A SHARED DECISION-MAKING PROGRAM HEART TESTS

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1 A SHARED DECISION-MAKING PROGRAM HEART TESTS

2 This program content, including this booklet is copyright protected by Health Dialog Services Corporation (HDSC), a related entity of Bupa Health Dialog Pty Limited (Bupa Health Dialog), who is licensed to use the material in Australia. You may not copy, distribute, broadcast, transmit, perform or display this program or any part thereof, without permission from Bupa Health Dialog. You may not modify the contents of this program without permission from Bupa Health Dialog. You may not remove or deface any labels or notices affixed to the program package. Bupa Health Dialog Pty Limited 2012

3 FOREWORD As Bupa s Chief Medical Officer I m delighted to introduce Bupa s Heart Tests Shared Decision Guide. Making decisions about the steps needed to improve your health and make more informed choices can be complicated. This guide offers practical advice to help you better understand your condition and tests choices, and support your discussion with your treating health professional. By keeping better informed you can be more confident that the care you receive is appropriate to your personal circumstances, priorities and preferences. We are grateful to Dr Leo Mahar, 1 Director of cardiology at the Royal Adelaide Hospital and Professor Mark Harris 2 and his team 3 from the University of NSW who have reviewed this valuable tool. They have confirmed that it is based upon high quality, evidence based resources, and aligns with current Australian practice and guidelines. We hope this Shared Decision Guide will be useful to you and your health professional when you are needing to make decisions together about yours or your family s health and health care. Important instructions: The information in this program is not intended to be medical advice, a diagnosis of your condition, or a treatment recommendation. It is intended to help you learn about your symptoms, conditions, and various options so that you can participate more effectively in making decisions about your health with your doctor. Not all of the options discussed may be appropriate for your individual medical situation. Talk with your doctor about how the information presented relates to your specific condition. Bupa Health Dialog does not approve or authorise care or treatment. If you have questions about whether a particular treatment is covered by your private health insurance, please contact your private health insurer. For more information Visit bupa.com.au 1Leo Mahar has been practising cardiology for 30 years. He is currently the Clinical Director of the Cardiovascular Service at the Royal Adelaide Hospital and is a former president of the Cardiac Society of Australia and New Zealand. 2Mark Harris is foundation Professor of General Practice and Executive Director of the Centre for Primary Health Care and Equity at UNSW. 3Dr Nighat Faruqi, Centre for Primary Health Care and Equity at UNSW. 1

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5 HEART TESTS ABOUT THIS PROGRAM What is Shared Decision-Making TM? 4 TYPES OF HEART TESTS Electrocardiogram 12 Communicate openly with your healthcare provider About Shared Decision-Making TM Programs 4 4 Exercise stress test 13 Nuclear stress test 13 Stress echocardiogram 13 How can this program help you? 4 Are the options discussed in this program appropriate for you? Who made this program? 5 How can you know if the information in this program 5 is up-to-date? INTRODUCTION 6 Be sure this information is right for you! HEART HEALTH AND HEART DISEASE How the heart works 8 Heart tests and heart attacks 8 What are the reasons for having a heart test? Coronary angiography 15 What you should know about blocked vessels and heart attacks Chest pain and heart attacks are caused by different blockages Different treatments for chest pain and heart attacks Heart CT scan 19 MAKING YOUR DECISION Exercise stress test is a good place to start Deciding about coronary angiography and stents Deciding what s right for you 23 DEFINITIONS OF MEDICAL TERMS 24 FOR MORE INFORMATION 26 RESEARCH PUBLICATIONS 28 3

6 ABOUT THIS PROGRAM ABOUT THIS PROGRAM WHAT IS SHARED DECISION-MAKING? Shared Decision-Making is working with your doctors and other healthcare professionals to make decisions about your care. In Shared Decision-Making, your doctor is the expert in medicine, but you are the expert on how you feel and what s important to you. Together you make up a decision-making team. Family, friends, and other healthcare providers may also be part of this team. Participating in healthcare decisions helps ensure that you are getting the care that best meets your needs. To do this, you ll need to be informed about your condition and the different ways to manage it. You ll also need to think about how each management approach can affect you so that you can choose what makes the most sense for you. COMMUNICATE OPENLY WITH YOUR HEALTHCARE PROVIDER Getting good care also requires good communication between you and your healthcare team. To get the right care, you and your doctor or other healthcare professional, need to talk about your health goals and what you re able to do to protect or improve your health. ABOUT SHARED DECISION-MAKING PROGRAMS This Shared Decision-Making program is provided through Bupa Health Dialog for your individual use. The program is designed to support your participation in an informed dialogue with your healthcare provider as you work together to make important decisions about your health. Shared Decision-Making programs are based on medical evidence researched and evaluated by the Informed Medical Decisions Foundation. The Informed Medical Decisions Foundation has been working for over two decades to advance evidence-based shared decision making through research, policy, clinical models and patient decision aids. Visit informedmedicaldecisions.org for more information. HOW CAN THIS PROGRAM HELP YOU? The information in this program can help you prepare to talk with your doctor so you are ready to ask questions and discuss how you feel about your healthcare options. Then you and your doctor can talk about which option may be best for you and make a decision together a shared decision. You might be wondering, is this information right for me? Where did it come from? How can I use it? In this program, you ll find answers to these and other questions you may have. 4

