Noninvasive Diagnostic Testing

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Noninvasive Diagnostic Cardiac Testing

Echocardiogram

Procedure overview

What is an echocardiogram?

echocardiogramAn echocardiogram is a noninvasive (the skin is not pierced) procedure used to assess the heart's function and structures. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves at a frequency too high to be heard. When the transducer is placed on the chest at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves bounce or "echo" off of the heart structures. These sound waves are sent to a computer that can create moving images of the heart walls and valves.

An echocardiogram may utilize several special types of echocardiography, as listed below:

  • M-mode echocardiography. This, the simplest type of echocardiography, produces an image that is similar to a tracing rather than an actual picture of heart structures. M-mode echo is useful for measuring heart structures, such as the heart's pumping chambers, the size of the heart itself, and the thickness of the heart walls.

  • Doppler echocardiography. This Doppler technique is used to measure and assess the flow of blood through the heart's chambers and valves. The amount of blood pumped out with each beat is an indication of the heart's functioning. Also, Doppler can detect abnormal blood flow within the heart, which can indicate a problem with one or more of the heart's four valves, or with the heart's walls.

  • Color Doppler. Color Doppler is an enhanced form of Doppler echocardiography. With color Doppler, different colors are used to designate the direction of blood flow. This simplifies the interpretation of the Doppler technique.

  • 2-D (two-dimensional) echocardiography. This technique is used to "see" the actual motion of the heart structures. A 2-D echo view appears cone-shaped on the monitor, and the real-time motion of the heart's structures can be observed. This enables the doctor to see the various heart structures at work and evaluate them.

  • 3-D (three-dimensional) echocardiography. 3-D echo technique captures three-dimensional views of the heart structures with greater depth than 2-D echo. The live or "real time" images allow for a more accurate assessment of heart function by using measurements taken while the heart is beating. 3-D echo shows enhanced views of the heart's anatomy and can be used to determine the appropriate plan of treatment for a person with heart disease.

Other related procedures that may be used to assess the heart include resting or exercise electrocardiogram (ECG or EKG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest X-ray, computed tomography (CT scan) of the chest, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and cardiac CT scan. Please see these procedures for additional information.

Reasons for the procedure

An echocardiogram may be performed for further evaluation of signs or symptoms that may suggest:

  • Atherosclerosis. A gradual clogging of the arteries over many years by fatty materials and other substances in the blood stream that can lead to abnormalities in the wall motion or pumping function of your heart. 

  • Cardiomyopathy. An enlargement of the heart due to thickening or weakening of the heart muscle

  • Congenital heart disease. Defects in one or more heart structures that occur during formation of the fetus, such as a ventricular septal defect (hole in the wall between the two lower chambers of the heart).

  • Congestive heart failure. A condition in which the heart muscle has become weakened to an extent that blood cannot be pumped efficiently, causing fluid buildup (congestion) in the blood vessels and lungs, and edema (swelling) in the feet, ankles, and other parts of the body.

  • Aneurysm. A dilation of a part of the heart muscle or the aorta (the large artery that carries oxygenated blood out of the heart to the rest of the body), which may cause weakness of the tissue at the site of the aneurysm.

  • Valvular heart disease. Malfunction of one or more of the heart valves that may cause an abnormality of the blood flow within the heart.

  • Cardiac tumor. A tumor of the heart that may occur on the outside surface of the heart, within one or more chambers of the heart (intracavitary), or within the muscle tissue (myocardium) of the heart.

  • Pericarditis. An inflammation or infection of the sac that surrounds the heart.

An echocardiogram may also be simply performed to assess the heart’s overall function and general structure.

There may be other reasons for your doctor to recommend an echocardiogram.

Risks of the procedure

For some patients, having to lie still on the examination table for the length of the procedure may cause some discomfort or pain.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Before the procedure

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

  • Generally, no prior preparation, such as fasting or sedation, is required.

  • Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

  • Notify your doctor if you have a pacemaker.

  • Based on your medical condition, your doctor may request other specific preparation.

During the procedure

An echocardiogram may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.

Generally, an echocardiogram follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your glasses, dentures, or hearing aids if you use any of these.

  2. You will be asked to remove clothing from the waist up and will be given a gown to wear.

  3. You will lie on a table or bed, positioned on your left side. A pillow or wedge may be placed behind your back for support.

  4. You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. The ECG tracings that record the electrical activity of the heart will be compared to the images displayed on the echocardiogram monitor.

  5. The room will be darkened so that the images on the echo monitor can be viewed by the technologist.

  6. The technologist will place warmed gel on your chest and then place the transducer probe on the gel. You will feel a slight pressure as the technologist positions the transducer to obtain the desired images of your heart.

  7. During the test, the technologist will move the transducer probe around and apply varying amounts of pressure to obtain images of different locations and structures of your heart. The amount of pressure behind the probe should not be uncomfortable. If it does make you uncomfortable, however, let the technologist know.

  8. After the procedure has been completed, the technologist will wipe the gel from your chest and remove the ECG electrode pads. You may then put on your clothes.

