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Heart disease can often be identifiedthrough signs and

symptoms that are de-tectable before a heart

attack or other medicalemergency.

HEART DISEASE, LIKE MOST DIS-eases, has symptoms and signsthat can help you determine if you

need to visit your doctor. A symptom is something like pain or

other discomfort. If you were walkingbarefooted, for instance, and stubbed yourtoe on a rock, it would hurt. This pain isa symptom. It is subjective and cannot bemeasured. Your toe may also turn red orblack and blue as a result of the injury.This is a sign. You can see the change inthe color and so can your doctor.

History and Physical Exam

When you visit your doctor’s office orgo to the emergency room, the first ques-tion you will be asked is, “Why are youhere?” He is asking you to talk about yoursymptoms to the best of your ability, suchas, “My chest hurts,” or “I am short ofbreath,” or “My ankles are swollen,” etc.

This information is recorded as the“chief complaint,” or the main reasonyou sought medical help. The doctorwill next ask how long you’ve had thisproblem and compile what is called a “his-tory of the present illness.”

Your general medical history willalso be taken: what drugs you are con-

suming; if you have had allergic reac-tions to any medicines; any previous op-erations. You will be asked about prob-lems related to your head and brain;your eyes, ears, nose, and throat; yourlungs and your heart; your abdomen,gall bladder, and intestines; your uri-nary system and genitalia; your armsand legs; and so forth. That is called a“review of systems.”

When the questioning is done, a phys-ical examination will be performed tocheck the results of the review of systems.Each time you’re admitted to the hospital,you will undergo a new history, review ofsystems, and physical examination.

Chest Pain

When people think about heart dis-ease, the first symptom that usuallycomes to mind is chest pain. However,chest pain can be caused by a number ofconditions, only some of which are relat-ed to the heart. Following are some com-mon causes of chest pain:

♥ gall bladder attack♥ inflammation of the pericardium

(pericarditis), which usually hurtsmore when you breathe

C H A P T E R F O U R

SIGNS AND SYMPTOMS OFHEART PROBLEMS

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S T A T E O F T H E H E A R T

♥ back problems♥ conditions related to the aorta

(sometimes the aorta begins to tearapart, called aortic dissection, andthis can cause severe pain in thefront of the chest or in the back)

♥ conditions in the esophagus andsometimes even a hiatal hernia

♥ inflammation of the lungs♥ conditions in the upper abdomen

Angina Pectoris

The most common type of chestpain associated with the heart is a dis-comfort known as angina pectoris. Thiscondition, related to ischemia, is causedwhen the heart muscle itself does not getenough oxygen through the coronary ar-teries. Sometimes called simply “angina,”the condition is often described not somuch as pain but as discomfort. It maybe predictable, coming on with exerciseand going away with rest, or it may bemore unpredictable, coming on at rest andremaining. It can also be brought on bystress or extremely cold weather. However

it presents itself, angina is an importantwarning mechanism. The body is signal-ing you to take it easy or a heart attackcould develop.

There are several classic symptomsassociated with angina, including:

♥ a tightness, heaviness, or pressure ♥ a burning, crushing, or squeezing

feeling over a general area in the frontportion of the chest

♥ the feeling that somebody has justpiled heavy weights on your chest orthat your chest is in a vise (it can some-times almost take your breath away)

♥ a dull, aching pain, usually locatedjust to the left of the breastbone orsternum over the heart

♥ discomfort that radiates from thechest to the back or the neck andeven up to the jaw and teeth (some-times there is only jaw pain thatcomes and goes with exertion, orsometimes the angina radiates fromthe chest over the heart, or down onearm or the other, usually the left arm)

♥ in some patients, angina will actuallypresent as a pain or discomfort inthe upper abdomen and even causenausea. When this occurs, it can mimicgall bladder disease, esophageal dis-ease, or stomach ulcers

Angina doesn’t always mean pain.Sometimes it just appears as shortnessof breath, which doctors refer to as “angi-na equivalent.” In this case, there is usu-ally no pressure or pain.

In fact, some patients experience nosymptoms when their heart is not get-ting enough blood. They may not evenhave any angina in the midst of a heartattack. This is referred to as a “defectiveanginal warning system.” It is morecommon in diabetic patients, particular-ly those who have long-standing dia-betes and are being treated with insulin.

Angina that occurs for no particularreason while the patient is resting is re-

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Chest pain, known as angina pectoris, is

the classic symptom ofcoronary artery dis-

ease. Chest pain can,however, be caused by

other factors.

Ischemia:A condition that occurs

when a portion of the body, an organ ortissue, is not gettingenough oxygenatedblood. It is usually

related to a blockage inone of the arteries delivering blood to

that area.

