Coronary Artery Disease

content developed with: http://www.clevelandclinic.org/

An important aspect of diagnosing and treating heart disease is the physical exam. This exam helps your doctor determine what type of follow-up tests or procedures are necessary to fully diagnose your condition. These additional tests fall into the following categories:

  • Electrocardiographic tests evaluate the heart's electrical activity when the patient is at rest and active.
  • Laboratory tests include a number of blood tests used to diagnose and monitor treatment for heart disease.
  • Nuclear imaging produces images that measure the radiation emanating from different parts of the body after the patient has received an injection of a radioactive tracer material.
  • Ultrasound uses high-frequency sound waves to create graphic images of the heart's individual structures, its pumping action, and the direction of its blood flow.
  • Radiological imaging uses X-ray machines, computed tomography (CT), or magnetic resonance imaging (MRI) to photograph the internal structures of the chest.
  • Invasive tests involve inserting catheters into the blood vessels of the heart to get a closer look at the coronary arteries or to stimulate and test the electrical system of the heart.
  • Electrocardiographic tests

    These noninvasive tests use a device called an electrocardiogram to evaluate the heart's electrical activity.

    In our section on electrocardiograph tests you will find:

    • Ambulatory monitors
    • Electrocardiogram (EKG)
    • Exercise stress test (stress test, exercise electrocardiogram, treadmill test, graded exercise test, stress EKG)
    • Head upright tilt test (HUT, tilt table test, head-up tilt test)
    • Metabolic exercise stress test
    • Ambulatory monitors

      Ambulatory monitors are small, portable electrocardiograph machines that record the heart's rhythm. Each type has unique features related to length of recording time and ability to send recordings over the phone. The various types include a Holter monitor, loop monitor, and transtelephonic transmitter.

      Your doctor uses ambulatory monitors to:

      • Assess your heart rhythm over time
      • Correlate your symptoms with your heart rhythm
      • Diagnose abnormal heart rhythms: what kind they are, how long they last, and what may cause them
      • Guide treatment for abnormal heart rhythms
      • Holter monitor (also called ambulatory EKG): This device is a portable EKG recorder that you wear during your normal daily activities, including sleeping. It can be worn for one to three days.

        Small sticky electrode patches are placed on the skin of your chest. Wires are attached from the electrodes to a box about the size of a portable tape player that is worn on a belt or shoulder strap. The monitor continuously records and stores the heart's electrical impulses.

        While wearing the monitor, you will be asked to keep a diary of your activities and symptoms, such as fluttering feelings in your chest (palpitations), rapid heartbeats, and episodes of dizziness or faintness. Keeping track of the activities you were doing when your symptoms occurred is important, so your doctor can see what kinds of events are bringing on your symptoms.

        When you complete your Holter monitor test, a technician will play the tape on a computer that analyzes the recording and detects the appearance of any rhythmic abnormalities. The technician prepares a report with a printout of any abnormal heart rhythms for the doctor to study.

        Loop recorder (event recorder): This device is worn 24 hours a day except when showering or bathing. This monitor is worn for about a month and is used for patients who have less frequent arrhythmia episodes and symptoms.

        The technologist attaches small electrodes to your chest and attaches wires from the electrodes to a box about the size of a portable tape player. Like the Holter, the loop recorder can hook to your belt or shoulder strap.

        Whenever you feel symptoms, you depress a button. The monitor stores its recording of the event for the 60 seconds before your pushing the button and up to 40 seconds after the event is over. The loop recorder can store up to three events.

        The recording of the rhythm can be transmitted later over the phone lines. The technician will give the recordings to your doctor for review. If the reading indicates an emergency, the technician will instruct you to go to an emergency room.

        Transtelephonic transmitters: This device is not worn continuously. It is used only during the period when data picked up by the device are transmitted over the phone for evaluation by a physician. In the past, this type of transmitter was used for monitoring pacemaker function. However, now it also is used for patients with arrhythmias. It is particularly useful for evaluating symptoms that occur rarely, so usually are not evident during an office visit.

        When you develop symptoms, a strip of your current heart rhythm can be transmitted to your doctor's office over the phone using a monitor with two bracelets or by placing the monitor against your chest wall.

        Electrocardiogram

        Electrocardiogram (EKG): This test records the electrical activity of the heart onto graph paper.

        Your doctor uses the test to:

        • Assess your heart rhythm
        • Diagnose poor blood flow to the heart muscle (ischemia)
        • Diagnose a heart attack
        • Diagnose abnormalities of your heart, such as heart chamber enlargement and abnormal electrical conduction
        • What to expect: During a resting EKG, a technician will attach 10 electrodes with adhesive pads to the skin of your chest, arms, and legs. Men may have chest hair shaved to allow a better connection. You will lie flat during the test. It takes about 10 minutes to attach the electrodes and complete the test; the actual recording takes a few seconds.

          Your EKG patterns will be kept on file for comparison with future ECG recordings.

          Exercise stress test

          Exercise stress test (stress test, exercise electrocardiogram, treadmill test, graded exercise test, stress EKG): This test reveals how the heart responds to stress. It usually involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while heart rate, blood pressure, and your heart's electrical activity are monitored.

          Your doctor uses the test to:

        • Determine if there is adequate blood flow to your heart during increasing levels of activity
        • Evaluate the effectiveness of your cardiac treatment plan
        • Determine the likelihood of your having coronary artery disease and gauge the need for additional testing.
        • Identify abnormal heart rhythms.
        • Help you develop a safe exercise program.
        • To prepare:

          • Do not eat or drink anything except water for four hours before the test.
          • Ask your doctor what medications should be taken on the day of your test. If you use an inhaler for breathing, bring it to the test. If you are diabetic, ask your physician how to adjust your medications the day of your test.
          • Wear comfortable clothes and soft-soled shoes suitable for walking. Women should wear a bra.
          • What to expect: Small, sticky electrode patches are attached to 10 areas of your chest. Men may expect to have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor that will chart your heart's electrical activity during the test.

            You will begin to exercise by walking on a treadmill or pedaling a stationary cycle. The degree of difficulty will gradually increase until you are exercising very hard. At regular intervals, the lab personnel will ask how you feel. Be sure to tell them if you feel chest, arm, or jaw pain; shortness of breath; dizziness; or any other unusual symptoms. It is normal for your heart rate, blood pressure, and breathing rate to increase during the test, as well as the amount you perspire. In addition, the lab personnel will watch for any symptoms or changes on the EKG monitor suggesting the test should be stopped.

            After the test you will walk or pedal slowly for a couple of minutes to cool down. Your heart rate, blood pressure, and EKG will continue to be monitored until readings begin returning to normal.

            The appointment lasts about 60 minutes; the actual exercise time is usually between seven and 12 minutes.

            Head upright tilt test

            Head upright tilt test (HUT, tilt table test, head-up tilt test): This test is used to determine the cause of fainting spells and syncope (temporary and brief loss of consciousness resulting from a sudden fall in blood pressure). The test involves being tilted, always with the head up, at different angles for a period of time (two minutes at 30 degrees, then two minutes at 45 degrees, then up to 45 minutes at 70 degrees). Heart rhythm, blood pressure, and other symptoms are closely monitored and evaluated with changes in position.

            Your doctor uses the test to:

            • Determine the cause of fainting spells.
            • Evaluate heart rhythm, blood pressure, symptoms, and sometimes other measurements with change of position.
            • To prepare:

              • Do not eat or drink anything except water for four hours before your test. If you must take medications, drink small sips of water to help you swallow your pills.
              • Take all your medications as prescribed. If you have diabetes, check with your doctor about how to adjust your diabetic medications.
              • Wear comfortable clothes. You may be asked to wear a hospital gown during the procedure. It is best not to wear any jewelry or bring valuables.
              • Most likely, you will be able to go home after the test. You should bring someone with you to drive you home after the test.
              • What to expect:

                Before the test you will be asked to lie on a motorized bed that can be tilted to different degrees, as described above. Your feet will rest against a metal plate for support when you are tilted upright. The nurse will start an intravenous (IV) line in your arm to give you medications and fluids during the procedure, and, if necessary, to treat your symptoms and/or blood pressure and heart rate changes. The nurse will connect you to several monitors (for monitoring your heart's electrical activity, your blood pressure, and sometimes respiration and the level of oxygen in your blood). For your safety, soft straps will be secured across your body before the test begins.

                While you lie quietly with your legs still, the bed will be tilted at different angles. Although you may feel no symptoms at all, you should be sure to report any feelings of lightheadedness, nausea, or dizziness, any palpitations (fluttering in the chest) or blurred vision. The HUT lasts about one hour and 15 minutes.

                At the end of the test, the findings may indicate you need the test repeated or that you will need further tests. If a repeat tilt test is performed, it will be given with up to three segments, each with a supine (flat) and a 70-degree portion. Your doctor may give you a medication called isoproterenol, which causes your heart to respond as if you were exercising. It may make you feel nervous, jittery, or that your heart is beating faster or stronger. This feeling will go away as the medication wears off.

