This section will describe the partnership steps that are taken to helping you achieve a potential cure or control of your condition. While most of these steps are generic for any condition they will provide a template of a mutual understanding of expectations from each step. Not all steps are required for every illness, sometimes we receive the results of these tests from your primary care doctor or cardiologist. Other time we will order additional tests dependent on your condition.

Step 1: Consultation

Consultation is the process where we sit down to review your particular condition including symptoms. Symptoms can typically include palpitations, shortness of breath, dizziness, chest pain, fluttering in the chest. Occasionally there are no symptoms to review and your condition maybe one of prevention or your doctor found an incidental finding on the electrocardiogram (EKG (LINK). After understanding your symptoms we review how often you are plagued by them and how long they last for. We then review your history and try to understand how long you have had these symptoms.

After the initial investigation into the problem we then will review your medical history to better understand your risk factors and what is causing the current problem. This process is more important for certain conditions such as patients with pre-existing heart conditions such as heart attacks, angioplasty, bypass surgeries, patient who have had heart problems from birth.

After a review of the tests that have already been done a plan is formularized. The plan will review all treatments options that may be available for your condition. The plan may entail additional testing. Risks and benefits of each treatment will be reviewed and a treatment plan will be initiated.

GOALS of the consultation includes:

1. For the healthcare provider to truly understand what you are feeling
2. To review how severe your condition is or how much it bothers you
3. Review if additional testing is required
4. Review treatment plans available
5. Review which treatment plan you are comfortable with and if it is appropriate medically

Step 2: Physical Exam
Your doctor will start with a physical exam, asking you about:

• Your medical history
• Any symptoms you may have

Your doctor will also check for:

• Heart enlargement
• Irregular heart sounds
• Abnormal sounds in the lungs
• Swelling or tenderness of the liver
• Water retention

Step 3: Electrocardiogram (EKG)
Usually an electrocardiogram is done as part of the initial visit. Since the electrical activity of the heart is fluid and constantly changing on a beat to beat basis, the EKG is only a snap shot of the heart’s electrical system. It provides useful information regarding the circuits of the heart. It is a simple test. This is a painless test using electrode patches on your skin that shows how electrical signals travel through your heart and prints them out on paper.

Parts of an EKG

The spikes on an EKG recording are called waves. Each wave tells your doctor a story about how your heart is working:

• The P-wave shows your heart's upper chambers (atria) contracting
• The QRS complex shows your heart's lower chambers (ventricles) contracting
• The T-wave shows your heart's lower chambers (ventricles) relaxing

Insert EKG strip with labels.

GOALS of an ECG:

1. Identify whether there are electrical abnormalities of the heart
2. Identify risk factors that may reflect future problems in the heart’s conduction system

Step 4: Blood Tests
Occasionally laboratory blood tests are done they can show how well your kidneys and other organs are functioning normally. Other organs especially the thyroid gland may be responsible for creating heart rhythm disorders.

Step 5: Chest X-Rays
A chest x-ray can show whether you have an enlarged heart or fluid around your lungs. These features can be suggestive of heart failure or sometimes other heart conditions.

Step 6: Echocardiogram
This test (also called an echo) uses ultrasound to create images of your heart as it is beating. The echo helps your doctor learn about your:

• Heart valve function
• Heart wall thickness
• Blood flow through the heart
• Strength of the heart muscle

The echocardiogram also provides your doctor with another important heart measurement: ejection fraction (also called EF). Ejection fraction helps doctors gauge heart failure severity because it measures the percent of blood pumped out of the ventricles during each beat. A normal ejection fraction is approximately 50%-65%. A person with heart failure often has an ejection fraction less than 40%. This number is an important number to remember as it is a powerful risk factor for sudden cardiac death and other potential dangerous arrhythmias.

Step 7: Stress Testing
Test overview

The patient either walks on a treadmill or is given IV medication which simulates exercise while connected to an EKG machine. Using ECG and blood pressure monitoring alone, the test is variously called a cardiac stress test, exercise stress test, exercise treadmill test, exercise tolerance test, stress test or exercise ECG test. If radioactive isotopes are also used then it is usually called a nuclear stress test. Patient lay under a camera to then pick up the radioactive material that goes to the heart muscle. This is compared to resting images to see if there is a relative difference between the stress images and resting images. If there is the likelihood that the heart artery supplying that region of the heart has a block is high. However, balanced global reductions may still not be recognized because absolute blood flow is not quantitatively measurable, only regional comparative variations.

Purpose

The purpose of a stress test is to detect if an heart artery is blocked. Like all tests, stress testing has problems with both falsely positive and falsely negative results compared with other clinical tests, this is because it is not directly looking at the heart artery but at the flow to the muscle. Other tests maybe needed to further investigate a positive test.

Step 8: Cardiac Catheterization (angiogram)
In a heart (or cardiac) catheterization, one or more catheters are inserted into a blood vessel in your leg, with x-ray guidance. Catheterization can help determine the:

• Extent of coronary artery disease
• Amount of blood flowing through your blood vessels and heart

A catheterization involves:

• Numbing the groin area
• Placing a catheter into a blood vessel in the groin
• Threading the catheter through the vessel into the heart
• Conducting tests on your heart arteries by injecting dye or contrast material