C H A P T E R F O U R : S I G N S A N D S Y M P T O M S O F H E A R T P R O B L E M S

ferred to as “rest angina.” It usually in-dicates a more severe degree of coronaryartery disease. Severe rest angina mayeven wake up a sleeping person. Usuallyit can be relieved by putting nitroglycerintablets under the tongue.

Heart Attack (Myocardial Infarction)

Although angina doesn’t necessarilymean you are about to have a heart attack,any change in your condition should beacted upon quickly. Typical signals of animpending heart attack include anginathat is more severe or lasts longer thana few minutes.

The chest discomfort associated witha heart attack, or myocardial infarction,may last for several hours (longer thana usual angina episode) and may notrespond to nitroglycerin tablets, or evenintravenous nitroglycerin at the hos-pital. Heart attack victims may requireintravenous morphine or other drugs torelieve the pain.

Although heart attack symptoms areusually clear, heart attack victims maynot experience any angina and may “justnot feel well.” In some cases, patients re-port a sudden onset of heartburn andshortness of breath. These are often ex-plained away as merely indigestion andonly later will the actual cause becomeclear. Sometimes heart attacks are evendiscovered long after they have occurred,and, in retrospect, patients recall nosymptoms at all.

Difficulty Breathing

The medical term for shortness ofbreath is dyspnea. It is often describedas a hunger for air. It can be the symp-tom of an underlying problem, such aslung disease or anemia, or simply thenormal result of exertion, such as vigor-ous exercise.

There are certain types of dyspneathat occur at night and are usually relat-

ed to heart failure. A person may sudden-ly wake up very short of breath and haveto sit up in bed. A window may have to beopened for fresh air. After sitting uprightfor a while, the person is finally able to re-sume a normal breathing pattern. This iscalled paroxysmal nocturnal dyspnea.Some people must have their head andchest elevated to avoid shortness of breathwhile sleeping. Some can only sleep sittingup in a chair. This type of dyspnea iscalled orthopnea.

Dyspnea can be caused by many con-ditions. In patients with defective heartvalves, blood may leak backwards into thelungs. This excess fluid in the lungs caus-es the lung tissues to swell, resulting inshortness of breath. Other patients maysuffer from heart muscle problems, calledcardiomyopathy. This can cause the bloodto back up into the heart and lungs, alsoresulting in dyspnea.

Shortness of breath associated withheart disease can cause coughing andwheezing, although coughing and wheez-ing are frequently due to other problems aswell, such as lung disease. Smokers oftensuffer from both heart and lung disease.

Of the most severe forms of heartfailure, one type of advanced shortness ofbreath is called pulmonary edema. In thiscondition, the lungs literally fill with fluid.Patients are treated with powerful diuretics,which eliminate some excess fluid throughthe kidneys. They may also be given drugsto help the heart contract more forcefully. Inmost cases, pulmonary edema can be treat-ed with medicines, but it can be so severethe patient may have to be connected to amechanical ventilator. If a ventilator is need-ed, most patients can be removed from it ina day or two. In other patients, dependingupon the underlying cause, further inter-vention may be necessary.

Patients who are short of breath tendto breathe more rapidly. This rapid breath-ing is known as tachypnea. It can be as-sociated with heart failure but isn’t al-ways. Hyperventilation is a somewhat dif-

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Cardiomyopathy:A condition in whichthe heart muscle is notable to contract orfunction properly.

Dyspnea:The sensation of beingshort of breath.

Tachypnea: Abnormal rapid breathing.

Hyperventilation:Breathing fast in such a manner that the carbon dioxide level in theblood falls to an abnormal level.

S T A T E O F T H E H E A R T

ferent type of rapid breathing. If you’rehyperventilating, it feels as if you can’tcatch your breath, and you breatherapidly. The cause may actually be ananxiety attack unrelated to heart dis-ease. Often a physician is needed to dis-tinguish between tachypnea and hyper-ventilation.

Coughing Up Blood (Hemoptysis)

Coughing up blood is occasionallyrelated to heart disease but is more com-monly associated with lung disease andother respiratory problems. When it isassociated with heart disease, it mayoccur during acute pulmonary edema, orswelling of the lung tissues. One of theclassic causes of pulmonary edema andhemoptysis is a narrowing of the mi-tral valve, called mitral valve stenosis.This narrowing is a late consequenceof rheumatic fever.

Fatigue

Fatigue, or feeling tired or weak, canbe caused by a number of different con-

ditions, including heart failure, depression,a low red-blood-cell count (anemia), orhypothyroidism, meaning your blood isdeficient in thyroid hormone. It can alsobe caused by some drugs used to treatheart disease, like metoprolol, a betablocker, or verapamil, a calcium block-er. These drugs cause the heart muscleto contract less forcefully. When con-tracting with less force, the heart muscledoes not need as much oxygen and isable to function satisfactorily even whensome of the coronary arteries areblocked. On the other hand, because theheart is not pumping as much blood, thepatient may feel fatigued, tired, or weak.Sometimes doctors need to adjust drugtreatment to reduce fatigue.

