Tel: 830-620-1272 HOME Our Physicians Patient Resources Available Services Locations FAQs In Office Services Abdominal Aneurysms An Abdominal Aneurysm is defined loosely as a dialation of a section of the aorta allowing then for aneurysm formation. We offer full spectrum of in-office screening services to review your condition, provide you with an ongoing treatment plan. While often uncommon for a cardiologist to manage the treatment of Abdominal/Aortic Aneurysms1. At New Braunfels Cardiology our physicians have received the necessary training and posses the skills needed to do just that. We are also able to help detect the potential for this condition early on through routine cardiovascular exams such as those above in our office. If you have have been diagnosed with an Abdominal Aneurysm, or are in post-operative treatment stagefor such a condition our caring physicians and specialists are here to help you in your recovery process. Or if something seem unusual and you suspect you may have experienced or exhibit symptoms of this condition we are here to help! Abnormal Aortic Ultrasound Ultrasound technology allows doctors to "see" inside a patient without resorting to surgery. A transmitter sends high frequency sound waves into the body, where they bounce off the different tissues and organs to produce a distinctive pattern of echoes. A receiver "hears" the returning echo pattern and forwards it to a computer, which translates the data into an image on a television screen. Because ultrasound can distinguish subtle variations between soft, fluid-filled tissues, it is particularly useful in providing diagnostic images of the abdomen. Ultrasound can also be used in treatment. Properly performed, ultrasound imaging is virtually without risk or side effects. Some patients report feeling a slight tingling and/or warmth while being scanned, but most feel nothing at all. Ultrasound waves of appropriate frequency and intensity are not known to cause or aggravate any medical condition, though any woman who thinks she might be pregnant should raise the issue with her doctor before undergoing an abdominal ultrasound. The value of ultrasound imaging as a medical tool, however, depends greatly on the quality of the equipment used and the skill of the medical personnel operating it. Improperly performed and/or interpreted, ultrasound can be worse than useless if it indicates that a problem exists where there is none, or fails to detect a significant condition. Basic ultrasound equipment is relatively inexpensive to obtain, and any doctor with the equipment can perform the procedure whether qualified or not. Patients should not hesitate to verify the credentials of technicians and doctors performing ultrasounds, as well as the quality of the equipment used and the benefits of the proposed procedure. In cases where ultrasound is used as a treatment tool, patients should educate themselves about the proposed procedure with the help of their doctors--as is appropriate before any surgical procedure. Also, any abdominal ultrasound procedure, diagnostic or therapeutic, may be hampered by a patient's body type or other factors, such as the presence of excessive bowel gas (which is opaque to ultrasound). In particular, very obese people are often not good candidates for abdominal ultrasound. Ultrasound includes all sound waves above the frequency of human hearing--about 20 thousand hertz, or cycles per second. Medical ultrasound generally uses frequencies between one and 10 million hertz (1-10 MHz). Higher frequency ultrasound waves produce more detailed images, but are also more readily absorbed and so cannot penetrate as deeply into the body. Abdominal ultrasound imaging is generally performed at frequencies between 2-5 MHz. An ultrasound machine consists of two parts: the transducer and the analyzer. The transducer both produces the sound waves that penetrate the body and receives the reflected echoes. Transducers are built around piezoelectric ceramic chips. (Piezoelectric refers to electricity that is produced when you put pressure on certain crystals such as quartz). These ceramic chips react to electric pulses by producing sound waves ( they are transmitting waves) and react to sound waves by producing electric pulses (receiving). Bursts of high frequency electric pulses supplied to the transducer causes it to produce the scanning sound waves. The transducer then receives the returning echoes, translates them back into electric pulses and sends them to the analyzer--a computer that organizes the data into an image on a television screen. Because sound waves travel through all the body's tissues at nearly the same speed--about 3,400 miles per hour--the microseconds it takes for each echo to be received can be plotted on the screen as a distance into the body. The relative strength of each echo, a function of the specific tissue or organ boundary that produced it, can be plotted as a point of varying brightness. In this way, the echoes are translated into a picture. Tissues surrounded by bone or filled with gas (the stomach, intestines and bowel) cannot be imaged using ultrasound, because the waves are blocked or become randomly scattered. A patient undergoing abdominal ultrasound will be advised by their physician about what to expect and how to prepare. As mentioned above, preparations generally include fasting and arriving for the procedure with a full bladder, if necessary. This preparation is particularly useful if the gallbladder, ovaries or veins are to be examined. In general, no aftercare related to the abdominal ultrasound procedure itself is