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Nuclear Stress Test

Nuclear Stress Test OR Myocardial Perfusion Scan

Diagnosis,

Diagnostic tests for heart diseases

Heart diseases

A nuclear stress test is a non – invasive cardiac imaging test used to capture pictures of the heart at rest and after exercise. It is also known as a Myocardial Perfusion scan and is used to evaluate blood flow into the heart muscle. Cardiologists generally recommend this test to diagnose and determine the proper treatment for coronary artery disease. 

How is Nuclear Stress Test performed? :

The patient is connected to an electrocardiogram (ECG) machine with electrodes attached to his chest and back. It helps to keep track of his heartbeat during the test. His blood pressure is also continuously monitored throughout the test. An IV (intravenous) line is started on his arm, and he is asked to exercise using a treadmill or an exercise bike. If the patient cannot exercise, drugs that stimulate the heart rate (like adenosine or dobutamine) are administered.

The patient is asked to stop at reaching the maximal exercise point, and a small amount of radioactive material is injected via the IV line. This radioactive material (thallium or sestamibi) is called a radioactive tracer. He is then asked to lie flat or sit completely still on a table for 10 to 45 minutes while the gamma camera captures pictures of his heart. This imaging session reveals blood flow distribution to the heart muscle during peak exercise and the heart’s ejection fraction.

After this session, the patient may leave the area for 3 to 4 hours before the second set of scans begin. During this resting period, the patient is instructed to refrain from caffeinated drinks, soda, and chocolate. For the second set of scans, the patient will be injected with a second tracer, and another set of pictures are taken. It shows the resting blood flow to the heart muscle. The IV line is removed after the necessary images are captured. In some labs, the resting part of the test is done first or on a different day.

Are there any risks involved in it? :

The common problems associated with it are chest pain, fatigue, headache, and shortness of breath. Arrhythmias, palpitations, and heart attacks are some of the rare complications of this test.

FAQs: Nuclear Stress Test

What are preparations required from the patient? The patient must fast for 4 hours and not drink caffeinated drinks for 24 hours before the test. He/She must also avoid sodas, chocolates, pain relievers containing caffeine, and nitrate medications before the test. The patient is generally advised to wear comfortable clothing and shoes for the test.

How long does it take? It takes around 3 to 4 hours to complete the test. 

Who performs it? A nuclear cardiovascular technician performs this diagnostic test.

How much does Myocardial Perfusion scan cost? It costs around Rs. 10K to 15K to get this test done.

When can I go home after the procedure? The patient can resume his normal activities and go home immediately after the test.

References:

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How does Intravascular Ultrasound quantify Plaque?

Diagnosis,

Diagnosing a Heart Problem

https://youtu.be/GGac4_ARcjI

Heart Diseases/Disorders

Intravascular ultrasound (IVUS) is used to view the insides of coronary arteries and quantify arterial plaque.

IVUS is an invasive diagnostic test. It combines echocardiography with cardiac catheterization and is also known as intravascular echocardiography. It is frequently done together with a percutaneous coronary intervention, such as angioplasty, to treat coronary artery disease.

What is arterial Plaque?

Arterial plaque is made up of materials that enter the artery wall from the bloodstream. These include cholesterol, fat, calcium, waste products from cells, and a clotting agent called fibrin.  (Image credit)

As it builds up, plaque may cause the arterial internal rupture, allowing a blood clot to form. Arterial clots (thrombosis) can block local blood flow completely, or they may break free and cause dangerous blockages elsewhere.

How is Intravascular Ultrasound performed?

The patient is often asked to don a hospital gown and lie down on the procedure table. An IV (intravenous) line is connected to his arm, and a mild sedative is administered to aid in relaxation. Some patients may also require general anesthesia. The groin area is cleaned (where the catheter will be inserted). The Groin area is shaved, cleaned, and covered with a surgical drape. The technician then anesthetizes and inserts a sheath into the artery or vein at the puncture site. 

The catheter is guided into the coronary artery via the sheath and threaded to the target site through the blood vessel. This is done with the help of ultrasound guidance or x-ray. On reaching the target site, the transducer located at the end of the catheter emits sound waves. These waves are then bounced off by the artery walls and received by the transducer as echoes. A monitor finally converts the echoes to images to produce pictures of the inside of the blood vessels. The catheter can be moved to capture the images of the vessels at different sites. When the technician completes the procedure, he removes the catheter. It stops the bleeding at the puncture site by applying pressure. Sometimes, a closure device may be used to control the bleeding.   