Fatigue can also be a symptom ofheart failure because the heart is notpumping as much blood.

Swelling (Edema)

The medical term for swelling, inwhich tissues become engorged withexcess fluid, is referred to as edema.Edema can be caused by a number of

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Fatigue is but one of many symptoms

that can alert the individual that medical

diagnosis and/or treatment is in order.

C H A P T E R F O U R : S I G N S A N D S Y M P T O M S O F H E A R T P R O B L E M S

different problems and tends to occur inparts of the body affected by gravity.Swelling may start in the feet and anklesand, as it gets more severe, may involvethe entire leg. In certain severe cases itmay extend to the abdomen.

Edema can occur in the legs as a re-sult of problems like kidney failure, liverfailure, blood clots in the veins in thelegs, and local infections in the legs.Sometimes mild swelling in the feet andankles is related to nothing more than sit-ting in a chair for a long time, such as inan airline seat during a long flight. It canalso be caused by having your legscrossed for extended periods.

If edema involves the lungs, it is usu-ally due to heart failure. The lungs becomeswollen or edematous, and this is typ-ically what causes the shortness of breathassociated with heart failure.

Edema caused by heart failure mayfirst show itself in swollen feet and ankles.The usual treatment is diuretic drugs,which will cause you to eliminate fluidthrough your kidneys. Heart failure mayalso be treated with drugs that dilate thevessels, or with a drug like digitalis (alsocalled digoxin or Lanoxin), which has anumber of effects but is also believed tocause the heart to contract more vigor-ously and thereby relieve the heart fail-ure to some degree, thus relieving theswelling also.

A severe form of swelling is calledanasarca. This swelling extends through-out the body but affects the legs and ab-domen more than the chest and the face.It can be caused by severe heart failure. Itcan also be caused by other problemssuch as liver failure or kidney failure,and in severe forms of anasarca, one mayaccumulate extra fluid inside the abdomi-nal cavity, which is called ascites.

Edema, anasarca, and ascites, whencaused by heart failure, result becausethe failing heart is no longer able to pumpthe appropriate amount of blood. As a re-sult, the blood backs up, blood pres-

sure rises in the lungs, and blood ispushed further backwards to the liver andother abdominal organs. This causes thefluid in the blood to leak out through theblood vessels into the tissues.

Pleural Effusion (Fluid in the Chest)

Pleura are the thin membranes thatline the inner wall of the chest cavity andthe surface of the lung. Normally, thepleura of the chest cavity come in con-tact with the pleura of the lung. Pleuralmeans “related to the pleura,” and effu-sion in this case refers to fluid that hasescaped from blood vessels or othersmall vessels called lymphatics.

Therefore, a pleural effusion is fluidthat abnormally collects in the chestcavity between the inside chest wall andthe lung. The fluid is not inside the lung.Sometimes, several quarts of fluid can ac-cumulate. When a large volume of fluid ac-cumulates in either the right or left chestcavity, it can interfere with lung functionbecause the lungs cannot fully expand,and this can cause shortness of breath.Pleural fluid usually either is clear or hasa slight yellowish straw color. In manycases, it is quite similar to the serumor plasma of the blood, without thered and white blood cells.

There are many causes of pleural ef-fusions. They could develop as a resultof heart failure, liver failure, or kidney fail-ure or be related to a tumor in thechest. Sometimes, fluid can accumulatein the chest cavity for other reasons,such as an infection. In this case, the ma-terial may be pus. Sometimes the fluid isbloody, and when related to trauma, thefluid may actually be blood.

The treatment of pleural effusiondepends on its cause. The simplest andmost immediate way to treat a pleuraleffusion is to do a procedure called apleurocentesis, or “chest tap,” in which asmall spot of skin on the chest is anes-thetized, a needle is inserted through

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Anasarca:A generalized swellingof body tissues due to excessive fluid, usually from failure of an organ like theheart, kidney, or liver.

Ascites:An abnormal accumu-lation of serum-likefluid in the abdomen.

Pleurocentesis:Also referred to as a‘chest tap’. A procedurein which a hollow tubeis inserted through theskin into the chest cavity. This is usuallydone by attaching aneedle to a syringe sofluid that is abnormallypresent in the spacebetween the innerchest wall and lung can be removed.

S T A T E O F T H E H E A R T

the chest wall into the chest cavity, andthe fluid is drained off. Sometimes, if itrecurs or if the pleural fluid is ratherthick and won’t come through the needle,a small incision is made in the side ofthe chest and a plastic tube about thediameter of a finger is inserted into thechest cavity to drain this fluid. Rarely, amajor surgical procedure is necessary toremove this fluid and treat the underly-ing cause.

