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Click on the name of a test to read more about it:
The stress test is performed when the patient has complaints, or provider has concerns regarding the possibility of coronary artery disease or heart damage. There are other reasons that a stress test might be performed, such as to evaluate a patient for rhythm disturbances, evaluate the patient for peripheral arterial disease- blockages in the arteries of the legs, or to determine whether a therapy that has been recommended or initiated has achieved its desired effect. A stress test can be performed utilizing a number of different methods. In general, regardless of the method chosen, a stress test involves the placement of electrodes on the chest of the patient. Electrocardiograms are performed during the stress test at varying intervals and will be compared to the resting electrocardiograms obtained. These will assist in the determination as to whether a test is considered normal or abnormal. There are other times during a stress test that electrocardiograms will be performed. These might include the need to determine what the cause of an irregular heart rhythm might be. A stress test performed with only electrocardiograms and no imaging methods caries a higher frequency of being falsely positive or falsely negative. The test in all likelihood will be performed with some method of imaging- echocardiographic or nuclear. Heart Care Center is pleased to be able to offer a number of different stress testing methods in order to determine the cause of chest pain or rhythm disturbances. A stress echocardiogram is performed to evaluate the motion of the heart, the function of the valves, the chamber sizes, the muscle movement, and the great vessels that come from or lead to the heart. This test in conjunction with the electrocardiogram has been very useful in determining the absence or presence of coronary artery disease. The echocardiogram portion of the study is performed at rest and immediately after exercise. The resting echocardiogram and the exercise echocardiogram are then compared for changes. Some of these changes are normal and some are abnormal. NUCLEAR STRESS TESTING At other times, the healthcare provider may determine that a nuclear stress test will suite the patient better than a stress echocardiogram. A nuclear stress test looks specifically at the way blood flows through the heart muscle and also looks at the overall function of the heart. A nuclear stress test is performed by first starting an intravenous access. After that, a small amount of radioactive material called a tracer will be injected into the vein and will go to the heart among other organs. Pictures are then taken at rest of the heart from many different angles. Following that, the patient will undergo stress testing via any number of different modalities. At the peak of the stress test, an additional amount of radioactive material will be injected and pictures will be taken following the completion of the stress portion of the study. The resting and stress pictures will then be compared and a determination will be made along with the interpretation of the electrocardiograms performed as to whether there is evidence of blockage in the arteries of the heart. Stress testing can be performed with exercise or may be performed with pharmacologic agents. These agents or drugs, simulate exercise, and give us the same result as exercise might provide. We only use these pharmacologic agents, however, in the event that the patient is unable to exercise to the level needed to achieve an accurate result. The agent chosen is determined based upon the overall health issues the patient has. This test will take approximately 4 hours to complete. Please bring a lunch or other snack to be taken when you are instructed to do so.
An echocardiogram is a test performed on the heart by using high frequency ultrasound. It is very similar to the type of study performed on a pregnant woman when looking at a developing baby. Care is taken during all testing to maintain and protect your personal privacy and modesty.
The ultrasound is bounced off of the heart structures and a picture is made of the heart on a monitor, to be interpreted by the interpreting physician. The ultrasound technician who performs the study, is highly trained, educated and registered with a certifying agency in the performance of these tests. During the test, electrocardiogram electrodes will be placed on the chest in order to monitor your heart rhythm during the echocardiogram. Additionally, a gel, which is water soluble and not staining, will be placed on your chest in order to achieve the highest quality ultrasound images possible. The heart is imaged from a number of different angles, so you will notice that you may be asked to lie on your back or your side, or to extend your neck in order to achieve images of the structures that are needed to complete this study. An echocardiogram can be used to evaluate a patient’s valves, heart muscle, heart motion, chamber sizes, and can be used to evaluate the great vessels that either enter into or leave the heart. During the performance of the echocardiogram, you may hear noise that represents blood flowing through the chambers of the heart and the across the valves. Associated with this noise you may notice color flashes of red, blue, yellow, white, orange, to name a few on the monitor. These sounds and sights represent the direction that blood is flowing at that particular time and are used to determine whether disease is present or not. This type of study is called a Doppler examination. After the test is complete, you will be asked to clean the gel off of your chest with a towel or gown. The study will be interpreted by the physician either immediately or later that day. In any event, within 24-48 hours, on working days, you will receive a phone call from a practice provider and the results of the test will be discussed with you. This same echocardiographic technique can be used to perform a stress echocardiogram in conjunction with the stress test described elsewhere. This test will take approximately 75 minutes to complete.
