Believe me, I know my way around hospitals better than anyone would want to. So my aim in on this page is to share with you some hard-earned information that may make your life easier and less anxious.
Here’s the role I’d like to play for you. You know how, when you visit your neighborhood drugstore with a new prescription, the pharmacist asks if you have any questions? I want to be like that pharmacist, someone who can help you as you struggle to understand confusing (and sometimes conflicting) information, someone you have known and trusted for years. My purpose is to help you find your way down the road to knowing your own heart health.
Truthfully, there are only so many tests that can possibly be prescribed for you, and I’ve had all of them—every single procedure, blood test, and stress-related treadmill trip that you’ll be likely to face. So think of me as your guide through the bewildering labyrinth of hospital corridors, and hospital procedures. Ladies, talking to me is like talking to your sister who had three children before you had your first baby. It’s comforting to hear from someone who has actually been through it.
Now then, let’s get going.
You are experiencing chest pain, shortness of breath, rapid pounding heartbeats, sweating, and a feeling of impending doom. You’re a mess. You’ve tried to reason with yourself that you’re only having, say, a panic attack—not a heart attack. After all, panic attacks are certainly common; many of us have experienced them at one time or another. You’ve read a few articles and talked with your friends. The body reacts to anxiety by producing stress hormones, and it’s these stress hormones that are causing your symptoms, right?
But your chest continues to burn; dizziness, weakness, nausea, and severe indigestion (along with a heightened sense of anxiety) are flooding over you. Are you having a panic attack or a heart attack? Both can display similar symptoms, and panic attacks are nothing to scoff at. But symptoms that last for more than two or three minutes, or pain that leaves and then returns, could signal a heart attack. Only by having testing can a correct diagnosis be made.
You decide to go see your doctor—or maybe even go to the emergency room—because you can’t talk yourself into believing you’re having a panic attack. Good for you!
The physical examination is always the first stop on your journey to heart health. That walk down the hallway to the patient room never changes, does it? And somehow it’s always necessary to step on that blasted scale—no matter how we’re dressed or what time of day it is. (No doubt you’ve observed throughout this book my aversion to scales of all kinds.)
As a long-time patient I’ve learned some tricks, however. I try to make all my appointments early. I wear lightweight clothes and flip-flops, even if it’s cold outside, in an attempt to reduce the dreaded scale shock. (Of course, I live in California.) Actually, I do know why they have to take your weight initially. It’s because your body-mass index (BMI) is an important heart risk factor. Once we have that established, however, what woman wants to weigh herself continually?
Waiting, waiting in my puke-green gown open at the back. Hold on, since it’s a checkup for my heart, should the opening be in the front instead? I’ll be embarrassed if I put it on wrong. For the record, you won’t find this checkup to be much different from any other checkup—blood pressure, pulse, listening to your heart with a stethoscope, questions about medications. Pretty much the usual drill.
Oh, and a blood test is prescribed. This test requires a 12-hour fasting period—no eating at all—before they draw your blood. I hate fasting, for any purpose! I look up the type of blood test that’s on my prescription. Advanced lipid testing. Not everyone needs advanced lipid testing—I’m having this blood test after my diagnosis of heart disease. The advanced lipid testing is simply the designation for the in-depth process that directly measures the amount of lipids in your body. In the normal range, lipids are necessary for good health. But when lipids are out of the normal range, they may represent a risk factor associated with heart disease. If your lipids are out of normal range, you (and your doctor) have several options, including diet, exercise, and drug therapy that will help return them to normal and maintain the health of your heart and body.
Either way, though, your initial blood test will be a fasting blood test for blood count, basic blood profile that addresses kidney and liver function, blood sugar, albumin, and the electrolytes such as sodium, potassium, and calcium. The full lipid profile I mentioned immediately above really should be done, so be sure to ask if it has been ordered, since who can ever read the scribbles on a prescription form?
