How can you tell if your heart is ailing? The cardiologist explains

Cardiovascular diseases are the most common cause of death in the world, and according to the PZH report, before the outbreak of the coronavirus pandemic in Poland, they accounted for over 40 percent. total deaths. At the same time, cardiology is one of the fastest developing fields of medicine. Due to technological progress, its diagnostic capabilities have increased enormously, and doctors can literally monitor the anatomy and work of the heart on an ongoing basis. Cardiologist, Dr. Krzysztof Pujdak, MD, PhD presents a range of heart examinations used by European doctors on a daily basis.

1. The heart echo is one of the basic examinations of the heart. Thanks to him, the cardiologist diagnoses, among others valvular pathologies, as well as an EKG that monitors the rhythm of the heart
2. The resting and stress ECGs are the first diagnostic line of a cardiologist
3. Computed tomography of the coronary vessels gives a picture of the coronary vessels, their possible closure, narrowing or calcification
4. Cardiac scintigraphy performed in two steps – at rest and during exercise – will determine if the patient has ischemic heart disease
5. Coronary angiography is an invasive test that allows the cardiologist to heal the arteries, e.g. by stenting or ballooning
6. More current information can be found on the Onet homepage.

Monika Zielniewska, Medonet: Until recently, the stethoscope was the basic working tool of most doctors, now it is mainly used by family doctors. Does a cardiologist need traditional headphones in the XNUMXst century?

Dr. Krzysztof Pujdak: The stethoscope is a very old instrument, but before it was invented, doctors used various strange looking trumpets to auscultate the patient’s lungs and heart. Today, it is still one of the basic tools of a doctor’s work, and it is still being improved. We now have a new generation of stethoscopes equipped with a membrane, but the analysis of what the doctor hears during the examination is done not by the doctor, but by special software. The results of auscultation are displayed on the monitor screen in real time. In general, it does not matter whether we use a traditional or electronic stethoscope, because with each of them we can hear heart murmurs and auscultate the lungs.

What does the cardiologist infer from these heart murmurs?

You can hear the valves working with a stethoscope, so your doctor can diagnose valvular defects. Currently, the final diagnosis is of course made after more advanced examinations, but a suspicion of a valvular defect can be made after a physical examination, i.e. using a stethoscope. Examination of the lungs and heart with a stethoscope is part of every physical or physical examination of the patient. Medics learn this skill in the third year of studies. However, I must admit that the physical examination, due to the technicization of medicine, and especially the technicization of cardiology, is increasingly being overlooked. I do not auscultate the patient at the Emergency Room with a stethoscope. It is a waste of time, I immediately give it an echo, i.e. ultrasound of the heart, and it is in fact a modern cardiologist’s stethoscope.

What does the echo of the heart allow?

It allows you to see all valve pathologies, systolic and diastolic function of the heart chambers and their possible enlargement. Thanks to it, I can determine if the heart is hypertrophied, for example due to high blood pressure or valve defects. In summary, echocardiography allows the doctor to see the valves, the heart muscle, examine the heart cavities and see if they are the correct size. This examination displaced the stethoscope in the hospital because it is very fast and much more accurate. Nowadays, doctors are not able to auscultate hearts as well as their teachers did, but they should be able to do echoes well.

Perhaps every patient associates a cardiologist with an ECG test?

Cardiac electrocardiography is another test from the pool of the so-called basic research, but checking for something other than the heart echo. In contrast, it monitors the electrical function of the heart, its rhythm. This is a very old test, but it allows you to exclude or confirm cardiac arrhythmias. In addition, the ECG assessment allows us to determine whether there has been any damage to the heart, e.g. in the course of the so-called of acute coronary syndromes, i.e. whether it is a heart attack or related conditions. Since the ECG, in addition to arrhythmias, shows us the heart damage in the course of the infarction, we can use it to determine the patient’s condition after a heart attack. There are a few other diseases that we can suspect by looking at an EKG, but more comprehensive tests are needed to make a definitive diagnosis.

