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What is Stress Echocardiography? Know its Purpose, Procedure, and Results

Stress echocardiography, also known as an echocardiography stress test or stress echo is a test that indicates the functioning of the heart and the blood vessels. This test uses ultrasound imaging to assess how efficiently the heart muscle is pumping blood in the body. It is very useful in determining the decrease in the flow of blood to the heart due to reasons such as narrowing or blocking of the coronary arteries. This test mainly evaluates how well the heart functions under stressful conditions. This stress could be triggered by exercising on a treadmill or through a medicine known as dobutamine. The medication is used in cases where the concerned person is unable to exercise; this medication imitates the effects of exercise on the heart. 

However, in general cases, the test is performed while the patient is exercising on a treadmill or a stationary cycle. During this time, the doctor monitors the condition of the heart, including blood pressure and the rhythm. When the heart rate reaches its maximum, ultrasound images are used to evaluate if the heart muscles are receiving the required quantities of blood and oxygen, while exercising.

Purpose of the stress echocardiography test

A stress echocardiography test may be conducted in situations where the patient experiences chest pain which might be caused due to coronary artery diseases or in cases where a patient suffers myocardial infection (heart attack). The stress echocardiography test can also be used to determine the level and intensity of exercise that can be undertaken by a patient who is in cardiac rehabilitation. Additionally, the test is also used to assess the effectiveness of treatment, such as:

  • Bypass grafting
  • Angioplasty
  • Anti-arrhythmic medicines

The test is very safe and non-invasive with minimum or no complications; some rare complications might include an abnormality in heart rhythm, dizziness, lack of consciousness or heart attack. 

Procedure of the stress echocardiography test

The test takes about 45 to 60 minutes and can be conducted in the doctor’s office or at an echocardiography lab. It is a simple test with rare complications. Hence, to ensure there is no risk of problems in the test, the doctor might suggest a few measures to follow before the test, these include:

  • No eating or drinking at least three to four hours prior to the test
  • No smoking on the day of the test
  • Check with the doctor before taking caffeine in any form
  • Check with the doctor for all medications that you might be regularly taking; certain medications can hamper the results of the test and create complications; thus those might be avoided on the day of the test
  • Wear running shoes and comfortable clothes.

Once that is taken care of the actual procedure of the stress echocardiography test begins. The test is divided into three stages, including:

Resting echocardiography: This is a critical step because this will help assess the functioning of the heart at rest and compare it with the functioning when stressed. In this step, the doctor first sticks small patches on the chest, known as electrodes which are connected to an ECG (Electrocardiograph) machine. This ECG machine evaluates the functioning of the electrical activity of the heart, more specifically, the heart rate and the regularity of heart rhythms. The doctor will also monitor your blood pressure during this time. Once this is done, the patient will be asked to lie on the side to go through resting echocardiography that will provide in-depth insight into the movement of the heart and health of internal structures, while resting. This will be done by applying a special gel to the skin and using a device called a transducer to emit sound waves and produce images.

Stress test: In this step, the doctor aims to increase or maximize the rate of your heart to record and analyse its functioning. The patient will be asked to exercise on a treadmill or a stationary cycle for 7-10 minutes or until the patient feels extremely tired. This will shoot the heart rate of the patient, helping in the assessment. During this time, ultrasound images of the heart muscles are taken to analyse the condition of the heart. The mode and intensity of exercise will depend on the patient’s condition; incase a person feels dizzy, weak or has pain in the chest – the doctor must be immediately informed.

Stress echocardiography: This test is conducted when the patient is asked to stop exercising because the heart rate has significantly risen, providing enough data for analysis. When the patient is asked to stop exercising, more ultrasound pictures of the heart are recorded till the time the heart rate, blood pressure return to normal. This helps to actually evaluate the working of the heart muscles under stressful conditions. 