In addition, the advanced lipid testing measures total cholesterol, HDL and LDL cholesterol, and triglyceride levels; hs-CRP and Homocysteine are also ordered because they may show abnormalities that are predictive of heart disease. I advise you to ask that your thyroid function, called TSH (thyroid-stimulating hormone) be checked as well. An underactive thyroid can sometimes be associated with high cholesterol levels.
In addition, I’ve had an episode where my thyroid became hyper—overactive rather than underactive (called hyperthyroidism). It scared me because the symptoms of hyperthyroidism seemed to mimic the symptoms of a heart attack. My heart was having unusual palpitations, I had cold sweats, and I felt really lousy. So you might consider asking to have that TSH blood test; since they already have that needle in your arm, what’s another tube of blood? That’s how I look at it.
What I don’t like about full lipid profiles is that usually they can’t be performed in your familiar local doctor’s office. Because it’s a complicated blood test, in my area, for instance, there are only two places to choose from. Both are overcrowded, and being there makes me feel like I’m sicker than I am. I’ve learned to leave an hour before these labs are open, bring a book or newspaper, and just sit outside and relax, trying to be one of the first patients. You can’t eat or drink coffee anyway, so why not get out of the house?
If you opted to go to the emergency room, you probably had an electrocardiogram (EKG). If you went to your own doctor, however, an EKG might be prescribed, or even performed on the spot if they have the necessary equipment. If you’re reading this book and have never had any reason to have an EKG, good for you. You are either one healthy person, fairly young—or you know how to avoid medical situations. Even before heart disease, I had many EKG’s. It seems you can’t have surgery of any kind without one.
* Update, all of 2015 I did not have to do anything more than lift up my shirt while having my EKG, yah. But, to make it very simple: For an EKG, you’ll be asked to remove all clothing above your waist. If you’re lucky (and many times I have not been lucky), you are given at least a paper gown of some sort in an effort to preserve your dignity. You lie down on a table. A number of circular sticky adhesive patches are placed on your ankles, arms, and upper body. (Women: Usually the technician has to move your breast a bit, because one or two of the adhesive patches must be placed strategically under your breasts.) In any case, the testing doesn’t take long to perform. If the results are abnormal, however, you may be asked to stay right on that table with those sticky patches on your body until they decide if they wish to redo the test.
An EKG simply measures the electrical activity of the heartbeat. With each beat, an electrical impulse travels through the heart. This impulse causes the heart muscle to squeeze and thus pump blood. The EKG does not hurt. It does not send any electricity into the body. Of course, a slight minor risk could be a skin irritation from those sticky patches, which I seem to get every time.
This simple test can help a doctor determine how long the electrical impulse takes to pass through the heart. The EKG can reveal, among other things:
• abnormally fast or irregular heart rhythms;
• abnormally slow heart rhythms;
• abnormal conduction of cardiac impulses (which may suggest underlying cardiac or metabolic disorders);
• evidence of a prior heart attack;
• evidence of an evolving, acute heart attack;
• evidence of an acute impairment in blood flow to the heart during an episode of a threatened heart attack;
• adverse effects on the heart from various heart diseases or systemic diseases, such as high blood pressure and thyroid conditions.
Please be aware that some women have abnormal EKG’s, or EKG’s that fail to show the presence of early heart disease. This is your time to be your own advocate! Side note: EKG and ECG mean the same procedure. EKG was favored due to the similarity of a completely different test EEG.
If your test results are normal, then you might have no further need of testing. However, please be aware that some women have abnormal EKG’s, or EKG’s that fail to show the presence of early heart disease. This is your time to be your own advocate! If you have doubt about the results of your EKG, or if your symptoms continue, have your heart checked out. Again.
Then there is the Holter monitor, which is usually prescribed when a patient has heart palpitations (a sensation of fast or irregular heart rhythm). This device works like a portable EKG machine. (I wore one during my visits to cardio rehab.) I highly recommend this test if you feel what you suspect might be symptoms of heart problems—and if those feelings keep happening when you’re not at your doctor’s office.
