Electrocardiogram (ECG or EKG)

 The heart is a pump and it squeezes when a highly sophisticated sequence of electrical current spreads through it, stimulating it to contract. Abnormalities in this electrical current result in abnormalities of heart rate and rhythm. An ECG is a very simple test to look at your heart rate, rhythm and understand if there are problems with the electrical system of the heart. 

What kind of problems can an ECG diagnose?

  1. Heart rate: can be too fast or too slow
  2. Rhythm: can be normal, originate from the upper chamber (atria) or the lower chamber (ventricles). 
  3. Speed of electrical conduction: the heart has an electrical cable system. Sometimes these cables are diseased, resulting in delay in speed of electrical conduction. 
  4. Heart attack: if you have previously suffered a significant heart attack, or are actively experiencing chest pain from a heart attack (minor or major) or unstable angina, an ECG is a very valuable tool. If abnormal, it can be diagnostic for a heart attack. A normal ECG does NOT mean that your heart is entirely normal.
  5. Thickness of the heart: the left ventricle of the heart can become thick for several reasons. An ECG may be able to diagnose enlargement of the atria or thickness of the ventricles. 

Is there any risk in ECG?

No. An ECG is a very simple, easy test free of risk. 

  • On your chest, 10 electrical patches with glue will be placed on various locations. 
  • Electrical wires will be attached to each patch and connected to a machine. 
  • Your heart’s electrical activity will be recorded and printed. 
  • The test takes 5 minutes or less. 
  • To ensure there is good contact between the patches and skin, some men may need a small amount of hair to be shaved from their chest. 

There is no discomfort or risk in doing an ECG.

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Echocardiogram (commonly referred to as “echo”)

What is an “echo”? 

An echocardiogram is an ultrasound of the heart. Sound waves are emitted by a probe placed on the chest, reach the heart and are deflected back to the probe. These sound waves create images of the various structures of the heart, including muscle, heart valves, blood, pericardium, blood vessels and other tissues within and outside the heart. There is no radiation involved in an echo.

1. Is it uncomfortable to have an echo?


There is no needle involved and no pain caused during an echo. The only discomfort in some patients may be from the need to lay on their left side, if they have pre-existing back pain. The patient’s position can be altered to make them comfortable. Patients will also feel a gentle pressure and the slightly cold sensation of a gel which is used to obtain pictures, but this is always tolerated.Is there any risk in an echo?
No. Sound waves do not carry any risk, including that to a fetus is the patient is a young, pregnant woman. There is no risk of any minor or major complication.

2. What information is gained by an echo?

Echo allows your cardiologist to “see” your heart moving. While a lot of information can be gained in an echo, the top 5 important areas an echo helps to evaluate are:

1. Heart function: How well the heart is pumping is evaluated by measuring the “ejection fraction” or “EF”, which is a percentage of the blood pumped during each heart beat. For example if the heart has 100 ml of blood in it when full, and pumps 50 cc of blood with each heart beat, the EF is 50/10 or 50%. 

  • Normal EF: 55-75%. A heart never empties itself completely so EF is never 100%. 
  • Mildly decreased EF: 45-50%
  • Moderately decreased EF: 35-45%
  • Severely decreased EF: <35%

2. Is every area of the heart pumping strongly or is there any sign of muscle weakness? Normally, every area of the heart squeezes normally and equally. If there has been a previous heart attack, or some other cause, one or more areas of the heart pump may not squeeze strongly, or may not squeeze at all. This is important to know to treat the patient.

3. Evaluation of all 4 heart valves. There are 4 heart valves, two in the right heart, 2 in the left heart. Each valve can become leaky, called valve regurgitation, or become stiff, called valve stenosis. The degree of regurgitation or stenosis can be mild, moderate or severe. It is important to quantify any problem and treat accordingly.

4. Heart chambers: the heart has four chambers, two atria (upper chambers) and two ventricles (lower chambers). All four chambers have a normal size in men and women. Enlargement of one of more chambers of the heart can have serious consequences or may reflect a significant underlying problem. An echo allows accurate measurement of the size, thickness and function of each chamber of the heart.