                Metabolic exercise stress test

                Metabolic exercise stress test (metabolic stress test): This test measures the performance of the heart and lungs while they are under physical stress. It involves walking on a treadmill or pedaling a stationary bike at increasing levels of difficulty, while being closely monitored and breathing through a mouthpiece and/or facemask.

                Your doctor uses the test to:

                • Determine how fit your heart and lungs are
                • Determine if symptoms of shortness of breath or chronic fatigue are due to a medical problem (such as heart or lung disease) or due to poor fitness
                • Measure your heart's ability to do work
                • Determine if certain surgical treatments are appropriate for you
                • Evaluate the effectiveness of your cardiac treatment plan
                • Help you develop a safe and effective exercise program
                • To prepare:

                  • Do not eat or drink anything except water for four hours before the test.
                  • Do not drink or eat caffeine products (cola, Mountain Dew, chocolate, coffee or tea) for 24 hours before the test. Caffeine may interfere with the results of your test. Be sure to check the labels of over-the-counter products or medications for caffeine content.
                  • Do not smoke on the day of the test.
                  • Ask your doctor what medications should be taken on the day of your test. Some heart medications should not be taken—ask your doctor for specific guidelines. If you use an inhaler for breathing, bring it to the test. If you are have diabetes, ask your physician how to adjust your medications the day of your test.
                  • Wear comfortable clothes and soft-soled shoes suitable for walking. Women should wear a bra.
                  • What to expect:

                    A technician will attach small, sticky electrode patches to 10 areas of your chest. Men may expect to have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test.

                    Before you start exercising, the technician will perform a resting EKG, measure your heart rate and take your blood pressure. You also will be asked to breathe through a mouthpiece and/or face mask for a few minutes before the test begins and throughout your test. A clip will be placed on your nose so you breathe only through your mouth.

                    You will begin to exercise by walking on a treadmill or pedaling a stationary cycle. The degree of difficulty will gradually increase until you are exercising very hard. Your blood pressure, heart rate, EKG, and other breathing measurements will be taken throughout the test.

                    At regular intervals, the technician will ask how you feel. Since you will be unable to talk with the mouthpiece or mask in place, they will ask you questions that can be answered by nodding "yes" or shaking "no." Be sure to tell them if you feel chest, arm, or jaw pain; shortness of breath; dizziness; lightheadedness; or any other unusual symptoms. It is normal for your heart rate, blood pressure, and breathing rate to increase during the test, as well as the amount you perspire. You may also have a dry mouth from breathing through the mouthpiece. The lab personnel will watch for any symptoms or changes on the EKG monitor that suggest the test should be stopped.

                    After the test you will walk or pedal slowly for a couple of minutes to cool down. Your heart rate, blood pressure, and EKG will continue to be monitored until the readings begin returning to normal. The appointment will last about one hour and 15 minutes; actual exercise time is usually between five and 12 minutes.

                    Laboratory

                    Various blood tests help determine whether you have coronary artery disease or are at risk for developing it.

                    Lab values listed in the following sections are those for the Cleveland Clinic Foundation Laboratory. Abnormal test results do not always indicate disease. You should discuss all blood test results with your doctor.

                    In this section on laboratory tests you will find:

                  • Lipid blood tests
                  • Blood tests to determine risk of coronary artery disease
                  • Blood sugar tests
                  • Electrolyte tests
                  • Enzyme and proteins tests
                  • Blood tests for those taking blood thinners
                  • Lipid blood tests

                    Lipid blood tests measure the amounts of various fat or fat-related substances in the blood.

                    Total cholesterol (TC): Directly linked to risk of heart and blood vessel disease. Cholesterol is a fatty molecule in the blood that is produced by the liver and consumed in animal products. Your body needs cholesterol to maintain the health of your cells. But too much leads to coronary artery disease.

                    Target values:

                    • 75-169 milligrams per deciliter (mg/dL) for those age 20 and younger
                    • 100-199 mg/dL for those over age 21
                    • To prepare: This test may be measured any time of the day without fasting. However, if the test is drawn as part of a total lipid profile, it is best to have no food or drink except water for 12 hours before the tests. For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                      High-density lipoprotein (HDL): High blood levels of this fatty molecule, known as the "good" cholesterol, are usually linked to a reduced risk of heart and blood vessel disease. Many researchers believe HDL is "good" because it removes excess cholesterol from the blood.

                      Target value: Greater than 45 mg/dL, but the higher your HDL, the better

                      To prepare: This test may be measured any time of the day without fasting. However, if the test is drawn as part of a total lipid profile, it is best to have no food or drink except water for 12 hours before the tests. For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                      Low-density lipoprotein (LDL): High blood levels of this fatty molecule, known as the "bad cholesterol," are linked to an increased risk of cardiovascular disease, including coronary artery disease, heart attack, and death. Reducing LDL has become a major treatment target for cholesterol-lowering medications.

                      Target values:

                      • Less than 70 mg/dL for those with heart or blood vessel disease and for other patients at very high risk of heart disease
                      • Less than 100 mg/dL for high-risk patients (for example: some patients who have multiple risk factors for heart disease)
                      • Less than 130 mg/dL for individuals who are at low risk for coronary artery disease
                      • To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                        Triglycerides (TG): High blood levels of triglycerides are associated with heart and blood-vessel disease. The blood level of this type of fat is mostly affected by alcohol and foods such as sugar and fat. Other causes of a high TG level can be obesity and thyroid or liver disease.

                        Target value: Less than 150 mg/dl

                        To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                        Blood tests to determine your risk of CAD

                        These blood tests help to determine your risk for coronary artery disease and guide your treatment.

                        Lipoprotein a (Lp[a]): Researchers do not yet know all the functions of Lp(a), but if a patient's level is greater than 30 mg/dl he or she has a greater risk of suffering a heart attack or stroke. An elevated level of Lp(a) also is linked to the development of fatty matter vein grafts after bypass surgery, to coronary artery narrowing after angioplasty, and to the development of blood clots.

                        Target value: Less than 30 mg/dL

                        To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                        Apolipoprotein A1 (Apo A1): Apo A1 is the major protein of HDL. Low levels are associated with an increased risk of early heart and blood vessel disease, and are more common among people who eat a high-fat diet, have central obesity, and are inactive.

                        Target value: More than 123 mg/dL

                        To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                        Apolipoprotein B (ApoB): This protein is found in cholesterol particles. Recent research suggests ApoB may be a better overall marker of risk than LDL alone.

                        Target value: Less than 100 mg/dL for individuals at low or intermediate risk, and less than 80 mg/dL for high-risk individuals, such as those with known cardiovascular disease or diabetes. 

                        To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                        Fibrinogen: This blood protein is necessary for clotting. High levels may be an independent risk factor for cardiovascular disease. Higher blood pressure, excess body weight, elevated blood levels of LDL, diabetes, and advancing age are linked to higher levels of fibrinogen. Alcohol use and exercise are related to lower fibrinogen levels.

                        Target value: Less than 300 mg/dL

                        To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy.

                        High Sensitivity C-reactive protein (hs-CRP): The presence of this protein in the blood indicates a heightened state of inflammation in the body. Inflammation is the body's normal response to physical problems such as fever, injury, and infection. In addition, studies show that elevated CRP correlates with increased risk for heart attack, stroke, peripheral vascular disease, and reclosing of coronary arteries after angioplasty.

                        There are data to suggest that statin therapy for patients with elevated hsCRP and normal LDL levels can reduce the risk of cardiovascular disease, stroke, and death. Testing for hsCRP may not be appropriate for all patients, particularly those at intermediate risk due to presence of risk factors other than elevated cholesterol. Discuss the value of testing with your treating physician.

                        Target values:

                        • Less than 1.0 mg/L—low risk for heart and blood vessel disease
                        • 1.0-2.9 mg/L—intermediate risk for heart and blood vessel disease
                        • Greater than 3.0 mg/L—high risk for heart and blood vessel disease
                        • To prepare: Blood can be drawn for this test any time of the day without fasting. This blood test should not be done in individuals who have had an illness or infection, especially if they have had a fever.

                          Myeloperoxidase (MPO): High levels of myeloperoxidase are associated with an increased risk of a major adverse cardiac event such as heart attack, need for revascularization, and development of cardiac death. A marker of vascular inflammation and vulnerable plaque, elevated levels of MPO are associated with an increased risk of these events in people without known heart disease, those with complaints of chest pain, and those with known heart disease or multiple traditional risk factors. Elevated levels of MPO suggest the need for increased global preventive risk reduction efforts, including closer attention to reducing LDL levels, diet and exercise, and low-dose aspirin therapy if not contraindicated.

                          Target value: Less than 400 pM

                          To prepare: This test may be measured any time of the day without fasting. For the most accurate results, an EDTA plasma sample is recommended.

                          N-terminal-pro-B-type natiuretic peptide (NT-proBNP): High levels of NT-proBNP are associated with both an increased risk of cardiovascular disease and its complications (heart attack and development of heart failure), as well as increased strain on the heart.

                          Target value: Less than 125 pg/ml

                          To prepare: This test may be measured any time of the day without fasting.

                          LDL-associated PLA2 (PLAC): The PLAC test is a blood test that measures the level of lipoprotein-associated phospholipase A2 (Lp-PLA2), an enzyme associated with vascular inflammation, as well as the risk of stroke and heart attack elevated levels are associated with increased cardiac risks; however the increases may also be due to inflammation that is not arterial in nature.