Results of the stress echocardiography test

A stress echocardiography test is simple and very useful to know if there are any problems with the heart’s functioning. The test is extremely reliable, and the results are simple to interpret. If the results of the stress echocardiography test are normal, it implies that the heart is healthy, it is receiving an adequate supply of blood and oxygen even in stressful conditions, and that there is no blockage or narrowing of the coronary arteries. 

However, if the results of the stress echocardiography test are negative, the reasons can be intense and would need medical attention. Abnormal results indicate that the heart is devoid of essential nutrients, blood and oxygen during times of stress due to issues such as coronary artery diseases or a previous heart attack that has damaged the heart tissues. 

This test is also very useful in determining if the current cardiac rehabilitation plan of the patient is working effectively. In case, the results indicate otherwise, a change in medications and treatment may be opted for. 

In all, stress echocardiography is very useful in the early diagnosis of heart problems and risks of heart attacks. It is a simple, non-invasive and a very reliable test.

Life after Heart Bypass Surgery

heart bypass surgery is performed to restore the blood flow and oxygen to the heart by using blood vessels from another part of the body – such as chest, or leg veins – and connecting them with blood vessels that are below or above the blocked or narrowed artery; hence, leading to a bypass for the compromised artery. The number of arteries used to connect is dependent on the severity of the condition. The procedure is highly successful and is one of the prime methods used to correct blockages, narrowing or leakages in arteries. While the surgery itself might be quite strenuous, it is widely used to cure heart problems. But just the heart bypass surgery is not sufficient to guarantee good heart health and minimise chances of another heart problem or attack. The problems of the heart have been cured, but the underlying process of build of plaque could further block the carotid arteries leading to the brain, stop blood flow to the legs, or kidneys. In such cases, the patient might also suffer from a stroke, or several other diseases. However, if risk factors that can trigger health problem are removed, the chances of a healthy heart post a heart bypass surgery increase to large extent. Life after heart bypass surgery would require some strict modifications in lifestyle and adoptions of certain processes.

Slow Healing Process: Post a heart bypass surgery, the recovery period would be long and one must let the body regain strength slowly and steadily. Make steady improvements each day but never pressurise the heart in any condition. Consult the doctor about the involvement in physical activities.

No Smoking: Life after a heart bypass surgery will strictly restrict smoking. Smoking damages the lining of the arteries causing fat to build up, which ultimately leads to narrowing of the artery and hampering of flow of blood in the body. Not just smokers but even non-smokers are highly subject to developing heart diseases due to prolonged exposure to smoke.

Regular Medications: Once the heart bypass surgery is done, the doctor will advise certain medications to enhance the recovery of the heart and regain its strength. It is very critical to ensure that no dosages of the medicines are missed. These medications could include blood thinners (to restore blood flow), thrombolytics (to dissolve clots), nitroglycerin (to widen blood vessels), antiplatelet (to prevent new clots), and pain killers (to cub the pain). During the intake of these medicines, the body might experience few negligible changes such as sensitivity to bruise easily, longer bleeding from clots, etc.

Healthy Diet: After a heart bypass surgery, life needs to bring in changes in diet. Unhealthy foods that are high on cholesterol, sodium, trans fat, saturated fat, etc. should be avoided. Instead, foods such as green leafy vegetables, fish, whole grains, seeds, low-fat dairy, dry-fruits, fibre, etc. should be consumed and fit into the regular diet. Also, the diet should be full of nutrition.

Easy Physical Activity: One of the major causes of a heart problem is physical inactivity. Hence, once the heart problem is cured via a heart bypass surgery, the physical activity needs to improve. However, no strenuous workouts should be undertaken; only low-to-moderate physical activities such as walk should be assumed. Remember to not lift anything heavier than 10 pounds up until six weeks of heart bypass surgery. One can also resume sexual activity post consultation with the doctor.

Lowering Stress: Once done with the heart bypass surgery, one could practice yoga, meditation or increase involvement in hobbies to reduce overall stress and maintain heart health. It is necessary to manage stress after the heart bypass surgery because stress is also another factor responsible for heart problem. Stress increases heart rate and also shuffles the blood pressure, causing a lot of damage to the arteries.

