What tests might I have to undergo for angina?

Your doctor will examine you, check your weight and blood pressure and listen to your heart for certain sounds and noises in your chest. Your blood should be checked when you have not eaten overnight to measure the fat content (cholesterol – see the section Risks of high cholesterol levelsin Chapter 2).
Your doctor may want to do an electrocardiogram(ECG) (see below) which is a means of checking the way the heart works and whether there is any damage. An exercise electrocardiogram (see question below) on a treadmill machine or bicycle may be used to assess how well your heart behaves under stress and how much you can do.
Some people may be sent to a specialist heart doctor (a cardi ologist) who may suggest that you have anangiogram, with a cardiac catheter inserted (see the section Angiogrambelow).
ECG

My doctor is sending me for an ECG next week. I am not sure what this involves – will it mean time in hospital for an operation?

No, and it is painless and takes only 10 minutes to do. An electro ¬cardiogram (ECG in the UK, EKG in Europe or the USA) is a simple painless test which looks at the electrical activity of the heart. It tells the doctor about your heart rate, whether you are likely to have a heart attack and if you have any hardening of your arteries, and whether your heart’s rhythm is regular or not.
You will have electrodes (usually sticky pads) applied to your arms and legs, and six are placed across your chest (see Figure 3.2) to record the electrical activity in your heart, while you are not doing anything. Men with hairy chests may need a small area shaved. The resulting ECG trace gives an electrical picture of your heart. It is not dangerous and you cannot be electrocuted!
What does an exercise ECG involve?

Angiogram
I have been told to go to the hospital for an angiogram. What is this and what does it involve?

Acoronary angiogram (pronounced ‘ann-gee-o-gram’) is also known as cardiac catheterisation. This is a technique for establishing if there are any narrowings in your coronary arteries, how severe they are and whether they represent an increased risk of heart attack (see Figure 3.4). If narrowings are severe and in dangerous places, the doctor will then know that surgery is the best treatment for you. An angiogram can also give information about the heart valves and the quality of the muscle pump (left ventricle) and whether there is any damage.
The test involves small tubes (catheters) being passed through your arteries. Special X-rays are then taken of the coronary arteries and the heart muscle. When a dye is injected into the tube, any narrowings will be shown and any danger discovered. This test is straightforward but only done when there is a probability of narrowing that could be corrected by an operation or by the technique of angioplasty (see question later on Percutaneous transluminal coronary angioplasty).
You will usually be in and out the same day. You will be given a ward bed and have nothing to eat or drink for 4 hours before the test as, just occasionally, the dye used to show up the arteries can make people feel sick.
You may be given medicine to help you relax. You will be taken to the catheter laboratory usually by a porter or a nurse. Some hospitals use trolleys, others wheelchairs and, in many, you simply walk down with the nurse. The laboratory nurses will introduce themselves and you will meet the cardiologist who is doing the angiogram. The ‘cath
lab’ is full of sophisticated equipment all designed to help diagnose your problem.
You will be asked to lie on a table (usually it is rather hard!) beneath an X-ray camera, which will make a noise when in use. TV screens will show the procedure as it’s happening, so that you can watch what’s going on (if you want to). There are two ways of doing the angiogram – one from the arm and one from the leg. Most procedures are done from the leg, but different hospitals have different procedures, and the leg procedure may not be suitable for some people because of hardened leg arteries.
A local anaesthetic is applied to the top of your leg and you will feel a needle prick followed by a stinging numbing sensation. This is the only discomfort that you should feel. A fine tube is passed through the artery all the way to your heart. You will not feel this tube. Once the tube (the catheter) is safely in place, dye is injected into the arteries and the ventricle (pumping chamber) and pictures will be taken. You will hear the camera run several times as pictures are taken from different angles, and the camera will move over your chest to the left and right. Imagine your arteries to the heart are like a big tree and that you are walking around the bottom looking up at all the big and little branches; as you move around, any area of overlap becomes clear. So it is with the camera: it moves to unravel the branches so that nothing is missed. You may be asked to hold your breath from time to time and your arms may be put over your head if they are in the camera’s way.
The whole procedure usually takes less than 30 minutes and often only 10–15 minutes.

I am told I need an angiogram but I saw on TV a new kind of  angiogram using CT scanning. What’s this?

It’s known as 64-channel multi-detector computed tomography (MDCT). It is an outpatient specialised X-ray procedure which can take pictures of your arteries in less than half an hour. You have an injection in a vein (not an artery) and your heart is slowed, usually by taking a beta-blocker drug beforehand, as this leads to better pictures. It’s an exciting new technique which does not replace an angiogram but can be used instead when the diagnosis of heart disease is unlikely but the doctor is not certain. It also is used when the person is at risk but has no symptoms – for example, someone with diabetes who has no chest pain but an abnormal ECG. It does involve X-rays so cannot be used casually in a check-up. New scanners are being introduced which are claimed to reduce X-ray exposure by 80% so this is going to be an exciting area of development with the possibility of repeated scans to monitor progress.
MRI does not involve X-rays so can I have an MRI instead of an angiogram?
Not yet. Magnetic resonance arteriography (MRA) can show up any problems in the aorta and renal (kidney) arteries but not yet in the coronary arteries. Magnetic resonance imaging (MRI) can tell us about the structure and pumping of the heart.

Is there any difference between an angiogram from the arm or the leg?