An EKG is a test that shows us the condition of the heart here and now, especially when it comes to heart rhythm. Meanwhile, our patients often suffer from cardiac arrhythmias occurring, for example, once a month or once a week, and of course, when they reach the doctor who registers the ECG, this rhythm may be completely normal. It is a very common phenomenon, so in such cases we have to try to somehow capture and correlate the patient’s complaints with the electrocardiographic image. We need to have an ECG at the time of a rapid heart attack, or when a patient faints when his heartbeat may be too slow.

I guess you have another exam in hand?

We have various options, the simplest is an EKG holter, i.e. an EKG test for 24 or 48 hours. Unfortunately, here too we have no guarantee of success, because as I mentioned, rhythm disturbances may occur less frequently than once every 48 hours. Usually we are unlucky and the disorder does not occur while the patient is wearing a recorder, but we manage. We can implant him the so-called event recorder, i.e. a flash drive-sized device that is implanted under the skin. It can record the ECG of the heart for up to several years. In the event of disturbing symptoms, the device transmits the ECG to the doctor, e.g. via a cellular network, and he or she can easily check remotely what is happening. We find out immediately that there are deviations from the norm in the form of cardiac arrhythmias in the memory of the event recorder, as they are detected by a specially designed algorithm. We get a practically made diagnosis that we only need to verify. There are also simpler diagnostic methods, the rash of which has occurred in recent years.

What?

The heart function can be monitored by e.g. smartwatches or small portable ECG devices, which patients buy online and use them on their own during attacks of arrhythmias or palpitations. The idea is to check whether their subjective symptoms, such as irregular heartbeat or rapid heartbeat, are actually reflected in the ECG image.

I’ve also heard of an exercise ECG.

The exercise ECG is not used to diagnose arrhythmias, but to diagnose cardiac blood flow disorders. This means that it enables the diagnosis of coronary heart disease, or ischemic heart disease. It will show characteristic changes – acute or chronic. We do the exercise ECG on a treadmill or on a bicycle. If the patient has narrowed coronary vessels and the heart muscle has insufficient blood supply, exercise causes a greater demand for oxygen and provokes the appearance of characteristic changes in the ECG record. Often, thanks to such an examination, we are able to put forward a suspicion of coronary artery disease, which in the next step must be confirmed by invasive or non-invasive tests. Resting and exercise ECGs are our first line of diagnosis, however, if we suspect a serious disease, such as cardiac arrhythmias or coronary artery disease, we must verify them with more detailed tests.

So what tests are used to detect coronary artery disease?

If we suspect coronary artery disease (ischemic heart disease) on the basis of the resting and stress ECG and we want to further diagnose the patient, we have invasive and non-invasive methods at our disposal. These include, for example, computed tomography of the coronary vessels. This is a typical computed tomography using X-rays and injected intravenous contrast. Using good software and good equipment, we can obtain an image of the coronary vessels that supply the heart muscle with blood and see possible closures, strictures or calcifications, etc. Another non-invasive method is scintigraphy. It is used to detect disorders of the blood supply to the heart. First, we give the patient a radioactive agent that collects in the heart muscle. Usually, the test is performed in two stages. The first is scintigraphy at rest, the second during exercise.

If a patient has a coronary artery stenosis, they are usually manifested by symptoms. Typical are chest pains or shortness of breath with exertion. A patient who suffers from stable coronary artery disease has stenosis, but no discomfort at rest, only during stronger exertion. If the resting scintigraphy shows no abnormalities, the distribution of the contrast agent in the myocardium will be very nice, and the test should be performed during exercise. It may be exercise on a treadmill, on a bicycle, or exercise often practiced in my workplace, caused by drugs that accelerate the heart rate and thus increase the heart’s need for oxygen.

Such a test may show that some part of the heart muscle, such as the front wall, will not have as much contrast agent as it does at rest and other parts of the heart. There will be a significant difference between the blood supply to the heart at rest and during exercise. It is a very good marker of ischemic disease, which includes, for example, one coronary artery and a frequent indication for invasive examination – coronary angiography.

A koronarografia to?