DOBUTAMINE STRESS TESTING Dobutamine is a compound derived from a naturally occurring product in the body called epinephrine or adrenaline. It is very short-acting and simulates exercise. During the administration of this drug, the patient will notice that the heart is beating faster and stronger. At times, a rhythm abnormality might occur as a result of the use of this medication. This is a short-lived event and is easily reversed when the drug is discontinued. The physician or provider is in the room at all times during the administration of this medication. It is generally out of the blood stream in 8-10 minutes after turning off the intravenous infusion.
LEXISCAN
STRESS TESTING Lexiscan is a derivative of a normally occurring compound in the body called adenosine. Adenosine is used by the body for many different functions including the synthesis of DNA, which is the genetic material. It is used inside and outside of cells to communicate between cells and it acts directly in the arteries of the heart to cause dilatation. We use Lexiscan, a derivate of adenosine, to determine the absence or presence of coronary artery disease. It is also short-acting, usually out of the blood stream in 7 minutes after its administration and has its peak effect at 1-2 minutes after administration. You may notice a flushing sensation, some very mild shortness of breath, some chest pressure, and even occasionally nausea. These side effects pass very quickly and are not dangerous to you. If you have a history of asthma and are wheezing at the time of the test, or if you have lung disease and are wheezing at the time of test, then Lexiscan will not be administered. If you have asthma or lung disease and are not wheezing at the time of the test, Lexiscan can be safely used. Heart Care Center is proud of its record of providing quality testing from registered ultrasound and nuclear technicians. Our Nuclear Technician is certified by the Nuclear Medicine Technology Certification Board. All of our Ultrasound Technicians are certified by the American Regitry of Diagnostic Medical Sonographers and are Registered Diagnostic Cardiac Sonographers. Some have attained or are in the process of attaining the Registered Vascular Technician status. Russell Silverman, M.D., F.A.C.C. has gone to great lengths to provide quality equipment and certified laboratories to assure that the quality of the study being performed meets the expectations of nationally recognized leaders in these specific areas. Heart Care Center has achieved certification in echocardiography from the Intersocietal Commission on Accreditation of Echocardiographic Laboratories, certification in vascular studies from the Intersocietal Commission on Accreditation of Vascular Laboratories, and certification in nuclear studies from the Intersocietal Commission on Accreditation of Nuclear Laboratories.
CAROTID
ULTRASOUND A carotid ultrasound is a non-invasive study performed on the carotid arteries. The carotid arteries are responsible for delivering blood supply to the brain. Strokes occur when these vessels are severely diseased or occluded. The technicians performing these studies follow the stringent guidelines set forth to assure that the quality of the study meets the expectations of the interpreter and the Intersocietal Commission for Accreditation of Vascular Laboratories. Heart Care Center has a registered vascular technician on its staff that oversees the performance of these studies and assures quality control.