Are there any risks involved in it? :

The risks associated with this test are arrhythmia, blood clots, kidney failure, and allergic reactions to the medications used during IVUS. Some rare complications that may arise due to an IVUS are heart attack, stroke, and blood clots in the lung.

Read about how to diagnose heart disorders

FAQs: Intravascular Ultrasound

What are preparations required from the patient? The patient is generally advised to wear loose and comfortable clothing to the test. He/She is asked to remove all jewelry and metal objects before the test. Suppose the patient is diabetic or has kidney disease. In that case, it must be specifically mentioned to the doctor before the test.

How long does it take? IVUS might take less than an hour to several hours to complete.  

Who performs it? Interventional cardiologists perform this test in a cardiac catheterization lab or interventional radiology suite.

How much does Intravascular Ultrasound cost? It costs around Rs. 40K to 50K to do an IVUS.

When can I go home after the procedure? After the test, the patient is asked to lie down for about 2 to 6 hours to prevent bleeding. If the test is done together with angioplasty, the patient will be required to stay in the hospital for 12 to 24 hours. After this period, he is allowed to go home.

References:

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Holter Monitoring for measuring Heart’s electrical activity

Diagnosis,

A Holter monitor is a type of electrocardiography (ECG) device primarily used for cardiac monitoring. It is frequently employed to record the electrical activity of the patient’s heart continuously for around 24 to 48 hours or even longer. Doctors may also recommend this test to observe the occasional cardiac arrhythmias that are difficult to identify using a standard ECG.

Read Arrhythmia: When the heart rhythm goes for a toss!

How is Holter Monitoring performed? :

The Holter monitor recording is generally done on an outpatient basis. The patient will be asked to remove his clothes from the waist up, and a gown or sheet will be provided to cover up his body. The regions on the chest where the electrode patches will be attached are cleaned. If the patient has a hairy chest, then the technician shaves or clips some hair to ensure that the electrodes stick closely to the skin. After this, the technician sticks the electrode patches to the patient’s chest and abdomen. These are then connected to the Holter monitor using wires.

The monitor can either be slung across the shoulders and neck, attached to the waist, or carried in a pocket. Once the monitor is set in place, the patient is permitted to return to his daily routine. The patient can carry out usual work, household chores, or exercise while wearing this monitor but refrain from doing certain activities. These include bathing, showering, swimming, and having x – rays while wearing the monitor. He will also be asked to stay away from high–voltage areas and places with large magnets or metal detectors during the test period.

Apart from this, the patient will be issued specific instructions to keep a diary of the activities and symptoms experienced throughout the test. The date and time of onset of symptoms such as chest pain, shortness of breath, etc., must be noted in the diary.

These will be compared with the changes in the ECG recorded by the Holter monitor at the end of the test.

Read about various diagnostic tests to assess risk of heart diseases.

Are there any risks involved in it? :

Holter monitors are safe and do not cause any pain or complications to the patient. But, there is a possibility of mild skin irritation and tissue breakdown at the application site as the electrodes are attached using tapes or adhesives.

Other Diagnostic tests

FAQs: duration, cost and preparation

What preparations are required from the patient?

 The patient is not required to fast before the test.  He is advised to bathe or shower before having the monitor fitted.

How long does it take?

The Holter monitor is a continuous test that records the heart rate and rhythm for at least 24 to 48 hours.

Who performs Holter Monitoring?

A cardiac technician generally attaches the Holter monitor to the patient.

How much does it cost?

It costs around Rs. 2K to 4 K to get a Holter monitor test done.

When can I go home after the procedure?

The patient can resume his normal routine and diet after the test period.

References:

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Exercise Stress Test: How is it performed?

Diagnosis,

Heart Disorders

How heart disorders diagnosed?

An exercise stress test is a cardiac diagnostic test that evaluates the heart’s ability to respond to stress. It helps to diagnose coronary artery disease and assess the patient’s health condition after a heart attack. But, it is not recommended for patients with unstable angina and extreme obesity. The stress required for this test is either induced by exercising on a treadmill or by pedaling a stationary exercise bike.    

How is the Exercise Stress Test performed?

Several small sticky metal discs called electrodes are attached to the patient’s chest. These are connected to the electrocardiogram (ECG) machine through wires called leads. The ECG machine records the electrical activity of the patient’s heart, and this is monitored during the study. The patient’s heart rate and blood pressure are also checked. (Image credit)

Sometimes, a patient may be asked to wear special headgear and breathe through a snorkel-like mouthpiece. This is done to assess how well the patient breathes while exercising. After this, a patient will be asked to walk on a treadmill or pedal an exercise bike.