7 ARE THE OPTIONS DISCUSSED IN THIS PROGRAM APPROPRIATE FOR YOU? Some of the options in this booklet may not be appropriate for your individual medical situation. Talk with your doctor about how the information in this program relates to your specific health condition. Note that neither Bupa Health Dialog or any of its related entities approve or authorise care, treatments or tests. The care, treatments or tests described in this program may not be covered by your private health insurance. If you have questions about whether your private health insurance provides cover in respect of a particular treatment or test, speak with your private health insurer or your doctor. WHO MADE THIS PROGRAM? Bupa Health Dialog and the Informed Medical Decisions Foundation produced this program booklet. In accordance with the relevant requirements of the licence provided to Bupa Health Dialog, it has been adapted from the original version produced for use in the United States. Information regarding suitability for publication in Australia was provided by the University of New South Wales Centre for Primary Health Care and Equity. To ensure the content is appropriate and acceptable for Australian consumers and health professionals, Australian clinical practice guidelines have been reviewed and the Australian healthcare system, language and culture taken into account. Bupa Health Dialog does not profit from any of the treatments discussed in the program. HOW CAN YOU KNOW IF THE INFORMATION IN THIS PROGRAM IS UP-TO-DATE? All booklets are reviewed regularly and updated. If you received this program some time ago, or if someone passed it along to you, do not use it. The information may be out of date. To make sure you have the most recent program, please visit bupa.com.au. Please use the product number located on the back of the booklet to determine if you have the most recent copy. Note: Italics are used in this booklet to emphasise key words or to identify medical terms. See the Definitions of medical terms section for a description of medical terms that are in italics. ABOUT THIS PROGRAM 5

8 INTRODUCTION INTRODUCTION You re reading this booklet because your doctor has suggested you have a medical test to learn about the health of your heart. There are many reasons why a doctor might suggest heart testing. This booklet focuses on three common reasons: 1. You have chest pain and don t know what s causing it. 2. You have heart disease and your chest pain (angina) is getting worse. 3. You have risk factors for heart disease but no chest pain. The next chapter gives more detail on these three situations, and the information in this booklet is organised around these situations. You may feel anxious just thinking about having heart tests. The information in this booklet is designed to reassure you. It explains the role you can play in deciding which heart tests to have and as you ll discover, what you think about heart tests really matters. The choices you make now can affect your daily life for years to come. It s important to be informed about heart tests before you have them. Information from the tests you have can help you better understand your treatment options and what might be best for you. Taking certain medications (such as aspirin and statins) and changing some daily habits (such as getting more exercise and stopping smoking) might be all you need to do to help you live longer. Taking other medicines (such as beta blockers or calcium channel blockers) might be all you need to relieve your symptoms. Procedures and surgery may provide extra symptom relief for people taking medicines who still have chest pain. However, as surprising as it may seem, for many people, medicines are the most effective way to live longer and reduce the chance of having a heart attack. After reading this booklet, talk with your doctor about any questions you have. That way you can gain peace of mind about getting the heart tests that are right for you. Several medical tests are used to learn about the health of your heart. Each one provides a specific type of information. The test or tests that are right for you depend on these key things: why your doctor has suggested testing what you hope to learn from the tests how you and your doctor plan to use this information. 6

9 BE SURE THIS INFORMATION IS RIGHT FOR YOU! This booklet is for you if your doctor has suggested heart disease testing because you are in one of the following situations: Situation 1: If you have chest pain and don t know what s causing it. You may want to know if your chest pain is related to your heart, or something else. If your chest pain turns out to be heart related, you may want to know your chance of having a serious problem, such as a heart attack, and what treatments might help you most. Situation 3: If you have risk factors for heart disease but no chest pain. You don t have chest pain, but there are things (called risk factors ) in your medical history that increase your chance of heart problems. For example, you may: have diabetes have high blood pressure have high cholesterol smoke cigarettes have a family history of heart attacks at a young age (before age 55 in men or age 65 in women). INTRODUCTION Situation 2: If you have heart disease and your chest pain (angina) is getting worse. You already know that your chest pain, called angina, is related to your heart. Your symptoms may be happening more often, or maybe your medicine isn t controlling the pain as well as it used to. You might be wondering if a heart procedure might help. Heart tests can help find out why your chest pain is getting worse. The information from the test can suggest whether changing or adding a medicine may be enough or whether a procedure might offer more relief. If you have a lot of risk factors, your doctor might recommend heart testing to better estimate your chance for having a heart attack. A test can also help your doctor suggest a treatment that helps most to lower that risk. This information is not right for people who... have symptoms that could be warning signs of a heart attack (see Warning Signs of a Heart Attack on page 8) have no chest pain or other chest symptoms and no risk factors for heart disease have risk factors for other chronic heart conditions, such as an irregular or abnormal heartbeat, or heart failure have other serious health problems not related to the heart, such as advanced cancer or severe lung disease are pregnant. 7