After the procedure

You may resume your usual diet and activities unless your doctor advises you differently.

Generally, there is no special type of care following an echocardiogram. However, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Online resources

The content provided here is for informational purposes only, and was not designed to diagnose or treat a health problem or disease, or replace the professional medical advice you receive from your doctor. Please consult your health care provider with any questions or concerns you may have regarding your condition.

This page contains links to other websites with information about this procedure and related health conditions. We hope you find these sites helpful, but please remember we do not control or endorse the information presented on these websites, nor do these sites endorse the information contained here.

American College of Cardiology

American Heart Association

National Heart, Lung, and Blood Institute (NHLBI)

National Institutes of Health (NIH)

National Library of Medicine

Transesophageal Echocardiogram

What is a transesophageal echocardiogram?

TEE.jpgA transesophageal echocardiogram (TEE) uses echocardiography to assess how well the heart works. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves at a frequency too high to be heard. When the transducer is placed at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves bounce or "echo" off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer displays the echoes as images of the heart walls and valves.

A transesophageal echocardiogram is done by inserting a probe with a transducer down the esophagus rather than placing the transducer on the chest in a transthoracic echocardiogram.

By inserting the transducer in the esophagus, TEE provides a clearer image of the heart because the sound waves do not have to pass through skin, muscle, or bone tissue. For example, being overweight or having certain lung diseases can interfere with images of the heart when the transducer is placed on the chest wall.

Certain conditions of the heart, such as mitral valve disorders, blood clots or masses inside the heart, a tear of the lining of the aorta and artificial heart valves, are better seen with TEE.

A TEE may use one or more of several special types of echocardiography, as listed below:

  • M-mode echocardiography. This, the simplest type of echocardiography, produces an image that is similar to a tracing rather than an actual picture of heart structures. M-mode echo is useful for measuring heart structures, such as the heart’s pumping chambers, the size of the heart itself, and the thickness of the heart walls.
  • Doppler echocardiography. This Doppler technique is used to assess blood flow through the heart’s chambers and valves. The amount of blood pumped out with each beat is an indication of the hearts functioning. Also, Doppler can detect abnormal blood flow within the heart, which can indicate a problem with one or more of the heart’s four valves, or with the heart’s walls.
  • Color Doppler. Color Doppler is an enhanced form of Doppler echocardiography. With color Doppler, different colors are used to designate the direction of blood flow. This simplifies the interpretation of the Doppler technique.
  • 2-D (two-dimensional) echocardiography. This technique is used to view the motion of the heart structures. A 2-D echo view appears cone-shaped on the monitor. It shows the real-time motion of the heart’s structures. This lets the doctor to see the various heart structures at work and evaluate them.
  • 3-D (three-dimensional) echocardiography. This technique captures three-dimensional views of the heart structures with greater depth than 2-D echo. The live or “real time” images allow for a more accurate assessment of heart function by using measurements taken while the heart is beating.

Why might I need a transesophageal echocardiogram?

Transesophageal echocardiography may be done to evaluate signs and symptoms that may suggest:

  • Atherosclerosis. This is a gradual clogging of the arteries by fatty materials and other substances in the blood stream. It happens over many years.
  • Cardiomyopathy. This is an enlargement of the heart due to thickening or weakening of the heart muscle.
  • Congenital heart disease. These defects in one or more heart structures occur during formation of the fetus. This includes ventricular septal defect (hole in the wall between the two lower chambers of the heart).
  • Heart failure. A condition in which the heart muscle has become weakened to an extent that blood can’t be pumped efficiently. This can cause fluid buildup (congestion) in the blood vessels and lungs, and edema (swelling) of the feet, ankles, and other parts of the body.
  • Aneurysm. This is a weakening and bulging of a part of the heart muscle or the aorta (the large artery that carries oxygenated blood out of the heart to the rest of the body).
  • Heart valve disease.  Malfunction of one or more of the heart valves that may block blood flow within the heart.
  • Cardiac tumor. A tumor of the heart may occur on the outside surface of the heart, within one or more chambers of the heart , or within the muscle tissue of the heart.
  • Pericarditis. This is an inflammation or infection of the sac that surrounds the heart.
  • Infective endocarditis. This is an infection of the heart, usually affecting the heart valves. 

Additional reasons for which a TEE may be done include:

  • To assess the heart’s function and structures
  • To evaluate the heart during open-heart surgery after procedures, such as coronary artery bypass or valve replacement or repair
  • To evaluate the heart during non-cardiac surgery

There may be other reasons for your doctor to recommend a TEE.

What are the risks of a transesophageal echocardiogram?

Possible risks associated with a transesophageal echocardiogram include:

  • Breathing problems
  • Heart rhythm problems
  • Infection
  • Bleeding
  • Injury to the mouth, throat or esophagus 

If you have known problems of the esophagus, such as esophageal varices, esophageal obstruction, or radiation therapy to the area of the esophagus, you may not be able to have a TEE. Your doctor will evaluate you carefully before having the procedure.