The leg approach does not involve stitches but pressure is needed for 10 minutes or so to stop the bleeding (a tiny hole is made in the artery by a fine needle). To prevent re-bleeding, you will be advised to rest in bed for 4–6 hours. This technique is ‘percutaneous’ which means ‘through the skin’ but no surgical cut is involved. Devices have been developed to ‘plug’ the hole in the artery and, if you are a suitable candidate, the artery will be closed and you will not need pressure on the groin. You will rest in bed for about an hour and then get up and about, going home sooner.
The arm approach is usually percutaneous at the wrist (radial artery) and does not need bed or chair rest for more than an hour.
The arm approach at the elbow can be percutaneous but often needs a cut and then stitches (the jargon we use is cut-down). Again, you are up and moving very soon. The wrist and leg techniques are the most common. The wrist approach is being used more frequently but is not suitable for everyone.

I have been on warfarin tablets for some time now, to prevent blood clots. Do I need to stop or reduce my warfarin before the angiogram?

Warfarin is a medication used to prevent blood clots from forming. It is not always necessary to stop or reduce warfarin with an angiogram taken from the arm, but it is essential with the leg approach to prevent severe bruising. We usually advise four days of no therapy before an angiogram. Always remind the doctor that you are taking warfarin so your clotting can be checked before the procedure.

I’m taking aspirin every day – do I need to stop this for the angiogram?

No, this is not necessary. The mild blood-thinning action of aspirin helps prevent clotting in the artery narrowings but it does not usually significantly increase the tendency to bruising or bleeding. The same applies if you are taking clopidogrel as an alternative to aspirin, or both together.

Is the angiogram at all painful?

The only discomfort should be the injection of local anaesthetic. When the dye is injected into your muscle pump, you may feel hot and flushed with a strange warm feeling in your bottom. This passes quickly. Sometimes, when the catheter is in the pumping chamber, your heart may appear to miss a beat or flutter for a few seconds. Don’t be afraid; this is all routine.
After the procedure,pressure will be applied to your groin to stop the bleeding (about 15 minutes) and you will be asked to rest in bed for 4–6 hours while the small hole in your artery closes. If your arm has been used, a pressure bandage will be applied to your wrist.

Is the angiogram procedure dangerous?

All tests have a slight risk but in an experienced centre the complication rate is about 1 in 1000. Remember that this figure includes emergency cases and people who are ill as well as people undergoing routine tests. The test is never done without a good reason and the risks are very low.

What happens after I have had my angiogram?

Most departments have a recovery area, but if this is not avail ¬able your ward nurse will collect you from the ‘cath’ department and take you back to your bed on the ward. If you have had an angiogram by the leg approach, until you are safely back in bed, you may be asked to press on the leg used and to keep it as straight as possible. This is to prevent further bleeding from the site. This rarely happens but, if it does, don’t panic; press as the nurse or doctor did and call for help.
Your nurse will record your pulse and blood pressure at frequent intervals to check that all is well. The site of the catheter insertion will be checked and the pulses felt in your feet or arm. If you notice any blood, apply pressure as before and tell your nurse. If your arm or leg feels cold, also tell the nurse.
If the arm has been used, you will get up almost straight awaybut, if the leg is used or a ‘plug’ has not been inserted, you will be asked to remain in bed for 4–6 hours, still keeping that leg straight. When you wish to go to the toilet, the nurse will bring the urinal or bedpan. If you have had a leg angiogram, you can usually get out of bed after 4–6 hours (1–2 hours if a plug has been inserted). Check when it is safe to get up. Don’t get up without checking first.

How long after my angiogram will I get my results?

When your films have been developed and studied, the doctors will come to discuss the results of your angiogram with you, usually the same day. Some hospitals have a weekly conference so there may be a delay. Any further treatment that you may need, either medical or surgical, will then be discussed with you, either before you go home or in the outpatient clinic after the conference.
If the coronary arteries are hardened, the doctor will be able to show you your results by means of a diagram.
What happens after I have been discharged from hospital, following the angiogram?

Problems are rare. Sometimes the leg is bruised but this slowly fades over 2–3 weeks. Occasionally a hard lump, like a gland, is felt in the groin: this is just a bruise again. Don’t worry – if it is tender, take painkillers. Have a quiet evening when you get home, but you can be up and about the next day. Any sticking plaster is best removed in the bath the following morning. If you have had a leg angiogram, you should avoid strenuous exercise for 48 hours. If you have had an arm cut-down angiogram, you need to make arrangements for stitch removal if the non-dissolvable sort have been used – your family doctor will do this at about seven days. If pain continues,or the scar looks red and swollen, go to your doctor. It is unusual, but infection can occur and antibiotics will then be needed.
If you are taking warfarin, you should start your tablets again the same day, although it is a good plan to confirm this with the hospital doctor before leaving. Those who work can get back to work usually in a couple of days; driving is possible also the next day.

I always thought that angina was a man’s problem. Do women get angina?

Coronary disease is the most important cause of death and disability in women. It is seven times more likely to cause premature death in women than breast cancer. Angina is just as much a woman’s problem as a man’s (see the section Women and coronary artery diseasein Chapter 2).

I have had my angiogram and my arteries are clear, but I still have angina. My doctor says that I have Syndrome X – what does this mean?

This is a condition which is more common in women. There is no extra risk of a heart attack or dropping dead, but nearly two-thirds of people with chest pain and normal arteries who suffer from angina are significantly limited by it. It is very difficult to treat. Drugs that relax the arteries to try and improve the blood flow (nitrates, calcium antagonists, nicorandil) may help. It is important to rule out other problems that may mimic angina, in particular a hiatus hernia or excess stomach acid.
People who suffer from Syndrome X can help themselves by:
•    not smoking;
•    exercising as much as possible;and
•    losing weight if they need to.

It is a very frustrating condition to treat and we do not have all the answers – some people are helped, some are not. It is important, however, not to give up trying to help. It is a real condition and not ‘in the mind’.

Reference:
All questions are answered through articles indexed in www.PubMed.com and edited by: Dr G. Jackson in Heart Health 4th edition.