10 HEART HEALTH AND HEART DISEASE HEART HEALTH AND HEART DISEASE Information in this chapter includes: How the heart works Heart tests and heart attacks What are the reasons for having a heart test? How the heart works To understand heart testing, it helps to know a little about the heart and how it works. Your heart is a muscle, and it needs good blood flow to provide it with oxygen and nutrients so it can work properly. The heart gets its blood supply from vessels called coronary arteries. Coronary arteries a buildup of plaque (pronounced plark or plak ), which is made of cholesterol and other materials. This condition is called coronary heart disease or coronary artery disease. This booklet will call it heart disease. Heart tests and heart attacks When a blood vessel that supplies your heart becomes completely blocked, the part of the heart muscle that doesn t get enough oxygen can be permanently damaged. This is what happens in a heart attack. In an emergency situation, when a person has symptoms that suggest a possible heart attack, doctors will usually do heart tests. (You can learn more about these symptoms in Warning signs of a heart attack below.) If heart tests are recommended and it s not an emergency, it s worth taking the time to learn about heart tests so that you can talk with your doctor and together decide which tests might be most useful for you. The coronary arteries supply blood to the heart muscle. If the blood vessels that supply your heart become partly blocked and cannot supply enough blood, your heart muscle can briefly not get enough oxygen. This can cause chest pain called angina. It is often a sign that the blood vessels have been narrowed by 8

11 Warning signs of a heart attack In the movies, people having heart attacks clutch their chests, gasp in pain, and collapse. But in real life, heart attacks may start with only mild discomfort. Recognising the warning signs and taking quick action can greatly improve survival and recovery. Warning signs If you have any of the following symptoms and they last for 10 minutes, are severe or are getting worse, call triple zero (000) immediately and ask for an ambulance. If dialling 000 does not work from your mobile phone, you can try calling 112. Chest discomfort. Most heart attacks involve discomfort in the centre of the chest that lasts for more than a few minutes, or goes away and comes back. The discomfort can feel like uncomfortable pressure, squeezing, fullness, or pain. Discomfort in other areas of the upper body. Can include pain or discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath. Often comes along with chest discomfort. But it also can occur without chest discomfort. Other symptoms. May include breaking out in a cold sweat, nausea, or light headedness. What to do First, call 000 for an ambulance or ask someone else to call. Don t hesitate because you re embarrassed or think your symptoms will go away. Every minute counts! Chew aspirin after calling 000, chew a 300 milligram aspirin tablet. Aspirin reduces the risk of heart attack and of dying from a heart attack. Chewing the aspirin works better than swallowing it whole. Enteric coated aspirin works more slowly and is not recommended, unless it s the only kind of aspirin you have available. What are the reasons for having a heart test? Heart tests can be used for different purposes. This chapter gives details about three common situations for having heart tests and explains the purpose of testing for each situation. Depending on your situation, different tests may be appropriate. Situation 1: If you have chest pain and don t know what s causing it. In this situation, your doctor might suggest heart tests that: show whether your chest pain is caused by heart disease or another problem estimate your chance of having a heart attack in the future. Keep in mind that many conditions other than heart disease can cause chest symptoms. These conditions can include: heartburn muscle injury from a blow to the chest, heavy lifting, coughing or vomiting, or even laughing inflammation of the tissue that connects the ribs to the breastbone nerve pain, such as from shingles lung conditions; fluid around the heart; and pain caused by problems in the stomach, gallbladder, oesophagus, or other organs. Heart tests can show whether your chest pain is likely to be related to the heart or to one of these other problems. If the pain is heart-related, tests can also help figure out how serious the problem may be. HEART HEALTH AND HEART DISEASE 9

12 HEART HEALTH AND HEART DISEASE Situation 2: If you have heart disease and your chest pain (angina) is getting worse. In this situation, your doctor might suggest heart tests that: estimate your chance of having a heart attack in the future estimate how much heart muscle might be damaged if a heart attack were to happen give you and your doctor more information about which treatments might do the most to relieve your symptoms and reduce your risk of heart attack. Keep in mind that chest pain symptoms that are caused by heart disease often have a predictable pattern. This type of chest pain (angina) can happen with situations such as, physical activity, emotional stress, or heavy meals, and it goes away when you rest or take medication. You might feel pain or discomfort right in the chest or you might have discomfort in the jaw or around the stomach. Sometimes a change in the usual pattern of angina is a sign of an urgent situation that requires immediate medical care. Some symptoms might suggest a possible heart attack. Even if the changes are minor or happen slowly, it s important to talk with your doctor to see if these changes may be related to heart disease and whether a change in medication or a heart test may be recommended. Situation 3: If you have risk factors for heart disease but no chest pain. In this situation, your doctor might suggest heart tests that: determine whether you have a heartrelated problem estimate your chance of having a heart attack in the future estimate how much heart muscle might be damaged if a heart attack were to happen give you and your doctor more information about which treatments might do the most to help reduce your risk of heart attack. If you have a lot of risk factors, your chance of heart disease is higher, and heart tests might help you and your doctor decide what steps to take to reduce your risk of heart disease. 10

