INVESTIGATION AND TREATMENT OPTIONS
Not everyone with risk factors needs to be investigated or treated for heart disease. Symptoms and physical examination findings determine the type of test the patient needs and if any treatment is necessary. It is always important to consult with your doctor.

INVESTIGATIONS
There are various types of investigations that can assist your GP or Consultant Cardiologist to assess whether you have cardiovascular disease. Not all investigations are required to make the diagnosis of heart disease and this will be determined by your GP or Consultant.

Chest-pain Clinics
Patients suspected of having chest pain of cardiac origin are referred to chest-pain clinics by their GP. A full cardiac assessment and, if appropriate, an ETT (Exercise Tolerance Test or Treadmill Test) are taken at the clinic. Depending on the results, the patient is referred for the appropriate treatment or is discharged.

Blood Test
Measuring the fasting blood sugar for diabetes and cholesterol levels for hyperlipidaemia will help identify any undiagnosed risk factors. This is usually done by your G.P.

ECG – Electrocardiogram
An ECG is a quick, painless and easy to perform test used to measure the electrical activity of the heart. Sticky pads are placed across your chest, wrists and ankles. These will be connected to leads and a machine will record the rate and rhythm of your heart. The ECG can provide valuable information about your heart. If it is not entirely normal, more tests may be needed.

Exercise Tolerance Test
(Treadmill or Stress Test)
This test is sometimes called a stress test and it monitors your heart rate and blood pressure continuously while you are exercising on a treadmill. This test does not involve being admitted to hospital. You will be given an outpatient appointment to attend the hospital. You will need to wear clothing that you will be comfortable exercising in. Several sticky pads will be positioned on your chest and ECG leads will be connected to measure your heart rate and rhythm whilst you exercise on a treadmill. The recording of your blood pressure, heart rate and rhythm can allow your doctor to decide if further tests are needed.

Echocardiogram
Echocardiography is a helpful diagnostic imaging tool which uses ultrasound technology. This test uses sound waves to show the pumping action of the heart. It is also used to see whether if there is any damage to the heart muscle or valves. The equipment used is an advanced ultrasound machine that can image your heart with the help of gel that is placed on the chest during the examination. This test does not require you to be admitted to hospital and you will be made an appointment to go to hospital as an outpatient.

Stress Echocardiogram
This is a similar examination to the echocardiogram and the same machine is used. In this test, the heart is made to beat faster and stronger using a special drug called “dobutamine”. This is injected into the arm whilst pictures of the heart are taken to see how the heart muscle responds to a faster and stronger heart beat. Some people feel slightly dizzy or nauseous during this test.

Myocardial Perfusion scan also known as a Thallium Scan or a Myoview scan
This test is used to observe the function of the heart muscle at rest and during exercise. This test does not involve admission to hospital. A set of pictures of your heart is taken when you are resting. The heart is also made to beat faster and harder either using physical exercise or using medication. At this point the second set of pictures of your heart is taken. A direct comparison of the heart muscle can then be made between rest and exercise. A Cardiac Perfusion MRI can also be used to assess the blood supply to different areas of the heart.

CT coronary angiogram
CT coronary angiogram involves taking pictures of the coronary arteries using x-rays. Narrowing in the coronary arteries can be identified early on with the use of CT imaging. Early detection can help to determine lifestyle adjustments and treatment options to avoid future heart disease.

CT uses X-ray exposure and women who are pregnant or potentially pregnant are advised not to have this scan.

Coronary Angiogram/Cardiac Catheterisation
Coronary angiography is carried out in a Cardiology Catheter Laboratory by a Cardiologist. A coronary angiogram offers a detailed record of the coronary arteries and their structure. You will need to be admitted to hospital in the morning and will be able to go home in the evening. The procedure takes approximately 30 minutes. This procedure is done under local anaesthetic, which means you will be awake. A needle is inserted into one of the blood vessels, either in the arm or in the groin. A small tube (catheter) is then advanced through the blood vessel and positioned at the opening of the heart arteries. A special dye is then injected into the arteries. This demonstrates any possible narrowing or blockages in the coronary arteries.