If this fluid is present because ofheart failure, it can frequently be treatedby medicine that addresses the heart fail-ure. Diuretic drugs cause the patient toexcrete excess fluid through the kidneys,and this will help the pleura to reabsorbthis excess fluid in the chest cavity.

Small pleural effusions are fre-quently present after heart operationsand usually are reabsorbed naturallyduring the first few weeks after thesurgery. Occasionally, pleurocentesisis necessary to draw off this fluid, andsometimes a second pleurocentesismay be necessary. Sometimes a chesttube has to be placed to remove thisfluid. Usually, once it has been treatedafter heart surgery, pleural effusion doesnot recur.

Loss of Consciousness, Fainting,Blackouts (Syncope), and

Lightheadedness (Near Syncope)

Losing consciousness, fainting, pass-ing out, or blacking out are medicallyknown as syncope. It is usually causedwhen the brain does not get enough blood,and it can be related to heart diseaseand other conditions.

Pilots flying fighter jets like the F-16can get lightheaded or black out whenthey make a very tight turn, such as a9G (nine times the force of gravity) turn,during which blood pools in their legsand not enough of it gets to their head.This problem can be avoided with a spe-cial suit that inflates during a tight turn

and compresses the legs, abdomen, andchest to keep more blood in the head.

Syncope can be related to disease inthe arteries that go from the aorta to thebrain. If these become narrow or blocked,the result may be a syncopal episode. Inthe worst-case scenario, tiny pieces ofatherosclerotic material may break offfrom the artery wall and go to the brain,which can cause a stroke.

A relatively common problem withthe aortic valve is aortic stenosis, in whichthis heart valve becomes blocked and notenough blood gets through. When a per-son with aortic stenosis is exercising, notenough blood may be getting to the brain.The person may become lightheaded andfeel as if they are going to pass out. Theymay even pass out. It is usually just fora few seconds, but it can be very frighten-ing and even dangerous.

Syncope can also be caused by otherheart problems. For example, if yourheart beats in an abnormal rhythm calledan arrhythmia, your heart rhythm maybecome very slow, or even miss a fewbeats or several beats in a row. Thiscauses lightheadedness or even un-consciousness that passes after theheart begins beating again. You may alsodevelop syncope as a result of veryfast heart rhythms; so fast, in fact — inthe range of 180 to 250 beats per minute— that the heart is no longer able to ef-fectively pump blood. In this case, notenough blood gets to the brain.

Vasovagal Fainting and Dizziness

Vasovagal fainting (neurocardiogenicsyncope) is believed to be the most com-mon type of syncope. It is estimated that3 percent of emergency room visits in theUnited States are for this type of fainting.Vasovagal technically refers to the effectthe vagus nerve has on the blood ves-sels, but in a broader sense it refers to theeffects various nerves have on the heartand blood vessels.

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Vagus Nerve:A nerve running from

the base of the skullinto the abdomen. It

gives off branches tovarious structures,

and its main effect onthe heart is to slow

heart rate.

C H A P T E R F O U R : S I G N S A N D S Y M P T O M S O F H E A R T P R O B L E M S

The two types of nerves that affectthe heart and blood vessels are calledsympathetic nerves and parasympathet-ic nerves (like the vagus nerve). If thesenerves are too sensitive, they can causeepisodes of low blood pressure or slowheart rate or both. This may temporarilystarve the brain of blood.

One test used to determine if a vaso-vagal reaction is the cause of fainting iscalled the tilt-table test. The patient liesflat on the back on a special table and isconnected to an electrocardiogram ma-chine. Under close observation by aphysician, the table rotates to an uprightposition that may cause a vasovagal reac-tion or other neurologically related typeof fainting.

Several medications can effectively treatthese types of problems. Occasionally thesepatients may need a heart pacemaker.

Dizziness is different from lighthead-edness in that a person feels uncomfort-able, as if the room is spinning, but usu-ally does not feel as if he or she is about topass out. A good example is the feelingthat occurs after getting off a ride such asa roller coaster at an amusement park.Dizzy spells can also be caused by ear dis-orders or other problems. In many cases,people misinterpret their dizziness as a

cardiac problem, although it is not relatedto their heart.

Palpitations

A palpitation occurs when you canactually feel your heart beating. It may bejust one heartbeat that seems strongerthan the others or a series of heart-beats — and it can be uncomfortable.Palpitations are sometimes felt when yourheart switches into a different rhythm,beats extra beats, or misses beats.Sometimes palpitations are more notice-able at night when you’re lying still in bed.They can be felt in your chest, up in yourneck, or even in your ear. You may even beable to hear your heart pulsating.