13 11 HEART HEALTH AND HEART DISEASE

14 TYPES OF HEART TESTS TYPES OF HEART TESTS Information in this chapter includes: Electrocardiogram Exercise stress test Nuclear stress test Stress echocardiogram Coronary angiography What you should know about blocked vessels and heart attacks Chest pain and heart attacks are caused by different blockages Different treatments for chest pain and heart attacks Heart CT scan This booklet describes four common types of heart tests, what the tests can show, the possible harms or risks of the tests, and things to think about if you are considering the tests. The four common types of heart tests explained in this booklet are: Electrocardiogram (also called an ECG) Exercise stress test (also called a stress test, exercise electrocardio gram, exercise tolerance test, treadmill test, stress ECG, or exercise ECG) Coronary angiography (also called heart cath, cardiac catheterisation, cardiac cath, angiogram, coronary angiogram, or angiography) Heart CT scan (also called coronary computed tomography angiogram, CTA, or coronary CT scan). Electrocardiogram (also called an ECG) This test can be done alone or done as part of other tests, such as the exercise stress test. How it is done An electrocardiogram is a test that shows the electrical activity of your heart when you are at rest. To keep things simple, this booklet uses the term ECG to mean electrocardiogram. An ECG is done while you are lying down. Several patches with sensors to detect electrical signals from your heart will be attached to your body. The electrical signals are recorded as lines on paper or on a computer screen. The patterns made by the lines provide important information about your heart health. What it can show An ECG can help your doctor identify a variety of heart problems. It can show an irregular heartbeat, abnormal changes in the size or shape of the heart or its chambers, whether a previous or other problem may have damaged the heart. An ECG can be a useful baseline test (a starting point that future tests can be compared with). The next several chapters give more information on these tests. 12

15 Exercise stress test (also called a stress test, exercise electrocardiogram, exercise tolerance test, treadmill test, stress ECG, or exercise ECG) How it is done An exercise stress test is an ECG usually done while you are exercising on a treadmill or a stationary bike. The test shows how well the heart works when it needs to pump harder and faster during exercise. If you cannot exercise, you can be given certain medicines to make your heart pump harder and faster or to enlarge the heart arteries. Nuclear stress test For a nuclear stress test, a mildly radioactive material is injected into your bloodstream. This material allows the doctor to see the blood flow to your heart muscle on images that are taken during and after the test. There are several different names for this test, including: stress test with nuclear imaging thallium (THAL-ee-um) stress test (sometimes known as a thallium scan) sestamibi (ses-tah-mib-ee) myocardial (my-o-car-dee-al) perfusion imaging. TYPES OF HEART TESTS Most experts say a stress test is the best way to find out if chest pain is due to a heart problem. What it can show If you have chest symptoms, an exercise stress test can indicate whether your symptoms are caused by heart disease and if so, how serious it is. Your doctor can use the results to estimate your chance of having a heart attack in the near future. See page 14 for more information about the chances of having a heart attack. A stress test is often done with imaging if there is greater concern about blood flow to your heart muscle. Imaging allows your doctor to see how well the heart muscle is working and whether parts of the heart muscle are not getting enough blood. This additional information may help your doctor make a more accurate estimate of your chance of having a heart attack in the near future. The information also helps your doctor estimate how much heart muscle might be damaged if a heart attack were to happen. Common tests with imaging include the nuclear stress test and stress echocardiogram. A stress test with imaging can show how well blood is flowing to the heart muscle. Stress echocardiogram (or stress echo) An echocardiogram is another type of imaging that may be done with a stress test. It uses ultrasound or sound waves to show how well the heart muscle works before and after you exercise. Comparing the results gives your doctor detailed information about your heart health. A stress echo does not involve x-rays or radiation exposure. Possible harms A stress test is safe no more risky than if you walked briskly uphill for several minutes. The test is stopped if you get out of breath, start to have chest pain, or can t exercise any longer. If you have a nuclear stress test, you will be exposed to a low level of radiation. If you are concerned about exposure to radiation, talk with your doctor. What to think about Most experts say that an exercise stress test is the best way to find out how likely it is that your chest pain is due to a heart problem. The results can also be used to estimate your risk of having a heart attack or dying from heart disease in the next 4 to 5 years. For most people, this risk is low. The next page describes things to keep in mind about the exercise stress test. 13

16 TYPES OF HEART TESTS Situation 1: If you have chest pain and don t know what s causing it. Experts recommend that most people with chest pain have an exercise stress test before having other heart tests. It is generally the best way to find out whether your chest pain is related to your heart. If the exercise stress test shows that your chest pain probably is heart related, the results from the test can help your doctor find out how serious your heart problem may be, estimate your chance of having a heart attack, and decide whether other tests might be useful. Situation 2: If you have heart disease and your chest pain (angina) is getting worse. Experts recommend that most people in this situation have an exercise stress test, often with imaging. The test results can help your doctor estimate your chance of having a heart attack. When the test is done with imaging, the doctor can see how much heart muscle is not getting enough blood. You can talk with your doctor about the results and whether you may want to consider changing your medication or having a procedure to improve blood flow, such as putting in a stent or having bypass surgery. Situation 3: If you have risk factors for heart disease but no chest pain. If there is reason to be concerned about your heart health (such as if you have a high risk of developing heart disease in the next 5 years), an exercise stress test may be helpful. If you have the test and learn that your chance of having a heart attack is higher than expected, you and your doctor may decide to take immediate steps to lower it. You can also discuss whether more heart tests may be helpful. Whether or not you have an exercise stress test, your doctor can recommend ways to lower your risk of having a heart attack. This might include changing daily habits (eg getting more exercise or quitting smoking) and taking certain medicines (eg aspirin or statins). What you should know about the results of an exercise stress test An exercise stress test gives you information about your risk for having a heart attack or dying from heart disease in the next 4 to 5 years. At first, knowing this may seem scary. But you might actually feel better knowing the test results. Most people who have an exercise stress test are found to have a low risk of heart problems in the near future. If 100 people with chest pain have an exercise stress test, the results of the test place them into one of three groups: Low risk about 60 to 80 people are at low risk. Moderate risk about 19 to 35 people are at moderate risk. High risk about 1 to 5 people are at high risk. No one test can predict what will happen to you. But, when researchers study large groups of people, this is what they find happens over 4 to 5 years to people in each group: In the low-risk group: 1% to 3% (1 to 3 out of 100 people) will have a heart attack or die from heart disease, and 97% to 99% will not. In the moderate-risk group: 5% to 9% (5 to 9 out of 100 people) will have a heart attack or die from heart disease, and 91% to 95% will not. In the high-risk group: 21% to 28% (21 to 28 out of 100 people) will have a heart attack or die from heart dis ease, and 72% to 79% will not. You can see that even in the high-risk group, most people will not have a heart attack in 5 years. And even in the low-risk group, a few people will have a heart attack within 5 years. 14

