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How Diagnosing Heart

Disease Works
by Carl Bianco, M.D.

Heart disease is the leading cause of death in the U.S. Because it is so common, there is a
good chance that heart disease will affect you in some way and you will need to see a doctor
about your heart. This article discusses how physicians go about diagnosing heart disease so
that you can understand the process. In the next article, How Heart Attacks and Angina Work,
we will discuss Atherosclerosis (the cause of Coronary Artery Disease). This leads to the
main diseases of the next article - Angina and Heart Attacks.

It would be a good idea to read the Article How the Heart Works prior to reading this article for
background on the Anatomy and functioning of the heart.

The Definition of Heart Disease

Heart disease is any condition that causes your heart to malfunction. When the words "heart
disease" are used generically, what people are usually referring to is Coronary Heart Disease
which leads to heart attacks and angina, ultimately caused by Atherosclerosis. But there are a
wide range of other diseases of the heart. For example:

? Congestive Heart Failure

? Valvular Heart Disease - Diseases of the heart valves
? Cardiac Arrhythmias - Irregular heartbeats
? Diseases of the Pericardium (sac around the heart)
? Diseases of the Myocardium (heart muscle)
? Endocarditis (infection of a heart valve)
? Congenital Heart Disease - birth defects of the heart

In this article we will focus on Atherosclerosis, Angina and Heart Attacks, but we will discuss
many of the others because the diagnostic tools used to diagnose Atherosclerosis often
recognize other problems as well.

Diagnosis of Heart Disease

Modern medicine has a number of tools that are available to help determine what is
happening inside your heart. They include:

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? History and Physical Examination

? Electrocardiogram
? Chest X-Ray
? Blood Tests
? Stress Tests
? Echocardiogram
? Cardiac Catheterization

Each of these techniques is described in detail in the sections that follow.

History and Physical Examination

Even in this technologic age in which a wide assortment of tests are available to the
physician, the primary source of information about your heart comes through a history and
physical exam.

There are no symptoms that occur only in heart disease. However, one of the most common
symptoms of heart disease is chest pain. When a part of the heart muscle (myocardium) is
not getting enough blood (usually due to a blockage in one of the coronary arteries), chest
pain can result. Chest pain from heart disease usually feels like a tightness, pressure or
squeezing sensation. It is usually located in the center of the chest but can also be located off
to the side. Usually it is brought on by exertion and relieved by rest.

Chest pain can also originate from other areas that are near the heart such as the
Pericardium (the sac around the heart), Aorta, Lung, Pleura (lining of the Lung), muscles and
bones of the chest or the Gastrointestinal Tract (Esophagus or Stomach). Also, someone can
have heart disease and not have any chest pain.

Another symptom that can occur in heart disease is shortness of breath. This can occur at
rest, with exertion, or when lying down. Palpitations are an awareness of one's heartbeat and
can occur in heart disease. This can cause a feeling that your heart is beating too fast or too
slow, skipping beats, or beating irregularly. Passing out (syncope) can occur from heart
disease if the heart is temporarily not pumping out enough blood. Nausea or vomiting can
also be a symptom of heart disease. Profuse sweating (diaphoresis) can sometimes
accompany heart disease. Of course there are other causes for sweating.

During a physical exam, your physician listens to your heart with a stethoscope. The
stethoscope is placed in certain pre-determined areas where each heart valve is heard
loudest. If a murmur is heard loudest at that valve's location, chances are that that is the valve
that is malfunctioning. Also, listening to the lungs with a stethoscope can reveal the presence
of fluid which can be the result of heart disease.

Electrocardiogram
An Electrocardiogram (EKG or ECG) records the electrical activity of the heart from the
surface of the chest using electrodes placed on each arm and leg and six placed on the chest.
These electrodes are connected by wires to an EKG machine. 12 different tracings are
produced and this is called a 12 lead EKG. Each tracing gives a view of the heart from a
different angle. The 12 leads of an EKG are called I, II, III, aVR, aVL, aVF, and V1, V2, V3,
V4, V5, and V6. Depending on which EKG lead is involved, your physician can tell during a
heart attack which part of the heart it is occurring in. Then, based on his knowledge of

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anatomy, he can determine which artery is blocked.

The EKG gives the physician information about :

1. heart rate
2. heart rhythm
3. adequacy of blood supply to the heart
4. presence of a heart attack
5. enlargement of the heart
6. inflammation around the heart (pericarditis)
7. effects of drugs and electrolytes on the heart

Here is an example of a normal 12 lead EKG:

Chest X-Ray
A Chest X-ray is a useful tool in the evaluation of heart disease. It shows the size and shape
of the heart, which can be enlarged in Congestive Heart Failure. Enlargement of the heart
(cardiomegaly) can also be present in diseases of the heart valves and congenital heart
disease. Enlargement of the outline of the heart can also be caused by excess fluid in the
pericardium (sac around the heart). If too much fluid is present, it can compress the heart.
Usually the most important part of the Chest X-Ray in the evaluation of heart disease is the
condition of the lungs. Fluid build-up in the lungs is commonly caused by heart failure. The
outline of the vessels near the heart can also be seen on a Chest X-Ray and can help the
physician in the diagnosis of Aortic Aneurysm (localized enlargement in the wall of the Aorta)
or Aortic Dissection (tearing of the wall of the Aorta). Here is an example of a normal Chest X-
Ray:

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Blood tests

A heart attack occurs when a coronary artery is blocked, causing a lack of blood and then
death to the heart muscle served by that artery. When the muscle dies it releases certain
chemicals into the blood that were present in those muscle cells. These can be measured and
if present are evidence of a heart attack. Each chemical becomes measurable and persists in
the blood for different times. These chemicals are CPK, CPK -MB, Troponin and Myoglobin.
The following table shows the behavior of these chemicals in the blood:

Lab Test Begins to rise Peak Duration Found in

CPK 4-8 hours - 48-72 hours Heart, Brain, Skeletal Muscle
CPK-MB 3-4 hours 12-24 hours 48 hours Heart
Myoglobin 1-2 hours 4-6 hours 24 hours Heart, Skeletal Muscle
Troponin 3-6 hours 12-24 hours 1 week Heart

Stress Test
A stress test is a commonly used procedure to evaluate coronary artery disease. It is also
called an exercise stress test or an exercise tolerance test. Stress tests are useful
because exercise can reveal abnormalities not seen on an EKG of a heart at rest. A person's
EKG, blood pressure, and symptoms are monitored first at rest, then while walking on a
treadmill or pedaling a bicycle, then after exercising. The exercise is gradually increased until
a target heart rate is reached (85% of maximum heart rate). If severe EKG changes, chest
pain, severe shortness of breath, blood pressure changes or cardiac arrhythmias occur then
the test may need to be stopped.

When certain EKG changes occur the test is considered positive. If a person cannot exercise
then medications can be given (dipyridamole) that stress the heart without exercise. Even
more information can be obtained if certain radioactive materials (thallium-201 or Technetium
99m sestamibi) are injected into a patient during the stress test. These chemicals are then

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detected by a special camera just after exercise and 4 hours later. These materials can help
detect areas of decreased blood flow as well as areas where heart attacks have occurred.
The effectiveness of the heart's contraction can be determined by measuring the ejection
fraction or percent of blood pumped out of the heart with each contraction.

Echocardiogram

An Echocardiogram is a painless procedure that uses an ultrasound beam to view the heart in
motion. The procedure is similar to that used to monitor a fetus. An ultrasonic transducer,
which looks like a microphone, transmits and receives the ultrasound waves. It is placed on
the chest wall and moved around to view different heart structures. Ultrasound waves are
reflected only when they reach the edge of two structures with different densities. The
reflected waves produce a moving image of the edges of heart structures which are displayed
on a screen and recorded on tape.

The types of Echocardiograms are M-mode, 2 -D and doppler. M-mode is a one dimensional
view of a small section of the heart as it moves. 2 -D echocardiogram produces a moving two
dimensional slice of the heart. Doppler ultrasound is used to evaluate the velocity and
turbulence of blood flow in the heart.

Echocardiograms can evaluate:

1. the presence of any abnormal fluid collection in the sac around the heart (pericardium).
2. the chamber size, thickness of the heart muscle wall and how well it is functioning.
3. the function of the heart valves - whether they are obstructing blood flow or leaking.
4. any abnormal connections between chambers and vessels that may exist in congenital
heart disease.
5. wall motion abnormalities that occur when the heart muscle is not receiving enough
blood.
6. the presence of aneurysms, clots, tumors, vegetations (bacterial growths) on the valves.

Cardiac Catheterization
This procedure is the "gold standard" for evaluating cardiac anatomy and function. During a
Cardiac Catheterization X-ray movies are taken to show the anatomy of the coronary arteries,
heart chambers, major vessels, valves and congenital heart defects. It is also used to assess
the adequacy of heart contractions (ejection fraction), pressures in different areas of the heart,
output of the heart, or the amount of oxygen and carbon dioxide in different areas of the heart.
It can also be used to treat blocked coronary arteries by blowing up a small balloon at the site
of blockage to create a larger opening (called angioplasty).

After sedating the patient, the cardiologist places a catheter (small tube) into an artery (to look
at the left side of the heart) or vein (to look at the right side of the heart) in the upper leg or
arm. The catheter is advanced to the heart. Dye is injected into the catheter and X-rays
movies are taken and recorded on film. The X-ray movies are taken at different angles to see
if any blockages are present in the coronary arteries. This procedure is invasive and has rare
complications such as heart attacks, stokes, abnormal heart rhythms, allergic reactions,
perforation (puncture of a blood vessel or chamber of the heart), and even death.

Here is an example of a cardiac catheterization in which the catheter is placed into the

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Femoral Artery, it is then advanced through the Aorta and into the Heart.

Understanding Atheroschlerosis
In the next article, How Heart Attacks and Angina Work, we will discuss Atherosclerosis (the
cause of Coronary Artery Disease). This leads to the main diseases of the next article -
Angina and Heart Attacks. Click here to start the next article.

About the Author

Carl Bianco, M.D., is an emergency physician practicing at Dorchester General Hospital in
Cambridge, MD, located on the Eastern Shore of Maryland. Dr. Bianco attended Medical
school at Georgetown University School of Medicine and received his undergraduate degree
from Georgetown University majoring in nursing and pre-med. He Completed an internship
and residency in Emergency Medicine at Akron City Hospital in Akron, Ohio.

Dr. Bianco lives near Baltimore with his wonderful wife and two wonderful children.

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http://www.howstuffworks.com/heart-diagnosis.htm/printable 5/6/2002