There are also many other investigations for a variety heart disease.

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These investigations will provide enough information for your doctor and your Consultant Cardiologist to decide:

If your heart is healthy

If you need to start on medication

If you have narrowing or blockages in your coronary arteries

If you need an angioplasty to open the narrow areas in your coronary arteries

If you need to have open heart surgery

TREATMENT
There are a number of treatment options and these will need to be discussed with both your doctor and your specialist.

Medication
There are a number of tablets that may be prescribed by your GP or your Consultant Cardiologist to relieve your symptoms and reduce your risk of having a heart attack. These work by thinning your blood, reducing your cholesterol and lowering your blood pressure.

Percutaneous Coronary Intervention (PCI) also known as Angioplasty

Having angina or a heart attack means that you are likely to have narrowings or blockages in your coronary arteries. This results in a reduced blood supply to your heart muscle. In some cases, the narrowing and blockages in the coronary arteries can be treated with angioplasty. This procedure is carried out in the cardiology catheter lab by a cardiologist. An angioplasty also involves a small tube (catheter) being passed from your groin or arm up to your heart. A very tiny wire is passed into the coronary artery. An un-inflated balloon is then threaded over the		Balloon inflating to position the stent Stent positioned in the coronary artery
wire and across the narrowed area of the coronary artery. Once across the narrowed area the balloon is inflated to flatten the bulge causing the narrowing. Although the narrowed area is now open, it is often necessary to keep this open using very small metal tubular scaffolding known as a stent. A stent is threaded over the wire positioned in the coronary artery. The stent is deployed in the correct position using a balloon which is inflated allowing the stent to spring open inside the artery.

Stents
There are many types of stent: They are usually divided into bare metal and drug eluting stents.

Coronary Stents
Coronary stents are made of medical stainless steel and are flat packed on a balloon during the manufacturing process. There are various diameters and lengths to suit each narrowing. The chosen stent size is positioned to cover the length of the narrowing and expanded in the coronary artery using the balloon. Once placed in the coronary arteries, stents remain in their original position permanently. This may remain open and without problem for many years. However, there is a chance of new narrowings inside the stent. This is called “In-stent restenosis”. The medicines that you are prescribed can reduce the risk of this happening.

Drug Eluting Stents
Drug eluting stents (drug coated stents) are manufactured with a drug coating over the surface of the stent. This drug is gradually released into the coronary artery wall over several weeks to reduce the likelihood of re-narrowing. It is important to take all the medications prescribed by your doctor after having a stent placed, to reduce the chance of a narrowing developing again.

Coronary Artery Bypass Surgery
In cases where there are multiple narrowing or blockages in your coronary arteries and where angioplasty is not suitable, you may be advised to have surgery. This is carried out by a cardiothoracic surgeon under general anaesthetic and the operation can take between three and four hours. The surgeon will make an incision down the middle of your breastbone (sternum). Arteries or veins are then taken from your chest, arms or legs and are used as conduits to bypass the narrowing in your coronary arteries. You may stay in hospital for ten days after your surgery and it may take up to three months to recover fully.

There are many more treatments for a variety of heart conditions.

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Narrowings or blockages in the coronary artery









Transcatheter interventions for valvular disease
The heart has four valves which help control the flow of blood between its four chambers. Valvular heart disease occurs when there is an abnormality such narrowing or leakage of the valves. Various treatments are available for valvular heart disease. These include medical therapy or surgical repair or replacement of the diseased heart valve.

There are treatments for patients with valvular disease that do not involve open heart surgery. Such procedures include TAVI (Transcatheter Aortic Valve Implantation) for patients with severe narrowing of the aortic valve (aortic stenosis) who are not suitable for conventional aortic valve replacement because of their co-morbidities. The Miraclip procedure is used for patients with a leaking mitral valve (mitral regurgitation). These minimally invasive techniques are performed in the cardiology catheter laboratory without the need for cardiopulmonary bypass surgery. They offer an alternative therapy in high risk patients who would otherwise have a poor prognosis without surgery. These procedures are only available in certain Hospitals.