If you are allergic to or sensitive to medications or latex , tell your doctor.

If you are pregnant or think you may be, tell your doctor.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

How do I get ready for a transesophageal echocardiogram?

  • Your doctor will explain the procedure to you and offer you the chance to ask questions.
  • You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.
  • You will need to fast for a certain period prior to the procedure. Your doctor will tell you how long to fast, whether for a few hours or overnight.
  • If you are pregnant or think you may be, tell your doctor.
  • Tell the doctor if you are allergic to or sensitive to medications, local anesthesia, or latex.
  • Tell your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
  • Tell your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure.
  • Your doctor may request a blood test prior to the procedure to determine how long it takes your blood to clot. Other blood tests may be done as well.
  • Tell the doctor if you have heart valve disease, a congenital heart condition, or a history of endocarditis (infection of the heart valves).
  • You may receive a sedative prior to the procedure to help you relax. If a sedative is given, you will need someone to drive you home afterwards.
  • Based on your medical condition, your doctor may request other specific preparation.

What happens during a transesophageal echocardiogram?

A TEE may be done on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.

Generally, a TEE follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure. If you wear dentures or any oral prosthesis, they will be removed prior to the insertion of the TEE probe.
  2. If you are asked to remove clothing, you will be given a gown to wear.
  3. You will be asked to empty your bladder prior to the procedure.
  4. An intravenous (IV) line will be started in your hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed.
  5. You will lie on a table or bed, positioned on your left side. A pillow or wedge may be placed behind your back for support.
  6. You will be connected to an electrocardiogram (EKG) monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure.
  7. A local anesthetic spray will be applied to the back of the throat. This will numb the back of your throat to make passing the TEE probe more comfortable.
  8. You will receive a sedative medication in your IV before the procedure to help you relax.
  9. If indicated, oxygen will be given through nasal tubes.
  10. The room will be darkened so that the images on the echocardiogram monitor can be seen by the doctor.
  11. The TEE probe will be passed through your mouth and down your throat. You may be asked to swallow to help pass the probe.
  12. Once the probe is in the right place, the images are taken.
  13. After the necessary images are taken, the probe will be removed from your throat.

What happens after a transesophageal echocardiogram?

You will be moved to a recovery area, where nurses will monitor your heart rate, EKG, blood pressure, and oxygen levels.

When your gag reflex has returned, your vital signs are stable, and you are more alert, the EKG electrode pads, the oxygen probe, and the IV will be removed. You may get dressed.

You may feel weak, tired, or groggy for the rest of the day of the test. You should feel normal by the day after the procedure. Your throat may be sore for a few days after the procedure due to the insertion of the TEE probe.

If the procedure was done on an outpatient basis, you may be discharged home, unless your doctor determines that your condition requires further observation or hospital admission.

If you received sedation, you will need to have someone drive you home.

You may resume your usual diet and activities unless your doctor advises you differently.

Generally, there is no special type of care following a TEE. However, your doctor may give you other instructions after the procedure, depending on your particular situation.

Next steps

Before you agree to the test or the procedure make sure you know:
  • The name of the test or procedure
  • The reason you are having the test or procedure
  • The risks and benefits of the test or procedure
  • When and where you are to have the test or procedure and who will do it
  • When and how will you get the results
  • How much will you have to pay for the test or procedure

 

Holter Monitor

Procedure overview

What is a Holter monitor?

The Holter monitor is a type of electrocardiogram (ECG or EKG) used to monitor the ECG tracing continuously for a period of 24 hours or longer. A standard or "resting" ECG is one of the simplest and fastest procedures used to evaluate the heart. Electrodes (small, plastic patches) are placed at certain locations on the chest and abdomen. When the electrodes are connected to an ECG machine by lead wires, the electrical activity of the heart is measured, interpreted, and printed out for the doctor's information and further interpretation.

When symptoms, such as dizziness, fainting, low blood pressure, prolonged fatigue, and palpitations, continue to occur without a definitive diagnosis obtained with a resting ECG, your doctor may request an ECG tracing to be run over a long period of time, using the Holter monitor.

322506.jpg

Certain dysrhythmias and arrhythmias (abnormal heart rhythms), which can cause the symptoms noted above, may occur only intermittently, or may occur only under certain conditions, such as stress. Dysrhythmias of this type are difficult to obtain on an ECG tracing that only runs for a few minutes. Thus, the doctor will request a Holter monitor to allow a better opportunity to capture any abnormal heartbeats or rhythms that may be causing the symptoms. The Holter monitor records continuously for the entire period of 24 to 48 hours. Some Holter monitors may record continuously but also have an event monitor feature that you activate when symptoms begin to occur.

You will receive instructions regarding how long you will need to wear the recorder (usually 24 to 48 hours), how to keep a diary of your activities and symptoms during the test, and personal care and activity instructions, which include keeping the device dry while you are wearing it.

What is an event monitor?