The performance of a carotid ultrasound is done utilizing an ultrasound machine. The ultrasound image is achieved utilizing the most up-to-date ultrasound imaging equipment available. The patient will lie on his or her back and the neck area will be exposed. Great care is taken to avoid any contamination of the patient’s clothing with the ultrasound gel. The ultrasound gel is a water soluable material that assists in achieving high quality images. It will be applied to either side of your neck where the carotid arteries travel. The carotid arteries provide blood supply to the entire brain in conjunction with two smaller vessels that go up the back of the neck called vertebral arteries. All of these arteries will be imaged to the best of our ability and a number of measurements will be made. You will hear sound that represents blood flowing through these arteries and you may see colors flashing, which represent direction of blood flow. This test will then be evaluated and interpreted by the registered interpreting physician. Within 24-48 hours of the performance of the study, during normal working days, the patient will be informed of the results. At times, further testing may be necessary if significant blockage is noted to be present in these arteries. This test is used in patients who may be threatening to have a stroke or who may have already had a stroke or an event that is transient and has resolved. This test is also used when, by physical examination, a noise called a bruit is heard in the neck. The bruit might represent a blockage causing blood to flow turbulently through the artery and, thus, making this abnormal sound. This study will take approximately 30-60 minutes to complete.
TRAN-CRANIAL DOPPLER EXAMINATION A transcranial Doppler examination is performed when it is necessary to determine if a patient’s symptoms might be from an abnormality in blood flow in the base of the brain. The Circle of Willis is a very special area in the base of the brain that provides blood supply to most of the brain. It can be likened to a traffic circle. Blood flows in and out through a number of different arteries and blood flow can even reverse in these vessels to supply blood to areas that are in need of it. This is a very specialized test to look at the cause of stroke when it is not evident by other testing. It is frequently used to determine if a small hole in the heart- allowing a small blood clot to enter into the arteries- has actually contributed to the neurologic event that may have taken place. At times, an injection of saline or salt water with the patient’s own blood mixed in can be injected into an arm vein and the flow might be noted in the Circle of Willis through the transcranial evaluation. This would be an abnormal finding and strongly suggestive of a small hole in the walls that divide the two top chambers of the heart. This is called a patent foramen ovale. You will hear this term used if a trans-cranial Doppler examination with a bubble study is requested. You will note that gel is applied to a number of different sites on the skull including the eyes (the eyes are shut of course), the temple, the area in front of the ears on both sides, the areas behind the ears on both sides, and at the base of the skull in the back. This will all be explained to you by the technician as the study is performed. You will hear noise, which will represent the flow of blood through these very special arteries in the base of the brain. Usually within 24-48 hours on normal working days, you will be informed of the results of this study and if any further testing is needed. Based upon the results of any of these tests noted above, it may be recommended that you have further investigations. You may be asked to have an intravenous line inserted in your arm. This is used to inject about 10 mL of a mixture of sterile saline, with about 1 mL of your own blood and about 1/10 of the milliliter of air. This combination is agitated together. It bubbles will rise to the top of the syringe and only the microsized bubbles are injected into your arm. This test will help identify certain defects in the heart chambers that might allow microscopic clots to pass into the circulation of the brain and potentially cause a stroke. This test may take about 30 minutes. The risk of this test is extremely small and strokes are not caused by this type of study as a rule. Rest assured that Dr. Silverman and the staff of Heart Care Center only refer patients to other physicians who are of the highest quality and training in the performance of invasive studies. These might include a heart catheterization, an angiogram of the legs, an angiogram of the head and neck, or other invasive or non-invasive studies. These will be discussed with you fully before a further referral is made. Your questions will be answered to the best of our ability.
PERIPHERAL ARTERIAL DISEASE Peripheral arterial disease is a rapidly expanding area of interest as it is responsible for loss of limb and function due to blockage in the arteries that provide blood to the legs and arms. Peripheral arterial disease is associated with coronary artery disease and vice versa. At least 50% of patients who have a blockage in an artery of the heart may have a blockage in artery of the leg, arm or arteries of the head and neck. As well, 50% of patients who have coronary artery disease may have an abdominal aortic aneurysm and those who might have an abdominal aortic aneurysm have at least a 50% chance of having coronary artery disease. You can see therefore that the relationship of vascular disease to the heart and to the peripheral arteries is a very closely related issue. You should not be surprised therefore that if a blockage is found in one area of the body, a blockage might be discovered elsewhere. We are certified and accredited to evaluate these issues. Our highly trained staff is overseen by a Registered Vascular Technician and Russell Silverman, M.D., who has specialized training and certification in the performance and evaluation of vascular testing.