17 Having the results of a stress test and knowing the risk group you re in helps you and your doctor make more informed decisions about what to do next. (See the Making your decision chapter on page 20.) Coronary angiography (also called heart cath, cardiac catheterisation, cardiac cath, angiogram, coronary angiogram, or angiography) How it is done This test has many different names. To keep things simple, this booklet uses the term coronary angiography. Coronary angiography shows the flow of blood in the vessels supplying the heart muscle. When having coronary angiography, you lie down and are given medication to help you relax. A long, thin, flexible tube called a catheter is put into a blood vessel in your upper thigh or arm. The tube is then threaded through the blood vessel to your heart. A material called a contrast agent is added through the tube. This material makes it possible to see the blood flow to your heart muscle on x-rays done during the test. You may feel flushed or very warm when this material is added. This feeling is temporary and not harmful. What it can show Coronary angiography can show the location and size of any blockages (plaques) that may be narrowing the coronary arteries that supply blood to your heart muscle. If the images show blockages, your doctor can estimate whether the blockages are large enough to be causing chest pain. The images also suggest how much heart muscle might be damaged if a heart attack were to happen. Coronary angiography usually does not show whether the blockages affect blood flow to the heart muscle. Possible harms Coronary angiography by itself is generally a safe test, but it does involve exposure to a low level of radiation. In addition, there are possible harms. Some of these can be serious, but are rare. They include: Bleeding or infection at the site where the catheter is inserted. Allergic reaction to the material (contrast agent) that is injected. A minor reaction may cause itching or rash. A more serious reaction can cause difficulty breathing. New or worsening kidney problems, especially in people who are older or who already have kidney disease. Serious harms, such as heart attack, stroke, or death. These happen in less than 1 out of 1,000 people. The risk of serious harms is higher in people over age 70 and for people who have heart failure or other serious heart problems. It s important to know that, if blockages are found, an angioplasty may be done and a stent inserted during coronary angiography. Before having this test, talk with your doctor about what you would want done if blockages are found. This can help you avoid receiving a treatment that you might not want because of its possible harms, or because you would prefer to try other options for reducing your symptoms. If you decide you want the doctor to do an angioplasty and put in stents if blockages are found, the possible harms are higher than from coronary angiography alone. Serious harms, such as heart attack, stroke, or death, happen in 3 to 6 out of every 100 people who have angioplasty and stents. About 94 to 97 people out of 100 will have no serious harms. TYPES OF HEART TESTS 15

18 TYPES OF HEART TESTS What to think about Coronary angiography can show the size and location of blockages, if they are present. Coronary angiography finds large blockages in about 38 out of every 100 people; the procedure finds no large blockages in about 62 out of every 100 people. Coronary angiography should only be done if the benefits exceed the risk. For example, if you have no blockages or the benefits are quite small, then the possible harm from having coronary angiography might outweigh any chance of benefit. Experts are studying how to determine which people would benefit from having coronary angiography, so that people without large blockages would not be offered the test. The text below describes the three situations with suggestions about when coronary angiography could be useful. Situation 1: If you have chest pain and don t know what s causing it. In most cases, if you are in this situation, you should have an exercise stress test before considering coronary angiography. Compared with coronary angiography, an exercise stress test is a less risky way to find out if your chest pain is due to heart disease. Situation 2: If you have heart disease and your chest pain (angina) is getting worse. Because you already know you have heart disease which means you know there are some blockages in the vessels that supply blood to your heart muscle coronary angiography may be a useful test for you. Coronary angiography can identify: where blockages are located if they re located in a vessel that supplies blood to an important part of your heart muscle how much they are blocking key blood vessels if they are large enough to cause symptoms. This information from coronary angiography can help you and your doctor make decisions about your treatment. Coronary angiography involves possible harms, because a catheter and contrast agent are put inside your body. But the advantage of knowing whether the blockages are causing symptoms or are dangerous may outweigh these harms. An exercise test with imaging may still be a useful first test in this situation, because it can show where heart muscle may not be getting enough blood flow. This helps your doctor identify which particular blockage is likely causing symptoms or may be dangerous. Your doctor can then treat it at the same time as the coronary angiography procedure by inserting a stent to open the blockage. However, it is also possible that bypass surgery, which is a separate procedure, could be recommended instead. Situation 3: If you have risk factors for heart disease but no chest pain. Coronary angiography is not an appropriate first test if you have no symptoms, even if you have risk factors for heart disease. This test should only be considered if you first have an exercise stress test that indicates you are likely to have serious heart disease. 16

