Heart Disease (Coronary Artery Disease) (cont.)
Benjamin Wedro, MD, FACEP, FAAEM
Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.
Daniel Lee Kulick, MD, FACC, FSCAI
Dr. Kulick received his undergraduate and medical degrees from the University of Southern California, School of Medicine. He performed his residency in internal medicine at the Harbor-University of California Los Angeles Medical Center and a fellowship in the section of cardiology at the Los Angeles County-University of Southern California Medical Center. He is board certified in Internal Medicine and Cardiology.
Melissa Conrad Stöppler, MD
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
In this Article
- What is heart disease?
- What are the risk factors for heart disease?
- What causes heart disease?
- What are the symptoms of heart disease?
- How is heart disease diagnosed?
- What is the treatment for heart disease?
- What is the prognosis for heart disease?
- Can heart disease be prevented?
- Heart Disease FAQs
- Find a local Cardiologist in your town
How is heart disease diagnosed?
The diagnosis of heart disease begins by taking the patient's history. The health care professional needs to understand the patient's symptoms and this may be difficult. Often, health professionals ask about chest pain, but the patient may deny having pain because they describe their symptoms as pressure or heaviness. As well, words may have different meanings. The patient may describe their discomfort as sharp, meaning intense, while the health care professional may understand that term to mean stabbing. For that reason, it is important for the patient to be allowed to take the time to describe the symptoms in their own words.
The health care professional may ask questions about the quality and quantity of pain, where it is located, and where it might travel. It is important to know about the associated symptoms including shortness of breath, sweating, nausea, vomiting, and indigestion, as well as malaise and fatigue.
The circumstances surrounding the symptoms are also important. Are the symptoms brought on by activity? Do they get better with rest? Since they began, is less activity required to provoke the symptoms? Do the symptoms wake the patient? These are questions that may help decide wither the angina is stable, progressing, or becoming unstable.
- With stable angina, the activity that is required to initiate the symptoms does not fluctuate. For example, a patient may state that their symptoms are brought on by climbing up two flights of stairs or walking one mile.
- Progressive angina would find the patient stating that the symptoms are brought on by less activity than previously.
- In the case of unstable angina, symptoms may arise at rest or wake the patient from sleep.
Risk factors for heart disease will be assessed including high blood pressure, diabetes, cholesterol control, smoking history, and family history.
Physical examination may not necessarily help make the diagnosis of heart disease, but it can help decide whether other underlying medical problems may be the cause of the patient's symptoms.
After the history and physical examination are complete, your health care professional will request more testing if heart disease is considered a potential diagnosis. There are different ways to evaluate the heart anatomy and function; the type and timing of a test needs to be individualized to each patient and their situation.
Most often, the health care professional, perhaps in consultation with a cardiologist, will order the least invasive test possible to determine whether coronary artery disease is present. Although heart catheterization is the gold standard to define the anatomy of the heart and to confirm heart disease diagnosis (either with partial or complete blockage or no blockage), this is an invasive test and not necessarily indicated for many patients.
Electrocardiogram (EKG, ECG)
The heart is an electrical pump and electrodes on the skin can capture and record the impulses generated as electricity travels throughout the heart muscle. Heart muscle that has decreased blood supply conducts electricity differently than normal muscle and these changes can be seen on the EKG.
A normal EKG does not exclude coronary artery disease; it means that there may be narrowing of the coronary arteries that has yet to cause heart muscle damage. An abnormal EKG may be a “normal” variant for a patient and the result has to be interpreted based upon the patient's circumstances.
If possible, an EKG should be compared to previous tracings looking for changes in the electrical conduction patterns.
It would make sense that during exercise, the heart is asked to work harder and if the heart could be monitored and evaluated during that exercise, the test could uncover abnormalities in heart function. That exercise may occur by asking the patient to walk on a treadmill or ride a bicycle while at the same time, an electrocardiogram is being performed. Medications (adenosine, persantine, dobutamine) can be used to stimulate the heart, if the patient cannot exercise because of poor conditioning or because of an underlying medical condition.
Ultrasound examination of the heart to evaluate the anatomy of the heart valves, the muscle, and its function may be performed by a cardiologist. This test may be ordered alone or it may be combined with a stress test to look at heart function during exercise.
A radioactive tracer that is removed from the blood by heart muscle cells can be used to indirectly assess blow flow to the heart. Technetium or thallium can be injected into a vein while a radioactive counter can be used to map out how the blood is distributed within heart muscle cells.
Cardiac computerized tomography (CT)
Using high speed CT scan, the anatomy of the coronary arteries can be evaluated, including how much calcium is present in the artery walls and whether there is blockage or narrowing present.
As mentioned above, this is the gold standard for coronary artery testing. A cardiologist threads a thin tube through an artery in the groin, elbow, and wrist into the coronary arteries. Dye is injected to assess the anatomy and whether blockages are present. If so, it is possible that angioplasty may be performed, where a balloon is inflated to squash an obstructing plaque into the wall of the artery to re-establish blood flow. A stent may be placed to keep the artery from narrowing again.
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