In the beginning, the treadmill or bike runs at a slower pace, but this is gradually increased every 2 to 3 minutes throughout the study. To further increase the heart rate, the treadmill or bike is tilted to resemble the effect of going up a hill. Read Tilt table test: Why is this test performed?

The nurse monitors the ECG patterns and blood pressure while the patient is exercising to see if the heart is getting enough oxygen during stress. The test is generally stopped once the target heart rate has been achieved. The patient can also stop the test if he experiences any difficulty while exercising. The ECG wires remain attached for about 10 to 15 minutes after the test till the heart rate returns to the normal resting value. During this cool-down phase, the patient is asked to either lie – down or sit quietly.

Are there any risks involved in Exercise Stress Test? :

As the test is performed under controlled conditions, there are no risks associated with it. It is often stopped before getting to the level of exercise that would cause the patient’s heart to struggle.

FAQs: Exercise Stress Test

What preparations are required from you?

 You must not eat or drink for 4 hours before the test. Besides, you must also refrain from consuming caffeinated drinks such as coffee and tea for 4 hours before the test. The patient must also avoid sodas, chocolates, and over–the–counter pain relievers before the test.

How long does it take?

An exercise stress test generally goes on for 10 to 15 minutes.

Who performs it?

It is generally done by stress test technicians or cardiology technologists.

How much does it cost?

It costs around Rs. 800 to Rs. 3K to get an exercise stress test done in India.

When can I go home after the procedure?

The patient can go home and resume his daily activities immediately after the test.

How is Electrophysiology Studies performed?

Diagnosis,

An electrophysiology study (EPS) is a minimally invasive procedure used to evaluate the heart’s electrical activity. Electrophysiology Studies are frequently done to detect abnormal heart rhythms or arrhythmias. The doctor may also recommend an EPS to see how well the patient responds to the anti-arrhythmic medicine.

How is Electrophysiology Studies performed?

 An IV (intravenous) line is connected to the patient’s arm. He is generally given a sedative but remains awake and responsive during the study. A nurse then records and continuously monitors the patient’s heart rate, blood pressure, breathing rate, and oxygen level. Following this, the region where the doctor will work is shaved and cleaned to prevent infection. This could be the groin or the neck. Sterile sheets are draped over the patient, and a local anesthetic is administered to numb the puncture site. The technician then inserts a small straw-sized tube into the vein in the groin or neck. This tube is called a sheath, and several catheters (usually 3 to 5) are guided into the vein through this. These are then guided to the heart by monitoring their position via a video screen. On reaching the target site, minute electrical impulses are sent to the heart by using the catheters. [1]

This stimulates the heart to beat at different speeds and reproduce the conditions for which the patient was recommended an EPS. Sometimes, medicines like adrenaline are used to induce cardiac arrhythmia during the study. The impulses produced by the heart are recorded by the catheters and helps to locate the region from where the arrhythmia originates. This process is called cardiac mapping. After completing the procedure, the catheters and IV lines are removed. Firm pressure is applied to the puncture site to prevent bleeding.

Are there any risks involved in it? :

There are no serious problems associated with an EPS. The minor complications that may arise include bleeding and bruising at the puncture site, damage to the blood vessel, and formation of blood clots.

FAQs: Electrophysiology Studies

What preparations are required from the patient?

The patient must not eat or drink for 6 to 8 hours before the test. He should notify the doctor if he has a history of any bleeding disorders and is taking medications for it. The physician may advise the patient to stop taking anticoagulants, aspirin, and other medications that affect blood clotting before the test.

How long does it take?

It usually lasts for about 1 to 4 hours.

Who performs Electrophysiology Studies?

The procedure is performed by an electrophysiologist in the electrophysiology lab.

How much does it cost?

The cost of an electrophysiology study is around Rs. 10K to 25K.

When can I go home after the procedure?

The patient will be asked to stay in bed for 4 to 6 hours without moving or bending his legs. After this, he can leave the hospital but must arrange for a ride home as he may feel drowsy after the test.

What is ECG, and how is it performed?

Diagnosis,

Electrocardiogram (ECG) is a non – invasive and harmless test used to assess the heart’s electrical activity. Contraction of the different regions of the heart to facilitate blood flow is maintained by the natural electrical impulses. These impulses are recorded as waves and intervals in the ECG. It gives information about the heart rhythm, the size and functioning of the heart chambers, and the heart rate. 