19 What you should know about blocked vessels and heart attacks Some people believe that they will live longer and prevent a heart attack if they have a stent or bypass surgery to open blood vessels in the heart that are blocked by more than 50% to 70%. Actually, these procedures on their own do little to reduce the chance of heart attack and death from heart disease. That s because stents or bypass surgery are only done to treat large blockages the kind that are less likely to cause heart attacks. This is why these procedures on their own do not reduce the risk of heart attacks. These procedures do not treat small plaques that are the common cause of most heart attacks. What these procedures can do is relieve chest pain (angina) by improving blood flow to the heart muscle. Different treatments for chest pain and heart attacks Treatments for relieving chest pain Medicines, such as nitrates, beta blockers, and calcium channel blockers, can help improve blood flow to the heart muscle and ease chest pain. If medicines don t help enough, heart tests can show the large blockages that are causing chest pain so they can be treated with stents or bypass surgery. The small plaques that cause most heart attacks are more common, usually can t be seen during heart tests, and are not treated with stents or bypass surgery. Medicines including aspirin and statins are the most effective way to lower the risk that these small plaques will break open and trigger a clot that causes a heart attack. In people who have already had a heart attack, these medicines greatly reduce the chance of another one and can help people live longer. TYPES OF HEART TESTS Stents and bypass surgery on their own do not reduce the risk of heart attacks. Heart attacks and chest pain (angina) are helped by different treatments because they have different causes. Chest pain and heart attacks are caused by different blockages Chest pain occurs when large blockages (plaques) limit the flow of blood to the heart muscle. Large blockages can cause chest pain, but they are less likely to cause a heart attack. Most heart attacks occur when small plaques break open and trigger a blood clot that blocks blood flow to an area of heart muscle. These small plaques are called unstable because they tend to break open. They are the most common cause of a heart attack. Treatment during a heart attack Treating heart attacks is different than preventing them. Stents or bypass surgery can reduce the damage to the heart during a heart attack. These procedures will quickly restore blood flow to heart muscle that is likely to be damaged during a heart attack. Medicines are the most effective way to lower the risk of having a heart attack. 17

20 TYPES OF HEART TESTS 18

21 Heart CT scan (also called coronary computed tomography angiogram, CT angiography, CTA, or coronary CT scan) How it is done A heart CT scan uses multiple x-rays to create a three-dimensional image of your heart and blood vessels. A material called a contrast agent is injected into your bloodstream to help show the flow of blood to your heart muscle. Some CT machines can create moving images (like a video) of the heart beating. Sometimes a medicine is given to slow the heartbeat so that the blood vessels can be seen more clearly in these images. Heart CT is not available at all hospitals. Another test, a heart CT calcium score, is different than the heart CT scan. Because the exact use for the results from the heart CT calcium score is still being studied, this test is not included in this booklet. What it can show The images from a heart CT may allow your doctor to see the location and size of blockages in the vessels that supply blood to your heart muscle. This information can help your doctor estimate your chance of having a heart attack or dying from heart disease during the next 2 to 5 years. A heart CT scan may also show other possible problems with your heart or nearby organs. Possible harms A heart CT is generally a safe test, but it does involve exposure to radiation (more than from a stress test with imaging or coronary angiography). In addition, there are possible harms. Some of these can be serious, but are rare. They include: Allergic reaction to the material (contrast agent) that is injected. A minor reaction may cause itching or rash. A more serious reaction can cause difficulty breathing. New or worsening kidney problems. Side effects from the medicines that may be used to slow your heartbeat. A heart CT scan may also show an abnormality that is not related to your heart. This may lead you or your doctor to think that more testing is needed. While spotting something that might be a problem may seem useful, in most cases, what is found turns out to be harmless. What to think about Because heart CT is a newer test, doctors are still studying when and how it can be most useful compared with other heart tests. According to experts, a heart CT scan is not an appropriate first test in any of the three situations described in this booklet. Although a CT scan can help your doctor estimate your chance of having a heart attack, you can get this same information from an exercise stress test, which involves no radiation exposure or risk of kidney problems. Then, based on the results of the exercise stress test, you and your doctor can decide if a heart CT scan or other test might add more information that could be helpful to you. TYPES OF HEART TESTS 19

22 MAKING YOUR DECISION MAKING YOUR DECISION Information in this chapter includes: Exercise stress test is a good place to start Deciding about coronary angiography and stents Deciding what s right for you Exercise stress test is a good place to start Most experts recommend that, except in emergencies, an exercise stress test is almost always a good place to start with heart testing. Decisions about having other tests and the order in which to have them should depend on your reason for having heart testing. If coronary angiography or a heart CT scan is being recommended before you ve had an exercise stress test, the most important question to ask your doctor is whether it would be reasonable to start with an exercise stress test instead. If you are wondering how to bring this up with your doctor, you might say that you have read that guidelines suggest most people should start with a stress test, and you re wondering what it is about your particular situation that makes your doctor recommend something different. An exercise stress test will help your doctor estimate whether your risk of having a heart attack or dying from heart disease is low, moderate, or high. 20