Palpitations can be purely normal,but not always. An abnormal palpitationoccurs when you can feel your heartbeating very rapidly or skipping beats orthere seem to be extra heartbeats. Thisproblem should be brought to your doc-tor’s attention.

Patients who have recently under-gone heart surgery frequently complainthey can feel their heart beating at night,particularly when they lie on their leftside. It’s noticed after they are home fora few weeks and have recovered to thepoint that many of their aches and painsare gone. This type of palpitation is oftencaused by adhesions or fibrous connec-tive bands forming around the heart dueto the heart surgery. One experiences thisfeeling because the heart pulls on theseadhesions as it beats. Usually this isnothing to worry about, and it typicallysubsides with time.

Your doctor can determine if any pal-pitation is an abnormal heart rhythm orjust the result of one of these other bother-some but less important causes. However,in general, people with heart diseaseand recent heart surgery also tend tobe more sensitive to their symptomsthan other people might be. This isunderstandable.

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During anelectrocardiogram, or ECG, the heart’selectrical rhythm is recorded. This is a useful test for detecting many cardiac abnormalities.

S T A T E O F T H E H E A R T

Skin Color

Changes in skin color may some-times be associated with heart diseasebut can also be due to many other caus-es. Children’s skin may have a bluishtint due to heart abnormalities they wereborn with in which unoxygenated bloodis pumped out to the body. The lips andthe fingernails may also be a bluishcolor. This is referred to as cyanosis.

Adult patients can have cyanosis forother reasons. Lack of oxygen in the bloodcan be related to heart conditions or othercauses such as lung disease.

Interestingly, there is a conditioncalled argyria or argyrosis. Argenti is the

Latin word for silver. Prior to World War II,there were some antibiotic-type sub-stances that contained silver and wereused to treat infection. Over time, the silveraccumulated in the skin, turning it a silverblue color. It is a rare condition today. Ihave seen only one man with this condi-tion and it was very noticeable becausehis skin was a bright silver blue.

Pale or almost white skin, fingernailsand lips are generally not caused by aheart condition but rather by a low redblood cell count, or anemia. In peoplewith darker skin colors, one can look atthe color of the tissue beneath the fin-gernails and toenails to check for cyanosisor anemia.

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Fig. 4.1:The artery on the left

is normal, or open, in contrast with the

occluded, or blocked,artery on the right.

Blocked arteries canlead to heart attack

or stroke by shutting off blood supply

to organs like the heart or brain. Fig. 4.1

C H A P T E R F O U R : S I G N S A N D S Y M P T O M S O F H E A R T P R O B L E M S

Shock

Shock can be caused by a numberof different abnormalities and is typical-ly accompanied by very low blood pres-sure. When shock is related to theheart, we refer to it as cardiogenicshock. Cardiogenic shock may be causedby a heart attack in which a large por-tion of the heart muscle suddenly dies. Itmay be due to one of the heart valvesrupturing, or it may be caused whenpart of the heart muscle between the leftand right ventricles (the septum) rup-tures. Another cause may be cardiactamponade, or a buildup of fluid betweenthe heart and the pericardium.

During cardiogenic shock, the amountof blood pumped by the heart cannotkeep the blood pressure in a normalrange. The pulse is usually very weakand sometimes described as “thready.” Theskin is usually cool and clammy. Becauseof the decreased amount of blood gettingto the brain, the person’s mental condi-tion may be very impaired, even to thepoint that the person is barely responsive.Breathing may be shallow. Pulmonaryedema may be present because the bloodis backing up into the lungs, causing thelung tissues to become swollen. Urineoutput is minimal. If this condition isnot treated quickly, the person may die.

Sudden Changes in Vision, Strength,Coordination, Speech or Sensation

If a person develops sudden changesin vision, strength, coordination, speech,or sensation, this could be due to astroke. If these signs and symptoms lastfor only several minutes or less, it iscalled a transient ischemic attack (TIA).However, if these symptoms persist beyondtwenty-four hours, this is called a stroke

or sometimes a CVA, which stands forcerebral vascular accident.

Strokes can result from many differ-ent causes. They can be caused by a bloodclot breaking loose from the heart or ar-teries and traveling to the brain. This iscalled an embolic stroke. An embolus issomething, usually a blood clot or ather-osclerotic material, that breaks looseand travels through the blood vessels. Anembolism could occur as the result of aninfected heart valve from which a clumpof infected tissue breaks off and travels tothe brain. Another common type of em-bolism occurs when a piece of cho-lesterol breaks off from plaque in anartery and travels elsewhere (Fig. 4.1).

