The diagnosis of heart disease is usually made from clinical history and physical examination. Certain complementary tests are used to confirm the diagnosis and determine the severity and consequences of the disease, and to facilitate treatment planning.
History and physical examination
First, the doctor asks about symptoms that suggest the possibility of heart disease, such as chest pain, shortness of breath, swelling of feet and ankles and palpitations. Then register the presence of other symptoms such as fever, weakness, fatigue, loss of appetite and malaise, which can point directly to a heart condition. Then the patient is asked about infections, exposure to chemicals, use of drugs, alcohol and snuff, family and work and recreational activities. Finally, it is necessary to know if a family member has had heart disease or other conditions and if the patient has a condition that might affect the cardiovascular system.
During the physical examination, recording the weight and general condition and see if there is pallor, sweating or sleepiness, as they are subtle indicators of heart disease. You should also take into account the mood and feeling of wellbeing, which may also be affected by heart disease.
It is important to determine the color of the skin, as pallor or cyanosis (a bluish discoloration) indicate anemia or low blood flow. These characteristics show that the skin receives insufficient oxygen through the blood because of a lung disorder, a dysfunction of the heart or circulatory problems of various kinds.
Take the pulse in the arteries of the neck, underarms, elbows and wrists, abdomen, in English, behind the knees and ankles and feet to ensure that blood flow is adequate and symmetrical on both sides. Also control blood pressure and body temperature, any abnormality may suggest heart disease.
It is important to examine the neck veins as they are directly connected to the right atrium and give an indication of the volume and pressure of the blood entering the right side of the heart. For this part of the examination, the patient is asked to stretch the upper body elevated at an angle of 45 degrees. Sometimes the patient can sit, stand or lie down.
The doctor pressed a finger skin of the ankles and legs and sometimes the lower back, in order to detect an accumulation of fluid (edema) in tissues that are below the skin.
An ophthalmoscope (an instrument that allows the inside of the eye) is used to observe the nerves and blood vessels of the retina (the light sensitive membrane that lies on the inner surface of the back of the eye). Visible abnormality can be found in the retina in case of hypertension, diabetes, atherosclerosis and bacterial infections of the heart valves.
The doctor looks at the chest to determine if the frequency and respiratory movements are normal and then taps the chest with the fingers to see if the lungs are filled with air, which is normal, or if they contain fluid, which is abnormal . The percussion also to determine whether the membrane surrounding the heart (pericardium) or covering the lungs (pleura) contain liquid. The stethoscope is used to listen to the sounds of breathing and whether the air flow is normal or if there is a blockage, and if the lungs contain fluid due to a heart condition.
The doctor places his hand on the chest to determine heart size and the type and strength of contractions during each heartbeat. Sometimes an abnormal blood flow and turbulence within the vessels or between chambers of the heart, causing a vibration that is perceived with the fingertips or the palm of the hand.
It is also possible to identify with a stethoscope the different sounds that cause the opening and closing of heart valves (auscultation). Abnormalities in the valves and other parts of the heart create turbulence in the bloodstream that generate characteristic sounds called murmurs.
Turbulent blood flow usually occurs when blood passes through valves close or not close properly.
Not all murmurs cause heart disease and not all murmurs indicate a disorder. In general, pregnant women have heart murmurs by the normal increase in the rate of blood flow. These harmless murmurs are also common in young children and older because of the speed of blood flow through the small structures of the heart. As the vessel walls, valves and other tissues will harden with aging, blood flow can become turbulent, even without a prior serious heart disease.
Placing the stethoscope on the arteries and veins anywhere in the body can detect signs of turbulent flow, called murmurs, caused by a narrowing of the vessels or abnormal communications between them.
Finally, we examine the abdomen to determine if the liver is enlarged by an accumulation of blood in major veins leading to the heart. An abnormal swelling of the abdomen due to fluid retention may indicate heart failure. It also explores the pulse and the diameter of the abdominal aorta.
Diagnostic tests
There is a wide range of tests and procedures to streamline and make more accurate diagnosis. Include records the electrical activity of the heart, x-ray, echocardiogram, magnetic resonance imaging (MRI), positron emission tomography (PET) and cardiac catheterization.
These tests usually have only a slight risk that increases with the complexity of the procedure and severity of underlying heart disease. With regard to cardiac catheterization and angiography, the possibility of the emergence of a major complication (such as a stroke, heart attack or death) is 1 per 1000. The stress test has a 1 in 5000 risk of developing heart attack or death. In fact the only risk of radioactive isotope tests comes from the small dose of radiation to the patient, which is actually lower than it receives with most X-ray examinations
Electrocardiogram
An electrocardiogram is a fast, simple and painless in which amplify the heart’s electrical impulses and recorded on paper moving. The electrocardiogram (ECG) to analyze the pacemaker that initiates each heartbeat, nerve conduction pathways of the stimuli and the speed (frequency) and heart rate.