                          Target values:

                          • <200 ng/mL—Normal value/low relative risk of cardiovascular disease
                          • 200-235 ng/mL—Intermediate relative risk of cardiovascular disease
                          • >235 ng/mL—High relative risk of cardiovascular disease
                          • To prepare: Blood should be collected after a 12-hour fast (no food or drink except water). For the most accurate results, wait at least two months after a heart attack, surgery, infection, injury, or pregnancy before testing.

                            Urine Albumin/Creatinine ratio (Ualb/Cr): Trace levels of albumin, a protein, in the urine can be a sign of an increased risk of kidney disease, complications from diabetes, and cardiovascular risks. If the Ualb/Cr ratio is elevated, it warrants close monitoring and control of blood pressure, including the possible use of specific types of blood pressure medications that help protect the kidneys. Aggressive global preventive risk reduction efforts, including closer attention to lipid levels, blood pressure control, and diabetes control (if relevant) are recommended.

                            Target values:

                            • >30 mg/g indicates an increased risk of cardiovascular disease and diabetic nephropathy
                            • Levels greater than 300 mg/g are consistent with clinical nephropathy
                            • To prepare: Requires a clean-catch spot urine sample done any time of the day without fasting.

                              Blood sugar tests

                              Hemoglobin A1C (HgbA1c): This lab test provides an overall "dosimeter" of glucose control for the lifespan of the red blood cell (90 days). Elevated levels indicate prediabetes and diabetes. Patients with diabetes are considered to have a "coronary artery disease risk equivalent."  This means they have an increased risk of having a cardiac event, and that a diabetic's risk of having a heart attack is the same as a nondiabetic who has already had a heart attack. Aggressive global preventive risk reduction efforts, including lower LDL goals, diet, exercise, and close attention to blood pressure, are recommended.

                              Target values: The American Diabetes Association guidelines indicate that patients with HgbA1c levels between 5.7%-6.4% are at increased risk of developing diabetes (i.e. are prediabetic), and lifestyle changes may be beneficial. HgbA1c levels greater or equal to 6.5% indicate diabetes.

                              To prepare: Blood can be collected any time without fasting.

                              Fasting Glucose (Gluc): This lab test indicates the level of sugar in the blood. Elevated levels indicate diabetes or conditions associated with "insulated resistance," in which the body doesn't handle sugar well (especially with obesity).

                              Target values:

                              • <100 mg/dL—normal
                              • 100-125 mg/dL—impaired fasting glucose (also considered “prediabetes”). Patients in this range are at increased risk of developing diabetes, and intervention by lifestyle modification may be beneficial.
                              • >125 mg/dL—If two or more fasting samples indicate levels in this range, the patient is considered to be diabetic.
                              • To prepare: Blood should be collected after a 12-hour fast (no food or drink, except water).

                                Electrolyte tests

                                These substances help regulate the proper balance of body fluids. Electrolyte abnormalities help reveal kidney, heart, and liver disease. Certain medications (such as diuretics and some heart pills) also can lead to abnormalities.

                                Sodium:

                                Normal range:
                                Male: 135-146 millimoles per liter (mmol/L)
                                Female: 132-148 mmol/L Magnesium:

                                Normal range:
                                Adult: 1.6-2.4 milligrams per deciliter (mg/dL) Potassium:

                                Normal range:
                                Adult: 3.5-5.0 mmol/L Enzymes and proteins

                                These blood tests detect cell damage.

                                Alanine aminotransferase (ALT, SGPT): This enzyme is measured to detect lever damage and hepatitis. Some medications, including statins to lower lipid levels, may elevate the ALT, which needs regular monitoring.

                                Target value: 5-50 units per liter (U/L)

                                To prepare: Blood may be drawn for this test any time of the day, without fasting.

                                Aspartate aminotransferase (AST; also called SGOT): This enzyme is released into the bloodstream following injury or death of cells. Increased AST is seen with liver disease, myocardial infarction, or heart attack and with the use of some medications, such as statins that reduce lipid levels. Like ALT, AST needs regular monitoring.

                                Target value: 7-40 U/L

                                To prepare: Blood may be drawn for this test any time of the day, without fasting.

                                Creatinine (Cr): Creatinine becomes elevated with illness, kidney disease, muscle injury, and with the use of some medications.

                                Target value: 0.7-1.4 mg/dl

                                To prepare: Blood may be drawn for this test any time of the day, without fasting.

                                Creatine kinase (CK): This enzyme rises when the heart or skeletal muscles are injured. Strenuous exercise, weightlifting, surgical procedures, and high doses of aspirin and other medications may cause elevated levels.

                                Target value: 30-220 U/L.

                                Some laboratories report the CK as percentages with CK-MD as one CK type; for example, CKBB: 0%; CKMB: 0-4%; CKMM: 96-100%

                                To prepare: Blood may be drawn for this test any time of the day, without fasting.

                                Lactate dehydrogenase (LDH): This enzyme is released in the blood with cell injury. It is often used as a marker to detect a heart attack. It is also elevated with liver and kidney disease, pernicious and megaloblastic anemias, malignancy, progressive muscular dystrophy, and pulmonary emboli.

                                Target value: 100-220 U/L

                                To prepare: Blood for this test may be drawn any time of the day, without fasting.

                                Myoglobin (Mb): This protein is found in certain types of muscles. Elevated myoglobin may indicate muscle injury or inflammation.

                                Target value: 30-90 nanograms per milliliter (ng/mL)

                                To prepare: This test may be measured any time of the day without fasting. Vigorous exercise right before the test may raise myoglobin levels.

                                Troponin T (cTNT): This blood protein is related to the heart muscle's ability to contract. For people experiencing chest pain or discomfort, its level may reveal acute damage to the heart muscle and impending risk of myocardial infarction.

                                Target value: 0.0-0.10 ng/mL

                                To prepare: Blood may be drawn for this test any time of day, without fasting.

                                Blood tests for those taking anticoagulants

                                When taking an anticoagulant, it is important to have your blood tested regularly to ensure you are taking your medications safely and are not at increased risk for bleeding.

                                Prothrombin time (PT): PT is a test to determine how fast it takes for your blood to clot. Usually when taking a "blood thinner," such as warfarin (Coumadin), the desired PT is about 1 1/2 times normal. When checking PT, your doctor will receive the results and let you know if you are taking the correct amount of blood thinner medication.

                                Target value: Normal range for an adult: 9.9-13 seconds.

                                To prepare: This test may be measured any time of the day without fasting.

                                International normalized ratio (INR): INR is tested for those on anticoagulant medications to prevent stroke, embolism, and heart attack.

                                Target value: Normal level for an adult: 0.9-1.2. Your doctor will determine your therapeutic range.

                                To prepare: This test may be measured any time of the day without fasting.

                                Nuclear imaging

                                Nuclear imaging is a method of producing images by detecting radiation from different parts of the body after the administration of a radioactive tracer material. Radioactive tracers are not dyes. They have no side effects. The amount of radiation a patient receives in a typical nuclear imaging scan is very low, similar to the exposure received in a routine chest X-ray. In most cases the tracers are injected into a vein. In some cases they may be given by mouth.

                                During the test or "scan," you lie on a table while a special "gamma" camera takes a series of pictures. A computer connected to the camera detects the radiation from the body organ being examined and forms a series of images. These images are interpreted by a nuclear medicine physician who searches for abnormal organ function or disease and then makes a diagnosis.

                                The amount of time nuclear imaging takes depends on the type of test. Most studies take about one hour or more. Some require more than one visit.

                                In our section on nuclear imaging you will find:

                              • Multigated acquisition scan (MUGA scan, nuclear ventriculogram, radionuclide scan)
                              • Thallium exercise stress test (stress thallium test, perfusion scan)
                              • Positron emission tomography (PET or cardiac viability study)
                              • Sestamibi exercise stress test (sestamibi stress test, stress perfusion scan, stress sestamibi)
                              • Multigated acquisition scan (MUGA)

                                Multigated acquisition scan (equlibrium radionuclide angiogram, blood pool scan): Your doctor uses the MUGA to evaluate the heart's pumping function.

                                What to expect:

                                A technician will attach electrodes with adhesive pads to the skin of your chest. Men may have patches of chest hair shaved to allow a better connection. The electrodes are hooked up to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test.

                                An intravenous (IV) line will be inserted into a vein in your arm. The technician will perform a resting EKG, measure your resting heart rate, and take your blood pressure.

                                The technician will ask you to lie on the exam table under a camera. A small amount of blood is withdrawn and mixed with a radioactive tracer. The radioactive tracer binds to the red blood cells, and the mixture is reinjected into the IV. The tracer stays in the bloodstream for several hours and does not enter your tissue cells.

                                A large camera, located above the table, is focused on the heart and analyzes the amount of radio-labeled red blood cells pumped out of the heart with each heartbeat. Several different pictures may be taken to look at different walls of the heart.

                                The MUGA scan takes about one to two hours to perform.

