Understanding the heart stress test

By Dr Pankaj Kshatriya, MD (Internal Medicine Specialist)


This week we will conclude our three-part series on heart disease. Over the last two weeks we have looked at the features, causes, diagnosis, management and prevention of heart attacks. This week we will look at a simple physical test that can tell us a lot about the health of your heart. This involves finding out how your heart deals with vigorous exercise. The exercise stress test is sometimes called the treadmill test, and it shows if the blood supply is reduced in the heart arteries. It also helps to know the kind and level of exercise suitable for patients.

The exercise test is recommended for use in women 50 years and older and in men 40 years and older. What do you mean by heart stress test?

A stress test is a procedure for assessing the effect of stress on the heart function and the blood supply. Stress may be induced by physical exercise or by the administration of a drug. During exercise healthy arteries dilate more than those with blockages. Narrowed arteries provide less blood and less oxygen to certain areas of the heart.

The lack of oxygen can cause symptoms such as chest pain or shortness of breath. An electrocardiogram done during the stress test shows any abnormality that helps your doctor to determine where the blocked arteries are.




What types of stress test are there?

There are many ways to stress the heart. This test can be performed by a treadmill known as the treadmill stress test or by some specific medications known as the pharmacological stress test.

What is a treadmill stress test?

A treadmill stress test involves stressing the heart by having the patient exercise on a treadmill. By using different grades of evaluation and speeds at regular time intervals, the heart rate is monitored. The higher the heart rate and blood pressure during stress, the more stress is applied to the heart.

Why do you need a stress test?

When you do an exercise stress test, your body works harder during the test. It requires more fuel and your heart has to pump more blood. The test can show if there is a lack of blood supply to the heart arteries. A stress test also helps the doctor to know the kind and level of exercise you need.

How do you prepare for the test?

Do not eat, smoke, drink beverages containing caffeine or alcohol for three hours before the test; continue all medication unless instructed otherwise. Wear comfortable shoes and loose clothing to permit exercise.

What happens during the test?

Certain leads known as cardiac chest leads are attached to your chest to monitor your heart.

Your heart beat, rate and blood pressure in lying down and standing positions are checked.

You walk slowly on the treadmill.

It tilts so you feel as if you are going up a small hill.

It changes speed to make you walk faster.

You can stop the test at any time if you need.

After slowing down for brief intervals you will sit or lie down and your heart rate and blood pressure will be checked.

What is monitored during the test?

Heart rate

Breathing

Blood pressure.

Heart activities (electrocardiogram).

How tired you feel.

What equipment is used?

The electrocardiography machine will record your heart beat and heart waves in an electrocardiogram. Tiny wires and electrodes are attached to your chest, through which your heart is connected to a monitor which records your heart waves.

Is there any risk during test?

There is very little risk - no more than if you walked fast or jogged up a big hill. If you have an arterial blockage in the heart you might develop chest pain during the test. This is a sign that your heart is not getting enough oxygen.

What do you do if you get any

symptoms during test?

If you get any symptoms like pain in the upper part of the body, sweating, head swinging, difficulty in breathing or heaviness, or tightness in chest during the test, it is important to alert the medical staff immediately.

Why is an exercise stress test required?

To diagnose heart disease

To diagnose chest pain related to the heart

To diagnose any chest discomfort (tightness/heaviness)

To diagnose shortness of breath related to the heart

To determine a safe level of exercise

To predict the risk of dangerous heart-related conditions such as a heart attack

To evaluate exercise tolerance when a person has unexplained fatigue or shortness of breath

To evaluate the blood pressure response to exercise in a person with borderline hypertension

To look for exercise induced serious irregular heartbeats.

To check the condition of the arteries which supply blood to heart muscles after angioplasty and by-pass surgery.

The result of a stress test will help your doctor decide if you have heart artery blockage or not, and if so, how severe it is.

What are the warning signs of a heart attack?

Chest pain

Chest discomfort

Tightness of chest or heaviness of chest

Discomfort in other areas of upper body

Shortness of breath with or without chest pain

Cold sweat, nausea, uneasiness, especially in a diabetic case

Sudden extreme fatigue (not associated with lack of sleep)

A heart lost is a life lost. Get to a hospital immediately if you experience signs of a heart attack or stroke.

What happens after a heart stress test?

Your doctor will decide what to do if your stress test is positive. Whether you need medications or further tests like a coronary angiogram all depends on the severity of abnormalities on the stress test.

In conclusion, a stress test is an important diagnostic aid to evaluate problems related to the proper functioning of your heart, and may make all the difference when you are being managed on medical treatment, where surgery would have been the logical course of events.
Read more on this article...

Heart attack Are you a ticking time bomb?