required. Arterial Brachial Index Testing The ankle-brachial index (ABI) is a measurement that is useful to your physician in evaluating the adequacy of the circulation in your legs. It can also be used to follow the improvement or worsening of leg circulation over time. To obtain the ABI, your physician measures your blood pressure in your ankle and in your arm. Your physician will compare the two numbers by forming a ratio to determine your ABI. Normally, the blood pressures in your ankle and arm should be about equal. But if your ankle pressures are lower than your arm pressures, your leg arteries are probably narrowed. To perform the ABI, your physician may use an ordinary blood pressure cuff and an ultrasound device. The ABI helps your physician diagnose arterial disease in the legs, but it is a general test and it does not specifically identify which arteries are blocked. Cardiac Event Monitoring Cardiac Event Monitoring is important because abnormal heart rhythms and their accompanying cardiac symptoms often come and go in a transient manner, they may be difficult to detect. Tests such as electrocardiograms only allow a doctor to look at the heart’s activity at one point in time. Until a patient is diagnosed with an arrhythmia, he or she may be at risk for future symptoms or events. To determine the cause of recurrent fainting, palpitations, unexplained stroke or atrial fibrillation, a patient’s heart must be monitored effectively over time so the doctor can diagnose the disorder accurately. Patient-activated, transtelephonic cardiac event monitoring is an economical, diagnostic tool which allows patients to record arrhythmia or ischemic episodes whenever and wherever they happen with the use of a miniature transmitter. Patients experiencing fleeting symptoms including angina, palpitations or unexplained dizziness have the capability of correlating these symptoms with their EKG's at the time they occur, then transmitting their EKG. In the event of an abnormal EKG, the ordering physician is notified immediately. Carotid Ultrasound Carotid Ultrasound is a simple, painless way of assessing blood flow through your carotid arteries. Atherosclerotic vascular disease (hardening of the arteries) continues to be of major concern to physicians in their treatment of aging patients. This is a progressive disease caused by a slow build-up of cholesterol deposits (Plaque) within the arteries. The deposits of plaque that form on the artery walls can cause a significant decrease of blood flow to muscles and vital organs. When this condition is present in the Carotid Arteries, there is a much higher risk of stroke. This is a treatable and surgically correctable condition. The Carotid Arteries are the major blood vessels supplying the head and brain with the necessary blood flow to deliver oxygen. They branch off of the aorta (the main artery leaving the heart) and with some variation between the right and left side of the body, travel up the throat, one on each side of the windpipe (right and left common carotid arteries). At about the jawbone, there is another branching into the external and internal carotid arteries. The external carotid supplies blood to the face, scalp and other external head tissues. The internal carotid supplies blood to the brain. It is at this branching that most plaque build-up occurs and therefore, most blockages are found. The major concern is for the blood flow through the internal carotid arteries as they supply the brain. What is the test? Ultrasound is a painless way to show the amount of blood flow in the carotid arteries inside your neck. Ultrasound uses sound waves and a type of sonar detection system to generate a black and white picture. This picture allows your doctor to see if there is narrowing of your carotid arteries, which is usually caused by cholesterol deposits. Narrowed carotid arteries are one cause of strokes, so this test is often used to evaluate patients who have had a stroke or who might be at a high risk for strokes. What happens when the test is performed? A sonographer will place some ultrasound gel on the imaging probe (transducer) and then place the probe on your neck against your skin. The sonographer will move the probe back and forth on your neck to take the images of your arteries from different views. During the test the machine will make a noise that sounds like your heartbeat--this shows that it is measuring the blood flow through the artery. Both sides of your neck will be checked the same way. The test usually requires from 30 to 60 minutes to perform. How the Carotid Ultrasound Exam is Done You will be asked to lie flat on your back (some adjustments can be made for those who require a pillow for support). A clear gel is applied to your neck and a transducer is gently placed to one side of the windpipe. The transducer is manipulated up and down the length of the neck to record the entire length of the carotid artery and blood flow measurements are recorded. The process is then repeated on the other side of the neck. Generally, one hour is allotted for the exam (from entering the clinic to leaving). Preparation for the Exam In general, there is no preparation for the exam. You will be asked to remove any jewelry from around the neck. It is advised that you wear a loose fitting, open necked shirt or blouse. Cholesterol Screening You May Be Required to Fast (not consume any food/drink, except water, for a defined period of time). Depending on your individual test your doctor will discuss the specifics with you. You may be required to fast prior to your exam, this will mean that you