                                Thallium exercise stress test

                                Thallium exercise or pharmacologic stress test (stress thallium test, perfusion scan): A thallium stress test combines nuclear scanning with exercise on a treadmill or stationary bicycle, or drugs (dipyridamole, adenosine, or regadenoson) can cause stress on the heart to assess blood flow to the heart muscle.

                                Your doctor uses a thallium stress test to:

                                • Determine if there is adequate blood flow to your heart during increasing levels of activity
                                • Evaluate the effectiveness of your cardiac treatment plan
                                • Determine the likelihood of having coronary artery disease and the need for future testing
                                • What to expect:

                                  Ten small areas of your chest are cleaned, and small sticky electrode patches are attached to these areas. Men may have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test.

                                  Your blood pressure and EKG recording will be taken before, during, and after exercise. You will have exercise stress by walking on a treadmill or pedaling a stationary cycle. The degree of difficulty will gradually increase. You will be asked to exercise very hard, until you are exhausted. At regular intervals, the lab personnel will ask how you are feeling. Tell them if you feel chest, arm, or jaw pain or discomfort; shortness of breath; dizziness; lightheadedness; or any other unusual symptoms. It is normal for your heart rate, blood pressure, breathing rate, and perspiration to increase during the test. The lab personnel will watch for any symptoms or changes on the EKG monitor that suggest the test should be stopped.

                                  If you are unable to exercise, you will receive one of the following 3 drugs: dipyridamole, adenosine, or regadenoson, through the IV catheter over a period of 30 seconds to 6 minutes. You may be asked to walk slowly on a treadmill while the drug is being administered. These drugs can cause nausea and headache, which usually go away quickly, but your physician can give you a medication in case they persist.

                                  At your maximum level of exercise or drug-induced stress, a small amount of thallium is injected into a vein. The thallium travels through the bloodstream and coronary arteries, and into the cells of the heart muscle. A camera detects the distribution of thallium in the myocardium. Because the thallium works as a tracer to indicate the areas of the myocardium that blood is reaching, regions that show less thallium have a loss of perfusion, or blood flow.

                                  After the test you will walk or pedal slowly for a couple of minutes to cool down. Your heart rate, blood pressure, and EKG will continue to be monitored until the levels begin returning to normal. The appointment lasts about 60 minutes, with the actual exercise time usually taking between seven and 12 minutes.

                                  Positron Emission Tomography

                                  PET (positron emission tomography or cardiac viability study): This imaging procedure uses radioactive tracers to create three-dimensional pictures of the tissues inside the body. It is used for patients unable to exercise on a treadmill or stationary cycle.

                                  A PET helps your doctor:

                                • Determine if there is adequate blood flow to the heart
                                • Assess the amount of damage to the heart after a heart attack
                                • Evaluate the effectiveness of your treatment plan
                                • To prepare:

                                • Do not eat or drink anything except water after midnight before your test. If you must take medications, drink only small sips of water to help you swallow your pills.
                                • Do not drink or eat caffeine products for 24 hours before the test, including over-the-counter medication such as Excedrin, Anacin, diet pills, and NoDoz.
                                • Ask your physician if you should take all of your heart medications on the day of the test. Do not discontinue any medication without first talking with your doctor.
                                • If you are diabetic, ask your physician how to adjust your medications the day of your test. If you own a glucose monitor, bring it with you to check your blood sugar levels before and after the test. If you think your blood sugar is low, tell the lab personnel immediately.
                                • Wear comfortable clothes. You may be asked to wear a hospital gown during the test.
                                • What to expect:

                                  During a PET scan, a technician will attach 10 electrodes with adhesive pads to the skin of your chest. Men may have chest hair shaved to allow a better connection. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test.

                                  An intravenous (IV) line will be inserted into a vein in your arm. The technician will perform a resting EKG, measure your resting heart rate and take your blood pressure.

                                  The technician will ask you to lie on the exam table under a camera. A small amount of rubidium will be injected into the IV. Rubidium is a radioactive tracer that allows the physician to view the blood flow in your heart when you are at rest. It is not a dye.

                                  The physician or nurse will administer a medication called dipyridamole, adenosine, or regadenoson into the IV for about four minutes. The medication will cause your heart to react as if you were exercising. It may cause a warm, flushing feeling and, in some cases, a mild headache.

                                  At regular intervals, the lab technicians will ask how you are feeling. Tell them if you feel chest, arm, or jaw pain or discomfort; shortness of breath; dizziness; lightheadedness; or any other unusual symptoms. The technicians also will watch for any changes on the EKG monitor that suggest the test should be stopped.

                                  After all the medication has entered your bloodstream, a small amount of rubidium will again be injected into the IV. The rubidium allows the physician to view the blood flow to the heart muscle while it is in stress. The IV will be removed from your arm once all the medication has entered your bloodstream.

                                  The appointment will take about three to four hours. The first part of the test will take about one hour. The second part will take about two hours, with the usual exercise time taking between seven and 12 minutes.

                                  Sestamibi or tetrofosmin exercise or pharmacologic stress test

                                  Sestamibi or tetrofosmin exercise or pharmacologic stress test (sestamibi stress test, stress perfusion scan, stress sestamibi): This diagnostic study uses a small amount of radioactive tracer injected into the body and a special camera to produce a computer image of the heart.

                                  Your doctor uses the sestamibi or tetrofosmin stress test to:

                                • Determine if there is adequate blood flow to your heart during increasing levels of activity.
                                • Evaluate the effectiveness of your cardiac treatment plan.
                                • Determine the likelihood of having coronary artery disease and the need for future testing.
                                • It is preferable to perform the exercise stress test using a treadmill or bicycle, but if you cannot perform such exercise, your doctor may use a drug such as dipyridamole, adenosine, or regadenoson to increase the blood flow to the heart muscle, which is similar to that induced with exercise.
                                • To prepare:

                                • Do not eat or drink anything except water for four hours before the test. You will be allowed to eat once the second part of the test is complete.
                                • Do not drink or eat caffeine products for 24 hours before the test, including over-the-counter medication that contains caffeine such as Excedrin, Anacin, diet pills, and NoDoz.
                                • Ask your doctor what medications should be taken on the day of your test. Do not discontinue any medication without first talking with your doctor.
                                • If you use an inhaler for breathing, bring it to the test.
                                • If you are diabetic, ask your physician how to adjust your medications the day of your test. If you own a glucose monitor, bring it with you to check your blood sugar levels before and after the test. If you think your blood sugar is low, tell the lab personnel immediately.
                                • Wear comfortable clothes and soft-soled shoes suitable for walking. Women should wear a bra.
                                • What to expect:

                                  A nuclear medicine technologist will start an intravenous (IV) line in the back of your hand and will inject a small amount of sestimibi or tetrofosmin into the IV line. These are radioactive tracers allow the physician to assess your heart function. They are not dyes. You will be asked to lie very still under a camera with your arms over your head for about 2 to 15 minutes. The camera will rotate around your body and record images that show the physician blood flow to each area of the heart muscle at rest.

                                  Next you will go to the stress lab. A stress technician will clean 10 small areas of your chest and place small sticky electrode patches on these areas. Men may expect to have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test.

                                  The technician will perform a resting EKG, measure your resting heart rate, and take your blood pressure. If you are able to exercise, you will start walking on a treadmill or pedaling a stationary cycle. The degree of difficulty will gradually increase. You will be asked to exercise very hard until you are exhausted. If you are unable to exercise, you will receive one of the following 3 drugs: dipyridamole, adenosine, or regadenoson through the IV catheter over a period of 30 seconds to 6 minutes. You may be asked to walk slowly on a treadmill while the drug is being administered. These drugs can cause nausea and headache, which usually go away quickly, but your physician can give you a medication in case they persist.

                                  At regular intervals, the lab personnel will ask how you feel. Be sure to tell them if you feel chest, arm, or jaw pain or discomfort; shortness of breath; dizziness; lightheadedness; or any other unusual symptoms. It is normal for your heart rate, blood pressure, breathing rate, and perspiration to increase during the test. The lab personnel will watch for any symptoms or changes on the EKG monitor that suggest the test should be stopped. Your blood pressure and EKG recording will be taken during your test.

                                  One minute before you stop exercising, a small amount of sestamibi or tetrofosmin will be injected in the IV. Once the sestamibi is administered, the IV will be removed.

                                  After the test you will walk or pedal slowly for a couple of minutes to cool down. Your heart rate, blood pressure, and EKG will continue to be monitored until the levels begin returning to normal. About 20-30 minutes after you have finished exercising or receiving the drug, you will be asked to again lie very still under the camera with your arms over your head for about 12-15 minutes. The camera will record images that show your physician how well blood flows through the coronary arteries to each area of the heart muscle during exercise.

                                  You may be asked to return the next day or within a week for a third scan. Your physician will tell you if you need to come back after reviewing the results of the second scan. The appointment lasts about three to four hours, with the actual exercise or drug stress time usually taking between seven and 12 minutes.

                                  Ultrasound tests

                                  Ultrasound tests are noninvasive tests that use ultrasound, or high-frequency sound waves, to create graphic images of the heart's structures, pumping action, and direction of blood flow.