A study that involves injecting contrast vessels into the vessels and viewing them at different projections thanks to X-rays. Coronary angiography has the great advantage that immediately after the examination one can start arterial treatment, e.g. stenting or ballooning (PTCA, PCI).

What do you do when the resting scintigraphy shows abnormalities?

If, for example, the anterior wall of the heart does not accumulate contrasting agent at rest, it means that it is damaged in the past. There are scars, e.g. a heart attack scar. This test will show if we are dealing with stable coronary artery disease, if there is any new lesion that only occurs at rest, and if so, if it makes sense to perform an invasive test. If it turns out that there is only a scar in the heart, it is not necessary to undergo invasive testing. More often, however, invasive tests will be required for appropriate treatment.

Does the cardiologist have any more tests up his sleeve?

An interesting test that shows changes in the myocardium and possible blood supply disorders is cardiac magnetic resonance imaging. However, we will not do this research in every center. It is quite complex and long-lasting, requiring special infrastructure. It can also be used to test perfusion, i.e. blood supply to the heart muscle, so it is useful in the diagnosis of coronary artery disease, cardiomyopathy, etc. diseases of the heart muscle. Unfortunately, the study is the most difficult to access for patients, not only in Poland, but also in most countries.

There is still invasive research.

I will start with catheterization of the heart, i.e. measuring the pressure inside the heart to diagnose congenital or acquired defects, such as valve or leak defects. The disadvantages of leakage, i.e. mixing of oxygenated and non-oxygenated blood, used to be catheterized as standard. Currently, we have better and better imaging diagnostics – echocardiographic examinations, e.g. transesophageal echo (ultrasound examination of the heart, made not from the outside, but through the esophageal probe). The patient swallows an endoscope with no camera at the end and an ultrasound head. Due to the fact that the esophagus adjoins the left atrium of the heart, we can very carefully examine the right and left atrium and the left ventricle. The valves are also clearly visible, and even minimal changes can be identified. Due to the fact that today we have such precise imaging tests, i.e. MRI, echo and computed tomography, cardiac catheterization has lost its value. Diagnostics goes in a non-invasive and anatomical direction. Rather, catheterization would show how it all works, we would see functional disorders and use them to conclude about the disease, and thanks to imaging diagnostics we see anatomy and see what needs to be fixed.

So what will happen with the coronary angiography?

Coronary angiography is a special type of cardiac catheterization, an examination that involves imaging the coronary vessels of the heart. It is a very common test for coronary heart disease. It visualizes the coronary vessels thanks to the catheter usually inserted through the radial artery located in the wrist. A catheter is a plastic tube through which we inject contrast (contrast agent) directly into the arteries. Thanks to the contrast in X-rays, we can see the state of the coronary vessels. The advantage of this test is that it can be used as an introduction to treatment. We do coronary angiography, see the changes and we can immediately treat them with ballooning, or coronary angioplasty, which consists in dilating the vessels and implanting a stent.

Are cardiac tests readily available today?

Except for the most basic types of ECG, tests can only be ordered by a cardiologist. The family doctor must first refer the patient to him, and this takes a while … Moreover, after a referral by the cardiologist for additional examinations, the patient has to wait for an appointment again (often several months). This procedure can be accelerated by hospitalization, because in hospitals the availability of specialist examinations is obviously better than in outpatient care.

Finally, what is the future of cardiological diagnostics in your opinion?

Cardiological diagnostics is moving towards the use of sensors in smartwatches, which is particularly useful in the diagnosis of cardiac arrhythmias. Thanks to these popular devices, ECG, or imaging of cardiac arrhythmias, has become easily accessible to everyone. I think we will wear fewer and fewer holters, or rather use more and more different smart wearables. Generally, diagnostics is heading towards non-invasive and imaging tests. We have more and more sensitive examinations, faster and faster magnetic resonance and computed tomography devices, so diagnostics are also faster, more accurate and less and less unreliable. However, invasive research will not lose its importance because it allows us to heal. Non-invasive testing is an introduction to either pharmacological treatment or invasive testing. So there is a trend: first we do non-invasive tests, and only in the next step we wonder if we need invasive tests.

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