At the Clinic
What to expect at your appointment, and recommendations for further investigation.
The Consultant will confirm the reason for your referral for the appointment. He or she will take a full history and examination, and may perform an ECG. There will then be a discussion on what the problem (if there is one) may be and what investigations are required to confirm or refute the diagnosis. You may be recommended to have any number of the cardiac investigations detailed below.
Cardiac Investigations
Blood Tests
Blood tests are undertaken for a number of reasons:
- to ensure that there is not a non-cardiac cause of your symptoms (eg anaemia)
- to rule out a serious acute problem (eg heart attack or blood clot in the lung)
- to assess your risk factors for heart disease (eg cholesterol)
- to have a baseline of certain measurements (eg kidney function) in case you are recommended to start on medications
Echocardiography
An echocardiogram is an ultrasound scan of your heart. It is non-invasive and takes around 30 minutes. It provides information on the structure and function of the heart. It is recommended in most patients who are referred to a cardiologist.
Extended ECG Monitoring
You may be asked to wear a patch or a monitor to record your ECG for an extended period of time (upto 14 days). This would be to investigate symptoms of palpitations, dizzy spells and/or blackouts. The ideal situation would be for you to experience your symptoms whilst wearing the monitor so that we can see what the ECG looks like, and therefore, whether your symptoms are likely to be cardiac. It may also be recommended if you have an abnormal resting ECG.
Ambulatory Blood Pressure Monitoring
This is recommended to confirm the diagnosis of Hypertension. The portable monitor takes regular BP readings, usually over a 24-48 hour period.
Exercise Stress ECG / Exercise Tolerance Test (ETT)
This is a test where you will be asked to exercise on a treadmill whilst connected to an ECG machine. During the test, you will have your heart rate and blood pressure monitored, whilst your ECG is being continuously monitored. This may be indicated if you are experiencing any symptoms on exertion, or to assess your heart rate and blood pressure response to exercise.
Exercise Stress Echocardiogram (ESE)
This is similar to the Exercise ECG, but also utilises echocardiography to assess your heart’s response to exercise. It is a more reliable test than the ETT in assessing whether you may have a restriction in the blood supply to your heart. It can also be used to assess a heart valve problem and whether you may benefit from a procedure (such as a stent).
Dobutamine Stress Echocardiogram (DSE)
If you are unable to exercise, we may recommend a DSE. This is the same as an ESE, but we inject a medication through a vein in your arm to speed your heart rate to mimic exercise.
Cardiac MRI/ Cardiac Perfusion MRI
Cardiac MRI provides a more detailed analysis of the structure and function of your heart, and could be recommended for a number of reasons. The scans take longer and can be more intrusive. We can undertake a stress study at the same time, which provides similar information to the ESE/DSE. Similar to a DSE, the stress component involves the administration of a medication through a vein to stimulate the heart.
Coronary Calcium Score (CCS) / CT Coronary Angiogram (CTCA)
A CCS is primarily undertaken to assess your risk of developing coronary artery disease. Deposits in the lining of the arteries of the heart (atheroma/ atherosclerosis) are the cause of developing restrictions in the blood supply and heart attacks. The deposits include calcium and the amount of this substance is measured by the scan. The more calcium, the more deposits in your arteries, and the higher your risk
A CCS can be done as an isolated test but is often done together with a CTCA. This is an invasive test requiring intravenous contrast (dye) to be injected through a vein. The heart is scanned whilst the contrast passes through the coronary arteries. This gives information on whether there are any significant blockages, which might be giving rise to symptoms. This is usually the first line investigation to investigate chest pain.
Invasive Coronary Angiography +/- “Proceed”
This is an invasive test which is performed under a local anaesthetic +/- sedation, usually performed as a day-case. A tube (sheath) is sited in an artery in the wrist (usually). Through the sheath, longer tubes called catheters are taken up to the arteries supplying your heart muscle. Contrast is injected through the catheter directly into the coronary arteries to assess if there are any significant blockages. This is recommended if any of the tests listed above are abnormal and give rise to a suspicion of significant blockages.
If the presentation is acute or unstable (chest pains at rest, abnormal ECG, elevated blood markers), suggesting that a heart attack is likely, urgent angiography is indicated. If you are suspected of having a heart attack (complete blockage of a coronary artery), then the angiogram would be performed immediately
Once the pictures are taken, further assessments of any potential problems can be further assessed with a test called a Pressure Wire Study, which gives reliable information as to whether a visible blockage is causing a significant restriction to a part of the heart, and therefore whether there is an indication to open the artery. There are other tools (eg intravascular ultrasound) which can also provide more detailed information on a problem
There are often a number of ways of managing coronary disease, and it is the accepted practice to discuss all the options with the patient to agree on the best way. Complex cases are usually discussed at a multi-disciplinary team meeting to obtain a consensus on the best treatment for the patient
If it is absolutely indicated that a blockage should be treated at the same time, it can be done as part of the procedure. This is called a Percutaneous Coronary Intervention (PCI) or Coronary Angioplasty, and involves placing a metal scaffold within the artery to relieve the blockage.