eat/drink nothing prior to the exam with the exception of water. The amount of time for fasting will be determined by your doctor, but most commonly is 12 hours. At the time of testing blood samples will be drawn according to the necessary tests to be ran. Samples Will Be Processed According to Physician Directive Once samples have been collected they will be processed. You will receive a call from your physician's office to notify you of results when the arrive. At that time the next steps will be discussed. Our Coumadin Clinic is designed to assist providers and their patients who take the anticoagulant drug known as Coumadin (Warfarin). the medication and its interactions with other medications and foods; the uses of the drug and the reason they are taking it; the expected effects of the medication; the importance of monitoring the medication level by regularly scheduled fingerstick testing; and other important aspects of being on Coumadin. Your cardiologist will enroll you in the clinic if you are being prescribed Coumadin as part of your treatment. An echocardiogram (echo) is a graphic outline of the heart's movement. During an echo test, ultrasound (high-frequency sound waves) from a hand-held wand placed on your chest provides pictures of the heart's valves and chambers and helps the sonographer 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. Assess the overall function of your heart Determine the presence of many types of heart disease, such as valve disease, myocardial disease, pericardial disease, infective endocarditis, cardiac masses and congenital heart disease Follow the progress of valve disease over time Evaluate the effectiveness of your medical or surgical treatments What Is Holter Monitoring? Holter monitoring is a continuous recording of your heart rhythm, usually for 24 hours, while you go about your usual daily activities. It is especially useful in diagnosing abnormal heart rhythms. What Does It Show? An abnormal heart rhythm, called an arrhythmia, is a change in either the speed or pattern of the heartbeat. During an arrhythmia, the heart may beat too fast, too slowly, or irregularly. An arrhythmia may be felt as a skipping or fluttering sensation in the chest (palpitations). It may also cause light-headedness, a fainting spell, chest pain, or shortness of breath. Some arrhythmias, however, may go unnoticed. Doctors can diagnose an arrhythmia by obtaining an electrocardiogram, or ECG, which is a recording of the heart's electrical activity. During a standard ECG test, the heart's electrical signals are recorded on a strip of moving paper. Quite often, an arrhythmia will not occur during the brief period (less than a minute) of actual recording at the doctor’s office. If your doctor suspects you have an arrhythmia, he or she will want to record the ECG over a longer period of time. Holter monitoring allows your doctor to record your ECG over a period of 24 hours or longer, while you go about your usual daily activities. How Does It Work? A Holter monitor is a small, portable recorder that is worn on a strap over your shoulder or at your waist. Three to five small, sticky patches, called electrodes or leads, are placed on your chest and connected to the recorder by thin wires. The electrical signals of your heart are picked up by the electrodes and are then transmitted to the monitor. The device records the electrical signals, either on tape or on a memory card. While wearing the monitor, you will be asked to keep a diary of your activities and symptoms. After the monitoring period, the doctor will compare the timing of your activities and symptoms with the pattern recorded on the ECG. Why Is Holter Monitoring Done? Here are a few situations where Holter monitoring may be done: •To detect arrhythmias that occur irregularly or only during certain activities. •To evaluate symptoms (such as dizziness, fainting, or chest pain) of possible heart disease. •To monitor how well arrhythmia treatments (such as medications or pacemakers) are working. •To detect poor blood flow to the heart muscle, which may indicate coronary heart disease. How Is the Test Done? You are fitted with the monitor and electrodes by a technician at the doctor’s office or test center. Several areas on your chest are carefully cleansed with alcohol and an abrasive lotion, to ensure that the electrodes have good contact with the skin. Men may need to have areas of their chest shaved. A FEW PRACTICAL TIPS •For the test, wear a loose-fitting blouse or shirt, with the buttons in front. •When sleeping, try to stay on your back with the recorder positioned at your side, so that the electrodes are not pulled off. •Do not get the electrodes, wires, or recorder wet. Do not swim, take a bath, or shower while wearing the recorder. •If one of the electrodes or wires comes loose, a light on the monitor will flash. Press on each electrode to try to restore contact. If you have difficulty, call your doctor or test center. •While wearing the recorder, avoid electric blankets, magnets, metal detectors, and high-voltage areas such as power lines. Signals from such devices may affect the recording. Keeping a Diary You will be asked to keep a diary during the period you wear the monitor. The diary is very important. It allows the doctors to correlate your activities and symptoms with the ECG recording. The information you will need to write in the diary includes the following: •Your activities (such as walking, climbing stairs, bowel movement, sexual activity, emotional upset, sleeping, taking medications, etc.). •Symptoms you experience (such as