5. Pericardium: The pericardium is a tough, leathery sac which surrounds the heart. 15 ml of thin fluid separates the heart from its pericardium, allowing the heart to squeeze without friction between its muscle and pericardium. Diseases of the pericardium can affect the heart function in significant ways. Sometimes, fluid builds up in the pericardial space, also called the pericardial sac. This can be due to trauma, bleeding, infection, cancer, inflammation or a complication related to heart surgery or other heart procedures. Fluid buildup in the pericardial sac can be mild, moderate or large in volume. Depending on how quickly fluid has built up and how much has accumulated, this fluid can choke the heart, resulting in the patient feeling short of breath, anxious, have low blood pressure, have sweating, fast heart rate with a weak pulse. If not detected in time, these symptoms can result in considerable discomfort and eventual death.

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Stress Test

Stress Echocardiogram

What is a stress test?

 A stress test is a way to assess if the patient’s symptoms of chest discomfort or shortness of breath is related to coronary artery disease (CAD). CAD means that there is a blockage in one of more of the arteries supplying blood to the heart. When arteries are blocked, patients can experience different symptoms including chest discomfort, shortness of breath, decline in energy, fatigue with exertion, nausea etc. 

Since many other conditions not related to the heart can also cause these symptoms, how does your doctor know whether your symptoms are related to CAD or to some other condition?

In a stress test, the goal is to obtain evidence that your symptoms are related to CAD. Therefore your heart is put to test by stressing it with exercise, making it work harder. This is done by asking the patient to walk briskly or run on a treadmill. As you work harder, your heart demands more oxygen and blood. If there is a blockage in your coronary arteries, blood supply will not increase in proportion to its needs, so you may experience symptoms of chest discomfort and/or shortness of breath. 

There are different kinds of stress tests. The best one is when a patient exercises on a treadmill. Not everyone can run on a treadmill, so the stress test can be modified to suit a patient’s physical capabilities to make it effective. The treadmill increases in speed and incline every 3 minutes and the stress test becomes harder. This can be modified to suit the patients ability to exercise.

Before a stress test, an echo of your heart is done to understand its function, movement of its various walls and study the heart valves. If any significant abnormality is found, the stress test may not be needed.

You are then hooked up to the stress test machine with electrical wires to obtain your ECG. A nurse will measure your blood pressure (BP) and heart rate (HR).

During a stress test, the patients heart rate, blood pressure and ECG are continuously monitored by a nurse and a cardiologist is also available if needed. If there is any concern at any time, the stress test can be stopped.

The patient is asked to exercise as much and as hard as is physically possible. When the patient can no longer exercise anymore due to symptoms or fatigue, the treadmill is stopped. You will be asked to very quickly lay down on a bed and turn on your left side. An echo sonographer will be ready to take pictures of your heart within 1 minute to see if there is any area of the heart muscle not squeezing well with exertion, or if the heart function has become weaker with exercise rather than becoming stronger. 

What does the cardiologist do with this information from a stress test?

Your exercise tolerance, blood pressure response, heart rhythm, ECG, symptoms, heart function and images of the heart moving tell a story about your heart. If your symptoms are reproduced by exercise and there is evidence of abnormality in your BP, rhythm, ECG, heart function or movement, you may have CAD. Further evaluation may be required with coronary angiography. Your cardiologist will talk further about that with you. 

Is there a risk in stress testing?

Yes, there is a very small risk in any stress test. The risk is related to :

  1. Whether or not you have CAD and how significant it is.
  2. Your heart function.
  3. Your valves, whether leaky or stiff.
  4. Heart rhythm. Some forms of heart rhythm disturbances can be serious or life threatening.

This is why a stress test is always monitored, a physician is always available and emergency drugs are kept to treat a patient immediately in the event of a patient suffering a serious cardiac emergency. The risk of death in stress testing is extremely low at 1%.