Healthy Weight: Post the heart bypass surgery, management of weight become very critical to maintain a healthy heart. Obesity is one the major reasons for a cardiac arrest and needs to be completely sorted. Soft workouts each day, healthy eating, controlled calories intake, nutritional food should be adapted to maintain a healthy weight.

Limited Alcohol Intake: Life after a heart bypass surgery will not allow excessive alcohol. Strict limitations need to be put upon quantity of alcohol consumed. Excessive alcohol consumption increases chances of high blood pressure, cardiomyopathy, stroke, irregular heartbeats, etc. Too much alcohol is also a contributor for obesity, alcoholism and more. All of which could trigger the heart problem again.

Follow-up tests: Another very important factor that needs to be followed strictly after a heart bypass surgery is to have regular check-ups to keep an eye on blood sugar levels, cholesterol levels, blood sugar levels, etc.

Overall, life after a heart bypass surgery might not be as bright as before, but it certainly is not gloomy. It is another chance at life and one that needs attentive care and strict modifications in lifestyle.

Clogged Arteries: Causes and Treatment

Clogged arteries or also known as arterial plaque is a serious medical condition in which the arteries are blocked due to buildup of fatty deposits known as plaque on the inner walls of the arteries. These blocked arteries tend to reduce or completely block the blood flow, thus greatly endangering the life of a person due to heart attack or stroke.

Arteries are the blood vessels, which carry the oxygen-rich blood throughout the body from the brain to the tips of the toes. Generally, healthy arteries have smooth and high-functional inner walls, which help the blood flow through them easily. A buildup of fatty deposits due to unhealthy diet, sedentary lifestyle, etc. in the inner walls of the arteries, causes them to become narrowed or even completely blocked in some cases; thus, increasing the danger for a person.

Clogged arteries are also the underlying condition for coronary heart diseases and other circulatory disorders.

Causes of Clogged Arteries

Clogged arteries are a typical result of the accumulation or buildup of the fibrous and fatty substance (made of fat, cholesterol and cellular waste) called plaque. This blockage or buildup may be caused due to several factors such as:

  • Bad cholesterol: This type of cholesterol sticks your arteries causing plaque buildup and blockage.
  • Saturated fats: These fats found in meat and dairy products lead to an increase of bad cholesterol and build-up of plaque in the coronary arteries.
  • Trans fat: A type of fat found in processed food that accumulates in the arteries and causes blockages.
  • High blood pressure
  • High triglyceride: Triglycerides are a type of fat that block the arteries and thus lead to building up of plaque
  • Diabetes: High blood sugar leads to coronary damage-causing blockages.
  • Obesity: Excessive weight causes multiple other conditions such as high cholesterol, high blood pressure, diabetes, etc. 
  • Smoking tobacco
  • Family history
  • Increasing age
  • Stress
  • Lack of exercise
  • Dosage of harmful drugs such as cocaine and amphetamines

Plaque starts developing from childhood or teen years and eventually causes clogging of the arteries by one’s middle age or even later. In response to the buildup of plaque in the inner walls of the arteries, the cells of the artery walls multiply and thus, let out additional substances, which further worsen the clogged arteries. As these deposits increase, the person develops a condition known as atherosclerosis which makes the arteries narrow and hard, thus reducing the blood flow.

Complications of Clogged Arteries

Depending on where the plaque accumulates, the clogged arteries can affect different parts of the body and lead to multiple medical conditions. These include:

Coronary artery disease: Coronary artery disease is a condition in which the coronary arteries, which are responsible for supplying blood, oxygen and nutrients to the heart tissue, are narrowed or blocked due to build-up of plaque. When these arteries are blocked or narrowed due to accumulation of plaque – fatty material within the walls of the arteries – the heart is restricted or limited of supply of oxygen-rich blood, causing severe symptoms including a heart attack in severe cases.

Carotid artery disease: The carotid arteries are located on either side of the neck and are responsible for supplying oxygen to the brain. The accumulation of plaque in these arteries can cause a stroke.