                                  In our section on ultrasound testing you will find:

                                  • Echocardiogram (echo, 2-D echo, cardiac ultrasound)
                                  • Dobutamine stress echocardiogram (dobutamine echo, pharmacological echocardiogram)
                                  • Transesophageal echocardiogram (TEE)
                                  • Exercise stress echocardiogram (exercise stress echo)
                                  • Echocardiogram

                                    Echocardiogram (echo, 2-D echo, cardiac ultrasound): During an echocardiogram test, ultrasound waves (high-frequency sound waves) from a hand-held wand placed on your chest are used to provide pictures of the heart's valves and chambers and help 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.

                                    Your doctor uses the echo to:

                                  • Assess the heart's function.
                                  • Determine the presence of congenital heart disease, heart tumors, and disease of the heart muscle, valves, and pericardium.
                                  • Evaluate the effectiveness of medical or surgical treatments.
                                  • Follow the progress of valve disease.
                                  • To prepare:

                                  • You can wear whatever you like. You will need to change into a hospital gown to wear during the procedure. Do not bring valuables.
                                  • You may eat and drink as you normally would on the day of the test.
                                  • Take all your medications at the usual times, as prescribed by your doctor.
                                  • What to expect:

                                    Three sticky electrodes will be attached to your chest and wired to an EKG monitor that charts your heart's electrical activity.

                                    You will lie on your left side on an exam table. A specialist called a sonographer will place a wand (called a sound-wave transducer) on several areas of your chest. The wand will have a small amount of cool gel on the end to help get clearer pictures.

                                    You may be asked to change positions during the exam to take pictures of different areas of your heart. You may be asked to hold your breath at times. You should feel no major discomfort during the test. You may feel coolness from the gel on the transducer and a slight pressure of the transducer on your chest.

                                    The echo test takes about 40 minutes.

                                    Dobutamine stress echocardiogram

                                    Dobutamine stress echocardiogram (dobutamine echo, pharmacological echocardiogram): In this type of stress echo test, a medication called dobutamine is injected through an intravenous (IV) line. The medication stimulates the heart to respond as if you were exercising. The test is used to evaluate your heart and valve function when you are unable to exercise on a treadmill or stationary cycle. Echo is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart's valves.

                                    To prepare:

                                  • Do not eat or drink anything except water for four hours before the test. Do not drink or eat caffeine products (cola, Mountain Dew, chocolate, coffee, or tea) for 24 hours before the test. Caffeine will interfere with the results of the test.
                                  • Ask your doctor what medications should be taken on the day of your test Your physician may ask you to stop taking some heart medications on the day of the test. He or she will give you specific instructions. If you have questions about your medications—ask your physician. Do not stop any medication without first talking with your doctor.
                                  • Your physician may also ask you to stop taking other heart medications on the day of the test. If you have questions about your medications—ask your physician. Do not stop any medication without first talking with your doctor.

                                    Since many over-the counter medications contain caffeine (such as diet pills, NoDoz, Excedrin, and Anacin), do not take any over-the-counter medication that contains caffeine for 24 hours before the test. Ask your physician, pharmacist, or nurse if you have questions about other mediations that may contain caffeine.

                                    If you have diabetes and take medications to manage your blood sugar, ask your physician how to adjust your medications the day of your test. Do not take your diabetes medication and skip a meal before the test. If you own a glucose monitor, bring it with you to check your blood sugar levels before and after your test. If you think your blood sugar is low, tell the lab personnel immediately. Plan to eat and take your blood sugar medication after your test.

                                    You can wear whatever you like. You will need to change into a hospital gown to wear during the procedure.

                                    What to expect:

                                    Wires from 10 sticky electrodes on your chest will be attached to an EKG monitor to chart your heart's electrical activity during the test. An intravenous (IV) line will be inserted into a vein in your arm so the dobutamine can be delivered directly into your bloodstream. A cardiac sonographer will perform a resting EKG, measure your heart rate and take your blood pressure.

                                    You will lie on your left side on an exam table so that a resting echo can be performed. The sonographer will place a wand (called a sound-wave transducer) on several areas of your chest. The wand will have a small amount of cool gel on the end to help get clearer pictures.

                                    A physician or nurse will administer the dobutamine medication into the IV while the cardiac sonographer continues to obtain echo images. Your heart rate will rise and you may feel it beating more strongly. It may cause a warm, flushing feeling and, in some cases, a mild headache. At regular intervals, lab personnel will ask how you are feeling and will check your EKG, blood pressure, and heart rate. The procedure is usually well tolerated, but occasionally there are complications. Lab personnel will watch for any symptoms or changes on the EKG monitor that suggest the test should be stopped. The IV will be removed once all of the medication has entered your bloodstream.

                                    The dobutamine stress echo takes about 60 minutes. The actual infusion time is usually 15 minutes. You should plan to stay in the waiting room for at least 30 minutes after completing the procedure, or until all the symptoms you have experienced are resolved.

                                    Transesophageal echocardiogram

                                    Transesophageal echocardiogram (TEE): During this test, an ultrasound transducer (which produces high-frequency sound waves) provides pictures of the heart's valves and chambers and helps the physician evaluate the pumping action. The ultrasound transducer is positioned on an endoscope (a long, thin, flexible instrument about 1/2 inch in diameter). The endoscope is placed into your mouth and passed into your esophagus (the tube from your mouth to your stomach) to provide a close look at your heart's valves and chambers without interference from the ribs or lungs.

                                    TEE is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart's valves. TEE is often used when the results from standard echo studies were not sufficient or when your doctor wants a closer look at your heart.

                                    To prepare:

                                  • You can wear whatever you like. You will change into a hospital gown for the procedure. Do not bring valuables.
                                  • Do not eat or drink anything for at least six hours before the test. Take your medications with only a small sip of water.
                                  • Take all your medications at the usual times, as prescribed by your doctor.
                                  • If you have diabetes and take medications to manage your blood sugar, ask your physician how to adjust your medications the day of your test.
                                  • Tell your doctor if you have any problems with your esophagus (tube connecting mouth to the stomach), such as hiatal hernia, problems swallowing, or cancer.
                                  • Bring someone with you to drive you home after the test. You should not drive until the day after the procedure. Sedation given during the procedure causes drowsiness and dizziness and impairs your judgment, making it unsafe for you to drive or operate machinery.
                                  • What to expect:

                                    An intravenous (IV) line will be inserted into a vein in your arm or hand so medications can be delivered when necessary. You will be connected to several monitors. An EKG monitor will chart your heart's electrical activity during the test; a blood pressure cuff will be placed on your arm to monitor your blood pressure, and an oximeter will monitor the oxygen level of your blood by means of a clip placed on one finger.

                                    You will be given a solution to gargle that will numb your throat. Anesthetic will then be sprayed at the back of your throat. Medication will be injected into the IV line to help you relax during the test. You may feel drowsy.

                                    You will be asked to lie on your left side on an exam table. A dental suction tip will be placed in your mouth to remove secretions. The doctor will insert a thin, lubricated endoscope into your mouth and down your throat (this part lasts a few seconds and might feel uncomfortable) into the esophagus. The tube does not interfere with your breathing. You may be asked to swallow at certain times to help pass the tube.

                                    Once the probe is in position, pictures of the heart are obtained at various angles (you will not feel this part of the test). Because of the sedative, you may not be entirely awake for the test.

                                    The TEE takes about 90 minutes.

                                    Exercise stress echo

                                    Exercise stress echo: This test involves exercising on a treadmill or stationary cycle and is used to evaluate heart and valve function.

                                    To prepare:

                                  • Do not eat or drink anything except water for four hours before the test. Do not drink or eat caffeine products (cola, Mountain Dew, chocolate, coffee, or tea) for 24 hours before the test. Caffeine will interfere with the results of the test.
                                  • Ask your doctor what medications should be taken on the day of your test. Your physician may ask you to stop taking some heart medications on the day of the test. He or she will give you specific instructions. If you have questions about your medications, ask your physician. Do not stop any medication without first talking with your doctor.
                                  • Since many over-the counter medications contain caffeine (such as diet pills, NoDoz, Excedrin, and Anacin), do not take any over-the-counter medication that contains caffeine for 24 hours before the test. Ask your physician, pharmacist, or nurse if you have questions about other mediations that may contain caffeine.

                                    What to expect:

                                    An EKG monitor will be hooked to your chest through sticky electrodes. A resting EKG will be performed and your resting blood pressure taken.

                                    You then will be asked to lie on your left side on an exam table so that a resting echo can be performed. The sonographer will place a wand (called a sound-wave transducer) on several areas of your chest. The wand will have a small amount of cool gel on the end to help get clearer pictures.

                                    Next, you will be asked to exercise on a treadmill or stationary bicycle at a gradually increasing rate until the point of exhaustion. The lab personnel will watch for changes on the EKG monitor that suggest the test should be stopped.

                                    When you cannot exercise any longer, you will get off the treadmill, quickly return to the exam table and lie on your left side for another echocardiogram. It is normal to feel a little unsteady when getting off the treadmill and onto the exam table for the echo as you stop exercising suddenly. If you were exercising on a bike, the sonographer may perform the echo test while you are still pedaling. You may be asked to quickly return to the exam table for another echocardiogram after exercising.