Strokes also occur as a result of aproblem in the brain itself, such as blockedblood vessels, the rupture of an aneurysm,or other types of bleeding. Strokes canaffect the function of your arms or legs,vision, speech, and swallowing, abilityto think, and sometimes other bodily func-tions. Stroke victims can even go into acoma or die.

Leg Pain (Claudication)

Leg pain caused by a lack of oxy-genated blood getting to the leg musclesis referred to as claudication. This typi-cally results from the same atheroscle-rotic process that blocks coronary arter-ies. As you exercise your legs, by walk-ing for example, they feel tired and startto ache. Resting causes the aching andtiredness to go away, and you can get upand walk further. The claudication mayoccur in various portions of the leg, includ-ing the calf, thigh, or buttocks, depend-ing on where the artery is blocked.However, tiredness in the legs or leg paincan also be due to other causes, includ-ing disc problems in the lower back.

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Cardiogenic Shock:A serious condition in which the heart is unable to pump enoughoxygenated blood toadequately supply thebody’s tissues.

Cardiac Tamponade:A process in whichfluid or blood clotsbuild up between the heart and the pericardium. Itinterferes with heartfunction and maycause the heart to failand even cause death.

Embolism:The partial or completeblocking of a bloodvessel by an objecttraveling through the bloodstream (usually a blood clot).

YOUR VISIT TO THE CARDIOLOGISTBy

John B. O’Connell, M.D.Cardiologist

Professor and ChairmanDepartment of Internal Medicine

Wayne State University School of MedicineDetroit, Michigan

Physician-in-ChiefDetroit Medical Center

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ACARDIOLOGIST IS A PHY-sician who has graduatedfrom an accredited med-

ical school and completed threeyears of internal medicine resi-dency training followed by threeor four years of cardiology train-ing. Most cardiologists are part ofa larger group, which is some-times contained within a broad-er group of medical specialistsincluding primary care physi-cians. Besides general cardiolo-gists, there are many differentsubspecialties in cardiology. Thosewith added knowledge in interpre-tation of diagnostics are callednoninvasive cardiologists. Thosewith special certification in theuse of radioisotopes are callednuclear cardiologists. Cardiologistsmay also specialize in intervention-al cardiology, meaning they areexperts in the use of angioplastyand stenting. Additionally, cardi-ologists may specialize in elec-trophysiology, which is the studyof rhythm disturbances or prob-lems with the electrical conduc-tion system of the heart. Thesecardiologists may prescribe high-

ly specific drugs to treat irregu-larities in the heart rhythm or usedevices (like implantable car-dioverter defibrillators and pace-makers) designed to regulate theheart rhythm or trigger theheartbeat. Other cardiologistshave specialized in treatmentof advanced heart failure andheart transplantation.

Why See a Cardiologist?

Most people see a cardiologistbecause of a referral from theirprimary care physician for chest

pain. In some cases, the causeof the chest pain is known to becoronary artery disease, and thereferral is made for more ad-vanced diagnostic testing andtreatment; in other cases, thecause of the chest pain isunknown. Other common reasonsfor referral include shortness ofbreath, congestive heart failurenot responsive to standard med-ical treatment, irregularities in theheart rhythm, blackout episodes(syncope), or palpitations.

In the past, almost all cardiol-ogists accepted referrals only fromphysicians. However, a welcomedchange is the self-referral, i.e.,the patient feels they should seea cardiologist. More cardiolo-gists are welcoming this sourceof patients.

Sometimes, there is littlechoice of cardiology referral. Thisis often the case when your in-surance carrier or health mainte-nance organization (HMO) man-dates the specific reason for thereferral (requiring extensive doc-umentation by the primary carephysician), and the cardiologist

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is willing to agree to the in-surance company’s financialarrangements and care plans.This method of referral is theleast acceptable to patients andphysicians alike.

How Is a Cardiologist Chosen?

If there is flexibility in refer-ral and the referral is throughyour primary care physician,that physician will commonlychoose a cardiologist with whomthey have a close relationship.Communication between theprimary care physician and thecardiologist is critical to a suc-cessful diagnostic and treat-ment plan. Your primary carephysician knows the most aboutyou and will presumably havea close relationship with you.Consequently, they will be able tointerpret the complexities of thevisit to a cardiologist. Typically, thecardiologist they choose will bein close proximity and oftenpractice in the same hospital en-vironment and sometimes even inthe same professional buildingor practice group.

Cardiologists are highly visi-ble subspecialists, and, as a re-sult, reputation is another com-mon reason for referral. It is ap-propriate to ask your physicianwhat other patients may havebeen referred to this cardiologistor to ask members of your so-cial group or church about thatcardiologist.