Peripheral artery disease: Peripheral arteries are blood vessels which carry blood to the legs. When these arteries are blocked or narrowed due to accumulation of the fatty substance, the amount of oxygen delivered to the legs is reduced. This leads to pain, numbness or severe infection in the legs or feet.

Treatment of Clogged Arteries

Clogged arteries are a serious condition which needs medical intervention, as soon as they are diagnosed. Treatment for clogged arteries depends on the place and severity of the arteries, the general health and age of the person, and past medical history. Some treatment options include:

Lifestyle changes: A healthy lifestyle can help manage the clogged arteries and even treat the condition. These lifestyle changes can help prevent the clogging of arteries, in the first place, provided they are taken up early in life. These changes include:

  • Eating a nutritious diet which is low in saturated fats and cholesterol. Also, sugar and excessive intake of carbohydrates are not good. While on the other hand, fruits and vegetables should be included in the diet.
  • Quitting smoking
  • Maintaining a healthy body weight
  • Being physically active and engaging in exercise and workout
  • Managing stress levels
  • Keeping health vitals in check such as blood sugar, blood pressure and blood cholesterol levels

Surgical or interventional treatment: In some cases, where the clogged arteries have triggered a serious condition, surgical intervention may be required. Some of the common procedures include:

Balloon Angioplasty: Balloon Angioplasty is a surgical procedure performed immediately after a heart attack to restore the flow of blood in the heart by removing the blockages from the coronary arteries. These blocked arteries are a cause of heart attack and thus, this course of treatment helps the person recover and rejuvenate heart health by opening the blood vessels and restoring the supply of blood to the heart. It is the most commonly opted course of treatment where the doctor inserts a catheter mounted with a tiny balloon into the blocked artery through an incision in the arm or groin. The doctors then guide the catheter to the exact spot of blockage by using special dyes, X-rays, etc. and once it’s in the right position – the tiny balloon is inflated to remove the blockage from the artery and clear the passage to allow blood flow by pushing the plaque build-up to the walls of the artery. Once the blood supply is regulated, the balloon is deflated and removed from the body. This procedure is often time followed by the placement of a stent – a stainless steel mesh – in the heart of the patient to ensure the arteries do not clog again in future. Some stents (such as drug-eluting stents) are medically coated to keep the arteries from narrowing again.

Stent Placement or Stenting: Post angioplasty, sometimes the doctors’ place a stainless steel mesh is known as a stent in the heart to ensure the arteries do not clog again. Some stents are also medically coated to avoid narrowing of the arteries in future. These stents are placed on top of the balloon on the catheter, such as that upon the opening of the balloon, the stent opens up and reinforces the walls of the artery.

Bypass Surgery: A heart bypass surgery is performed to restore the blood flow and oxygen to the heart by using blood vessels from another part of the body – such as the chest, or leg veins – and connecting them with blood vessels that are below or above the blocked or narrowed artery; hence, leading to a bypass for the compromised artery. The number of arteries used to connect is dependent on the severity of the condition. The procedure is highly successful and is one of the prime methods used to correct blockages, narrowing or leakages in arteries.

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Cardiac CT for calcium scoring

Cardiac CT for calcium scoring, also medically called the coronary calcium scan or coronary artery calcium (CAC) scoring is a type of test which measures the calcium-containing plaque in the arteries. The test uses special X-ray tests to get detailed pictures of the inside of the heart.

Most calcium is the body is found in the bones and teeth, which helps them stay strong and healthy. However, calcium accumulation in the arteries is not a healthy sign. Calcium accumulated plaque in the arteries can grow and then restrict the blood flow to the muscles of the heart. Measuring the level of calcified plaque via a cardiac CT can help the doctor to identify potential coronary artery disease, even before the person experiences any signs and symptoms.

The results of the CT scan help the doctor to determine the cause, intensity of the problem and then accordingly initiate treatment.