Event monitoring is very similar to Holter monitoring, and is often ordered for the same reasons. With an event monitor, you wear ECG electrode patches on your chest, and the electrodes are connected by wire leads to a recording device. Unlike the Holter monitor, however, which records continuously throughout the testing period of 24 to 48 hours, the event monitor records when you feel symptoms and trigger the monitor to record your ECG tracing at that time. An auto-trigger event monitor may be used to record rhythms when symptoms are rare or suspected to occur during sleep. The auto-trigger event monitor automatically records rhythm events that are faster or slower than normal and can also be manually activated if you experience symptoms.

When you feel one or more symptoms, such as chest pain, dizziness, or palpitations, you push a button on the event monitor recorder. Some monitors have a feature (memory loop recorder) which captures a short period of time prior to the moment you triggered the recording and afterwards. This feature can help your doctor determine more details about the possible change in your ECG at the time the symptoms started, and what was happening with your ECG just before you triggered the recorder. Other monitors, called "post-event recorders," simply start recording your ECG from the moment you trigger it.

Post-event recorders are quite small and some may even be worn on the wrist (similar to a wristwatch). Memory-loop recorders are about the size of a pager.

After you experience symptoms and record them, you will send the recording of the event to your doctor or to a central monitoring center. This transmission is generally done over the telephone or wirelessly using cellular technology. You will be instructed regarding how to transmit data. You will also keep a diary of your symptoms and corresponding activities (as done during the Holter monitoring procedure).

The heart's electrical conduction system

The heart is, in the simplest terms, a pump made up of muscle tissue. The heart's pumping action is regulated by an electrical conduction system that coordinates the contraction of the various chambers of the heart.

322252.jpgAn electrical stimulus is generated by the sinus node (also called the sinoatrial node, or SA node), which is a small mass of specialized tissue located in the right atrium (right upper chamber) of the heart.

The sinus node generates an electrical stimulus regularly at 60 to 100 times per minute under normal conditions. This electrical stimulus travels down through the conduction pathways (similar to the way electricity flows through power lines from the power plant to your house) and causes the heart's lower chambers to contract and pump out blood. The right and left atria (the two upper chambers of the heart) are stimulated first and contract a short period of time before the right and left ventricles (the two lower chambers of the heart).

The electrical impulse travels from the sinus node to the atrioventricular node (also called AV node), where impulses are slowed down for a very short period, then continue down the conduction pathway via the bundle of His into the ventricles. The bundle of His divides into right and left pathways to provide electrical stimulation to the right and left ventricles.

This electrical activity of the heart is measured by an electrocardiogram. By placing electrodes at specific locations on the body (chest, arms, and legs), a graphic representation, or tracing, of the electrical activity can be obtained. Changes in an ECG from the normal tracing may indicate one or more of several heart-related conditions.

Reasons for the procedure

Some reasons for your doctor to request a Holter monitor recording or event monitor recording include, but are not limited to, the following:

  • To evaluate chest pain not reproduced with exercise testing

  • To evaluate other signs and symptoms that may be heart-related, such as fatigue, shortness of breath, dizziness, or fainting

  • To identify irregular heartbeats or palpitations

  • To assess risk for future heart-related events in certain conditions, such as idiopathic hypertrophic cardiomyopathy (pathologically thickened heart walls due to an underlying genetic condition), post-heart attack with weakness of the left side of the heart, or Wolff-Parkinson-White syndrome (where an abnormal electrical conduction pathway exists within the heart)

  • To assess the function of an implanted pacemaker

  • To determine the effectiveness of therapy for complex arrhythmias

There may be other reasons for your doctor to recommend the use of a Holter monitor.

Risks of the procedure

The Holter monitor is a noninvasive method of assessing the heart’s function. Risks associated with the Holter monitor are rare.

Prolonged application of the adhesive electrode patches may cause tissue breakdown or skin irritation at the application site.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to wearing the monitor.

Certain factors or conditions may interfere with or affect the results of the Holter monitor reading. These include, but are not limited to, the following:

  • Close proximity to magnets, metal detectors, high-voltage electrical wires, and electrical appliances such as shavers, toothbrushes, and hair dryers

  • Smoking, certain medications

  • Excessive perspiration, which may cause the leads to loosen or detach

Before the procedure:

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the reading.

  • Fasting is not required.

  • Based on your medical condition, your doctor may request other specific preparation.

During the procedure

A Holter monitor recording is generally performed on an outpatient basis. Procedures may vary depending on your condition and your doctor’s practices.

Generally, a Holter monitor recording follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the reading.

  2. You will be asked to remove clothing from the waist up in order to attach the electrodes to your chest. The technician will ensure your privacy by covering you with a sheet or gown and exposing only the necessary skin.

  3. The areas where the electrodes patches are placed are cleaned, and in some cases, hair may be shaved or clipped so that the electrodes will stick closely to the skin. 

  4. Electrodes will be attached to your chest and abdomen. The Holter monitor will be connected to the electrodes with lead wires. The monitor box may be worn over the shoulder like a shoulder bag, or it may clip to a belt or pocket.