The Holter monitor records an EKG continuously for 24-48 hours, then plays back its readings in ultra-fast mode through a computer, allowing the doctor to see the status of the heart at all times during the monitoring period. Amazing, huh? Since the monitor can be worn during your daily activities, it helps the physician correlate symptoms of dizziness, palpitations, or blackouts. This recording over time is much more likely to detect any abnormal heart rhythms than the EKG, which lasts less than a minute. It can also help evaluate the patient’s EKG during episodes of chest pain—during which time there may be telltale changes to suggest ischemia (reduced blood supply to the muscle of the left ventricle)—and it may show extra heartbeats, periods of irregular heartbeats, periods of rapid heartbeats called SVT or VT (supraventricular tachycardia or ventricular tachycardia). All of these readings will help your doctor decide if you need further testing.
For me, it was comforting to know that, when I exercised or became agitated, the monitor might be able to give the doctor some signs of what I was experiencing. Request it, if you have any doubt. It’s a good test.
Even better, however, is an Event Monitor. Dr. Johnston prescribed that for me when I became his patient. It was great, too, because the event monitor only has two patches, compared to 12 with the Holter Monitor. Event monitors are small, portable devices that can carried in a purse or attached to a belt or shoulder strap like a portable tape or CD player. Event monitors are used to record heart rate and rhythms for longer periods when symptoms are infrequent. The monitors may be carried for several days or even a few weeks. Most monitors are designed to record the heart rate and rhythm only when a button or switch is turned on. For example, when a symptom occurs, the patient can turn on the event recorder, which would then record the heart rate and heart rhythm. The readings can be downloaded over the phone, allowing a cardiologist to determine if there was a problem when the symptom were occurring.
Now let’s say that these initial tests indicate that more testing is required. Maybe, for example, the initial tests showed a high level of LDL you could be prescribed more advanced blood tests, such as the ones I mentioned a few paragraphs earlier—which will show the presence of CRP, Homocysteine, and Lp(a). Elevated levels of CRP (for C-reactive protein), for instance, may provide evidence of arterial inflammation, which has been linked to future cardiovascular events. Homocysteine is an amino acid in the blood. Too much of it is related to a higher risk of coronary heart disease, stroke, or peripheral vascular disease (fatty deposits in the peripheral arteries). Homocysteine may promote atherosclerosis by damaging the inner lining of arteries and promoting blood clots.
If you have checked into the emergency room with the symptoms of a heart attack, then a blood test will show if you have indeed had an attack. How, you ask. Because when you’ve had a heart attack, cells in the heart die and release enzymes into your bloodstream. Measuring the amount of these markers in the blood can show how much damage was done to your heart. These tests are often repeated at intervals to check for changes. A troponin test, for example, checks the level of this enzyme in the blood. It is considered the most accurate blood test to see if a heart attack has occurred and how much damage was done to the heart. Other diagnostic tests include CK or CK-MB tests and myoglobin tests.
What I learned as a result of these in-depth blood tests was that I had a high level of Lp(a)—often referred to as the “heart attack cholesterol.” (Terrific news, huh?) This type of cholesterol is highly genetic and not terribly responsive to diet or exercise. By the way, high Lp(a) readings are not an excuse to neglect a healthy regimen of diet or exercise!
Then we have the noninvasive heart tests. The first one is usually the Exercise EKG Test. It could also be the Exercise Stress Echocardiography test (often known as the stress echo test) or the Exercise Stress with Nuclear Imaging. I lump these tests together for one reason: all three require that you exercise on a treadmill.
The first one I mentioned, the Exercise & Recording EKG Test, involves walking on a treadmill set at a higher elevation than you’d normally pick at the gym and recording an exercise EKG. (The technician can raise the elevation, too, as a means of testing your heart’s capacity and strength.) This test will detect atherosclerotic narrowing of the heart arteries. You wear the same kinds of patches as if you were having an EKG, but you’re exercising instead of lying on a metal table.