                                    Your heart rate, blood pressure, and EKG will continue to be monitored after exercise until the levels begin returning to normal.

                                    The appointment takes about 60 minutes. Actual exercise time is usually between seven and 12 minutes.

                                    Radiographic

                                    Radiographic tests are noninvasive tests that use X-ray machines or specialized equipment with computer technology to create pictures of the internal structures of the chest.

                                    In this section on radiographic testing you will find:

                                    • Calcium-score screenings heart scan
                                    • Cardiac computed tomography (CT, cardiac CT, or cardiac CAT scan)
                                    • Chest X-ray (CXR, chest film)
                                    • Coronary computed tomography angiogram (coronary CTA)
                                    • Magnetic resonance imaging (MRI)
                                    • Calcium-score screening heart scan

                                      Calcium-score screening heart scan: This test is used to detect calcium deposits found in atherosclerotic plaque in the coronary arteries. This test is best used along with a full evaluation of lipid blood levels as well as risk factors. State-of-the-art computerized tomography (CT) methods, such as this one, are the most sensitive approaches to detecting coronary calcification from atherosclerosis, before symptoms develop. However, because certain forms of coronary disease—such as "soft plaque" atherosclerosis—escape detection during this CT scan, it is important to remember that this test is not absolute in predicting your risk for life-threatening events, such as a heart attack.

                                      To prepare:

                                      Prior to the test, a blood lipid analysis by a specialized laboratory is recommended. This test can be obtained on the day of your exam and requires you to fast for 12 hours before the exam. You may take your medications as usual with sips of water.

                                      CT scanners use X-rays. Tell your technologist and your doctor if you are:

                                      • Pregnant
                                      • Undergoing radiation therapy
                                      • What to expect:

                                        The technologist will clean three small areas of your chest and place small, sticky electrode patches on these areas. Men may expect to have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test.

                                        During the scan, you will feel the table move inside a donut-shaped scanner. The high-speed CT scan captures multiple images, synchronized with your heartbeat. A sophisticated computer program, guided by the cardiovascular radiologist, then analyzes the images for presence of calcification within the coronary arteries. The calcium-score screening heart scan takes only a few minutes.

                                        After the procedure:

                                        You may continue all normal activities and eat as usual after the test.

                                        Cardiac computed tomography

                                        Cardiac computed tomography: A traditional CT scan combines many X-ray images with the aid of a computer to generate cross-sectional views of the body. Cardiac CT uses advanced CT technology with intravenous (IV) contrast dye to visualize cardiac anatomy, coronary circulation, and the great vessels.

                                        Your doctor uses the cardiac CT to evaluate:

                                      • The heart muscle
                                      • The coronary arteries
                                      • The pulmonary veins
                                      • The thoracic aorta
                                      • The sac around the heart (pericardium)
                                      • To prepare:

                                      • Do not eat solid food for four hours before your scheduled appointment. You may drink clear liquids, such as water, black coffee, tea, broth, or apple juice.
                                      • You may take your medications as usual with sips of water.
                                      • If you are diabetic, ask your physician how to adjust your medications the day of your test. If you think your blood sugar is low, tell the technologist immediately.
                                      • Tell your technologist and your doctor if you are: pregnant; allergic to iodine, shellfish or any medications; undergoing radiation therapy; over 60 years old; or have a history of kidney problems (you may be required to have a blood test to evaluate your kidney function prior to receiving any contrast agent)
                                      • What to expect:

                                        You will change into a hospital gown. A nurse will insert an IV line into a vein in your arm to administer contrast dye during your procedure.

                                        You will lie on a special scanning table. The technologist will clean three small areas of your chest and place small, sticky electrode patches on these areas. Men may have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test. You will be asked to raise your arms over your head for the duration of the exam.

                                        During the scan, you will feel the table move inside a donut-shaped scanner. You will receive a contrast agent through your IV to help produce the images. It is common to feel a warm sensation as the dye circulates through your body. Once the technologist is sure that all the information is collected, the IV will be removed.

                                        Although the whole procedure could take 30-45 minutes, the actual CT scan takes only a few seconds.

                                        After the procedure:

                                        You may continue all normal activities and eat as usual after the test.

                                        Your physician will discuss the results of your test with you.

                                        A note about CT and risk:

                                        Occasionally, patients experience an adverse reaction to the contrast agent. Some patients develop itching or a rash following the injection. These symptoms are usually self-limiting and resolve without further treatment. Antihistamines can be administered if needed for symptomatic relief.

                                        Rarely, a more serious allergic reaction, called an anaphylactic reaction, occurs that may result in breathing difficulty. This reaction is potentially life-threatening and would require medications and treatment to reverse the symptoms.

                                        CT scanners use X-rays. For your safety, the amount of radiation exposure is kept to a minimum. Because X-rays can harm a developing fetus, however, this procedure is not recommended if you are pregnant.

                                        Chest X-ray

                                        Chest X-ray (CXR, chest film): A very small amount of radiation is used to produce an image of the structures of the chest (heart, lungs, and bones) on film.

                                        Your doctor uses this procedure to:

                                        • Look at the structures of the chest (bones, heart, lungs)
                                        • Evaluate placement of devices (pacemakers, defibrillators) or tubes placed during hospitalization for treatment and monitoring (catheters, chest tubes)
                                        • Diagnose lung and cardiac diseases
                                        • To prepare:

                                          No special preparation is necessary. But tell the technician if you may be pregnant.

                                          What to expect:

                                          An X-ray can be performed in the hospital at the bedside or in the radiology department.

                                          Two views will be taken: You will be asked to stand very still with your chest against the cassette that contains the film. You will be asked to hold your breath for a few seconds to generate better images. Then you will be asked to do the same thing, but with your left side against the cassette.

                                          The entire test takes no more than 10 to 15 minutes.

                                          Coronary tomography angiogram

                                          Computed tomography angiogram (coronary CTA): This heart-imaging test—which generally is used only in specialized hospitals or research centers—helps your doctor determine whether either fatty deposits or calcium deposits have built up in your coronary arteries.

                                          How does it work?

                                          A coronary CTA comes from a special type of X-ray examination. Patients undergoing a coronary CTA scan receive an iodine-containing contrast dye as an IV solution to ensure the best images possible. The same IV in the arm may be used to give a medication to slow or stabilize the patient's heart rate for better imaging results. During the examination, which usually takes about 10 minutes, X-rays pass through the body and are picked up by special detectors in the scanner. Typically, higher numbers (especially 16 or more) of these detectors result in clearer final images. For that reason, coronary CTA often is referred to as "multidetector" or "multislice" CT scanning. The information collected during the coronary CTA examination is used to identify the coronary arteries and, if present, plaques in their walls with the creation of 3-D images on a computer screen.

                                          How is coronary CTA different from other heart tests?

                                          One of the most common heart tests is the coronary angiogram, or cardiac catheterization. This test is more invasive and requires more patient recovery time than coronary CTA. Patients who receive coronary angiograms must have a catheter, or small transport tube, threaded into their coronary arteries, which run along the outside of the heart. The catheter typically is inserted into a blood vessel in the upper thigh and then maneuvered up to the coronary arteries. The catheter then is used to inject the iodine dye needed for the test, which uses X-rays to record "movies" of the interior of the coronary arteries.

                                          Although coronary CTA examinations are growing in use, coronary angiograms remain the gold standard for detecting coronary artery stenosis, which is a significant narrowing of an artery that could require catheter-based intervention (such as stenting) or surgery (such as bypassing). On the other hand, this new technology has consistently shown the ability to rule out significant narrowing of the major coronary arteries and can noninvasively detect "soft plaque," or fatty matter, in their walls that has not yet hardened but that may lead to future problems without lifestyle changes or medical treatment.

                                          Who should consider coronary CTA?

                                          Overall, coronary CTA examinations have tended to help determine a lack of significant narrowing and calcium deposits in the coronary arteries, as well as a presence of fatty deposits. This test is particularly valuable in ruling out coronary artery disease. As a result, many physicians advocate the careful use of coronary CTA for patients who have:

                                          • Intermediate risk profile for coronary artery disease with the presence of suspicious cardiac symptoms.
                                          • Unusual symptoms for coronary artery disease (such as chest pain unrelated to physical exertion), but low to intermediate risk profiles for coronary artery disease.
                                          • Unclear or inconclusive stress-test results.
                                          • Patients with suspected congenital anomalies of coronary arteries.
                                          • For these types of patients, coronary CTA can provide important insights to their primary physician into the extent and nature of plaque formation with or without any narrowing of the coronary arteries. Coronary CTA also can noninvasively exclude narrowing of the arteries as the cause of chest discomfort and detect other possible causes of symptoms. But again, initial consultation with their primary physician is key for patients seeking to determine the appropriateness of coronary CTA.
                                          • Who should not have coronary CTA?

