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The following describes the various testing procedures used by physicians for evaluating cardiovascular impairments. It is important to be familiar with the tests because a cardiovascular impairment rating is, to a large degree, dependent upon symptoms associated with the applicant performing activities of daily living. As these symptoms may contain a subjective component, the Guides recommend the physician “obtain objective data about the extent of the limitation and integrate the findings with the subjective data to estimate the degree of permanent impairment” (AMA Guides, page 26). Different cardiovascular testing yields different data.
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Cardiovascular Impairment Tests
Adenosine Pharmacologic Stress Myocardial Viability Test: A perfusion test to diagnose aortic disease. This test is usually for individuals who cannot exercise or who exercise at a suboptimal level. The patient is administered medication (Adenosine or Dobutamine) to raise vasodilatation or stimulate myocardial demand to stress the patient's heart. Pictures are then taken.
Calcium-Score Screening Heart Scan: Used to detect calcium deposits found in atherosclerotic plaque in the coronary arteries. The test is a way to detect early coronary calcification from atherosclerosis, before symptoms develop. The doctor uses the calcium-score screening heart scan to evaluate risk for future coronary artery disease. If calcium is present, the computer will create a calcium "score" that estimates the extent of coronary artery disease based on the number and density of calcified coronary plaques in the coronary arteries.
Computed Tomography (CT) Scan: Cardiac CT is a heart-imaging test that uses CT technology with or without intravenous (IV) contrast (dye) to visualize the heart anatomy, coronary circulation, and great vessels (which includes the aorta, pulmonary veins, and arteries).
There are several types of CT scans used in the diagnosis of heart disease, including:
A. Calcium-Score Screening Heart Scan
B. Coronary CT Angiography (CTA)
C. Total Body CT Scan
Coronary Angiography: Coronary angiography can be used to identify the exact location and severity of CAD. Cardiac catheterization with angiography (coronary arteriography) is a technique that allows x-ray pictures to be taken of the coronary arteries. It is the most accurate test to detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-ray guidance to the openings of coronary arteries. Iodine contrast 'dye" is then injected into the arteries while an x-ray video is recorded. The dye can show whether plaque has narrowed or blocked any of the coronary arteries. Coronary arteriography gives the doctor a picture of the location and severity of narrowed artery segments. This information is important in helping the doctor select medications, percutaneous coronary Interventions (stent placement) or coronary artery bypass graft surgery (CABG) as the preferred treatment option.
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Coronary Computed Tomography Angiography (CTA): High-resolution, 3-dimensional pictures of the moving heart and great vessels are produced to determine if either fatty or calcium deposits (plaques) have built-up in the coronary arteries. Before the test, an iodine containing contrast dye is injected into an IV in the patient’s arm to improve the quality of the images.
C-Reactive Protein Testing: This test looks to see if the arteries are inflamed by measuring the blood for C-Reactive Protein (CRP). The body produces CRP during the general process of inflammation. Therefore, CRP is a ' marker" for inflammation, meaning ~ presence indicates an increased state of inflammation in the body Inflammation (swelling) of the arteries is a risk factor for cardiovascular disease. It has been linked to an increased risk of heart disease, heart attack, stroke and peripheral arterial disease.
Echocardiogram (ECHO): Echocardiography relies on ultrasound. ECHO Is an extremely useful tool for evaluating abnormalities within the heart. In fact, most heart problems can be diagnosed with ultrasound, avoiding the need for invasive heart catheterization for the vast majority of patients. Echocardiograms are used to measure the dimensions and shape of the structures of the heart, evaluate pressure gradients within the heart, visualize blood flow and valve leakage, evaluate the condition of the valves, identify abnormal blood-flow patterns, evaluate the pumping strength, and assess blood pressures in the arteries of the lungs. There are several types of echocardiograms. The most common echocardiograms are:
A. 2-D Echocardiogram provides a moving image that shows how well all the parts of the heart are working. These two dimensional images offer a view of the heart as if its layers were slices in a loaf of bread.
B. 3-D Echocardiogram is used for the assessment of mitral valve disorders, atrial septal defects (hole in the heart), left ventricular volumes and cardiac pathology, particularly valvular defects, cardiomyopathies, and congenitally malformed hearts. 3-D echocardiogram is unique given its ability to slice the virtual heart into infinite planes in an anatomically appropriate manner and to reconstruct 3-D images of anatomic structures.
C. Doppler Echocardlogram. A method for detecting the direction and velocity of moving blood within the heart. The technique may be used for detection of cardiac valvular insufficiency and stenosis as well as a large number of other abnormal flows.
D. Stress Echocardiogram. A stress ECHO is done under conditions that increase the work of the heart, so pumping capacity and efficiency of the heart, as well as any blockages of the coronary arteries, can be evaluated. Images of the heart are first taken at rest. Additional images are taken after the workload of the heart has been increased. Patients usually use a treadmill or a stationary bicycle to reach their peak exercise level. For patients who are unable to exercise, a medication is injected to simulate the effects of exercise on the heart. See Physiologic/Pharmacologic stress Testing.
E. Transesophageal Echocardiogram (TEE): For more detailed information about the heart valves and possible blood clots in the heart, a TEE may be necessary. In this procedure, the transducer is mounted on the tip of a flexible tube that is inserted through the patient’s mouth down into the esophagus. As the esophagus is close to the heart, the TEE provides a more detailed image of the heart valves and blood flow.
Electrocardiogram (ECG/EKG): This test measures the electrical activity of the heartbeat. With each beat, an electrical impulse (or "wave") travels through the heart. This wave causes the muscle to squeeze and pump blood from the heart. A normal heartbeat on ECG will show the timing of the top and lower chambers. The ECG gives too major kinds of information. First, by measuring time intervals on the ECG, a doctor can determine how long the electrical wave takes to pass through the heart. Finding out how long a wave takes to travel from one part of the heart to the next shows if the electrical activity is normal or slow, fast or irregular Second, by measuring the amount of electrical activity passing through the heart muscle, a cardiologist may be able to find out if parts of the heart are too large or are overworked.
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There are a number of tests that use some form of ECG, including:
A. Esophageal Electrophysiological Procedure. Used to diagnose or treat tachycardia (rapid or accelerated resting heart rate). A thin, soft, flexible plastic tube will be inserted into the nostril and positioned in the esophagus. Because the esophagus is close to the heart's upper chambers (atria), an ECG recording there gives more precise information than a regular ECG. An electrical stimulator may be used to make the heart beat faster to try to restart the arrhythmia. This helps the doctor make the right diagnosis.
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