palpitations, dizziness, fainting, chest discomfort, etc.). •The exact time at which these events occurred Halter Monitor Diary Time Activity Symptom* After you return the monitor, the recorded data are played back, scanned, and analyzed by a computer. The printed report is then reviewed by a doctor. Final results are usually available within a few days. Your doctor will discuss the results of the test with you during a future office visit. The results help the doctor accurately diagnose your condition and develop a treatment plan that's best for you. Cardiac perfusion imaging is a medical test that uses a radioactive substance, known as a tracer, to assess the flow of blood to the heart muscle. Generally, cardiac perfusion imaging is done after an exercise (stress) test. For patients who are unable to exercise adequately, it may be done after injection of a drug that mimics the effect of exercise on the heart. This is known as a pharmacologic stress test. The drug most commonly used for pharmacologic stress testing is adenosine (Adenoscan®). Another drug is dipyridamole (Persantine®). (Other terms often used to describe cardiac perfusion imaging include: myocardial perfusion scan, cardiac nuclear imaging, and radionuclide stress test. Based on the specific tracer that's used, it may also be called Thallium, Cardiolite, or Myoview scan.) What Does It Show? Cardiac perfusion imaging helps doctors diagnose coronary heart disease, which is caused by narrowed or blocked coronary arteries (the vessels that supply blood to the heart muscle). During the test, adenosine or dipyridamole is injected into a vein. The drug causes the coronary arteries to dilate (widen), which increases blood flow to the heart muscle. Arteries that are diseased cannot dilate as much as healthy arteries. As a result, blood flows mostly to areas supplied by healthy arteries. Once the dilating drug has been given, a small amount of tracer is injected into the vein. The tracer collects in those parts of the heart muscle that have good blood flow. The tracer gives off a small amount of radiation that is detected with a scanning camera. A computer processes the information and produces images that show how radioactivity is distributed in the heart. If an area of the heart receives less blood than the rest of the heart (because of a narrowed or blocked artery), it will pick up less radioactivity and will show up as a lighter area, called a "defect." Additional tracer is injected while you are at rest, and another set of images is taken. By comparing the stress and rest images, doctors can identify areas of the heart muscle with reduced blood flow as well as areas that are scarred from a previous heart attack. The images show the heart from two different "angles" during stress and at rest. The stress images show a "defect," which disappears at rest. This suggests a narrowing in the artery which supplies blood to that area of the heart muscle. You will be instructed not to eat or drink for at least 4 hours before the test. If you have diabetes and take medication for it, you will need special instructions. 1. •This test may not be right for patients who have a history of asthma, emphysema, or chronic lung disease. If you have any of these, be sure to let the doctor or nurse know. 2. •Do not take any medications that contain theophylline (such as Theo-Dur®, Theo-24®, Tlieolait®, or Uniphyl®) for 48 hours before the test. These medications can affect the test. If you do not know which medications to avoid, ask your doctor or nurse. 3. •Do not drink coffee, tea, cocoa, colas, or soft drinks containing caffeine (such as Tab™ or Mountain Dew™) for 24 hours before the test. Avoid chocolate. Avoid medicines containing caffeine (such as Anacin™ or Excedrin™). Wear comfortable clothing and shoes that are suitable for walking, as you may be asked to do low-level exercise. 4. •The procedure will be explained to you and you will be asked to sign a consent form. Feel free to ask any questions you may have. Cardiac perfusion imaging is generally performed at a hospital, test center, or clinic. It may be done on a single day or on two separate days. Usually, two sets of images are taken. One set is taken after the dilating drug has been given (the stress portion), another set is taken after a period of rest; Depending on the department’s routine, either the stress or the rest part may be done first. Stress Portion Several electrodes (small sticky patches) will be placed on your chest to obtain an ECG and monitor your heartbeat. An intravenous (IV) line will be inserted into a vein in your arm. The dilating drug (adenosine or dipyridamole) is then injected slowly through the IV into the vein. As the drug is given, you may feel flushed or experience chest pressure, headache, nausea, anxiety, dizziness, or shortness of breath. Be sure to let the doctor, nurse, or technologist know how you feel. If the side effects are severe or make you too uncomfortable, other drugs can sometimes be given to stop the effects. In some cases, you may be asked to perform low-level exercise after the dilating drug has been injected, This helps to improve the quality of the test and lessen side effects from the drug. Once the dilating drug has been given, or soon after, the radioactive tracer is injected into the vein. Next, you lie flat on a special table under a large scanning camera, During imaging, the camera moves slowly in an arc over the front of your chest, taking pictures of your heart from different angles. Remain still while the pictures are being token. The imaging part of the test takes about 20 to 30 minutes. Rest