                                            To date, coronary CTA has not been proven as effective as the coronary angiogram in detecting disease in the smaller heart arteries that branch off the major coronary arteries. For that reason, many physicians do not consider coronary CTA as an adequate substitute for coronary angiography in patients with strong evidence of narrowing of the coronary arteries. Such patients include those with a history of chest pain during heavy physical activity, a history of positive stress-test results, or a known history of coronary artery disease or heart attack. Coronary CTA also is of limited use in patients with extensive areas of old calcified, or hardened, plaque, which is often the case in older patients. Patients who are extremely overweight or who have abnormal heart rhythms also tend not to be suitable candidates for this test because imaging quality is compromised.

                                            Magnetic resonance imaging

                                            Magnetic resonance imaging (MRI): MRI uses large magnets and radio-frequency waves to produce pictures of the body's internal structures; no X-ray exposure is involved. MRI acquires information about the heart as it is beating, creating moving images of the heart throughout its pumping cycle.

                                            Your doctor uses the MRI to evaluate:

                                          • The anatomy and function of the structures of the chest: heart, lungs, great vessels, and pericardium
                                          • Presence of disease, including ischemic heart disease, thoracic aortic disease, pericardial disease, right ventricular abnormalities, cardiac tumors, valve disease, heart muscle disease (cardiomyopathy), pulmonary artery disease, and complex congenital heart disease
                                          • To prepare:

                                            This procedure uses powerful magnets to create its images. For reasons of safety, anyone undergoing a scan should be free of certain metallic or magnetic items. Ask your doctor about whether an MRI scan is advisable for you and for a list of items that should be avoided when having a scan.

                                            If you are not claustrophobic, you will not require any sedation, so beforehand you can eat and take your medications as usual. If you are claustrophobic, you may want to ask your doctor to schedule your MRI with sedation. If you do so:

                                            • You may not eat any solid food for six hours before receiving your sedative to avoid nausea. You may have clear liquids (apple juice, gelatin, black coffee or tea, water) up to two hours before your medication time.
                                            • You should consult with your doctor about taking your medications.
                                            • You should have a companion to drive you home.
                                            • What to expect:

                                              An MRI technologist will place small sticky, electrode patches on your chest and back. Men may have their chest partially shaved to help the electrodes stick. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity during the test. Most likely, an intravenous (IV) line will be inserted into a vein in your arm for non-iodine-based contrast (dye) administration.

                                              The MRI scanner unit is a long tube that scans the body as you lie on a platform bed. It is fully lighted and ventilated and open at both ends. An intercom system allows you to talk to the scanner operators during the test. You will lie on your back on the scanner bed, with your head and legs elevated for comfort. During the exam, you will be asked to lie as still as possible. The technologist will ask you to hold your breath periodically for short periods to reduce blurring of the images from breathing motion.

                                              During scanning, you may hear loud banging noises, which can be muffled with headphones or earplugs you will receive before scanning begins.

                                              The MRI scan takes about 30 to 75 minutes, depending on the extent of the imaging needed.

                                              After the procedure you may resume your usual activities and normal diet immediately if you did not receive sedation. If you did, someone else should drive you home, and your doctor will give you instructions on when you can eat, drink, and return to normal activities.

                                              Invasive tests

                                              These tests involve inserting catheters into the blood vessels of the heart to get a closer look at the coronary arteries or to stimulate and test the electrical system of the heart.

                                              In our section on invasive testing you will find:

                                              • Carotid angiography (carotid angiogram, carotid angio)
                                              • Intravascular ultrasound(IVUS)
                                              • Cardiac catheterization (cardiac cath, coronary angiogram)
                                              • Carotid angiography

                                                Carotid angiography (carotid angiogram, carotid angio): This imaging procedure involves inserting a catheter into a blood vessel in the arm or leg and guiding it to the carotid arteries with the aid of a special X-ray machine. Contrast dye is injected through the catheter so that X-ray movies of your carotid arteries (the arteries that supply your brain with oxygen-rich blood) can be taken.

                                                Your doctor uses carotid angiography to:

                                              • Evaluate or confirm the presence of narrowing or blockage in your carotid arteries
                                              • Determine risk for future stroke
                                              • Determine the need for further treatment (angioplasty or surgery)
                                              • To prepare:

                                                You can wear whatever you like to the hospital because you will wear a hospital gown during the procedure. Leave all valuables at home. If you normally wear dentures, glasses, or a hearing aid, plan to wear them during the procedure.

                                                Your doctor or nurse will give you specific instructions about what you can and cannot eat or drink before the procedure. Ask your doctor what medications should be taken on the day of your test. You may be told to stop certain medications, such as Coumadin (warfarin, a blood thinner). If you are diabetic, ask your physician how to adjust your medications the day of your test.

                                                Tell your doctor and/or nurses if you are allergic to anything, especially iodine, shellfish, X-ray dye, or latex or rubber products (such as rubber gloves or balloons). You might not return home the day of your procedure. Bring items with you (such as robe, slippers, and toothbrush) that may make your stay more comfortable. When you are able to leave, arrange for a companion to bring you home.

                                                What to expect:

                                                You will be given a hospital gown to wear. A nurse will start an intravenous (IV) line in your arm so that medications and fluids can be administered during the procedure.

                                                The angiography room is cool and dimly lit. You will lie on a special table. If you look above, you will see a large camera and several TV monitors. The nurse or doctor will clean your skin at the site where the catheter (narrow plastic tube) will be inserted (arm or groin). Sterile drapes are used to cover the site and help prevent infection. It is important that you keep your arms and hands down at your sides and not disturb the drapes.

                                                Small, sticky electrode patches will be placed on your chest. The electrodes are attached to an electrocardiograph (EKG) monitor that charts your heart's electrical activity.

                                                You will be given a mild sedative to relax you, but you will be awake and conscious during the entire procedure. The doctor will use a local anesthetic to numb the site. A plastic introducer sheath (a short, hollow tube through which the catheter is placed) will be inserted into a blood vessel in your arm or groin. A catheter then is inserted through the sheath and threaded to the arteries of your neck.

                                                When the catheter is in place, the lights will be dimmed and a small amount of "contrast material" will be injected through the catheters into your arteries. The contrast material outlines the vessels that provide circulation to your brain. When the contrast material is injected, you may feel hot or flushed for several seconds. This is normal and will go away in a few seconds. Tell the doctor or nurses if you feel an allergic reaction (itching, tightness in the throat), nausea, chest discomfort, or any other symptoms.

                                                The X-ray camera will be used to take photographs of the arteries of the head and neck. You may be asked to hold your breath or turn your head in different directions while the X-rays are taken. When all the images have been taken, the catheter will be removed and the lights will be turned on.

                                                After the procedure:

                                                The catheter and sheath are removed.

                                                You will need to be on bed rest for several hours.

                                                You will need to drink plenty of liquids to clear the contrast material from your body. You may feel the need to urinate more frequently.

                                                Your doctor will tell you if you are able to return home or will need to stay overnight. In either case, you will be monitored for several hours after the procedure. You will need a companion to drive you home.

                                                Treatment, including medications, diet, and future procedures will be discussed with you prior to going home. Care of the wound site, activity, and follow-up care will also be discussed.

                                                Intravascular ultrasound

                                                Intravascular ultrasound (IVUS): In this procedure, a miniature sound probe (transducer) on the tip of a coronary catheter is threaded through the coronary arteries and, using high-frequency sound waves, produces detailed images of the arteries' interior walls.

                                                Your doctor uses IVUS to:

                                              • View the artery from the inside out, making it possible to evaluate the amount of disease present and how it is distributed
                                              • Determine the need for further treatment (angioplasty or bypass surgery)
                                              • Determine the need for aggressive management of risk factors prior to onset of symptoms and advanced disease
                                              • Determine the predictors of transplant coronary artery disease
                                              • To prepare:

                                                You can wear whatever you like to the hospital because you will wear a hospital gown during the procedure. Some procedures may require an overnight stay. If you normally wear dentures, glasses or a hearing aid, plan to wear them during the procedure.

                                                Your doctor or nurse will give you specific instructions about what you can and cannot eat or drink before the procedure.

                                                Ask your doctor what medications should be taken on the day of your test. You may be told to stop certain medications, such as Coumadin (warfarin, a blood thinner) or aspirin. If you have diabetes, ask your physician how to adjust your medications the day of your test.

                                                Tell your doctor and/or nurses if you are allergic to anything, especially iodine, shellfish, X-ray dye, or latex or rubber products (such as rubber gloves or balloons), or penicillin-type medications.

                                                Arrange for a companion to bring you home.

                                                What to expect:

                                                You will be given a hospital gown to wear. A nurse will start an intravenous (IV) line in your arm so that medications can be administered during the procedure. You will lie on a special table. The nurse will clean your skin at the groin. Sterile drapes are used to cover the site and help prevent infection. It is important that you keep your arms and hands down at your sides and not disturb the drapes.

                                                Small, sticky electrode patches will be placed on your chest. The electrodes are attached to an electrocardiograph (EKG) monitor, which charts your heart's electrical activity. You will be given a mild sedative to relax you, but you will be awake and conscious during the entire procedure.

                                                The doctor will use a local anesthetic to numb your groin site. A plastic introducer sheath (short, hollow tube through which the catheter is placed) is inserted in the groin. A catheter (narrow plastic tube) will be inserted through the sheath and threaded to the arteries of your heart. Through the catheter, a wire with an ultrasound tip will be passed into your coronary arteries. Once the catheter is within the coronary artery, a series of cross-sectional pictures of the artery are produced.