To perform an ECG, are placed small metal contacts (electrodes) on the skin of the arms, legs and thorax of the patient, measuring the flow and direction of electric currents in the heart during each heartbeat. Each electrode is connected by wires to a machine that produces a specific path, which varies with the electrode. Each tracing represents the recording of electrical activity in one part of the heart, the different paths are called derivations.
Usually, an ECG is done whenever suspected heart disease. This test helps to identify a number of these disorders, including abnormal rhythms, arrival insufficient blood and oxygen to the heart and excessive hypertrophy (thickening) of the heart muscle, which may be the consequence of hypertension. An ECG also evident when the heart muscle is thin or nonexistent because they have been replaced by non-muscular tissue, this picture may be the result of a heart attack (myocardial infarction).
Stress Test
The exercise endurance tests provide information about the existence and severity of coronary artery disease and heart disease. An exercise tolerance test, which allows control of ECG and blood pressure during the latter, may reveal problems that would appear at rest. For example, if the coronary arteries are partially blocked, the heart can have a sufficient blood supply at rest but not when you do something physical. A simultaneous pulmonary function test to distinguish the limitations caused by heart disease, lung disease or a combination of both.
The test consists of riding a bike or walking on a treadmill at a certain pace that is gradually increased. The ECG is monitored continuously and blood pressure is measured at intervals. The exercise tolerance test is continued until heart rate reaches between 80 and 90 percent of the maximum possible value according to age and sex. If symptoms such as dyspnea or chest pain, cause significant distress or if there are significant abnormalities in ECG or blood pressure recording, the session is interrupted before.
If for some reason can not exercise, you can perform an electrocardiogram, which provides information similar to that of the exercise tolerance test without exercise. This is injected a drug such as dipyridamole or adenosine, which increase the blood supply to normal heart tissue and decrease the blood supply to the diseased tissue, which mimics the effects of physical exercise.
The stress test suggests the presence of coronary artery disease when certain anomalies in the ECG, the patient developed angina or blood pressure decreases.
No test is perfect. Sometimes problems are found in patients who suffer from coronary heart disease (false positive) and, sometimes, not detected in those who actually have it (false negative). In patients with no symptoms, especially if they are young, the chance of heart disease is low, despite an altered test. However, the exercise tolerance test is often used as a control in apparently healthy people, for example, before starting an exercise program or an assessment for life insurance. If there are many false positives, this can cause considerable discomfort and health costs. Therefore, many experts do not endorse the routine use of this test in asymptomatic subjects.
Continuous ambulatory electrocardiography
Arrhythmia and insufficient blood flow to the heart muscle can result in a brief or unpredictable. Therefore, the detection of these problems requires the use of a portable continuous ECG recording. The patient wears a small battery powered device (Holter monitor) that records the ECG for 24 hours straight. While wearing the device, write in a diary the time and type of symptoms. The recording is processed through a computer that analyzes the speed and heart rate, look for changes in electrical activity that can indicate inadequate blood flow to the heart muscle and records every heartbeat for 24 hours. Symptoms that point in the paper are compared with those detected in the ECG.
If necessary, the ECG is transmitted to a computer by telephone from the hospital or doctor’s office for immediate reading as symptoms appear. Sophisticated portable devices simultaneously recorded ECG and EEG (a measure of brain electrical activity) in patients with loss of consciousness. These records help to differentiate between epileptic seizures and heart rhythm abnormalities.
Electrophysiological Exploration
Electrophysiological tests are used to evaluate severe abnormalities in the rhythm or electrical conduction. Through the veins or, occasionally, through arteries, tiny electrodes are inserted directly into the heart chambers to record the ECG and to identify the pathways by which circulating electric shock.
Sometimes, intentionally causes an abnormal heart rhythm during the test to find out if a particular drug is effective in stopping or altering an operation can be useful. If necessary, your doctor may cause the heart to return quickly to its normal rhythm by a brief electric shock (cardioversion). Although this test is invasive and requires anesthesia, is very safe: the risk of death is 1 in 5000 scans.
Radiologic
In case of suspicion of heart disease, chest X-rays necessary to practice in front and in profile. X-rays show the shape and size of the heart and marked the silhouettes of the vessels in the lungs and chest. Observed abnormalities can easily shape and size of these structures, and other abnormalities, such as calcium deposits within the heart tissue. Chest X-rays also reveal the condition of the lungs (especially of blood vessels) and the presence of liquid inside or around them.
The enlarged heart may be due to heart failure or an abnormal valve. But sometimes, the size may be normal even in people who have serious heart disease.
In constrictive pericarditis, characterized by the heart be constricted by scar tissue, the heart was not enlarged heart failure even appears.