Need for the test

 The doctor may ask the patient for cardiac CT to get a better understanding of the heart disease or when the treatment course is yet to be decided. A cardiac CT scan uses specialized X-ray technology, known as multidetector-row or multislice computerized tomography (CT) to obtain images of the plaque deposits in the blood vessels of the heart.

Plaque is a fatty composition of cholesterol, calcium and other materials found in the blood. It accumulated over time and sticks to the walls of the arteries, causing narrowing or blockages and further heart problems. Plaque restricts the flow of oxygen-rich blood to the muscles of the heart. It can also burst, thereby leading to the formation of blood clots that travel through the bloodstream and cause a heart attack.

Use of the test

A cardiac CT scan is used to detect the intensity of the situation, assess the presence of calcium in the plaque and accordingly frame the further course of action in terms of the treatment plan. The cardiac CT scan is most helpful in cases where the patient has a moderate risk of heart disease or the exact cause of the heart problem is not clear. This scan can also help people to make important lifestyle modifications and follow treatment.

However, the heart scan requires the person to be exposed to radiation. Even though the exposure is considered safe, yet the scan is not recommended if the risk of radiation is more than the benefit. That said, a heart scan is not recommended for the below types of patients:

  • Men under the age of 40 and women under the age of 50 years since it is very unlikely to detect calcium at a younger age
  • People with a very low risk of heart problem because detecting calcium with such patients is not easy unless they have a family history of heart problems
  • People who have a high risk since the scan will provide no details than already known. This is very applicable for heavy smokers or people with diabetes and high cholesterol levels
  • Patients that have symptoms or existing diagnosis of coronary artery disease, since the scan does not provide any information on the progression of the problem or risk
  • People who recently got a coronary calcium heart scan

Preparation for the cardiac CT scan

Before making the appointment for the cardiac CT scan, the patient must ask the doctor about any special instructions or other important things including the time of arrival, identification, paperwork, etc.

The doctor might advise the patient to avoid caffeine and smoking for at least four hours before the scan. Once, the patient is in the examination room, he/she will be asked to change into a medical gown. All jewellery in the neck or the chest will need to be removed.

Procedure for the cardiac CT scan

Before starting the procedure, the doctor will attach sensors known as electrodes to the chest. These electrodes are connected to an electrocardiogram (ECG or EKG), which records the patient’s heart activity during the exam. This also coordinates the timing of the X-ray images between the heartbeats, when the muscles relax.

During the scan, the patient is asked to lie on their back on a table which slides into a tube-like structure known as a CT scanner. The head of the patient is outside the scanner at all times. During this time, the patient can be given an injection or a medication to slow the heartbeat and get clear images of the heart and the arteries. The medication can help calm the patient.

The patient will need to lie still and hold their breath for a few seconds until told to release. During this time, the X-rays pictures are taken and the procedure only takes about 10-15 minutes.

After the procedure, the patient does not need to follow any special instructions and can go home the same day by driving on own. Normal activities and everyday schedule can be followed without any hassle or precaution.

Results of the cardiac CT scan

The results of the tests are expressed as Agatston score, which is a number that reflects the total area of calcium deposits and the density of these deposits. The results can be read as:

  • Zero indicates that there is no trace of calcium in the heart and there is a low chance of heart attack in the future
  • A score between 100-300 implies that there is a moderate level of calcium in the heart, which is relatively associated with a high risk of heart attack and other heart diseases over the coming five -6 years
  • Any score greater than 300 implies an urgent need for treatment since it represents high to severe disease or heart attack risk

Overall, a higher score implies higher risk. Moreover, a percentile score also represents the persons’ risk in comparison to others of the same age or sex.

Difference between TAVR and SAVR – Risks and benefits

Aortic Stenosis is a condition where the aortic valve of the heart does not open completely because of the thickened valve leaflets, causing irregular heart functioning and creating pressure on the left ventricle of the heart – which is mainly responsible for pumping blood. In such a condition, the heart responds by thickening the walls to retain the pumping pressure. However, it might weaken the heart and even lead to heart failure, if not treated in time. Two major treatments for Aortic Stenosis are Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (SAVR).

