itself or becomes normal after treatment with medication.
• Kidney damage. Rarely, the contrast material can damage the kidneys, possibly causing kidney failure. People with diabetes and kidney disease are at greatest risk for kidney damage.
• Endocarditis.
• Cardiac tamponade.
• Pneumothorax.
• Puncture of the heart or one of its blood vessels. This could require immediate open-heart surgery to repair.
• Liver tears, which are more likely in infants and children than in adults.

Some people experience an allergic reaction to the contrast material, with hives and itching and, rarely, shortness of breath, fever, and shock. These allergic reactions can usually be controlled with medications.

Less serious complications include pain, swelling, and tenderness at the catheter insertion site or an irritation of the vein by the catheter (superficial thrombophlebitis). This can usually be treated with warm compresses. The catheter site may also bleed slightly, especially if you received a blood thinner (anticoagulant) before the procedure. Blood may collect and pool under the skin where the catheter was inserted. This is called a hematoma and usually goes away in a few days.

Occasionally, the sedative medications given before the cardiac cath can cause temporary problems with urination following the procedure. In this situation, a thin flexible tube (urinary catheter) may be temporarily placed in your bladder.

There is always a slight risk of damage to cells or tissues from being exposed to any radiation, including the low levels of X-ray used for this test. However, the risk of damage from the X-rays is usually very low compared with the potential benefits of the test.

Pacemaker placement
Surgery Overview
A pacemaker can be used to replace the function of the natural pacemaker of the heart when the heart is beating too slowly.

A pacemaker is a small, battery-powered device that sends out weak electrical impulses that cause the heart muscle to contract. The pacemaker itself is a waterproof object about the size of a silver dollar. A pacemaker consists of wires (leads) that transmit electricity to the heart and the pulse generator and battery that generate the electrical impulses.

Pacemakers can be surgically placed into the chest through a small incision (a permanent pacemaker), or they can be worn outside the body and attached to the heart through a wire threaded through a neck vein (a temporary pacemaker). Temporary pacemakers are used only while a person is in the hospital.

Many times the pacemaker is set to work only when the heart rate falls below a certain predetermined rate (demand mode).

The battery in a permanent pacemaker usually lasts 5 to 15 years. Your doctor will monitor your pacemaker regularly to decide when the battery should be changed.

What To Expect After Surgery
It is normal for the surgical wound to be somewhat painful and swollen for a few days after the procedure. This can usually be controlled with medications. The wound may also appear mildly red for a few days; however, if the area of redness enlarges, you should notify your doctor. You should also call your doctor if the wound starts to bleed, fluid starts to drain from the wound, fevers develop, or the pain at the surgical site worsens.

If there are no other problems, most people who have a permanent pacemaker surgically implanted can go home the next day. You can usually return to normal activities within 6 weeks. For several weeks after having a pacemaker implanted, you may be asked not to lift more than 5 pounds or raise the affected arm over the shoulder.

Suggested guidelines for permanent pacemaker follow-up include the following:

• Before you are discharged from the hospital, you usually will have a full evaluation, including a chest X-ray, an electrocardiogram (EKG, ECG), and a pacemaker check. One week to 10 days after discharge, your incision will be checked.
• 6 to 8 weeks after placement of the pacemaker, you generally will have a full evaluation, including an EKG, and have your pacemaker checked.
• 3 to 6 months after placement, you generally will either visit your doctor or clinic in person or have your pacemaker checked over the phone. Information can be sent directly over the phone to a computer on the other end of the line. This computer prints the information and it can be reviewed by your doctor.
• About every 1 to 3 months, you will generally be asked to have your pacemaker checked over the phone.
• Once or twice per year, you will be asked to visit your doctor to have a full evaluation of your pacemaker. If the battery life is low, the battery will need to be replaced. (Although people refer to this procedure as a battery change, the entire pacemaker is actually replaced so that you can benefit from new circuitry and any new features that have recently been added to pacemakers.) This involves a surgical procedure similar to the initial implantation, except that the battery change is often a more simple procedure since the leads are already in place. The batteries may last 5 to 15 years depending on the type of device and the frequency that the device is used. The leads are routinely tested when the battery is replaced. If they are functioning adequately, the new pacemaker may simply be connected to the existing leads. However, if there is a problem with the old lead system, it may be wise to replace the lead system while inserting the new pacemaker.

Pacemakers work by monitoring the electrical activity of your heart. The devices contain sensitive electronics and a small computer, and can be affected by strong magnetic or electrical fields. The table below lists various electrical and magnetic sources that are safe and sources that you should avoid.

Ambulatory Electrocardiography
Ambulatory electrocardiography (EKG or ECG) monitors the electrical activity of your heart while you go about your usual daily activities. Many heart problems occur only during certain activities, such as exercise, eating, sex, emotional stress, bowel movements, or even sleeping. A continuous 24-hour recording is much more likely to detect any abnormal heartbeats that occur during these activities.

Holter monitoring
The most common type of ambulatory monitoring is called Holter monitoring. The recording device of a Holter monitor is worn on a strap at your waist or over your shoulder. The electrical signals of your heart are picked up by two small metal pads (electrodes) attached to your chest, and these are connected to the recorder by wires. Holter monitoring provides a continuous 24- to 72-hour record of the electrical signals from your heart. While wearing the Holter monitor, you will also be asked to keep a diary of all your activities and symptoms. After the monitoring period, your health professional will compare the timing of your activities and symptoms with the recorded heart pattern.

Many people have irregular heartbeats (arrhythmias) from time to time. The importance of irregular heartbeats depends on the type of pattern they produce, how often they occur, how long they last, and whether they occur at the same time you have symptoms. Because arrhythmias can occur irregularly, it may be difficult to record an arrhythmia while you are in the doctor's office. A standard EKG monitors only 40 to 50 heartbeats during the brief period you are attached to the machine. A Holter monitor records about 100,000 heartbeats in 24 hours and is much more likely to detect a problem.

Cardiac event monitoring
Another kind of ambulatory EKG monitoring is the cardiac event monitoring. The monitor is used when symptoms of an abnormal heart rhythm occur infrequently. A cardiac event monitor can be used for a longer time than a Holter monitor and so is more likely to record an abnormal heart rhythm that occurs infrequently. The information collected by a cardiac event monitor also can often be sent over the phone to a doctor's office, clinic, or hospital.

Two types of cardiac event monitors are available:

• Presymptom (looping memory) event monitor. This is a small device that attaches to the chest with electrodes. The smallest type of presymptom event monitor is about the size of a pager. It constantly records heartbeats. When symptoms occur, you press a button on the monitor to make a permanent recording of your heart rhythm. This type of monitor also saves a small amount of information about how your heart was beating before the save button was pressed (presymptom recording). This feature is especially useful for people who pass out when their heart problems occur and can press the button only after they wake up.
• Postsymptom event monitor. This small device is used only when symptoms of the heart problem occur. It does not have electrodes that are attached to the chest. One type is worn on the wrist like a watch. When symptoms occur, you press a button to start the EKG recording. The other type is a device that you carry where you can reach it easily, such as in your purse or pocket. When symptoms occur, you press the back of the device against your chest and then press a button to start the recording. The back of the device has small metal discs that function as the electrodes. These handheld monitors can be very small (some are about the size and shape of a credit card).

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