The appearance of the pulmonary blood vessels is often more important to diagnose the appearance of the heart. For example, dilation of the pulmonary arteries near the heart, but narrowed in lung tissue suggests an enlarged right ventricle.
Computed Tomography
Regular computed tomography (CT) is rarely used to diagnose heart disease, but can detect structural abnormalities of the heart, pericardium, major vessels, lungs and support structures within the chest. The computer system creates cross-sectional images of the entire chest using X-rays and shows the exact location of the anomalies.
The modern CT scan is much faster (cinetomografía computerized) and provides a mobile three dimensional image of the heart. This test is used to estimate structural abnormalities and movement.
Radioscopy
Fluoroscopy (fluoroscopy) is a continuous scanning X-ray on a screen showing the movement of the heart with each beat and lungs as they inflate and deflate. However, since it involves a relatively high dose of radiation, has been replaced by echocardiogram and other tests.
Fluoroscopy is used even when they perform a cardiac catheterization or electrophysiologic examination. It may be useful for the diagnosis sometimes difficult, valvular disease and congenital heart defects.
Echocardiogram
Echocardiography is one of the most widely used techniques for the diagnosis of heart disease because it is noninvasive, uses no x-rays and provides images of excellent quality. This test is harmless, painless, inexpensive and widely available.
For echocardiography using high frequency ultrasound waves, emitted by a recording probe (transducer) that hit the heart structures and blood vessels, and rebound, producing a moving image displayed on a video screen and that can be recorded on a tape or printed. Changing the position and angle of the probe, there are the heart and major blood vessels from several angles to get a detailed picture of the structure and cardiac function. For more clarity, or to analyze structures in the back of the heart, you can enter a transducer in the esophagus and record the signals from the back of the heart, a procedure called transesophageal echocardiography.
Echocardiography detects motion abnormalities of the heart chambers, the volume of blood pumped with each beat, the thickness and diseases of the sac around the heart (pericardium) and the presence of fluid between the pericardium and the heart muscle.
The main types of ultrasound examinations include M-mode, two-dimensional, Doppler and color Doppler. For the test with M-mode ultrasound, the simplest technique, by directing a single beam of ultrasound toward the desired heart. The two-dimensional echocardiography is the most commonly used and produces real two-dimensional images, by way of “sections” generated by computer. The Doppler technique detects movement and the turbulence of the blood and can create a color image (color Doppler). Color Doppler helps to determine and display on the direction and speed of movement in the chambers of the heart and vessels. The images allow us to see if the heart valves open and close properly, blood leaks if closing them and how much and if blood flow is normal. Likewise, it can detect abnormal communications between blood vessels or between the heart chambers, and also determine the structure and operation of vessels and chambers.
MRI
Magnetic resonance imaging (MRI) is a technique that uses a powerful magnetic field to produce detailed images of the heart and chest. This sophisticated and extremely expensive imaging technique is still in an experimental phase for use in the diagnosis of heart disease.
The person is placed inside a large electromagnet that causes a vibration of the nuclei of atoms in the body, producing a characteristic signals, which are converted into two and three dimensional images of cardiac structures. In general, it is not necessary to use contrast. Sometimes, however, paramagnetic contrast agents administered intravenously to facilitate the identification of a low blood flow to the heart muscle.
A disadvantage of MRI is that every image needs more time to be produced with CT. Because of the motion of the heart, the images obtained with MRI are more blurred than those obtained with CT. In addition, some people feel claustrophobic as they must remain motionless in a small space in a gigantic machine.
Studies with radioactive isotopes
They consist of intravenous injection of trace amounts of labeled substances, coupled with radioactive isotopes (indicators or tracers), exposure to radiation is lower than when performing radiographs. The indicators are rapidly distributed throughout the body, including the heart, and are detected with a gamma camera. The display includes an image that is stored on the computer for later analysis.
In the technique of computed tomography single photon emission, different types of radiation recording cameras can record a single image or produce a series of cross-sectional images amplified by the computer. This computer can also generate a three dimensional image.
Studies with radioactive isotopes are particularly useful in the diagnosis of acute chest pain of unknown cause. On the other hand, in patients with narrowing of the coronary arteries, are used to determine how this affects the constriction of blood supply to the heart and its functioning. This procedure is also used to check the increase of blood flow to heart muscle following heart bypass surgery or similar, as well as to determine the prognosis after a heart attack (myocardial infarction).
Blood flow passes through the heart generally considers thallium-201 injected into a vein and images obtained during exercise testing. The amount of thallium-201 absorbing cells of the heart muscle depends on the circulation. At the time of maximum effort, the heart area with less blood supply (ischemia) shows less radioactivity (produces an image weaker) than the surrounding muscle with normal contribution. In patients unable to exercise, an intravenous injection of dipyridamole or adenosine mimics the effects of exercise on blood flow. These drugs divert the blood supply to the damaged vessel to normal.