                                                Tell the doctor or nurses if you feel chest discomfort or any other symptoms during the procedure.

                                                The IVUS procedure takes about 60 minutes.

                                                After the procedure:

                                                The catheters and sheath are removed. Pressure will be placed on leg artery. You will need to lie flat and keep the leg straight for three to six hours to prevent bleeding. A pressure dressing will be applied tightly on the groin. The nurse will check your bandage regularly, but call your nurse if you think you are bleeding (have a wet, warm sensation) or if your toes begin to tingle or feel numb.

                                                You may be admitted overnight for observation. The nurse will remove the pressure dressing the morning following your procedure. Your doctor will tell you if you are able to return home or should stay for further treatment. Treatment, including medications and diet, will be discussed with you before going home. Care of the wound site, activity, and follow-up care will also be discussed.

                                                Cardiac catheterization

                                                Cardiac catheterization (cardiac cath or coronary angiogram): In this imaging procedure a catheter is inserted into a blood vessel in the arm or leg and guided to your heart with the aid of a special X-ray machine. Contrast dye is injected through the catheter so that X-ray movies of your valves, coronary arteries, and heart chambers are taken.

                                                Your doctor uses cardiac catheterization to:

                                                • Evaluate or confirm the presence of heart disease (such as coronary artery disease, valve disease, or disease of the aorta)
                                                • Evaluate heart muscle function
                                                • Determine the need for further treatment (angioplasty or bypass surgery)
                                                • To prepare:

                                                  You can wear whatever you like to the hospital because you will wear a hospital gown during the procedure. If you normally wear dentures, glasses, or a hearing aid, plan to wear them during the procedure to assist with communication.

                                                  Your doctor or nurse will give you specific instructions about what you can and cannot eat or drink before the procedure. Ask your doctor what medications should be taken on the day of your test. You may be told to stop certain medications, such as Coumadin (warfarin, a blood thinner). If you have diabetes, ask your physician how to adjust your medications the day of your test.

                                                  Tell your doctor and/or nurses if you are allergic to anything, especially iodine, shellfish, X-ray dye, penicillin-type medications, or latex or rubber products (such as rubber gloves or balloons).

                                                  You might not return home the day of your procedure, so bring items with you (such as robe, slippers, and toothbrush) that will make your stay more comfortable. When you are able to leave, arrange for a companion to bring you home.

                                                  What to expect:

                                                  Bring a list of your medications (including over-the-counter) and dosages. When you arrive for your appointment, tell your nurse if you are taking Coumadin (warfarin), Plavix (clopidogrel), diuretics (water pill), or insulin. Also remind the staff if you are allergic to anything, especially iodine, shellfish, X-ray dye, penicillin-type medications, or latex or rubber products (such as rubber gloves or balloons).

                                                  You will be given a hospital gown to wear. A nurse will start an intravenous (IV) line in your arm so that medications and fluids can be administered during the procedure.

                                                  The cardiac catheterization room is cool and dimly lit. The air must be kept cool to prevent damage to the X-ray machinery that is used during the procedure. You will be offered warm blankets to make you more comfortable.

                                                  You will lie on a special table. If you look above, you will see a large camera and several TV monitors. You can watch your cardiac cath on the monitors.

                                                  The nurse will clean your skin at the site where the catheter (narrow plastic tube) will be inserted (arm or groin). The catheter insertion site may be shaved. Sterile drapes are used to cover the site and help prevent infection. It is important that you keep your arms and hands down at your sides, under the sterile drapes.

                                                  Small, sticky electrode patches will be placed on your chest. The electrodes are attached to an electrocardiograph (EKG) monitor, which monitors your heart rate and rhythm.

                                                  You will be given a mild sedative to relax you, but you will be awake and conscious during the entire procedure. In some cases, a urinary catheter may be needed during the procedure.

                                                  The doctor will use a local anesthetic to numb the site. A plastic introducer sheath (a short, hollow tube through which the catheter is placed) is inserted into a blood vessel in your arm or groin. A catheter will be inserted through the sheath and threaded to the arteries of your heart. You may feel pressure as the introducer sheath or catheter is inserted, but you should not feel pain. Tell the nurse or doctor if you feel any pain.

                                                  When the catheter is in place, the lights will be dimmed and a small amount of contrast material will be injected through the catheters into your arteries and heart chambers. The contrast material outlines the vessels, valves, and chambers. When the contrast material is injected into your heart, you may feel hot or flushed for several seconds. This is normal and will go away in a few seconds. Tell the doctor or nurses if you feel an allergic reaction (itching, tightness in the throat), nausea, chest discomfort, or any other symptoms.

                                                  The X-ray camera will be used to take photographs of the arteries and heart chambers. You may be asked to hold your breath while the X-rays are taken. When all the photos have been taken, the catheter will be removed and the lights will be turned on.

                                                  You may have an interventional procedure (to treat your coronary artery disease) combined with your cardiac catheterization.

                                                  After the procedure:

                                                  The catheter and sheath are removed. If the catheter was inserted in the arm, the incision will be bandaged and you will need to keep your arm straight for at least an hour. You will be observed for a few hours to monitor any symptoms or side effects of the procedure. Be sure to tell your nurse if you think you are bleeding (wet, warm sensation) or feel any numbness or tingling in your fingers.

                                                  If the catheter was inserted at the groin, the incision will be closed with applied pressure, a suture device, or a "plug." A "plug" is a material that works with your body's natural healing processes to seal the artery. You will need to lie flat and keep the leg straight for two to six hours to prevent bleeding (less time if a plug was used). Your head cannot be raised more than 30 degrees (about two pillows high). Do not try to sit or stand.

                                                  A sterile dressing will be placed on the groin area to protect it from infection. The nurse will check your bandage regularly, but call your nurse if you think you are bleeding (have a wet, warm sensation) or if your toes begin to tingle or feel numb.

                                                  You will need to drink plenty of liquids to clear the contrast material from your body. You may feel the need to urinate more frequently. This is normal. If you are on bedrest, you will need to use a bedpan or urinal.

                                                  Your doctor will tell you if you are able to return home or will need to stay overnight. In either case, you will be monitored for several hours after the procedure. Treatment, including medications, diet, and future procedures, will be discussed with you before going home. Care of the wound site, activity, and follow-up care will also be discussed.

                                                  The cardiac catheterization procedure takes only about 30 minutes, but plan to spend about five to nine hours from the preparation through the recovery time.

                                                  Physical exam

                                                  Physical exam: This exam always begins with you telling the doctor in your own words how you are feeling, what is bothering you, and what symptoms you are experiencing. The results of the exam will help your doctor make decisions about additional tests and treatment options.

                                                  What to bring to your doctor visit:

                                                • Current medication and allergy list
                                                • Prior test and lab results
                                                • Any measurements your doctor has asked you to keep track of (such as blood pressure, blood sugar, or daily weight readings)
                                                • Records from all doctor or emergency room visits
                                                • List of symptoms
                                                • When you describe your symptoms, it is important for you to include:

                                                • Whether you feel unusual discomfort
                                                • Where it is located
                                                • What the discomfort feels like—dull, achy, sharp?
                                                • How long it lasts
                                                • Whether there is anything you notice that seems to prompt the discomfort—a meal? Exercise?
                                                • What relieves the discomfort—rest, medications, a change in position?
                                                • The doctor will look at your skin for good color, which shows that your body is getting an adequate supply of oxygen-rich blood. Your doctor will also feel your skin for warmth and feel your pulse to check your heart's rate, rhythm, and regularity. Each pulse matches up with a heartbeat that pumps blood into the arteries. The force of the pulse also helps evaluate the amount (strength) of blood flow to different areas of your body. Your doctor will check for swelling, which is a sign that your heart is not pumping efficiently.

                                                  Your doctor will use a stethoscope to listen closely to the sounds the heart makes with each heartbeat. The doctor can evaluate your heart and valve function and hear your heart's rate and rhythm by listening to your heart sounds.

                                                  Abnormal sounds include: Murmur, an abnormal whooshing sound made by blood flowing abnormally through the heart. This may indicate a leaky heart valve.

                                                  Click, an abnormal sound made by a valve that is stiff or stenotic.

                                                  Your doctor will also measure your blood pressure. This is the force or pressure exerted in the arteries by the blood as it is pumped around the body by the heart. It is recorded as two measurements: systolic pressure in the arteries during the period of the heart's contraction (the higher number), and diastolic pressure in the arteries when the heart is relaxed between heartbeats (the lower number). Normal blood pressure for an adult, relaxed and at rest, is less than 140/90.

                                                  Your age, the condition of your heart, your emotions, medications, and whether you are active or at rest all can affect your blood pressure. One high reading does not mean you have high blood pressure. It may be necessary to measure your BP at several different times to find out your typical value.

                                                  Last reviewed on 3/9/2011

                                                  U.S. News's featured content providers were not involved in the selection of advertisers appearing on this website, and the placement of such advertisement in no way implies that these content providers endorse the products and services advertised. Disclaimer and a note about your health.