All the services performed by SJHG are either performed or closely monitored by one of your physicians in conjunction with one of our highly-trained technicians.
All of the non-invasive diagnostic studies are performed on an out-patient basis, in the comfort of one of our offices. Tilt Table Testing, the one exception, is performed on an out-patient basis in Our Lady of Lourdes Medical Center.
Invasive diagnostic studies are all done in a hospital setting and patients are frequently discharged the same day. Most interventional procedures will require at least one overnight stay and are performed at the New Jersey Heart Institute (Our Lady of Lourdes Medical Center). Appropriate instructions will be given at the time you make your appointment.
ELECTROCARDIOGRAM (ECG): An ECG is a record of the electrical activity of the heart. During this test, electrodes are placed on each arm and leg and at 6 points on the chest. If the ECG is abnormal, it may mean or suggest different types of heart problems. The ECG can provide important information about the heart rhythm, a previous heart attack, increased wall thickness of the ventricles, signs of insufficient oxygen delivery to the heart muscle or an ongoing heart attack, and problems with conduction of the electrical signals from one part of the heart to another. A normal ECG does not exclude heart disease.
STRESS TESTING (EXERCISE STRESS TEST): The treadmill test is basically a continuous ECG monitoring during physical exertion with close attention to the blood pressure and heart rate. Its' major use is to detect significant coronary artery disease (blockages in the coronary arteries). Frequently it is used as part of the evaluation of patients with chest pain and palpitations (irregular heartbeats). It also provides assessment of exercise capacity, circulation to the legs, and blood pressure and heart rate response to exercise. The test is performed according to standard protocols. The most commonly used is the Bruce protocol. It consists of two or three-minute stages at increasing speed and slope. This allows physicians anywhere in the world to communicate and compare test results. One of the end-points of the exercise test is to achieve at least 85% of the age-predicted maximum heart rate. If a patient has a significant narrowing in the coronary arteries, the exercise may elicit chest discomfort (angina pectoris) or changes in the EKG. Although the regular treadmill test is extremely useful, it can occasionally miss coronary artery disease. Nuclear imaging or Echocardiography done in conjunction with exercise testing will improve the overall accuracy of the test and provide useful information in regard to the location and severity of the blockages.
NUCLEAR IMAGING STRESS TEST: This test uses the IV injection of a small amount of a radioactive substance called "Cardiolite" (in certain situations "Thallium" is used instead). A special camera ("gamma camera") is used to take pictures of the heart at "rest" and after "stress" (sometimes on two different days). This medication gets to the heart muscle through the coronary arteries. Normally there is uniform uptake of this radioactive substance. However, if there is a blockage in one or more of the coronaries, there will be a "decrease” in the size and degree of uptake, and these changes will correlate with the number, location, and severity of the coronary artery disease. This study provides more accurate and detailed information than that provided by a regular treadmill test. This test is frequently used to evaluate patients with chest pain or after an angioplasty to detect re-blockage of the dilated artery and after coronary bypass surgery to assess the integrity and function of the bypass grafts done.
If the patient cannot exercise, a "chemical stress test" will be used. This involves the use of an IV medication (instead of exercise) that increases the blood flow to the heart (coronary vasodilators, such as adenosine or persantine ). These types of stress tests are used in patients who cannot exercise such as those with severe lung disease, arthritis, prior leg amputation or stroke, etc. Our Center uses state-of-the-art equipment and computer software, which is operated with the strictest quality control.
STRESS ECHOCARDIOGRAM: This test combines the treadmill test and the echocardiogram. A resting echocardiogram is done and repeated immediately after the exercise. Both digitized studies are compared side by side. Patients with blocked coronary arteries have transient abnormal motion of part of their heart muscle after exercise, which can be seen with the echocardiogram.
ECHO – DOPPLER CARDIOGRAPHY: This is a simple office test that uses ultrasound to image the heart (image is formed by bouncing sound waves off the heart). It is painless and entirely non-invasive. This test provides a detailed analysis of the structure and function of the heart. The information provided includes: size and thickness of the walls of the heart, the strength of the heart muscle as a pump (extremely important after a heart attack), congenital anomalies of the heart, and detailed assessment of the heart valves for narrowing or leakage and presence of tumors or clots. It allows initial assessment and follow-up of prosthetic heart valves. In essence this study provides vital information that is necessary in most patients with known heart disease or patients with symptoms that suggest it. Our Cardiology Center has the latest equipment available as well as caring and skillful technologists that operate it.