Portion A tracer will be injected one other time, and another set of pictures will be taken while you are at rest. These images are then compared to the images taken during the exercise part of the rest. Cardiac perfusion imaging can take from 2 to 5 hours. If you are an outpatient, you may be allowed to leave the test area between the two parts of the test. Or, you may be asked to return the next day for more imaging. The radiation exposure during perfusion imaging is small, and the doses used are safe. However, if you are pregnant, suspect you may be, or are a nursing mother, be sure to let your doctor know. The injection of dilating drugs is also safe. A small amount of risk does exist, however, because the heart is stressed. Possible rare complications include severe shortness of breath, abnormal heart rhythms, and heart attack. Trained personnel are there to handle any emergency PAD/PVD Screening Peripheral Arterial Disease (PAD), more commonly known as hardening of the arteries, affects about eight million Americans. It is a condition in which the large and mediumsized arteries supplying blood to the legs become narrow or clogged, constricting the flow of blood. PAD is caused by atherosclerosis, a gradual process in which cholesterol and scar tissue build up, forming a substance called plaque that clogs the artery. PAD not only causes pain and disability, it also is associated with a much higher risk of heart disease. Peripheral Arterial Disease Screening o A quick, easy and non-invasive procedure, PAD screening is done by using the anklebrachial index (ABI). After removing your socks and shoes, you will have pressure cuffs placed around your upper arms and ankles. A small ultrasound device will then measure the systolic blood pressure in your limbs. Who should have a peripheral arterial disease screening? How often should I get a peripheral arterial disease screening? How do I prepare for a peripheral arterial disease screening? Even though not everybody with PAD experiences symptoms, these warning signs may indicate arterial issues: Pain during exercise, which is relieved during rest Constant leg pain, tingling, burning or loss of sensation Patients with coronary artery blockages may have minimal symptoms and an unremarkable or unchanged EKG while at rest. However, symptoms and signs of heart disease may become unmasked by exposing the heart to the stress of exercise. During exercise, healthy coronary arteries dilate (develop a more open channel) than an artery that has a blockage. This unequal dilation causes more blood to be delivered to heart muscle supplied by the normal artery. In contrast, narrowed arteries end up supplying reduced flow to it's area of distribution. This reduced flow causes the involved muscle to "starve" during exercise. The "starvation" may produce symptoms (like chest discomfort or inappropriate shortness of breath), and the EKG may produce characteristic abnormalities. Most commonly, a motorized treadmill is used for exercise, while a stationary bicycle is used in some exercise laboratories. A regular stress test is considered in the following circumstances: •Patients with symptoms or signs that are suggestive of coronary artery diseases (CAD). •Patients with significant risk factors for CAD. •To evaluate exercise tolerance when patients have unexplained fatigue and shortness of breath. •To evaluate blood pressure response to exercise in patients with borderline hypertension. •To look for exercise-induced serious irregular heart beats. Please remember that the regular stress test is heavily dependent upon interpretation of EKG changes produced by exercise. Therefore, the reliability drops drastically if there are significant EKG changes at rest (for example in patients with long standing high blood pressure, an artificial cardiac pacemaker, use of medications like digitalis, or presence of a bundle branch block pattern, etc.). In all such cases, the physician will usually order an Echo Stress Test or a Nuclear Stress Test, particularly if he or she is suspecting coronary artery disease. However, a regular stress may be sufficient in stable patients or those with a low suspicion of coronary artery disease who are being assessed for exercise tolerance (for example, prior to undergoing a structured exercise or rehab program). How is a Regular Treadmill Stress Test Performed? The patient is brought to the exercise laboratory where the heart rate and blood pressure are recorded at rest. Sticky electrodes are attached to the chest, shoulders and hips and connected to the EKG portion of the Stress test machine. A 12-lead EKG is recorded on paper. Each lead of the EKG represents a different portion of the heart, with adjacent leads representing a single wall. The treadmill is then started at a relatively slow "warm-up" speed. The treadmill speed and it's slope or inclination are increased every three minutes according to a preprogrammed protocol (Bruce is the commonest protocol in the USA, but several other protocols are perfectly acceptable). The protocol dictates the precise speed and slope. Each three minute interval is known as a Stage (Stage 1, Stage 2, Stage 3, etc. Thus a patient completing Stage 3 has exercised for 3 x 3 = 9 minutes). The patient's blood pressure is usually recorded during the second minute of each Stage. However, it may be recorded more frequently if the readings are too high or too low. As noted earlier, the EKG is constantly displayed on the monitor. It is also recorded on paper at one minute intervals. The physician pays particular attention to the heart rate, blood pressure, changes