Being me, I wore a cute sweatsuit with matching tennis shoes for my first such follow-up test. My very first exposure to this test was in the hospital, where I didn’t get to choose my attire. I did learn, however, that you can request hospital-provided pants; maybe it’s just me, but I appreciated being able to wear them with my gown. In my own mind, it made my outfit complete and helped me feel more in control of my situation. But let me save you some time. You’ll be asked to change into a gown (open at the back, of course); all that would be seen of your cute sweatsuit, I discovered, is about two inches of the legs.
False positives (that is, results that indicate falsely the presence of coronary artery disease) are more common in people who before the test would have been considered to have only a very small chance of having this disease, who are taking certain medications, and who have pre-existing abnormal EKG’s. Let me tell you: I can do 30-45 minutes at the gym on a treadmill, but 10 minutes on the treadmill test makes me feel like a perspiring, overweight old woman. Maybe it’s a combination of the level of intensity, the incline, and the doctor and nurse standing beside you in case you keel over, but don’t feel bad if you have a hard time with this test.
Most important, women seem more likely to register a false positive on this test. False negative tests also occur. Remember that my first test was an exercise stress test in the hospital, and it had only a “slight finding.”
The next type of test—the exercise stress test with echo—allows the physician to see how the patient’s heart is functioning while the patient is engaging in physical exertion. I recommend that women request this test first, if possible. Having the doctor see your heart while you’re panting on the treadmill seems to me to be the best option. This test can be useful to determine:
• the extent of a coronary artery blockage;
• the prognosis of patients who have suffered a heart attack;
• the effectiveness of cardiac procedures done to improve circulation in coronary arteries; and
• the cause(s) of chest pain.
Another type of stress test calls for the physician to inject a radioisotope such thallium or cardiolyte into your vein before you walk on the treadmill. (Do not allow this test to be performed if you think you might be pregnant.) This test is particularly useful in patients who have poor echo images, certain types of EKG abnormalities, or severe underlying heart muscle disease.
Here’s how the nuclear stress test works: When the patient reaches his or her near maximum level of exercise, a small amount of a radioactive substance is injected into the bloodstream. The isotope mixes with the blood in the bloodstream and enters the heart muscle cells. If a part of the heart muscle isn’t receiving a normal blood supply, less than a normal amount of the isotope will be found in those cells.
A second picture of the heart, taken after the injection of another dose of the isotope, will be made either before or after the exercise portion of this test when the heart has been at rest.
After exercising, the patient lies down on a special table under a camera that can take pictures of the irradiated blood flowing into the heart muscle. The pictures, made shortly after the exercise test, show blood flow to the heart during exercise. It is an effective way of finding out what’s going on inside your heart muscle. If, for example, the test shows that blood flow is normal during rest but not during exercise, then the heart isn’t getting enough blood while under stress. If the test is abnormal during both exercise and rest, then there’s limited blood flow to that part of the heart at all times, and you may have suffered a heart attack in the past.
A stress test may not be recommended for certain patients with known heart disease or other conditions. If you are a patient who may not be able to exercise using the treadmill, you’ll still be able to take the test. A drug or pharmacologic agent can be administered to simulate the rapid heartbeat achieved during exercise or alternately to increase blood flow to the heart.
Still another type of test—Electron Beam Computerized Tomographic (often referred to as EBCT) Imaging of the coronary artery—is used to detect calcium deposits found in atherosclerotic plaque in the coronary arteries. In the interest of full disclosure, I personally have not had this test; it only became available after I had already been diagnosed with heart disease. There’s no reason, in my opinion, to have this test if you’ve already been diagnosed with coronary artery disease, as I had been.
Amazingly enough, these tests are now offered at all sorts of locations, even at a big mall in our area! If you can afford it, go for it. It’s a very simple, non-invasive procedure. State-of-the-art computerized tomography (CT) is the most effective way to detect coronary calcification from atherosclerosis, before symptoms develop. I’ll repeat that: before symptoms develop. More coronary calcium means more coronary atherosclerosis, suggesting a greater likelihood of significant narrowing somewhere in the coronary system and a higher risk of future cardiovascular problems. Your doctor can use the calcium-score to evaluate the risk of future coronary events. Therefore, it’s important to realize that certain forms of coronary disease (“soft plaque” atherosclerosis, for example) can escape detection during this CT scan. So you need to know that the CT test may not be able to predict your degree of risk of a life-threatening event such as a heart attack. Nonetheless, don’t pass it up if you can afford it.