An ECG abnormality could either indicate a variation of the heart’s rhythm or a medical emergency.

How is ECG performed? :

The patient is asked to remove the clothes covering his upper half and change into a gown. He will then be instructed to lie on his back on the examination table or bed for the test. The patient needs to lie entirely still throughout the procedure to avoid false results due to altered tracing. False results may arise due to interference by the impulses generated by the other muscles. The technician may shave or clip small patches of hair on the patient’s chest, arms, or legs if they are very hairy.

This action is performed if needed, provided the electrodes do not stick closely to the skin. Small, sticky electrodes are then attached to the patient’s chest, wrists, and ankles. These are connected to a machine by the lead wires. After this, the technician enters some information into the machine’s computer and starts the ECG. During this time, the machine converts the heart’s electrical signals into wavy lines. It is then printed on an ECG paper. Once the tracing is completed, the leads are disconnected, and the skin electrodes are removed. 

Are there any risks involved in it? :

The entire procedure is safe and painless. While sticking the electrodes on the skin, the patient may feel a cooling sensation, but this is harmless. Some people may develop rashes or irritation to the patches, but this is very rare.

FAQs: ECG

What are preparations required from the patient? 

Fasting is not necessary before the test. The patient must notify the doctor about the medications taken by him. He must also inform the doctor if he has a pacemaker. It is generally advised to not drink cold water or exercise immediately before the ECG as these may give rise to false results.  [1]

How long does it take?

  An ECG generally gets over in about 5 to 10 minutes.

Who performs ECG?

It is generally done by a nurse or an electrocardiograph technician.

How much does it cost?

  An ECG generally costs around Rs. 150 to Rs. 300.

When can I go home after the procedure?

The patient can resume his normal activities and return home immediately after the test. 

Echocardiography: Diagnostic Cardiac Ultrasound Scan

Diagnosis,

Echocardiography is an ultrasound scan used to create pictures of the heart. It uses high–frequency sound waves to assess the structure and functioning of the heart valves and chambers. Generally, it is recommended for diagnosing heart conditions like atherosclerosis, cardiac tumor, atrial wall defects, or congenital heart disease. The test is also called diagnostic cardiac ultrasound.

How is Echocardiography performed? :

The patient will be asked to remove the clothing from the waist up and change it into a hospital gown. He will then be asked to lie on a table on his left side. Sometimes, the technicians keep a pillow or wedge to support the patient’s back. Once the patient is in the proper position, several electrodes are attached to his chest. The electrodes have wires that are hooked to the electrocardiograph (ECG) monitor. This monitors the patient’s heartbeat throughout the procedure. A lubricating gel is then applied to the patient’s chest, and a transducer probe is placed over it. The technician moves the probe to get the desired images of the heart. While moving the probe, the patient might feel a slight pressure on his chest.

Occasionally, he is asked to move, hold his breath, or take deep breaths briefly to get more transparent images. The probe produces sound waves that bounce off the heart and echo back. These waves are converted to a picture and displayed on a video monitor. These images are recorded and shown to the doctor. After the procedure, the gel is wiped off, and the ECG electrodes are removed. After this, he can change into his clothes. An intravenous contrast dye is injected if the technician cannot see the heart chambers correctly. During the entire scan, the room will be darkened to clearly allow the technician to view the echo monitor images clearly. 

Are there any risks involved in it? :

 Echocardiography is a non – invasive and painless test that has little to no risks associated with it. The possible complications include discomfort due to the positioning of the transducer and allergic reactions to the contrast dye.

FAQs: Echocardiography

What preparations are required from the patient? 

It may not be necessary to fast before the test. The doctor must be notified about the medications consumed by the patient. If the patient has any surgical implants or pacemakers in his body, this must be informed beforehand. All jewelry and metal objects that may interfere with the test must be removed before the test. 1

How long does it take?

The entire scan gets over in about 15 to 60 minutes.  

Who performs it?

 It is performed by cardiac sonographers or echocardiographers in a hospital.

How much does Echocardiography cost?

The cost of echocardiography ranges from Rs. 800 to Rs. 3K.  

When can I go home after the procedure?

The patient is generally allowed to resume his normal activities and go home immediately after the test.

Cardiac CT Scan- Cardiac Computed Tomography

Diagnosis,

A cardiac CT is a non – invasive and painless imaging test that uses x – rays to capture images of the heart. It helps to diagnose coronary artery disease and evaluate cardiac function. The CT scan can also assess scarring of the heart muscle, plaque buildup in the arteries, and fluid accumulation in the pericardial sac.