Once the person has rested a few hours, the second scan is performed. This shows in which areas of the heart is an absence of reversible flow, usually due to narrowing of the coronary arteries, and which have an irreversible scarring of the heart muscle, which in turn is often the result of a heart attack earlier.
If you suspect an acute myocardial infarction, using tracers containing technetium-99 instead of thallium-201. In contrast to thallium, which accumulates mainly in the normal tissue, technetium is active mainly in the diseased tissue. However, because the technetium is also concentrated in the bones, ribs, a bit difficult the assessment of the resulting images.
Technetium scintigraphy is used for the diagnosis of myocardial infarction. The injured heart area absorbs the technetium and the test can detect a heart attack from 12 to 24 hours after it began, until a week later.
Positron emission tomography
For positron emission tomography (PET), it marks a necessary nutrient for the functioning of the heart with a substance that emits radioactive particles, called positrons, and then injected intravenously. Within minutes the score reaches the heart area of interest to examine and explore an area detector and recorded the most activity points. From this information, a computer constructs a three dimensional image of the entire area, which shows the differences in activity in the regions of heart muscle. Positron emission tomography provides much sharper images than any other radioactive medical analysis. However, these tests are very expensive and not easily affordable. They are used in the field of research and also when testing simpler and less expensive are inconclusive.
Cardiac catheterization
Cardiac catheterization is based on inserting a small catheter (tube) into an artery or a vein, usually an arm or leg, that slides into the major vessels and chambers of the heart. To achieve the right side of the heart, the catheter is inserted into a vein, to reach the left side, is placed inside an artery. The catheters are inserted into the heart for diagnostic purposes so as to perform certain treatments. Before practicing this procedure is necessary to administer local anesthesia.
The catheter usually have at one end a measuring instrument or other device. Thus, according to the type, can measure pressure, see inside blood vessels dilate a heart valve or unblock an artery. The catheters are widely used in assessing the condition of the heart, as it is inserted without major surgery.
The pulmonary artery catheterization is the introduction, in a vein in your arm or neck, a specially designed catheter with a balloon at its end, which is passed through the atrium and ventricle to the beginning of the pulmonary artery. The catheter is used to measure blood pressure in the major vessels and the heart chambers and to determine the amount of blood leaving the heart to the lungs. Also blood samples can be drawn through the catheter to analyze the content of oxygen and carbon dioxide. Since introducing a catheter into the pulmonary artery can cause heart rhythm abnormalities during this procedure is carried out a continuous recording of the electrocardiogram. In general, these anomalies can be avoided by changing the catheter to another position. If this maneuver is not effective, the catheter is removed.
The catheter is also used to obtain blood samples for studies of metabolism. Through the catheter can be instilled contrasts drawn blood vessels and chambers of the heart on fluoroscopy. Anatomical abnormalities and blood flow can be observed and recorded on film while making films. Also, using some instruments through the catheter, can be obtained samples of heart muscle tissue inside the heart chambers for microscopic examination (biopsy). You can also separately recorded blood pressure in each chamber and in major veins and arteries, and the content of oxygen and carbon dioxide in the blood of different parts of the heart.
Finally, it is possible to evaluate the heart’s ability to pump blood from the analysis of motion of the left ventricular wall and calculating the efficiency with which expels the blood (ejection fraction). This analysis allows us to assess the injuries of the heart that have been developed because of ischemia from coronary artery disease or any other disorder.
Coronary angiography
Coronary angiography is the study of coronary arteries using a catheter. To this end, a thin catheter is inserted into an artery in the arm or groin to the coronary arteries. Fluoroscopy can be used (a continuous process X-ray) to guide the catheter. The end of the catheter is placed in the proper position and is injected into coronary arteries through the same contrast, which allows you to view its outline on a screen. The sequence of radiographs (cine) provides clear images of the heart chambers and coronary arteries. For example, coronary artery disease will manifest in the form of irregularities or narrowing of their inner walls. If a person has a disease of the coronary arteries, the catheter can also be used to remove the obstruction, this procedure is called percutaneous transluminal coronary angioplasty.
Some minor side effects produced by coronary angiography may appear immediately after injection. Generally, as the contrast is distributed throughout the bloodstream, the patient had a transient feeling of warmth, especially in the head and face. Increases heart rate and blood pressure decreases slightly. On rare occasions, there are more relevant reactions such as nausea, vomiting and cough. Severe reactions, which are very rare, may be shock, convulsions, kidney and heart failure. Allergic reactions ranging from skin rashes to a rare condition, sometimes fatal, disease called anaphylaxis. , There are also abnormalities in heart rhythm if the catheter touches the walls of the heart. The medical team that performed this procedure has the appropriate instruments and the ability to immediately address any of these side effects.
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