If you have the option of choos-ing your own cardiologist, youwill probably choose one basedon local reputation. However, somestandards for academic excellencehave been established. Board cer-tification is increasingly a re-

quirement for hospital staffprivileges in cardiovascular dis-ease. A cardiologist is certifiedby the American Board ofInternal Medicine in cardio-vascular diseases.

Your local medical society hasa roster of physicians in your com-munity and their board certifica-tion status. Additionally, inter-net sites such as WebMD’s atwww.webmd.com have a directoryof most physicians. The major pro-fessional organization for cardiol-ogists is the American College ofCardiology, which also lists car-diologists, including board certi-fication and fellowship (FACC) sta-tus, on its website, www.acc.org.

Board certification should notbe the only criterion becausemany practicing cardiologists areboard certified. Other public data-bases may list mortality for inva-sive procedures by each physician.

However, do not be fooled bysimple mortality statistics. Forexample, a cardiologist who is will-ing to perform highly technicalprocedures on patients at highrisk may have a higher mortali-ty than a physician who rou-tinely selects only the low riskcandidates. Physicians who per-form high-volume procedures onsick patients are most qualifiedto care for most problems.

Another major issue relatesto the relationship between car-diologists and cardiac surgeons.Many of the diagnostic studiesmay lead to coronary bypasssurgery or valve replacement orrepair. The close working rela-tionship between the cardiolo-gist and the cardiac surgeon ispart of the equation that shouldbe used in choosing the special-ist. Therefore, local reputation,

access, and understanding thequality of the cardiac surgicalprogram should be considered inthe decision. Finally, the reputa-tion of the hospital as a cardiovas-cular medicine and surgical cen-ter is also part of the equation be-cause those centers with nationalreputations for the quality of theircardiovascular medical and sur-gical teams are highly selectiveabout the physicians on their staff.

What Will Happen during My First Visit to the Cardiologist?

A typical cardiologist’s officehas the capability for many di-agnostic tests. The cardiologist’sstaff is familiar with cardiac prob-lems and trained in cardiopul-monary resuscitation.

Before you see the cardiolo-gist, a nurse or staff member willusually review your history, makesure your prior medical recordsare available, and perform an elec-trocardiogram (EKG or ECG).This is considered an extension ofthe cardiac examination. Althoughmany tests provide more specificinformation, an electrocardiogramremains a major screening toolfor rhythm abnormality, evi-dence of blood vessel disease,and damage to the heart, orheart muscle problems.

However, the ability of an elec-trocardiogram to give specific diag-noses is very limited. A cardiolo-gist will complete a standard his-tory and physical, and you will beasked to rehash information thatyou have already given to anoth-er physician. This is because ofthe very specific probing ques-tions to which cardiologists willseek answers in an effort to homein on your problem.

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During the initial visit, thecardiologist will probably only ob-tain tests to help diagnose theproblem. Very typically, these willbe noninvasive tests (no tubesor instruments inserted into yourblood vessels other than per-haps an intravenous line). Afterthese tests, the cardiologist willinform you of the results.

Once the results of the initialtests have been evaluated, fur-ther testing may be needed, andan invasive test (in which instru-ments or tubes are threadedthrough your blood vessels) maybe prescribed. In some cases,you may be referred to a cardiolo-gy subspecialist.

During the course of this test-ing, the cardiologist will communi-cate directly with your primarycare physician. Do not be intimi-dated if you are self-referred;physicians widely recognize theimportance of second opinions,and your self-referral should notplace a wedge between you andyour primary care physician.

Typical Diagnostic Tests

Noninvasive TestingFrequently, noninvasive tests

may be used as screening toolsbefore more complicated invasivetesting. The most common non-invasive diagnostic tests includethose designed to assess the prob-ability of coronary artery diseaseand review heart muscle function.

The test often used to de-tect coronary artery disease isthe treadmill exercise stresstest. In some cases, a simple ex-ercise test is performed inwhich the patient is monitoredby an electrocardiogram duringa walk on a treadmill that will

increase its speed and slopeuntil either a target heart rate isreached or a symptom or elec-trocardiographic finding worthyof discontinuation of the test re-sults. In more complicated sit-uations, including an abnor-mal resting electrocardiogramor poor specificity of treadmilltesting in a subgroup population(such as in women, for whom thetest is not as accurate), a nu-clear or echocardiographic studymay be added.

In the case of a nuclear study,a radioisotope, usually either thal-lium or Sestamibi (Cardiolyte), isinjected into your vein during peakexercise, and your heart is im-aged. You will be asked to returnfour to six hours after the initialimaging for a second scan. Thisimage will give the cardiologist aview of what blood flow to yourheart is like during rest, and thefirst image will show coronaryblood flow during exercise. Ifcoronary blood flow is abnormalduring exercise but normal dur-ing rest, coronary artery diseaseis likely, and the cardiologist mayrequest a catheterization.