in the EKG pattern, irregular heart rhythm, and the patient's appearance and symptoms. The treadmill is stopped when the patient achieves a target heart rate (this is 85% of the maximal heart rate predicted for the patient's age). However, if the patient is doing extremely well at peak exercise, the treadmill test may be continued further. The test may be stopped prior to achievement of the target heart rate if the patient develops significant chest discomfort, shortness of breath, dizziness, unsteady gait, etc., or if the EKG shows alarming changes or serious irregular heart beats. It may also be stopped if the blood pressure (BP) rises or falls beyond acceptable limits. Please note that the systolic BP (upper number) may normally rise to 200 at peak exercise. At the same time, the diastolic BP (lower number) remains unchanged or falls to a slight degree. In contrast, the BP of patients with hypertension or high BP will show a rise of both systolic and diastolic readings. The latter may rise above 90 - 100. The following recommendations are "generic" for all types of cardiac stress tests: •Do not eat or drink for three hours prior to the procedure. This reduces the likelihood of nausea that may accompany strenuous exercise after a heavy meal. Diabetics, particularly those who use insulin, will need special instructions from the physician's office. •Specific heart medicines may need to be stopped one or two days prior to the test. Such instructions are generally provided when the test is scheduled. •Wear comfortable clothing and shoes that are suitable for exercise. •An explanation of the test is provided and the patient is asked to sign a consent form. •How long does the entire test take? A patient should allow approximately one hour for the entire test, including the preparation. An isotope stress test is also known as a nuclear, thallium, Cardiololite, Myoview or dual isotope stress test, depending upon the method used. During exercise, healthy coronary arteries dilate (develop a more open channel) more than an artery that has a blockage. This unequal dilation causes more blood to be delivered to heart muscle supplied by the normal artery. In contrast, narrowed arteries end up supplying reduced flow to it's area of distribution. This reduced flow causes the involved muscle to "starve" during exercise. The "starvation" may produce symptoms (like chest discomfort or inappropriate shortness of breath), and EKG abnormalities. When a "perfusion tracer" (a nuclear isotope that travels to heart muscle with blood flow) is injected intravenously, it is extracted by the heart muscle in proportion to the flow of blood. The amount of tracer uptake helps differentiate normal muscle (which receives more of the tracer) from the reduced uptake demonstrated by muscle that is supplied by a narrowed coronary artery. In other words, areas of the heart that have adequate blood flow quickly picks up the tracer material. In contrast, muscle with reduced blood flow pick up the tracer slowly or not at all. Analysis of the images of the heart (taken by a scanning camera) can help identify the location, severity and extent of reduced blood flow to the heart. The reduced blood flow is known as ischemia (pronounced is-keem-ya). How is an Isotope or Nuclear Stress Test performed? The test is actually divided into three parts: A treadmill stress test, imaging at rest, and imaging after exercise. There are two common types of isotope used in the USA. They are thallium and technetium (which are marketed under the Trade names "Cardiolite" and "Myoview"). Some laboratories use a "dual isotope" technique, where thallium is used for the resting images and technetium is used for the stress pictures. Depending upon the isotope and protocol for the laboratory, resting images may be obtained either before stress or two to four hours after stress. The preparation for the test and the treadmill procedure is similar to that described under the Regular Treadmill Stress Test section. In patients who are unable to complete a high level of exercise because of physical limitations, stress to the heart is provided by pharmaceutical or chemical stimulation. The patient is brought to the exercise laboratory where the heart rate and blood pressure are recorded at rest. Sticky electrodes are attached to the chest, shoulders and hips and connected to the EKG portion of the Stress test machine. A 12-lead EKG is recorded on paper. Each lead of the EKG represents a different portion of the heart, with adjacent leads representing a single wall (see Regular Treadmill for details). The treadmill is then started at a relatively slow "warm-up" speed. The treadmill speed and it's slope or inclination are increased every three minutes according to a preprogrammed protocol. Bruce is the commonest protocol in the USA, but several other protocols are perfectly acceptable (see Regular Treadmill for details). . It is the protocol that dictates the precise speed and slope. Each three minute interval is known as a Stage (Stage 1, Stage 2, Stage 3, etc. Thus a patient completing Stage 3 has exercised for 3 x 3 = 9 minutes). The patient's blood pressure is recorded during the second minute of each Stage. However, it may be recorded more frequently if the patient's reading is outside too high or too low. The EKG is constantly displayed on the monitor. It is also recorded on paper at one minute intervals. The physician pays particular attention to the heart rate, blood pressure, changes in the EKG pattern, irregular heart rhythm, and the patient's appearance and symptoms. The treadmill is stopped when