PULSE-VOLUME RECORDING A pulse-volume recording is a test preformed on the legs to evaluate the patient for peripheral arterial disease. In general, 3-4 blood pressure cuffs are placed at specific areas on the legs and are inflated at different times. The object of these blood pressure cuffs is to evaluate the changes in volume that the legs undergo when the heart pumps blood into the arteries of the legs. These changes are then recorded and evaluated by the technician and the interpreting physician. A decision is made as to whether there is or is not a blockage. If it is felt that a blockage is present, then further evaluations utilizing ultrasound to image the arteries and measure the blood flow through these vessels may be recommended. This test will take about one hour.
PERIPHERAL ARTERIAL
DUPLEX IMAGING Peripheral arterial duplex imaging utilizes ultrasound to image the arteries and veins based upon the symptoms of the patient, and the areas of interest that need to be evaluated. An imaging gel is applied to the leg over the region where the arteries or veins being imaged are located. Utilizing a sophisticated ultrasound system, pictures will be obtained of the vessels in question. As well, the velocity of blood through these arteries and veins will be measured and interpreted as to whether there is or is not any significant blockage present. As with other ultrasound Doppler tests, you may hear sound which represents blood flowing through the arteries and veins. You may also see flashes of color on the monitor. This also represents the direction of blood flow. You will then be notified of the results of the study and as to whether any further investigation is necessary. This test will take between one and 2 hours to complete. You may be asked to return to the office at a later date for completion of the study if the study is felt to be too complex for taking longer than expected.
Russell Silverman, M.D.,F.A.C.C. is a highly trained cardiologist who has been Certified and Re‑Certified in Cardiovascular Diseases. He received his education and training at the State University New York-Upstate Medical University. He graduated medical school with honors as a member of the Medical Honor Society- Alpha Omega Alpha. As well as having achieved the F.A.C.C designation- Fellow of the American College of Cardiology- he has, through continued study and testing as well as participation in National and International studies achieved Fellowship in the American Society of Echocardiography (FASE). This designation is extremely difficult to obtain and maintain. Dr. Silverman has gone to great lengths to achieve these accolades in order to assure you, the patient, that the work being done on your behalf is at the highest level of knowledge and technology. Dr. Silverman has also achieved the designation of Registered Physician-Vascular Interpretation. This involves the performance of a number of different vascular studies and having passed a stringent examination showing proficiency and knowledge in the areas of vascular disease. Recently, Dr. Silverman has become a Fellow of the American College of Physicians. The American College of Physicians is an organization of internists who are recognized for quality of diagnosis and patient care and have shown continued education and achievement in the area of patient care. Associated with Dr. Silverman are a staff of nurse practitioners and physician assistants, who continue to learn and sharpen their diagnostic skills and ability. These individuals are overseen by Dr. Silverman and your care is discussed with Dr. Silverman. All patients seen by a Nurse Practitioner or Physician Assistant are discussed with Dr. Silverman. No patient’s care is ignored. In addition to the certified nurse practitioners and physician assistants, Dr. Silverman’s ultrasound technicians are all Registered Diagnostic Cardiac Sonographers. They have and continue to achieve high levels of ability and training by continually learning new techniques through discussions with Dr. Silverman and other ultrasound technicians. We have on staff as well, a Registered Vascular Technician, and I am proud to say that the other technicians are also in the process of achieving this designation. You can rest assured that the technicians who are performing your study are highly trained and committed to providing you with the highest level of expertise available. Heart Care Center will only have technicians, mid-level providers, nursing staff, and administrative staff of the highest quality. We will not accept anything, but the best for our patients.
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