23 If you are at high or low risk If an exercise stress test shows that your risk is either high or low, your next step may be clear. If you are at high risk, you and your doctor can discuss the benefits of more testing, such as coronary angiography. You and your doctor might also talk about taking medicines to help you live longer and relieve symptoms. If you want to see if medicines help, you could also repeat the stress test while taking medicines. If you are at low risk, the chance of getting any benefit from more testing is so low that even a small chance of harm can outweigh it. If you are at moderate risk If an exercise stress test shows that your risk is moderate, your next step may not be so clear. In this situation, it s a good idea to talk with your doctor about what steps you can take to reduce your chance of having a heart attack or having angina. These steps might include taking medicines, getting more exercise, and if you smoke, quitting. You and your doctor can then talk about whether more testing can add any more information that might change your treatment plan. An exercise stress test is almost always a good place to start with heart testing. Situation 1: If you have chest pain and don t know what s causing it. Experts recommend that most people with chest pain start by having an exercise stress test before other tests. The results will indicate whether your chest pain is or is not likely to be heart related. If your pain is heart related, you will learn how serious the problem may be. This can help you and your doctor make decisions about changing daily habits (getting more exercise or quitting smoking) and taking certain medicines (such as aspirin and statins) to help you live longer and other medicines to help relieve symptoms. If results suggest you may have a serious heart problem, you and your doctor can decide about having other heart tests. Situation 2: If you have heart disease and your chest pain (angina) is getting worse. If your angina has become more frequent or more severe, or it s no longer being controlled by medicine that used to help, you and your doctor can decide which of these options may be right for you: Change the dose of a medicine you already take, or try a different medicine before you have any heart testing. Have an exercise stress test, perhaps with imaging, to see if your worsening angina is a sign that blood flow to important parts of your heart muscle is being affected. Have coronary angiography or a heart CT scan to locate where and how much blood flow to your heart muscle may be blocked. If you would want to have a procedure (angioplasty and stents) or bypass surgery to help relieve your angina, these tests can help plan those treatments. MAKING YOUR DECISION 21

24 MAKING YOUR DECISION 22

25 Deciding about coronary angiography and stents If you are considering coronary angiography talk with your doctor about the benefits and risks of stents and whether stents are a good choice for you before you have the procedure and are not sure you want a stent put in at the same time of the procedure (if a blockage is found in a blood vessel), you might want to ask your doctor if it is possible to have the test without having stent treatment at the same time. Ask if you and your doctor can review the results when you are not sedated, so you can discuss whether medication, angioplasty, stents, or bypass surgery may be most helpful in your situation. By separating the heart test (coronary angiography) from the possible heart treatment (inserting stents), both you and your doctor have more time to carefully review your test results and make an informed decision about the treatment you prefer. On the other hand, once you understand the possible benefits and harms, you may prefer to have a stent inserted in the same procedure as the coronary angiography, and avoid the need for a second procedure. Situation 3: If you have risk factors for heart disease but no chest pain. If you have heart disease risk factors (such as diabetes, smoking, or family history of heart attack at a young age), your doctor can recommend steps you can take to lower your risk, even without any testing. If you have a lot of risk factors, your doctor might recommend stress testing to better estimate your chance of having a heart attack. The results may help you and your doctor make decisions about treatments to lower your risk. Deciding what s right for you In most situations, there might be more than one reasonable approach. As your doctor learns more about your heart health, he or she may discover things that make certain tests more useful than others. As you learn more about the tests and what they can show, you can be better prepared to talk with your doctor and decide together what s right for you. Consider how a heart test might help you reach your health goals: If your main concern is to avoid a heart attack or death from heart disease, an exercise stress test can help estimate your risk for these problems. If you re troubled by chest pain (angina) that cannot be controlled with medicines, or if the side effects of your angina medicines are too bothersome, consider coronary angiography. Coronary angiography can help identify blockages that may be causing chest pain and treat them (with stents). Discuss your questions and concerns with your doctor. He or she has experience with heart testing and can help match your needs with the right heart tests. That way you can feel confident you re getting the healthcare that s right for you. MAKING YOUR DECISION 23