Transcatheter Aortic Valve Replacement (TAVR) or Transcatheter Aortic Valve Implantation (TAVI) is a surgical method performed to repair a compromised, blocked or narrowed artery which was disrupting the blood and oxygen supply to the heart. This surgical procedure is recommended for patients who have a higher risk or are too sick or suffer from severe aortic stenosis, or too old for open-heart surgery. This breakthrough procedure is advanced than a standard valve replacement.

Where no other procedure guarantees long term benefits, this procedure provides a statistically significant mortality rate and is regarded as a boon for people who were considered inoperable. It was, in fact, first tested in 2002 on patients with severe aortic stenosis (a narrowing of the aortic valve opening), who were considered unfit for open-heart surgery. TAVI/TAVR outperformed in the trials with patients’ significantly better recording higher mortality rate.

Not only does a TAVI/TAVR procedure act as shining armour for a heart patient with no hope, it also has faster recovery time in general cases. The ease of performing, recovery time and the process is as simple and equivalent to that of a coronary angioplasty or in some cases even coronary angiography. In most cases, a patient is expected to recover within 3-4 days post a TAVI/TAVR procedure. During the recovery, the doctors will prescribe medicines and also follow up with tests and physical examinations.

That said, a TAVI/TAVR treatment has both benefits and risks involved. Some of the benefits include:

  • Reliable alternative to open-heart surgery
  • High survival rate
  • Less invasive
  • Less damage or chances of infection
  • Faster recovery period

Risks involved in a TAVI/TAVR procedure include:

  • Bleeding
  • Abnormal heartbeat and rhythm
  • Kidney disease
  • Adjustment problems with replaced valve
  • Stroke

On the other hand, Surgical Aortic Valve Replacement (SAVR) was the standard treatment for patients suffering from severe aortic stenosis, until the discovery of TAVR/TAVI. Surgical Aortic Valve Replacement istraditional,open chest surgery that replacesdamaged aortic valves and is recommended for patients whose condition is strong enough to manage this surgery and the recovery.  A SAVR is preferred for patients with low-risk. In SAVR procedure, an incision is made in the chest to reach the heart; once through, the heart is placed on a heart-lung bypass machine, while the damaged aortic valve is replaced with a new one. The heart is then restored and the incision is closed. SAVR has shown great results on patients who are suitable for the surgery. Though the recovery time post a SAVR procedure is long and approximately requires 5-7 days of hospitalization, plus at least 6 weeks of full recovery.

Benefits of choosing to a Surgical Aortic Valve Replacement are:

  • Lower chances of a permanent pacemaker
  • Matured method
  • Long span of valve

A SAVR procedure may involve certain risks such as:

  • Infection
  • Blood clots
  • Stroke
  • Irregular heart rate
  • Longer recovery time
  • Acute kidney injury
  • Blood transfusion

On one-to-one comparison, A TAVR scores much higher than a SAVR on various parameters such as non-invasiveness, shorter recovery period, lower risk of complications, uncertain life span of the valve, better quality of life, and estimated longer span of life. However, for cases where the patient needs a valve replacement, an open-heart surgery – SAVR is the ideal choice.

That said, there are multiple other factors (listed below) that play a significant role in evaluating the choice between TAVR and SAVR.

  • Anatomical parameters such as the size of the aortic valve and blood vessels, size of the aortic annulus, etc.
  • Type and severity of aortic disease such as coronary artery, multi-valve, bicuspid valve, etc.
  • Other health issues such as diabetes, lung problem, heart attack history. etc.
  • Frailty such as age, power grip, physical activeness, etc.

It is very important to weigh all benefits and risks while evaluating all options of treatment. Even the doctor will consider all factors and also conduct several tests such as an ultrasound, echocardiogram, cardiac CT scan, and cardiac catheterization to determine which procedure from TAVI/TAVR or SAVR is best suited to your condition.

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