the patient achieves a target heart rate (this is 85% of the maximal heart rate predicted for the patient's age). However, if the patient is doing extremely well at peak exercise, the treadmill test may be continued further. The test may be stopped prior to achievement of the target heart rate if the patient develops significant chest discomfort, shortness of breath, dizziness, unsteady gait, etc., or if the EKG shows alarming changes or serious abnormal heart rhythm. It may also be stopped if the blood pressure (BP) rises or falls beyond acceptable limits. Approximately one to 1 1/2 minutes prior to termination of exercise, the perfusion tracer or isotope is injected into the intravenous "plug" that had been placed in the forearm or hand. This is followed by a "flush" injection of saline (salt water) to make sure that all of the tracer is pushed into the blood circulation. After a brief waiting phase (that allows the tracer to be taken up by the heart muscle) the patient is placed under a scanning camera. Two sets of isotope images are obtained. One at rest, and one following exercise. Depending upon the isotope used and the protocol for a particular laboratory, the resting images may be obtained before the stress test, or a few hours later. The scanning camera rotates around the patient's chest, stopping to take individual pictures. The patient needs to lay flat and still during the scanning period which takes approximately 11 to 20 minutes, depending upon the type of scanning camera. Patients with severe claustrophobia should notify their physician (a mild tranquilizer before the test may minimize discomfort). The pictures or images are fed into a computer, which reconstructs them as "slices" of a three dimensional heart. These slices are presented in three views (vertical long axis or VLA, horizontal long axis or HLA and short axis or SA). It also computes the data and presents an aggregate "bull's eye" picture that compares the information to a data base of known normal cases. Areas that fall out side the expected normal range is presented as a blacked out area. In other words, your physician has an opportunity to view a three dimensional representation of your heart, examine individual "slices" and then compare the findings against those computed by the computer as "blackout plots. By comparing one wall against another, the physician can identify disease and assess its magnitude. Preparing for an Isotope Stress Test: The following recommendations are "generic" for all types of cardiac stress tests: •Do not eat or drink for three hours prior to the procedure. This reduces the likelihood of nausea that may accompany strenuous exercise after a heavy meal. Diabetics, particularly those who use insulin, will need special instructions from the physician's office. •Specific heart medicines may need to be stopped one or two days prior to the test. Such instructions are generally provided when the test is scheduled by the doctor's office. Call if you have any questions. •Wear comfortable clothing and shoes that are suitable for exercise. •An explanation of the test is provided and the patient is asked to sign a consent form. A patient should allow approximately two to four hours for the entire test, including the preparation. Dual isotope and technetium stress testing takes less time than thallium. You will be allowed to leave the lab and get a light snack or lunch in cases of thallium stress testing. How safe is an Isotope Treadmill Stress Test? The patient is exposed to a very small amount of radiation and the risk is minimal, if any. The risk of the stress portion of the test is very small and similar to what you would expect from any strenuous form of exercise (jogging in your neighborhood, running up a flight of stairs, etc.). As noted earlier, experienced medical staff is in attendance to manage rare complications like sustained abnormal heart rhythm, unrelieved chest pain or even a heart attack. In such cases, the patient is better off having the problem in the presence of experienced staff, rather than have it happen when they are exercising alone. What is the reliability of an Isotope Stress Test? If a patient is able to achieve the target heart rate and good quality images are obtained, an isotope treadmill stress test is capable of diagnosing important disease in approximately 85% of patients with coronary artery Approximately 10% of patients may have a "false-positive" test (when the result is falsely abnormal in a patient without coronary artery disease). Technical problems can occur when a patient is markedly overweight. Women may have an abnormality in the front portion of the heart because of overlying breast tissue. Some men may demonstrate an inferior wall abnormality because of a prominent diaphragm (muscular partition that separates the chest cavity from the abdomen). Patients who have a left bundle branch block on their EKG may also have a false abnormal test. A chemical or pharmacological stress test combines an intravenous medication) with an imaging technique (isotope imaging or echocardiography) to evaluate the LV. In these cases, the medication serves the purpose of increasing the heart load instead of using exercise. Stress causes normal coronary arteries to dilate, while the blood flow in a blocked coronary artery is reduced. This reduced blood flow may decrease the movement of the affected wall (as seen by echo), or have reduced isotope uptake in a nuclear scan. Agents that are commonly used in pharmacologic stress testing include dipyridamole, dobutamine and Adenosine (Trade name). The imaging portion of