The 64-Slice CT Scan (MRI Coronary Angiography and CT Coronary Angiography) is the hot new test that you might have seen on “Oprah,” as I did. When I saw this testing device featured on such a high-profile TV show, I assumed (mistakenly) that it wasn’t available to the general public. I figured that my only option for the most detailed testing would be the traditional “gold standard” test: the angiography. However, I’ve learned that many insurance companies cover this test. Mine did.
During my bout with hyperthyroidism, it was recommended that I have the 64-Slice CT Scan rather than the invasive angiogram. It was a spectacular option for me! In reading about this test, I learned that this machine is the most sensitive, accurate CT technology available in the world today—four times more sensitive than the previous generation of devices. If you are at risk for heart disease, stroke, or aortic aneurysm, then having a 64-slice scan can be the answer. This test has the power to reveal problems that can be missed in routine physicals and the early stages of diagnosis.
The 64-slice CT allows for the precise identification of both calcified and non-calcified plaques, and for the early initiation of treatment to prevent heart attacks and sudden cardiac death. Doctors can identify potentially life-threatening coronary artery disease at its earliest stage, without discomfort to the patient because the procedure is noninvasive. This scan also allows patients to find out the cause of unusual symptoms, to check out risk factors due to heredity, or to reassure themselves that they really are healthy.
The examination itself is non-invasive and nearly painless. A small intravenous (IV) catheter will be inserted into a vein in your arm. The so-called “contrast agent” will be injected into this catheter, allowing the doctor to see the images transmitted by the scanner.
Because the best images of the coronary artery are obtained with a heart rate or pulse of 55-70 beats per minute, you may be given a beta blocker about two hours prior to the exam. The goal is for the heart to be as still as possible during the scan, which results in clearer pictures. While waiting for my beta blocker to take effect, I started talking up a storm to the technician about my medical history, and about this book. Both the cardiologist and the technician listened to me in amazement—but I was allowed to sit next to the cardiologist while he viewed my arteries. Admittedly, I could barely tell you what I saw, or what it meant, but my point is that it doesn’t hurt to ask to be given a ringside seat.
Your doctor may discuss some of the preliminary findings with you immediately following the exam; however, the results of your scan must be processed by an experienced physician trained to read CT coronary angiography. It usually takes one hour or less from the time you arrive at the imaging center until the exam is completed.
A few details about the test itself: First of all, unlike an MRI scanner, which can be a very claustrophobic experience, the CT scan is a doughnut-shaped structure that does not have this effect. Trust me—I’ve had both, unfortunately. You lie on what looks a big bed, which slides inside a circular tube. But (and this is a big “but” for me and lots of others who share my claustrophobia) you are not enclosed. The machine itself does the moving, and it really doesn’t take long. You do have to change into a gown, but it covered me up well, and my clothes were tucked away in a locker.
During the scan, you are asked to hold your breath for about 10 seconds and to avoid moving. By the way, it’s normal to feel a warm sensation for a few seconds when the contrast agent (I just thought of it as plain old dye) is injected. Following your examination, you’ll be able to change back into your regular clothes.
Angiography is another type of test, but an invasive one. Angiography or arteriography (also called cardiac catheterization) is a medical imaging technique that allows the doctor to get an inside view of your arteries and the chambers of your heart. The image produced by this procedure is called an angiogram.
Here’s how it works: First they apply a local anesthetic to numb a specific area—usually your right inner groin. Then they make a very small incision there and insert a long thin tube into your femoral artery (one of the largest arteries, it leads directly to your heart). The doctor guides the slender tube all the way to your aorta (the main artery of your body) and into the beginning of your coronary arteries, where a contrast agent is injected.