HOLTER MONITORING: The Holter monitor is a continuous ECG recorded on audiotape over 24 hrs. The patients are sent home with the attached monitor to record the heart rhythm for 24 hrs. The patient is encouraged to perform their usual daily activities while wearing the monitor. A "diary" is given to the patients to write down any symptoms experienced during that period. The cardiologist then will be able to match the symptoms with abnormal heart rhythms. This test is used to detect and document any cardiac arrhythmias or simply to determine the patients' heart rate over a 24-hour period. If the heart rate becomes too slow, a permanent pacemaker may be indicated.
CAROTID DOPPLER: Ultrasound is used to provide 2-dimensional images of the blood vessels and doppler is used to assess the velocities of blood flow in the neck arteries that supply blood flow to the brain (blockages may result in strokes). Data obtained can tell if circulation is normal or provide vital information about the severity of the blockages and composition of the plaques. Therefore, it is not surprising that carotid doppler studies have become the technique of choice to detect, quantify and follow the progression of carotid vascular disease.
PERIPHERAL ARTERY DOPPLER: Ultrasound is used to provide 2-dimensional images of the blood vessels and doppler is used to assess the velocities of blood flow in the peripheral (leg) arteries that supply blood flow to the lower extremities. This study can determine if circulation is normal or provide information about the severity of the blockages. This study is used to evaluate patients with leg pain usually associated with walking (claudication) and can assist your physician in determining the problem and deciding about appropriate treatment.
TILT TABLE TESTING: This test provides an assessment of the neural reflexes, which when abnormal, may cause patients to faint from a condition called Neurocardiogenic Syncope. This simple test involves the placement of an IV, taking frequent blood pressure readings and continuous EKG monitoring, both lying down flat and with the table at 80 o (almost standing up). If normal, an IV medication isoprel or nitroglycerin may be given and the tilt is repeated.
ANKLE -BRACHIAL INDEX: This is blood pressure-doppler test to quickly assess adequacy of the peripheral circulation. This is indicated in people who smoke or have diabetes.
CORONARY HEART DISEASE (CHD) RISK CALCULATION: This is a simple calculation that allows your physician to come up with the 10-year risk of having a coronary event. Your age, total cholesterol, high density lipoprotein cholesterol (good cholesterol), blood pressure and smoking history are used in the calculation. This information will assist the doctor in determining risk and instituting appropriate treatment based on the National Cholesterol Education Program Adult Treatment Program III Guidelines.
Cardiac Catheterization (Coronary Angiography): Cardiac catheterization is an X-ray test that uses radiographic contrast (dye) to visualize the coronary arteries and pinpoint the presence and severity of blockages and, more importantly, to determine the best treatment available. If the test revealed blockages, the patient will be offered one of three treatments: medications only, angioplasty or bypass surgery.
The test is done on an outpatient basis. The patient is mildly sedated but awake during the procedure. A local anesthetic is used to numb the area (usually the right groin). Soft plastic tubes ("catheters") are inserted into the artery and then advanced under X-ray guidance. The dye is injected into the heart chambers and coronaries and pictures are taken from different angles. This is the best test available to find and visualize the blockages of the coronary arteries.
South Jersey Heart Group physicians, Doctors Godin, Kothari, Morris, Siegal and Zarrella perform these outpatient procedures at the Cherry Hill division of the Kennedy Health System and New Jersey Heart Institute (Our Lady of Lourdes Medical Center).
Renal Angiography: This test is done in a similar manner to Cardiac Catherization and frequently can be done at the same time when requested. This test involves the injection of dye into the renal arteries. Blockages are identified and best treatment options are determined.
Peripheral Angiography: This test is done in a similar manner to Cardiac Catherization and frequently can be done at the same time when requested. This test involves the injection of dye in the leg arteries. Blockages are identified and best treatment options are determined.
Electrophysiological Studies (EPS): Patients with serious disturbances of the heart's electrical system often require specialized testing, called EPS. This test is done to determine the mechanism of certain arrhythmias and to assess the risk of potentially fatal heart rhythms and sudden death. This procedure is done under local anesthetic, similar to a cardiac catheterization procedure. Small electrical cables are passed through the veins of the legs or arms, placed in specific positions of the heart under X-ray guidance. Electrical measurements are then made to diagnose the problem and decide the best treatment available. The test measures the electrical stability of the heart and tendency to develop potentially dangerous rhythms, all under controlled circumstances. Sometimes a short version of the test is repeated once on medications to see if they are working as expected.
Doctors Kothari, Morris and Momplaisir are experts in performing these vascular interventional procedures.