  5. Once you have been hooked up to the monitor and given instructions, you can return to your usual activities, such as work, household chores, and exercise, unless your doctor instructs you differently. This will allow your doctor to identify problems that may only occur with certain activities.

  6. You will be instructed to keep a diary of your activities during the recording period. You should write down the date and time of your activities, particularly if any symptoms, such as dizziness, palpitations, chest pain, or other previously-experienced symptoms, occur.

After the procedure

You should be able to resume your normal diet and activities, unless your doctor instructs you differently.

Generally, there is no special care following a Holter monitor recording.

Notify your doctor if you develop any signs or symptoms you had prior to the recording (for example, chest pain, shortness of breath, dizziness, or fainting).

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Stress Echocardiogram

What is an exercise echocardiogram?

stressTestAn echocardiogram is a noninvasive (the skin is not pierced) procedure used to assess the heart's function and structures. An exercise echocardiogram is performed to assess the heart's response to stress or exercise. During the procedure, a transducer (like a microphone) sends out ultrasonic sound waves at a frequency too high to be heard. When the transducer is placed on the chest at certain locations and angles, the ultrasonic sound waves move through the skin and other body tissues to the heart tissues, where the waves bounce or "echo" off of the heart structures. The transducer picks up the reflected waves and sends them to a computer. The computer displays the echoes as images of the heart walls and valves.

After the resting echocardiogram images have been obtained, the person will begin to exercise on a treadmill or stationary bicycle. The doctor will compare the resting echocardiogram with the test done immediately after exercise.

An exercise echocardiogram may use one or more of several special types of echocardiography, as listed below:

  • M-mode echocardiography. This, the simplest type of echocardiography, produces an image that is similar to a tracing rather than an actual picture of heart structures. M-mode echo is useful for measuring heart structures, such as the heart's pumping chambers, the size of the heart itself, and the thickness of the heart walls.

  • Doppler echocardiography. This Doppler technique is used to measure and assess the flow of blood through the heart's chambers and valves. The amount of blood pumped out with each beat is an indication of the heart's functioning. Also, Doppler can detect abnormal blood flow within the heart, which can indicate a problem with one or more of the heart's four valves, or with the heart's walls.

  • Color Doppler. Color Doppler is an enhanced form of Doppler echocardiography. With color Doppler, different colors are used to designate the direction of blood flow. This simplifies the interpretation of the Doppler technique.

  • 2-D (two-dimensional) echocardiography. This technique is used to visualize the actual structures and motion of the heart structures. A 2-D echo view appears cone-shaped on the monitor, and the real-time motion of the heart's structures can be observed. This enables the doctor to see the various heart structures at work and evaluate them.

  • 3-D (three-dimensional) echocardiography. This technique captures three-dimensional views of the heart structures with greater depth than 2-D echo. The live or "real time" images allow for a more accurate assessment of heart function by using measurements taken while the heart is beating. 3-D echo shows enhanced views of the heart's anatomy and can be used to determine the appropriate plan of treatment for a person with heart disease. 

Other related procedures that may be used to assess the heart include resting or exercise electrocardiogram (ECG or EKG), Holter monitor, signal-averaged ECG, cardiac catheterization, chest X-ray, computed tomography (CT scan) of the chest, electrophysiological studies, magnetic resonance imaging (MRI) of the heart, myocardial perfusion scans, radionuclide angiography, and cardiac CT scan. Please see these procedures for additional information.

Reasons for the procedure

An exercise echocardiogram, obtained after you have exercised on a treadmill or stationary bicycle, may be performed for the following reasons:

  • To assess the heart’s general function and structures

  • To assess stress or exercise tolerance in patients with known or suspected coronary artery disease

  • To determine limits for safe exercise in patients who are entering a cardiac rehabilitation program and/or those who are recovering from a cardiac event, such as a heart attack (myocardial infarction, or MI) or heart surgery

  • To evaluate blood pressure levels during exercise

  • To evaluate the cardiac status of a patient about to undergo surgery

There may be other reasons for your doctor to recommend an exercise echocardiogram.

Risks of the procedure

Possible risks associated with an exercise echocardiogram include, but are not limited to, the following:

  • Chest pain

  • Severely high blood pressure

  • Irregular heartbeats

  • Dizziness

  • Nausea, and extreme fatigue

  • Heart attack (rare)

If you are pregnant or suspect that you may be pregnant, you should notify your health care provider.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Certain factors or conditions may interfere with the accuracy of an exercise echocardiogram. These factors include, but are not limited to, the following:

  • Smoking or ingesting caffeine within three hours prior to the procedure

  • Chronic obstructive pulmonary disease

  • Beta-blocking medications may make it difficult to increase the heart rate during the test

Before the procedure:

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

  • You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.

  • Fasting may be required before the procedure. Your doctor will give you instructions as to how long you should withhold food and/or liquids. In some cases, cigarettes and caffeinated beverages, such as coffee, tea, and cola may be restricted two to three hours before testing.

  • If you are pregnant or suspect that you may be pregnant, you should notify your health care provider.

  • Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

  • You may be instructed to hold certain medications before the procedure, such as beta-blockers. Your doctor will give you specific instructions regarding medications.

  • Notify your doctor if you have a pacemaker.

  • Notify your doctor if you have the following conditions: aneurysm, severe hypertension (high blood pressure), severe heart valve disease, severe congestive heart failure, recent heart attack, pericarditis, or severe anemia (low red blood cell count).

  • Plan to wear loose, comfortable clothing for the exercise portion of the test, as well as a pair of comfortable walking shoes.

  • Based on your medical condition, your doctor may request other specific preparation.

During the procedure

An exercise echocardiogram may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor's practices.

Generally, an exercise echocardiogram follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear you glasses, dentures, or hearing aids if you use any of these.

  2. You will be asked to remove clothing from the waist up and will be given a gown to wear.

  3. You will be asked to empty your bladder prior to the procedure.

  4. You will lie on your left side for the first set of echo images. A pillow or wedge will be placed behind your back for support.

  5. You will be connected to an ECG monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure. The ECG tracing that will record the electrical activity of the heart will be compared to the images displayed on the echocardiogram monitor.

  6. The room will be darkened so that the images on the echocardiogram monitor can be viewed by the technologist or doctor.

  7. The technologist will place warmed gel on your chest and then place the transducer probe on the gel. You will feel a slight pressure as the technologist positions the transducer to obtain the desired image of your heart.

  8. The technologist will move the transducer probe around and apply varying amounts of pressure to obtain images of different locations and structures of your heart. The amount of pressure behind the probe should not be uncomfortable. If it does make you uncomfortable, however, let the technologist know.

  9. The different echocardiogram techniques described above (M-mode, 2-D, 3-D, Doppler, and color Doppler) may be used. You will not be aware of the different techniques except that during the Doppler or color Doppler, you may hear a "whoosh-whoosh" sound, which is the sound of the blood moving through the heart.

  10. Once the echocardiogram initial images have been obtained, you will use the treadmill or bicycle to begin exercising.

  11. You will exercise until you have reached your target heart rate (determined by the doctor based on your age and physical condition), or until you are unable to continue due to chest pain, leg pain, severe shortness of breath, or severe fatigue.

  12. Once you have reached your target heart rate, you may continue to exercise as tolerated, as exercise duration is an important component of the stress test result.

  13. You should notify the technologist if you feel any chest pain, breathing difficulties, sweating, or heart palpitations.

  14. Immediately following exercise, you will lie on the table or bed while a second set of echocardiogram images is obtained.

  15. After the procedure has been completed, the technologist will wipe the gel from your chest and remove the ECG electrode pads. You may then put on your clothes.

After the procedure

You may resume your usual diet and activities unless your doctor advises you differently.

Generally, there is no special type of care following an exercise echocardiogram. However, your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Online resources

The content provided here is for informational purposes only, and was not designed to diagnose or treat a health problem or disease, or replace the professional medical advice you receive from your doctor. Please consult your health care provider with any questions or concerns you may have regarding your condition.

This page contains links to other websites with information about this procedure and related health conditions. We hope you find these sites helpful, but please remember we do not control or endorse the information presented on these websites, nor do these sites endorse the information contained here.

American College of Cardiology

American Heart Association

National Heart, Lung, and Blood Institute (NHLBI)

National Institutes of Health (NIH)

National Library of Medicine

Cardiac Nuclear Imaging

What is a stress myocardial perfusion scan?

A myocardial perfusion scan is a type of nuclear medicine imaging test. This means that a tiny amount of a radioactive substance, called a radioactive tracer is injected during the scan to help show the tissue under study, in this case, the heart.

A stress myocardial perfusion scan is used to assess blood flow to the heart muscle when it is stressed. The heart is usually “stressed” from exercise. But, if you are unable to exercise, the heart can be stressed by taking a certain medication that increases your heart rate as it would during exercise.

After the radioactive tracer is injected, a special type of camera is used that can detect the radioactive energy from outside the body. The camera takes images of the heart during stress and again later at rest. The two sets of images are compared.

On the scan, the areas of heart muscle that do not absorb the radioactive tracer look different from the areas that do absorb it. The areas that absorb the tracer are healthy. The areas that do not absorb the tracer are damaged due to decreased blood flow. The damaged areas may be called “cold spots” or “defects.”

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Why might I need a stress myocardial perfusion scan?

Possible reasons a stress myocardial perfusion scan may be done include, but are not limited to:

  • Chest pain, either new onset or occurring over a period of days or longer
  • A diagnosis of coronary artery disease (CAD), which is the narrowing of the coronary arteries
  • After a heart attack (myocardial infarction, or MI) to assess heart muscle damage
  • To assess blood flow to areas of the heart muscle after coronary artery bypass surgery or other procedures that are done to improve blood flow to the heart muscle

There may be other reasons for your healthcare provider to recommend a stress myocardial perfusion scan.

What are the risks of a stress myocardial perfusion scan?

