Your Visit to the Cardiologist

The Big Heart Disease Lie

Cardiovascular Disease Causes and Possible Treatments

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Cardiologist Professor and Chairman Department of Internal Medicine Wayne State University School of Medicine Detroit, Michigan

Physician-in-Chief Detroit Medical Center

A CARDIOLOGIST IS A PHYsician who has graduated from an accredited medical school and completed three years of internal medicine residency training followed by three or four years of cardiology training. Most cardiologists are part of a larger group, which is sometimes contained within a broader group of medical specialists including primary care physicians. Besides general cardiologists, there are many different subspecialties in cardiology. Those with added knowledge in interpretation of diagnostics are called noninvasive cardiologists. Those with special certification in the use of radioisotopes are called nuclear cardiologists. Cardiologists may also specialize in intervention-al cardiology, meaning they are experts in the use of angioplasty and stenting. Additionally, cardiologists may specialize in elec-trophysiology, which is the study of rhythm disturbances or problems with the electrical conduction system of the heart. These cardiologists may prescribe high-

ly specific drugs to treat irregularities in the heart rhythm or use devices (like implantable cardioverter defibrillators and pacemakers) designed to regulate the heart rhythm or trigger the heartbeat. Other cardiologists have specialized in treatment of advanced heart failure and heart transplantation.

Why See a Cardiologist?

Most people see a cardiologist because of a referral from their primary care physician for chest pain. In some cases, the cause of the chest pain is known to be coronary artery disease, and the referral is made for more advanced diagnostic testing and treatment; in other cases, the cause of the chest pain is unknown. Other common reasons for referral include shortness of breath, congestive heart failure not responsive to standard medical treatment, irregularities in the heart rhythm, blackout episodes (syncope), or palpitations.

In the past, almost all cardiologists accepted referrals only from physicians. However, a welcomed change is the self-referral, i.e., the patient feels they should see a cardiologist. More cardiologists are welcoming this source of patients.

Sometimes, there is little choice of cardiology referral. This is often the case when your insurance carrier or health maintenance organization (HMO) mandates the specific reason for the referral (requiring extensive documentation by the primary care physician), and the cardiologist is willing to agree to the insurance company's financial arrangements and care plans. This method of referral is the least acceptable to patients and physicians alike.

How Is a Cardiologist Chosen?

If there is flexibility in referral and the referral is through your primary care physician, that physician will commonly choose a cardiologist with whom they have a close relationship. Communication between the primary care physician and the cardiologist is critical to a successful diagnostic and treatment plan. Your primary care physician knows the most about you and will presumably have a close relationship with you. Consequently, they will be able to interpret the complexities of the visit to a cardiologist. Typically, the cardiologist they choose will be in close proximity and often practice in the same hospital environment and sometimes even in the same professional building or practice group.

Cardiologists are highly visible subspecialists, and, as a result, reputation is another common reason for referral. It is appropriate to ask your physician what other patients may have been referred to this cardiologist or to ask members of your social group or church about that cardiologist.

If you have the option of choosing your own cardiologist, you will probably choose one based on local reputation. However, some standards for academic excellence have been established. Board certification is increasingly a re quirement for hospital staff privileges in cardiovascular disease. A cardiologist is certified by the American Board of Internal Medicine in cardiovascular diseases.

Your local medical society has a roster of physicians in your community and their board certification status. Additionally, internet sites such as WebMD's at have a directory of most physicians. The major professional organization for cardiologists is the American College of Cardiology, which also lists cardiologists, including board certification and fellowship (FACC) status, on its website,

Board certification should not be the only criterion because many practicing cardiologists are board certified. Other public databases may list mortality for invasive procedures by each physician.

However, do not be fooled by simple mortality statistics. For example, a cardiologist who is willing to perform highly technical procedures on patients at high risk may have a higher mortality than a physician who routinely selects only the low risk candidates. Physicians who perform high-volume procedures on sick patients are most qualified to care for most problems.

Another major issue relates to the relationship between cardiologists and cardiac surgeons. Many of the diagnostic studies may lead to coronary bypass surgery or valve replacement or repair. The close working relationship between the cardiologist and the cardiac surgeon is part of the equation that should be used in choosing the specialist. Therefore, local reputation, access, and understanding the quality of the cardiac surgical program should be considered in the decision. Finally, the reputation of the hospital as a cardiovascular medicine and surgical center is also part of the equation because those centers with national reputations for the quality of their cardiovascular medical and surgical teams are highly selective about the physicians on their staff.

What Will Happen during My

First Visit to the Cardiologist?

A typical cardiologist's office has the capability for many diagnostic tests. The cardiologist's staff is familiar with cardiac problems and trained in cardiopul-monary resuscitation.

Before you see the cardiologist, a nurse or staff member will usually review your history, make sure your prior medical records are available, and perform an electrocardiogram (EKG or ECG). This is considered an extension of the cardiac examination. Although many tests provide more specific information, an electrocardiogram remains a major screening tool for rhythm abnormality, evidence of blood vessel disease, and damage to the heart, or heart muscle problems.

However, the ability of an electrocardiogram to give specific diagnoses is very limited. A cardiologist will complete a standard history and physical, and you will be asked to rehash information that you have already given to another physician. This is because of the very specific probing questions to which cardiologists will seek answers in an effort to home in on your problem.

During the initial visit, the cardiologist will probably only obtain tests to help diagnose the problem. Very typically, these will be noninvasive tests (no tubes or instruments inserted into your blood vessels other than perhaps an intravenous line). After these tests, the cardiologist will inform you of the results.

Once the results of the initial tests have been evaluated, further testing may be needed, and an invasive test (in which instruments or tubes are threaded through your blood vessels) may be prescribed. In some cases, you may be referred to a cardiology subspecialist.