Percutaneous Transluminal Coronary Angioplasty (PTCA): The preparation for angioplasty is similar to a routine cardiac catheterization . In fact, PTCA frequently is performed at the same time of the initial catheterization. A thin plastic tube with a balloon at its distal end is placed at the level of the blockage in the coronary artery and inflated for a few minutes to expand the artery. The balloon is then deflated and removed. The patient is awake and usually goes home the next day. We often use this technique as emergency treatment of a patient having a heart attack.
Coronary Atherectomy: Atherectomy means removing the obstructive plaque (blockage). There are three techniques available:
- Extractional atherectomy, which consists of slowly rotating blades and a suction mechanism. Good for bypasses or blockages containing also large blood clots.
- Directional atherectomy, which uses a catheter which has a side-window on its tip and half a balloon in the other side. A rotating blade is advanced and "shaves off" the blockage. The little pieces are collected in the nose tip of the catheter and removed. This is good for large arteries with soft blockages.
- Rotational atherectomy (rotablator), the most recent advance, has an olive-shaped tip that rotates at high speed and literally drills the blockage into microscopic particles that dissolve in the circulating blood. This is good for calcified and hard blockages.
Coronary Stents: A stent is a small screen in a tubular shape made out of stainless steel that is expanded into the wall of the artery to hold it open. The procedure is the same as a balloon angioplasty. After the blockage has been open to some extent with a balloon, a second balloon with a small crimped stent is positioned at the place of the blockage and deployed. The expanded stent stays in the artery. The healing that occurs in the first 4-6 months will cover the stent which then has become part of the arterial wall. Stents have been shown to reduce the likelihood of re-blockage. Every few months, new and better stents are available, making this procedure easier allowing our cardiologists to treat some blockages that could not possibly be treated 1 or 2 years ago. The most recent is a drug-eluting stent that further decreases the chance of re-blockage. Stents are used in about 80% to 90% of angioplasties today. A stent cannot be used in some patients for a variety of reasons: the artery is too small or too tortuous, or the blockage is too distal in the vessel or involves an important side branch, etc. In addition to aspirin (81 mg), the patients are given PLAVIX for at least 9 months after the procedure to prevent clotting of the stent.
Renal Artery Angioplasty: This procedure is similar to Coronary Angioplasty-PTCA , except the balloon is placed at the site of obstruction in the renal arteries to remove the blockage.
Peripheral Artery Angioplasty: This procedure is similar to Coronary Angioplasty-PTCA , except the balloon is placed at the site of obstruction in the leg arteries to remove the blockage.
Dr. Raman performs the following electrophysiologic interventions.
Electrical Cardioversion: When the heart becomes irregular (atrial fibrillation) or is too fast (tachycardia), the heart may need to be "re-set" electrically. Paddles are placed over the chest and an electrical shock is delivered. This is accomplished with the patient asleep for few minutes (intravenous sedation). Although electrical cardioversion may be necessary on an emergency basis if patients are unstable with low blood pressure, it is usually performed electively as an outpatient. Patients may need to stay in the hospital for 1 or 2 days to monitor the heart rhythm if certain antiarrhythmic medications are used.
Radiofrequency Ablation: Certain types of arrhythmias may be treated and cured non-surgically. After the initial EPS , a special catheter may be used to selectively "burn" by radiofrequency the abnormal tissue causing the arrhythmia.
Permanent Pacemaker Implantation: If the heart rate is too slow, a pacemaker may be necessary to electrically stimulate the heart. Placement of a permanent pacemaker requires overnight hospital stay. This is done under local anesthetic. A small incision is made in the on the anterior chest wall (usually on the left side in right-handed patients), below the clavicle. A pocket is made under the skin and one or two tiny wires ("leads") are advanced through a vein into the right heart chambers. These leads are connected to the pacemaker battery and are sutured in place. The pacemaker will only pace the heart when the heart rate is below the pacer set rate. The battery lasts 3 to 12 years with an average of 5-7 years. Replacement of the pulse generator (battery) is easy, requiring only a few hours in the hospital.
Automatic Implantable Cardiac Defibrillator (AICD): Great advances have evolved to miniaturize these sophisticated life-saving devices to a size slightly larger than a regular pacemaker. AICDs continuously monitor the heart rhythm, detects abnormal rhythms, and the internal computer decides the best treatment, either pacing the heart or delivering a small electrical "shock" (like having internal paramedics!). Only a few years ago, the implantation of these devices required a major surgical intervention (open-heart surgery). However, now they are done in the Cath Lab under local anesthetic.
Cardiac Resynchronization Therapy (CRT): This recent advance is similar to the Permanent Pacemaker but in this procedure, two wires are connected between the pulse generator (battery) and both the right and left ventricles of the heart. CRT assists the heart to beat more efficiently and can improve symptoms of heart failure that isn't responding to usual medical treatment.