In the case of stress test-ing with ultrasonic techniques,an echocardiogram will be per-formed at successively harderlevels of exercise. If segmentsof the heart muscle contractless vigorously during exercisethan they do at rest, there isevidence for blood vessel dis-ease, and cardiac catheteriza-tion in all likelihood will berecommended. In some highlyspecialized centers, measure-ments of coronary blood flowmay include very sophisticatedtechnology such as magneticresonance imaging (MRI) or

positron emission tomography(PET scanning).

If you are unable to exerciseor walk on a treadmill, there aredrugs that may be given (dipyri-damole, adenosine, or dobuta-mine) that will enhance abnor-malities in coronary blood flowso that they can be imagedwith nuclear or echocardio-graphic techniques.

If your problem relates tocongestive heart failure, abnor-malities of your heart valves, orincreased thickness of your heartmuscle, an echocardiogram, oran ultrasound scan of yourheart, gives the cardiologistmuch information. Sometimesthe abnormalities in the back ofyour heart or your chest do notconduct sound waves well.The cardiologist may then sug-gest a transesophageal echocar-diogram (TEE), during which theprobe is swallowed and yourheart is seen from your esopha-gus. If you have abnormalitiesin blood vessels other than inyour heart, a Duplex scan utiliz-ing ultrasonic/Doppler tech-niques to determine flow maybe applied.

If your abnormality includesyour heart rhythm, a Holter mon-itor is quite valuable. This is asmall device the size of a transis-tor radio that records your ECGfor a day or two while you recordany symptoms you may have ina diary. If the palpitations orlightheaded episodes that bringyou to the cardiologist occuronly once in a while, an eventmonitor may be utilized. Youcan take this monitor home andcall a station where heart rhythmdetection occurs through a tele-phone monitor.

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Invasive TestingIf a noninvasive test indi-

cates you have serious problemswith your heart rhythm or pos-sible blood vessel disease, an in-vasive test may be ordered.

Cardiac catheterization withcoronary angiography is the mostcommon invasive test. During thistest, pressures within the heartare measured, dye may be inject-ed into the left ventricle, and dyeis injected into each of theblood vessels that suppliesblood to the heart. An x-raymovie of the heart is then made.

If the obstruction to bloodflow is localized, it can be repairedby balloon angioplasty and/orstenting (see Chapter Six). Thatprocedure may be done at thesame time as the cardiaccatheterization. A simple diag-nostic catheterization may re-quire only a few hours at thehospital. An interventional proce-dure may take longer in thehospital, but generally less thanone day.

Your cardiologist will discussthe result of your tests. If yourproblem is not a blood vessel inyour heart but one of your othermajor vessels such as a blood ves-sel to your legs, the cardiologistmay dilate those blood vessels asin coronary angioplasty.

If the problem is a rhythmdisturbance, an electrophysiolo-gist can perform an electrophysi-ologic study, in which your heartis stimulated and the heartbeatmeasured. Essentially, this is avery sophisticated and highlysensitive electrocardiogram. As aresult of this procedure, a recom-mendation may be made for apacemaker or for an implantablecardioverter defibrillator. Thisplacement is generally performedby the same electrophysiologist.

When Does a Cardiologist ReferPatients to a Cardiac Surgeon?

In the event of coronary arterydisease, for example, a cardiolo-gist will refer you to a heart sur-geon when blood vessel diseaseaffects multiple vessels and an-gioplasty is not practical. Thecardiac surgeon will then reviewthe angiogram and consult withthe cardiologist regarding thebest surgical approach for coro-nary artery bypass grafting.

Once the referral to a surgeonis made, your cardiologist will con-tinue to see you immediately be-fore and immediately after surgery.After hospitalization, which is gen-erally less than one week, the car-diologist and surgeon will both seeyou in follow-up until your surgical

wound is healed, at which time thesurgeon will typically send youback to the cardiologist for care.

If your postoperative coursewas not complicated, your cardiol-ogist will typically refer you to theprimary care physician but willsee you at regularly scheduled in-tervals: three months, six months,and one year after surgery.

Typically, an exercise stresstest will be performed either threeor six months after surgery andannually thereafter. Measurementof cholesterol level will occurwithin six weeks of surgery, andthe cardiologist and primary carephysician will confer about “sec-ondary prevention,” i.e., treat-ment measures designed to re-duce and reverse the blood vesseldisease (atherosclerosis) thatcaused your visit.

Cardiologists work in concertwith primary care physicians andcardiac surgeons. They are partof a team of physicians that aredirecting their efforts toward thewell-being of your heart andblood vessels.

However, the ultimate deter-minant of the success of cardio-vascular care is the patient, be-cause you are the fourth memberof the team. As a team member, itis your responsibility to ask all thequestions you may have.

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