Risks of the scan may include:

  • The exercise part of the test may lead to rare instances of abnormal heart rhythms, chest pain, or heart attack due to the stress on the heart caused by the exercise.
  • The needle used to put in the IV may cause some pain.
    The injection of the radioactive tracer may cause some slight discomfort. Allergic reactions to the tracer are rare.
  • If your heart is stressed using medication, you may feel anxious, dizzy, nauseous, shaky, or short of breath or chest pain for a brief period.

You may want to ask your healthcare provider about the amount of radiation used during the procedure and the risks related to your particular situation.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your healthcare provider prior to the procedure.

Certain factors may interfere with or affect the results of this test. These include, but are not limited to, the following:

  • Use of medications containing theophylline
  • Caffeine intake within 48 hours of the procedure
  • Smoking or using any form of tobacco within 48 hours of the procedure
  • Certain heart medications, such as those that slow the heart rate

How do I prepare for a stress myocardial perfusion scan?

  • Your healthcare provider will explain the procedure to you and ask if you have any questions.
  • You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if anything is not clear.
  • Tell your healthcare provider if you are allergic to or sensitive to medications, local anesthesia, contrast dyes, iodine, tape, or latex.
  • Fasting (not eating or drinking) may be required before the procedure. Your healthcare provider will give you instructions as to how long you should withhold food and/or liquids.
  • If you are scheduled for a pharmacologic myocardial perfusion scan, you will need to avoid taking any medications containing theophylline or caffeine. Coffee, even decaffeinated, is not allowed, as it contains some caffeine. Medications for asthma may contain theophylline. If you have asthma, inform your healthcare provider. Theophylline medications should be stopped 48 hours prior to the test.
  • Medications that contain caffeine and all food and drink containing caffeine should be held for 48 hours, too. Some over-the-counter medications that contain caffeine include Anacin, Excedrin, and NoDoz. Consult your healthcare provider for specific instructions.
  • If you are pregnant or think you may be pregnant, tell your healthcare provider. Radiation exposure during pregnancy may lead to birth defects.
  • If you are lactating, breastfeeding, tell your healthcare provider due to the risk of contaminating breast milk with the radioactive tracer.
  • Tell your healthcare provider of all medications (prescription and over-the-counter), vitamins, herbs, and supplements that you are taking.
  • Tell your healthcare provider if you have a pacemaker.
  • For an exercise scan, plan to wear loose, comfortable clothing, as well as comfortable walking shoes.
  • Based on your medical condition, your healthcare provider may request other specific preparation.

What happens during a stress myocardial perfusion scan?

A stress myocardial perfusion scan may be done on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your healthcare providers practice.

Generally, a stress myocardial perfusion scan follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
  2. If you are asked to remove your clothing, you will be given a gown to wear.
  3. An intravenous (IV) line will be started in your hand or arm.
  4. You will be connected to an electrocardiogram (ECG) machine with leads that stick to your skin and a blood pressure cuff will be placed on your arm.

Exercise myocardial perfusion scan:

  1. You will exercise on a treadmill. The intensity of the exercise will be gradually increased by increasing the speed of the treadmill.
  2. Your heart rate and blood pressure will be monitored. Once you have reached your maximal exercise point (determined by the healthcare provider based on your heart rate and age), the radioactive tracer will be injected into your IV line.
  3. After the tracer has been injected, you will continue to exercise for several minutes.

Pharmacologic myocardial perfusion scan:

  1. You will not exercise on a treadmill. Instead, you will lie on the table while a medication is injected into your IV.
  2. Your heart rate and blood pressure will be monitored.
  3. The tracer will be injected into your IV line.

Procedure completion, both methods:

  1. If you have any symptoms such as dizziness, chest pain, extreme shortness of breath, or severe fatigue at any point during the procedure, let the healthcare provider or technologist know.
  2. You will lie flat on a table while the images of your heart are taken. About 10 to 60 minutes (depending on the type of tracer used) after the tracer is injected, the gamma camera will begin to take pictures of your heart. In this special kind of test called SPECT (single photon emission computed tomography), the scanner rotates around you as it takes pictures. The table slides into the hole of the scanner, which is a large, donut-shaped machine.
  3. Your arms will be on a pillow above your head. You will need to lie very still while the images are being taken, as movement can affect the quality of the images.
  4. After the scan is completed, you may be allowed to leave the area, but will need to return for a second set of scans. The second set of scans will be taken 3 to 6 hours after the first set. During this time, you will not be allowed to eat or use tobacco and will be allowed limited water or decaffeinated/non-calorie liquids. In some cases, your healthcare provider may decide to have you return on another day for the second set of scans.
  5. The second set of scans will be much like the first set, but you will not need to exercise or get the medicine. You will lie on the table as before while the scanner takes pictures of your heart.
  6. Once the second set of scans has been completed, the IV line will be removed, and you will be allowed to leave, unless your healthcare provider tells you differently.

What happens after a stress myocardial perfusion scan?

Be sure to move slowly when getting up from the scanner table to avoid any dizziness or lightheadedness from lying flat for the length of the procedure.