26 DEFINITIONS OF MEDICAL TERMS Angina [an-ji-nuh or AN-juh-nuh]: Pain, discomfort, or pressure in the chest, arms, shoulder, or jaw, often during exercise, emotional stress, or heavy meals. Angina is a symptom of coronary heart disease. It is caused by reduced blood flow to part of the heart muscle. Angiogram [AN-jee-oh-gram]: A test that helps doctors look at the blood vessels of the heart to see if there is plaque that has built up and may be causing a blockage in an artery. The procedure involves passing a thin flexible tube (catheter) into the left side of the heart, usually from an artery in the upper thigh or the arm. A material called a contrast agent is injected through the catheter into the arteries and x-rays are taken. If a large or severe blockage is found, the doctor may recommend an angioplasty. Angioplasty [AN-jee-oh-plah-stee]: A procedure that increases blood flow through severely blocked vessels. The doctor inserts a thin tube called a catheter into an artery in the upper thigh or the arm and threads it into a severely narrowed coronary artery. The catheter carries a deflated balloon, which is inflated within the narrowed artery to compress plaque. Tiny mesh tubes called stents are often placed in the arteries to help keep them open longer. Beta blockers: Medicines that reduce the risk of heart attack in people with coronary heart disease. In people who have had a heart attack, taking beta-blockers reduce the chance of death from future heart attacks. They slow the heart rate, lower blood pressure, and may also be taken to treat irregular heart rhythms. Blood clot: A cluster of blood cells that form a clump. Blood clots normally help stop blood loss due to injury. A clot that occurs inside a coronary artery can completely block the flow of blood and cause a heart attack. Medicines can help stabilise plaques that can trigger a blood clot and reduce the chance of a heart attack. Blood pressure: The pressure of blood against the walls of the arteries, which is usually given as two numbers. The first, higher number is systolic blood pressure, which is the amount of pressure when the heart pumps blood out to the body. The second, lower number is diastolic blood pressure, which is the pressure of blood refilling the heart between beats. Bypass surgery: An operation that takes healthy blood vessels from the leg or chest to use in redirecting blood flow around portions of the coronary arteries that are blocked or narrowed by plaque. Calcium channel blockers: Medicines used to treat angina, high blood pressure, and some types of abnormal heart rhythms. These medicines relax the walls of the blood vessels, lower blood pressure, and make it easier for the heart to pump blood. Cholesterol: A type of fat found in the bloodstream. High levels of LDL (bad) cholesterol can contribute to the build-up of plaque and increase the risk of coronary heart disease. Coronary angiography: A procedure that involves passing a thin flexible tube (catheter) into the heart, usually from a blood vessel in the upper thigh or the arm. Also called cardiac catheterisation, heart catheterisation or heart cath. See angiogram. Coronary heart disease: A condition that results when arteries have been narrowed by a build-up of plaque, which is made of cholesterol and other materials. As the build-up grows, less blood can flow through the arteries and the heart muscle can t get the oxygen it needs. This can lead to chest pain (angina). Also called coronary artery disease or heart disease. Diabetes: A chronic disease that causes blood sugar levels to become too high. Diabetes increases the risk of coronary heart disease and heart attack. 24

27 Electrocardiogram [e-lek-tro-kar- dee-o-gram]: A test that records the heart s electrical activity. It can show how fast the heart is beating, and whether the rhythm of the heartbeat is steady or irregular. It is used to detect and evaluate many heart problems. Also called ECG. Exercise stress test: A test that records the effect of exercise on the heart. It provides an overall look at the health of the heart while a person is exercising. The information from this test can be used to estimate the risk of having a heart attack in the next 4 to 5 years. Also called an exercise tolerance test or stress test. Heart attack: Damage to the heart that happens when blood flow to a portion of the heart muscle is completely blocked. Also known as myocardial infarction or MI. It is one of the causes of acute coronary syndrome. Heart CT calcium score: A computed tomography (CT) test that uses a type of x-ray to detect calcium in the coronary artery walls. Heart CT scan: A computed tomography (CT) scan that uses x-rays to create detailed pictures of the heart and its blood vessels. Heartburn: A painful burning feeling in the chest or throat that occurs when stomach acid backs up into the oesophagus, the tube that carries food from the mouth to the stomach. Imaging: A type of test that uses x-rays or ultrasound or chemicals to show organs or tissue in the body. A stress test is often done with imaging to allow doctors to see how well blood is flowing to the heart muscle and how well the heart muscle is working. Imaging tests include exercise echocardiogram, heart CT scan, and nuclear stress test. Nitrates: Medication used to treat angina (chest pain) in people who have coronary heart disease. It works by relaxing the blood vessels so the heart does not need to work as hard and therefore does not need as much oxygen. Nuclear stress test: A test that allows the doctor to see blood flow to the heart muscle. A mildly radioactive material is injected into the body and images are taken during and after the test. Also called stress test with nuclear imaging, thallium stress test, and sestamibi myocardial perfusion imaging. Plaque [plark or plak]: A build-up of cholesterol, calcium, and other substances within the walls of an artery. When plaque builds up in the arteries that supply blood to the heart, a person is said to have coronary heart disease. Plaque can also build up in other arteries, such as those in the legs. Shingles: A disease caused by the same virus that causes chickenpox. The virus may reappear as burning, tingling, or itching, usually on one side of the body. The symptoms can occur before the rash appears. Side effect: A secondary effect, often a harm, caused by a medicine or treatment. Statins: Medicines that lower LDL (bad) cholesterol. Taking statins helps lower the risk of heart attacks. Stent: A tiny mesh tube that is used to prop open a coronary artery. Stents may be bare metal or, when coated with medicines, are called drug-eluting stents. Stress echocardiogram: A test that uses ultrasound or sound waves to determine how the heart muscle responds while a person is exercising. It is mainly used to diagnose and evaluate heart disease. Also called exercise echocardiogram or stress echo. Unstable plaque: A type of plaque that can break open or rupture and trigger a blood clot and cause a heart attack. Medicine can help stabilise these plaques and reduce the chance for having a heart attack. DEFINITIONS OF MEDICAL TERMS 25

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