By Dr Ritesh Kohli, MD (Physician)

Introduction
A heart attack is an injury to the heart muscle caused by a loss of blood supply. It usually occurs when a blood clot blocks the flow of blood through a coronary artery - a blood vessel that feeds blood to a part of the heart muscle. Interrupted blood flow to your heart can damage or destroy a part of the heart muscle. Signs and symptoms

Heart attacks have many variable signs and symptoms. Not all people who have heart attacks experience the same ones or experience them to the same degree.

Warning signs and symptoms of a heart attack include:

Pressure, fullness or a squeezing pain in the centre of your chest that lasts for more than a few minutes

Pain extending beyond your chest to your shoulder, arm, back, or even to your teeth and jaw

Increasing episodes of chest pain

Prolonged pain in the upper abdomen

Shortness of breath

Sweating

Impending sense of doom

Lightheadedness

Fainting

Nausea and vomiting

Causes

The factors that increase the risk of a heart attack include:

Men over 45 and women over 55

Smoking

Being overweight or obese

High blood pressure

A high blood cholesterol level

A diet high in saturated fats (animal fats)

Diabetes

A family history of heart disease

Lack of regular exercise

When to seek medical advice

During a heart attack, some people waste precious minutes because they don't recognize the important signs and symptoms - or they deny them. Some people also delay calling for help because they're afraid to risk the embarrassment of a false alarm. Of the people who die of heart attacks, about half die within the first hour after the onset of signs and symptoms.

Don't 'tough out' the symptoms of a heart attack for more than five minutes. Call emergency medical services for help. If you don't have access to emergency medical services, have someone such as a neighbour or friend drive you to the nearest hospital.

If it turns out you weren't having a heart attack, doctors may be able to pinpoint the cause of your signs and symptoms and treat them.

Screening and diagnosis

Ideally, your doctor should screen you during regular physical exams for risk factors that can lead to a heart attack.

Electrocardiogram (ECG)

This is often the first test done to diagnose a heart attack. This test records the electrical activity of your heart via electrodes attached to your skin.

Blood tests

Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Emergency room doctors may take samples of your blood to test for the presence of these enzymes.

Additional tests

If you've had a heart attack or one is occurring, doctors will take immediate steps to treat your condition. You may also undergo these additional tests:

Chest X-ray: An X-ray image of your chest allows your doctor to check the size and shape of your heart and its blood vessels.

Nuclear scan: This test helps identify blood flow problems to your heart. Trace amounts of radioactive material, such as thallium, are injected into your bloodstream. Areas of reduced blood flow to the heart muscle - through which less of the radioactive material flows - appear as dark spots on the scan.

Echocardiogram: This test uses sound waves to produce an image of your heart. An echocardiogram can help identify whether an area of your heart has been damaged by a heart attack and isn't pumping normally or at peak capacity.

Coronary catheterization (angiogram): This test can show if your coronary arteries are narrowed or blocked. A liquid dye is injected into the arteries of your heart through a long, thin tube (catheter) that's fed through an artery, usually in your leg, to arteries in your heart. As the dye fills your arteries, the arteries become visible on X-ray and videotape, revealing areas of blockage.

In the days or weeks following your heart attack, you may also undergo a stress test. Stress tests measure how your heart and blood vessels respond to exertion. You may walk on a treadmill or pedal a stationary bike while attached to an ECG machine. Or you may receive a drug intravenously that stimulates your heart similar to exercise. Stress tests help doctors diagnose coronary artery disease, which can cause chest pain and may underlie a recent or future heart attack.

Treatment

During a heart attack, act immediately.

Call for emergency medical help. If you even suspect you're having a heart attack, don't hesitate. Immediately call your local emergency number.

A heart attack is a medical emergency which demands both immediate attention and activation of the emergency medical services. The ultimate goal of the management in the acute phase of the disease is to salvage as much heart muscle as possible and prevent further complications.

First line

Oxygen, aspirin, glyceryl trinitate (nitroglycerin) and analgesia (usually morphine, are administered as soon as possible. In many areas, first responders can be trained to administer these prior to arrival at the hospital.

Once the diagnosis of myocardial infarction is confirmed, other pharmacologic agents are often given. These include beta blockers, anticoagulation (typically with heparin, and possibly additional antiplatelet agents such as clopidogrel. These agents are typically not started until the patient is evaluated by an emergency room physician or under the direction of a cardiologist.

Surgical and other procedures

In addition to medications, you may undergo one of the following procedures to treat your heart attack:

Coronary angioplasty: Emergency angioplasty opens blocked coronary arteries, letting blood flow more freely to your heart. Doctors insert a long, thin tube (catheter) that's passed through an artery, usually in your leg, to a blocked artery in your heart. At the same time, a metal mesh stent may be inserted into the artery to keep it open long term, restoring blood flow to the heart. When getting an angioplasty for heart attack treatment, studies have shown the sooner the better.