How is Cardiac CT Scan performed?

The CT scanner is a large tunnel-like machine with a sliding table attached to it. The patient is asked to lie down on this table, and electrodes will be attached to his chest to monitor his electrocardiogram (ECG). This ECG is connected to the computer that is attached to the scanner. It helps to monitor the heart rate during the scan. A contrast dye is then injected intravenously into the arm of the patient if needed. It is done to highlight the heart and the blood vessels to get a clearer picture. Once the dye is injected, the table will slide into the scanner.

Inside the scanner, the patient can hear a whirring or buzzing sound while the pictures are taken. Throughout the test, the patient can communicate to the technician via a two–way intercom. The technician may ask the patient to hold his breath for a few seconds to capture good quality images. Generally, the contrast media is injected at a high flow rate (4 – 5 mL/sec) for a cardiac CT scan compared to other CT scans. Apart from this, the patient is also administered with a beta-blocker and sublingual nitrate before the test. These medications are given to lower the heart rate, avoid arrhythmia, and dilate the coronary arteries. This scan is not recommended for pregnant, breastfeeding patients or anyone diagnosed with acute myocardial infarction.

Are there any risks involved in it? :

Due to exposure to a small dose of x – rays, cardiac CT has a slight risk of causing cancer, especially in patients below 40 years of age. The minor complication associated with cardiac CT scan is allergic reactions to the contrast dye.

FAQs:

What are preparations required from the patient? 

If contrast dye is to be used, then the patient must not eat for 4 to 6 hours or have caffeinated drinks for 12 hours before the test. Otherwise, he must refrain from eating for 2 hours before the test. Patients with kidney failure and those with metallic objects in the chest (pacemaker, surgical clips) should notify the doctor beforehand. 

How long does it take?

 The cardiac CT scanning takes about 10 to 15 minutes. 

Who performs it?

 A radiologist or radiology technologist generally does the cardiac CT scanning.

How much does it cost?

 The average cost of a cardiac CT scan lies around Rs. 6K to 12K.

When can I go home after the procedure?

The patient can usually go home and resume his normal activities immediately after the procedure.

References:

What is Angiography, and how is it performed?

Diagnosis,

Coronary angiography is a medical imaging technique used to view the heart’s chambers and coronary arteries. X-ray images of the arteries in the heart are called an angiogram. Narrowed, blocked, enlarged, or malformed blood vessels are generally detected via an angiogram. It also reveals the extent and severity of heart disease.

How is Coronary angiography performed? :

 A catheter is inserted in the patient’s forearm (radial artery) or groin (femoral artery) after anesthetizing the region. The catheter is then threaded to the heart through the arterial system. A contrast dye containing iodine is injected into the heart via the catheter on reaching the desired point. The distribution of the dye within the heart and blood vessels is recorded as the angiogram. Through this, the doctor can visualize the size of the artery openings. This test can also determine blockages in the coronary arteries due to plaque buildup. An angiogram also helps to identify the narrowed blood vessels or coronary artery stenosis. It is often used to diagnose an aneurysm, heart arrhythmias, or congenital defects in the heart. It is generally not recommended for patients with a low risk of heart attack or who don’t have angina symptoms.

Are there any risks involved in it? :

Angiography is a relatively safe test. However, there are some minor risks involved in it. Risks include temporary bleeding at the wound site, bruising, and the development of allergic rashes. Some rare but serious complications range from severe bleeding to even death. 

Coronary angiography: FAQs

What preparation is required from the patient? 

The patient is required to fast for four to six hours and discontinue medications that thin the blood before the test. Apart from this, blood tests are performed to check kidney function. The other tests recommended by the doctor before the angiography are electrocardiogram, chest x-ray, and cardiac CT (computed tomography).

How long does it take?

Coronary angiography is performed in over 30 minutes, but this may last longer at times. During the test, the heart rate and rhythm are generally monitored. 

Who performs it?

A cardiologist or a doctor who specializes in the heart conducts a coronary angiography.

How much does it cost?

The cost of coronary angiography ranges from Rs. 15K to Rs. 65K in India.

When can I go home after the procedure?

The patient needs to stay in the hospital overnight or for several hours after the test. After going home, the patient is advised to drink plenty of water and stay hydrated to flush out the dye from the kidneys. He is also asked to refrain from lifting heavy weights for a week to prevent bleeding from the groin. 

References:

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