You will be instructed to drink plenty of fluids and empty your bladder frequently for 24 to 48 hours after the test to help flush the remaining radioactive tracer from your body.

The IV site will be checked for any signs of redness or swelling. If you notice any pain, redness, and/or swelling at the IV site after you return home, you should notify your healthcare provider as this may be a sign of infection or other type of reaction.

Your healthcare provider may give you additional or alternate instructions after the procedure, depending on your particular situation. If the perfusion scan indicates you may have a serious or life-threatening cardiac disease, your healthcare provider may talk to you about a same-day cardiovascular procedure.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • The risks and benefits of the test or procedure
  • When and where you are to have the test or procedure and who will do it
  • When and how will you get the results
  • How much will you have to pay for the test or procedure

Electrocardiogram (ECG or EKG)

EKG

What is an electrocardiogram?

An electrocardiogram (ECG) is one of the simplest and fastest tests used to evaluate the heart. Electrodes (small, plastic patches that stick to the skin) are placed at certain locations on the chest, arms, and legs. When the electrodes are connected to an ECG machine by lead wires, the electrical activity of the heart is measured, interpreted, and printed out. No electricity is sent into the body.

Natural electrical impulses coordinate contractions of the different parts of the heart to keep blood flowing the way it should. An ECG records these impulses to show how fast the heart is beating, the rhythm of the heart beats (steady or irregular), and the strength and timing of the electrical impulses as they move through the different parts of the heart. Changes in an ECG can be a sign of many heart-related conditions.

 

Why might I need an electrocardiogram?

Some reasons for your doctor to request an electrocardiogram (ECG) include:

  • To look for the cause of chest pain
  • To evaluate problems which may be heart-related, such as severe tiredness, shortness of breath, dizziness, or fainting
  • To identify irregular heartbeats
  • To help determine the overall health of the heart prior to procedures such as surgery; and/or after treatment for conditions such as a heart attack (myocardial infarction, or MI), endocarditis (inflammation or infection of one or more of the heart valves); and/or after heart surgery or cardiac catheterization
  • To see how an implanted pacemaker is working
  • To determine how well certain heart medications are working
  • To get a baseline tracing of the heart's function during a physical exam; this may be used as a comparison with future ECGs, to determine if there have been any changes

There may be other reasons for your doctor to recommend an ECG.

What are the risks of an electrocardiogram?

An electrocardiogram (ECG) is a quick, easy way to assess the heart’s function. Risks associated with ECG are minimal and rare.

You will not feel anything during the ECG, but it may be uncomfortable when the sticky electrodes are taken off. If the electrode patches are left on too long they may cause tissue breakdown or skin irritation.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

Certain factors or conditions may interfere with or affect the results of the ECG. These include, but are not limited to:

  • Obesity
  • Pregnancy
  • Ascites (fluid buildup in the abdomen [belly])
  • Anatomical considerations, such as the size of the chest and the location of the heart within the chest
  • Movement during the procedure
  • Exercise or smoking prior to the procedure
  • Certain medications
  • Electrolyte imbalances, such as too much or too little potassium, magnesium, and/or calcium in the blood

How do I get ready for an electrocardiogram?

  • Your doctor or the technician will explain the procedure to you and let you ask questions.
  • Generally, fasting (not eating) is not required before the test.
  • Tell your doctor of all medications (prescribed and over-the-counter), vitamins, herbs, and supplements that you are taking.
  • Tell your doctor if you have a pacemaker.
  • Based on your medical condition, your doctor may request other specific preparation.

What happens during an electrocardiogram?

An electrocardiogram (ECG) may be done on an outpatient basis or as part of your hospital stay. Procedures may vary depending on your condition and your doctor’s practices.

Generally, an ECG follows this process:

  1. You will be asked to remove any jewelry or other objects that may interfere with the procedure.
  2. You will be asked to remove clothing from the waist up. The technician will ensure your privacy by covering you with a sheet or gown and exposing only the necessary skin.
  3. You will lie flat on a table or bed for the procedure. It will be important for you to lie still and not talk during the ECG, so that you don’t alter the tracing.
  4. If your chest, arms, or legs are very hairy, the technician may shave or clip small patches of hair, as needed, so that the electrodes will stick closely to the skin.
  5. Electrodes will be attached to your chest, arms, and legs.
  6. The lead wires will be attached to the electrodes.
  7. Once the leads are attached, the technician may enter identifying information about you into the machine's computer.
  8. The ECG will be started. It will take only a short time for the tracing to be completed.
  9. Once the tracing is completed, the technician will disconnect the leads and remove the skin electrodes.

What happens after an electrocardiogram?

You should be able to go back to your normal diet and activities, unless your doctor tells you differently.

Generally, there is no special care after an electrocardiogram (ECG).

Tell your doctor if you develop any signs or symptoms you had prior to the ECG (for example, chest pain, shortness of breath, dizziness, or fainting).

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • The risks and benefits of the test or procedure
  • When and where you are to have the test or procedure and who will do it
  • When and how will you get the results
  • How much will you have to pay for the test or procedure
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