Coronary artery bypass surgery: In rare cases, doctors may perform emergency bypass surgery at the time of a heart attack. Bypass surgery involves sewing veins or arteries in place at a site beyond a blocked or narrowed coronary artery (bypassing the narrowed section), restoring blood flow to the heart.

Next week, we will discuss lifestyle modifications that should be followed to reduce the incidence of heart attacks.
Read more on this article...

Is a clean-out of the womb (D&C) necessary?

By Dr Madhu Pandey Singh, MD (Obstetrics and Gynaecology)

The D&C (Dilatation and Curettage) is a small surgical procedure and perhaps one of the most misused. It literally entails opening the mouth of the womb to allow instruments into the uterus to scrape the contents of the uterus.

It is a procedure that may be done in a hospital using general anaesthesia or in a clinic using local anaesthesia, and is fairly minor.

Contrary to popular belief the uses of a D&C are quite specific, and it is not a cure for all female complaintsIt is useful for the following:

1. To diagnose conditions of the lining of the womb

2. To treat heavy bleeding. In this case, the material removed should be sent for a histopathology examination to the laboratory and at the end of it a pathology report must be provided for the patient.

3. To remove the products of pregnancy for an abortion or after a miscarriage.

A D&C may, therefore, be recommended for:

1. Heavy menstrual bleeding

2. An investigation of infertility

3. The diagnosis of cancer of the womb

4. An embedded Intra-Uterine Contraception Device (the Loop or the Copper-T, com monly called a 'five-years' stop').

5. An abortion

6. A miscarriage

7. Bleeding after menopause or abnormal bleeding while taking hormone replacement for diagnosis of the underlying problem

In all of the above except 4, 5 and 6, a pathology examination should be carried out on the material removed, and a report should be made available to the patient.

The risks from undergoing a D&C are:

- Risks due to anaesthesia

- A reaction to medication

- Risks from bleeding and infection

- Risks due t perforation of the uterus. This may occur because it is a blind procedure

and the womb may get injured.

- Scarring of the lining (endometrium)

Scarring of the lining of the womb

This occurs particularly when over zealous curettage or scraping of the lining is done, and this scarring may be severe enough to cause the patient to stop menstruating, as the lining of the womb is the tissue that is shed during a menstrual cycle and passes out as menstruation.

Scarring may cause severe pain and an inability to conceive.

Even if the scarring is minor and not severe enough to prevent the woman from seeing her periods or from conceiving, it can still cause the afterbirth of a pregnancy to be implanted at abnormal sites.

Myths and Unrealistic expectations from a D&C

In Guyana, women refer to it as a "clean-out" and believe that the womb needs to be cleaned out periodically by a doctor.

- They need to be reassured that the womb gets a monthly clean-out when the lining sheds with a period, and does not need to be physically cleaned out by undergoing a D&C.

- There is no need to have a D&C after the removal of an IUCD. It does not help in any way.

- With heavy periods, a D&C may help to reduce the flow for one or two cycles only,

and then the flow will once again be heavy, if medications such as hormones are not started, and a D&C is rarely needed for this purpose.

- A D&C does not by itself help any woman to conceive. The only use of a D&C in infer tility is to diagnose hormone problems, and if a D&C is performed on a patient trying to conceive, a histopathology report must be given to the patient detailing the findings.

- Patients with irregular bleeding due to underlying hormone imbalances do not benefit from a D&C as far as regulating their cycles is concerned.

Recovery from a D&C

Normally a patient can resume day-to-day activities the same day. They may have slight vaginal bleeding or cramps for a few days. Pain medication may be used. Tampon use and sexual intercourse is not recommended for a few days.

To summarize, the reasons to perform a D&C are very specific. Although it is a small procedure, the patient may end up with severe problems. The patient should have a clear picture of why this procedure is being recommended to her, and last but not least, except for abortions and miscarriages, the tissue removed must be sent for histopathology and a report from the laboratory should be provided to the patient.

In other words, if a clean-out is done, the scraping should not be discarded as it provides valuable material for diagnosis of what may be the patient's problem.

A D&C like any other surgical procedure should not be taken lightly and the patient before agreeing to the procedure must ask the care provider the following questions:

1. What is the reason for the D&C?

2. Is there a medical alternative such as hormones?

3. What are the long-term risks and benefits?

4. Is it going to aid in the diagnosis of the problem?

5. Will there be a histopathology report for the material removed?

Once the above questions are answered satisfactorily, the patient can be reasonably assured that the procedure is needed and/or will benefit her health.
Read more on this article...