The purpose of this incredible procedure, of course, is to allow the doctor to see inside your heart and the surrounding blood vessels. If there are blockages that are causing your symptoms, the doctor will be able to see them on a monitor sitting right beside you.
The procedure itself takes an hour or more, but the preparation and recovery time may add several hours. After the procedure, you’re required to lie flat for a period of time, and you may receive medication to reduce any discomfort. Once you get home, you’re not supposed to overexert for a day or two, and to gradually increase your activities until you reach your normal activity level.
In the not-too-distant past, the preferred treatment for blockages due to coronary artery disease (CAD) was a procedure known as balloon angioplasty. (I hope I’ve made it clear that CAD occurs when blood flow to the heart is restricted due to hardened arteries that have become clogged with plaque deposits.)
The goal of balloon angioplasty is to push the fatty plaque back against the artery wall to make more room for blood to flow through the artery. And improved blood flow may reduce the risk of heart attack and sudden cardiac death. Balloon angioplasty was also used as treatment for a heart attack in some emergency facilities. The way this procedure worked was much the same as the angiography I just described. The major difference is that a smaller catheter with a balloon attached is inserted through the diagnostic catheter into the coronary artery. When the balloon-tipped catheter reaches the site of the blockage, the balloon is rapidly inflated, pushing any plaque back against the arterial wall. The catheter is then removed.
These days, though, in most cases the doctor will implant a stent in that spot to hold the artery open. The stent—a little tube made of wire mesh—is fitted over the balloon. When the balloon is inflated, the stent expands and locks in place, forming a kind of scaffold that keeps the artery open. A newer type of stent called a drug-eluting stent gradually releases a drug that helps to keep the artery from closing again.
Other standard treatments for CAD include medication and bypass surgery, which involves constructing little detours around blocked coronary arteries using healthy blood vessels from elsewhere in the body. By the way, bypass surgery is now performed so often in the United States (nearly 500,000 times in 2003, according to the latest data available from the American Heart Association) that the patient may only need to stay in the hospital four to five days afterward.
I’m almost done with my guided tour, but I need to inform you of two other tests—both intended to rule out carotid artery disease. Looking back on what I went through, I certainly understand the need for these tests, though I did not understand at the time. The first was an MRI of my brain, which I was told was ordered to check for the presence of transient ischemic attacks, or TIA’s, which are actually little strokes that resolve within 24 hours. Not good things to experience, eh? But no one told me why they were doing this test until after the results. Fortunately, my brain MRI showed no presence of brain damage. (Yes, that sounds funny, especially if you know me.)
The other test was the Doppler ultrasound, which uses sound waves to check blood flow and measure the thickness of your carotid arteries. This test was quite simple. I laid on a table while what seemed like a microphone went up and down the sides of my neck. This is a great test to see if you are at risk of having a stroke.
The reason I feel it necessary to mention this last part is that strokes are the number-three killer in the United States, and a leading cause of disability among older Americans. Also, if you have carotid artery disease, you may also have coronary artery disease. Here are the risk factors for carotid artery disease (note that they are identical to those for coronary artery disease):
High levels of low-density lipoprotein cholesterol (bad cholesterol) and triglycerides in the blood.
Because my treating cardiologist was stunned to learn that I did indeed have heart disease, he made sure to also test for carotid artery disease. Fortunately, my tests showed no TIA’s or blockage. But my larger point in telling you about these tests is to emphasize that we owe it to ourselves to ask questions. Don’t have a test performed on you without knowing what it’s for.
And with that, my friends, we have completed our stroll down the yellow brick road of diagnostic testing. As I said at the beginning of this chapter, there are only so many tests that can possibly be prescribed for you, and I’ve had all of them. Knowledge is most certainly power. Somehow it seems right to me to give my mom the last word in this very serious chapter. She’s fond of saying, “If you live long enough, you will live long.” I think she means that our technology, medications, and treatments keep getting better, so we’re lucky to be living in these days of high-tech medicine.
But now I find that I can’t leave the last word for anyone else—even my mother! Learn! Ask questions! Inform yourselves. It’s your body! Your brain. Your heart.