During the course of this testing, the cardiologist will communicate directly with your primary care physician. Do not be intimidated if you are self-referred; physicians widely recognize the importance of second opinions, and your self-referral should not place a wedge between you and your primary care physician.

Typical Diagnostic Tests

Noninvasive Testing

Frequently, noninvasive tests may be used as screening tools before more complicated invasive testing. The most common non-invasive diagnostic tests include those designed to assess the probability of coronary artery disease and review heart muscle function.

The test often used to detect coronary artery disease is the treadmill exercise stress test. In some cases, a simple exercise test is performed in which the patient is monitored by an electrocardiogram during a walk on a treadmill that will increase its speed and slope until either a target heart rate is reached or a symptom or elec-trocardiographic finding worthy of discontinuation of the test results. In more complicated situations, including an abnormal resting electrocardiogram or poor specificity of treadmill testing in a subgroup population (such as in women, for whom the test is not as accurate), a nuclear or echocardiographic study may be added.

In the case of a nuclear study, a radioisotope, usually either thallium or Sestamibi (Cardiolyte), is injected into your vein during peak exercise, and your heart is imaged. You will be asked to return four to six hours after the initial imaging for a second scan. This image will give the cardiologist a view of what blood flow to your heart is like during rest, and the first image will show coronary blood flow during exercise. If coronary blood flow is abnormal during exercise but normal during rest, coronary artery disease is likely, and the cardiologist may request a catheterization.

In the case of stress testing with ultrasonic techniques, an echocardiogram will be performed at successively harder levels of exercise. If segments of the heart muscle contract less vigorously during exercise than they do at rest, there is evidence for blood vessel disease, and cardiac catheteriza-tion in all likelihood will be recommended. In some highly specialized centers, measurements of coronary blood flow may include very sophisticated technology such as magnetic resonance imaging (MRI) or positron emission tomography (PET scanning).

If you are unable to exercise or walk on a treadmill, there are drugs that may be given (dipyri-damole, adenosine, or dobuta-mine) that will enhance abnormalities in coronary blood flow so that they can be imaged with nuclear or echocardio-graphic techniques.

If your problem relates to congestive heart failure, abnormalities of your heart valves, or increased thickness of your heart muscle, an echocardiogram, or an ultrasound scan of your heart, gives the cardiologist much information. Sometimes the abnormalities in the back of your heart or your chest do not conduct sound waves well. The cardiologist may then suggest a transesophageal echocar-diogram (TEE), during which the probe is swallowed and your heart is seen from your esophagus. If you have abnormalities in blood vessels other than in your heart, a Duplex scan utilizing ultrasonic/Doppler techniques to determine flow may be applied.

If your abnormality includes your heart rhythm, a Holter monitor is quite valuable. This is a small device the size of a transistor radio that records your ECG for a day or two while you record any symptoms you may have in a diary. If the palpitations or lightheaded episodes that bring you to the cardiologist occur only once in a while, an event monitor may be utilized. You can take this monitor home and call a station where heart rhythm detection occurs through a telephone monitor.

Invasive Testing If a noninvasive test indicates you have serious problems with your heart rhythm or possible blood vessel disease, an invasive test may be ordered.

Cardiac catheterization with coronary angiography is the most common invasive test. During this test, pressures within the heart are measured, dye may be injected into the left ventricle, and dye is injected into each of the blood vessels that supplies blood to the heart. An x-ray movie of the heart is then made.

If the obstruction to blood flow is localized, it can be repaired by balloon angioplasty and/or stenting (see Chapter Six). That procedure may be done at the same time as the cardiac catheterization. A simple diagnostic catheterization may require only a few hours at the hospital. An interventional procedure may take longer in the hospital, but generally less than one day.

Your cardiologist will discuss the result of your tests. If your problem is not a blood vessel in your heart but one of your other major vessels such as a blood vessel to your legs, the cardiologist may dilate those blood vessels as in coronary angioplasty.

If the problem is a rhythm disturbance, an electrophysiolo-gist can perform an electrophysi-ologic study, in which your heart is stimulated and the heartbeat measured. Essentially, this is a very sophisticated and highly sensitive electrocardiogram. As a result of this procedure, a recommendation may be made for a pacemaker or for an implantable cardioverter defibrillator. This placement is generally performed by the same electrophysiologist.

When Does a Cardiologist Refer Patients to a Cardiac Surgeon?

In the event of coronary artery disease, for example, a cardiologist will refer you to a heart surgeon when blood vessel disease affects multiple vessels and an-gioplasty is not practical. The cardiac surgeon will then review the angiogram and consult with the cardiologist regarding the best surgical approach for coronary artery bypass grafting.

Once the referral to a surgeon is made, your cardiologist will continue to see you immediately before and immediately after surgery. After hospitalization, which is generally less than one week, the cardiologist and surgeon will both see you in follow-up until your surgical wound is healed, at which time the surgeon will typically send you back to the cardiologist for care.

If your postoperative course was not complicated, your cardiologist will typically refer you to the primary care physician but will see you at regularly scheduled intervals: three months, six months, and one year after surgery.

Typically, an exercise stress test will be performed either three or six months after surgery and annually thereafter. Measurement of cholesterol level will occur within six weeks of surgery, and the cardiologist and primary care physician will confer about "secondary prevention," i.e., treatment measures designed to reduce and reverse the blood vessel disease (atherosclerosis) that caused your visit.

Cardiologists work in concert with primary care physicians and cardiac surgeons. They are part of a team of physicians that are directing their efforts toward the well-being of your heart and blood vessels.

However, the ultimate determinant of the success of cardiovascular care is the patient, because you are the fourth member of the team. As a team member, it is your responsibility to ask all the questions you may have.

During diagnosis, a patient's medical history is obtained.


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