the test is identical to that used during Stress Echocardiography or Isotope Stress Testing (depending upon the technique employed) and is performed either in a cardiologists office, a satellite lab or the hospital. An intravenous line is started in the arm, the blood pressure is checked and an EKG recorded. The EKG is also constantly monitored on the screen. If Stress Echo is being performed, an echocardiogram is obtained before and immediately after administration of the stress producing medication. In cases of stress isotope testing, the resting images may be obtained before or approximately two hours after the stress (depending upon the lab and the employed isotope). The stress-producing medication is given intravenously, as per protocol. In cases of dobutamine, drug is given as a continuous drip with a gradual increase in the rate (at three minute intervals). The patient's heart rate accelerates and the isotope is given when 85% of the target heart rate is achieved. In cases of dipyridamole, the medication is usually given over four minutes, through the IV line. A drop in the diastolic (lower number) blood pressure is generally awaited before administration of the isotope. If a patient is able to perform mild exercise, he or she may be asked you to walk on a treadmill for a minute or so after the injection of dipyridamole. A patient should allow approximately two to four hours for the entire test, including the preparation. Dual isotope and technetium stress testing takes less time than thallium. The first part of the test generally takes an hour. The second part takes anywhere from 15 to 30 minutes. Between the two parts of a thallium test, you will be allowed to leave the lab and get a light snack or lunch. The patient is exposed to a very small amount of radiation and the risk is minimal, if any. The risk of the chemical stress portion of the test is very small and similar to what you would expect from any strenuous form of exercise (jogging in your neighborhood, running up a flight of stairs, etc.). As noted earlier, experienced medical staff is in attendance to manage the rare complications like sustained irregular heart beats, unrelieved chest pain or even a heart attack. In such cases, the patient is better off having the problem in the presence of experienced staff, rather than have it happen when they are exercising alone. Also, the stress medicine like Dobutamine can be immediately stopped if there are problems, The effects of dipyridamole (which can occasionally cause nausea or a headache can be reversed by aminophylline (an anti-asthma medication). Please also see the caution about asthma under the "Preparing..." section. Circulation Testing is a generalized term for many tests which help determine the rate, and many other characteristics of the blood flow throughout your entire body. Testing may be required to help diagnose conditions such as PAD, PVD, or many other conditions. Vein Ablation Treatment Endovenous (or vein) ablation is a minimally invasive outpatient treatment for venous insufficiency that is performed using ultrasound guidance. After applying local anesthetic to the skin over the vein, an interventional Cardiologist inserts a thin tube known as a catheter, about the size of a strand of spaghetti, into the abnormal saphenous vein. Through this catheter, laser or radiofrequency energy is applied to the inside of the vein to seal it closed. Reflux within one of the saphenous veins can lead to pooling in its tributaries (branches), causing visible varicose veins to develop and more blood for the surrounding normal veins to send back toward the heart. By closing the abnormal vein, the varicose veins—which are close to the skin—shrink and improve in appearance. In addition, once the diseased vein is closed, the surrounding healthy veins are no longer burdened by the leaking blood flow. Other healthy veins take over to carry blood from the leg, re-establishing normal flow. The treatment takes less than an hour and provides immediate relief of symptoms. Immediate return to normal activity with little or no pain. There may be minor soreness or bruising, which can be treated with over-the-counter pain relievers. No scars or stitches - because the procedure does not require a surgical incision, just a nick in the skin, about the size of a pencil tip. High success rate and low recurrence rate compared to surgery. The success rate ranges for vein ablation ranges from 93-97 percent. Venous insufficiency Risk Factors and Symptoms for Venous Insufficiency The incidence of venous insufficiency rises with age, and is also linked to a family history of varicose veins, a sedentary lifestyle, or to jobs that require people to spend many hours on their feet. Venous insufficiency can also be caused by a partial blockage of the veins, for example by a blood clot (a condition called deep vein thrombosis or DVT). The most common early symptom of venous insufficiency is chronically swollen ankles; the feet and calves may also swell. The swelling can be accompanied by a dull aching, cramping, or feeling of heaviness in the legs and feet that becomes worse after prolonged standing. As the condition progresses, people with venous insufficiency develop brown patches and deteriorating (flaking or hardening) skin around the ankles. If venous insufficiency is not treated, venous ulcers may develop on the lower legs. Doctors use an imaging test called a duplex ultrasound to determine if there is structural damage in the veins. 1626 E. Common St. New Braunfels Texas 78130 PH: 830-620-1272 Fax: 830-620-1274 Email: Administrator@nbcardio.com