Transcript
Matthew DeVane, DO FACC: Hi, I'm Doctor Matt DeVane.
Carolyn Lacey, MD FACC: And I'm Doctor Carolyn Lacey. We are cardiologists at John Muir Health and this is our podcast, Living Heart Smart.
Matthew DeVane, DO FACC: Our physician partners and colleagues are going to help guide you through many different and important cardiovascular topics to help keep your heart happy and healthy.
Carolyn Lacey, MD FACC: Thank you for listening and we hope you enjoy our show. Hi everyone. Thanks for joining us again for another episode of Living Heart Smart. And today it's just Matt and I talking to you.
Matthew DeVane, DO FACC: Yeah. Hey, hey. I'm excited to be back. Um, we've got some big things coming up. It's National Heart Month this February, so I'm looking forward to doing some some podcasts and having some great guests on in the next few weeks. But today we just thought it'd be the two of us.
Carolyn Lacey, MD FACC: I take it for granted that you all understand the terms that I use to explain your heart. And we as cardiologists, we talk in this language all day, every day.
Matthew DeVane, DO FACC: We do. And I think it's confusing to patients who just hear words like AFib or echo or myocardial infarction, which we just call me a lot of times, and we make the assumption that people know what we're talking about. And so I don't think that's always the case. And so that's why we're here.
Carolyn Lacey, MD FACC: Right? I think it's probably a lot of scary mumbo jumbo and uncharted territory for you. So being mindful of that, we created this new category for Living Heart Smart called Cardiology 101. It's to help teach you the basics about your heart conditions and testing we do for your heart, and I hope this helps alleviate concerns that you have to help you advocate for your heart health. So let's dive in.
Matthew DeVane, DO FACC: Yeah, I get a lot of patients that just new patients that I see in the office. And when I come in and listen to the heart, and then we start talking about testing and they say, well, you know, you just listen to my heart. Why do we need to do anything else? Well, unfortunately, listening doesn't give us the whole picture. And it's important for us to know about the condition of your heart in many forms. So let's just take a step back and try to look at the heart as a whole. It's a pretty co
mplex structure,
Carolyn Lacey, MD FACC: A lot.
Carolyn Lacey, MD FACC: Of moving parts.
Matthew DeVane, DO FACC: Yeah, literally there are. So I like to break the heart down into four main components. Um, I think of the first component as the electrical system of the heart, which drives the heart, electrical beats, which is your heart pumping. And then there are a couple of big pumps in the heart which drive blood around to inside your heart, as well as to your whole body. There are heart valves that keep the traffic and the blood flow going in one direction through your heart. And there's the heart arteries, which deliver the oxygen and nutrients to your heart muscle to keep it working nicely. So in order to see those four big pieces of the heart, it's going to take some testing and different tests.
Carolyn Lacey, MD FACC: And there's no one single test, right, to evaluate all of these parts all at one time.
Matthew DeVane, DO FACC: No, there's no one test that does it. So we've narrowed it down to the basic three here, which I'm going to be calling the heart trifecta. No, the cardiology trifecta. No.
Carolyn Lacey, MD FACC: He's going to call it a trifecta. He just made that up.
Matthew DeVane, DO FACC: DeVane trifecta.
Carolyn Lacey, MD FACC: Nobody else calls it that.
Matthew DeVane, DO FACC: All right, well, anyway, the three main tests that you may get at your cardiologist are the EKG, the echocardiogram, and the stress echocardiogram or stress test. So that's what we're going to talk about.
Carolyn Lacey, MD FACC: Do you want to tell us just briefly which each test what the what part that that looks at.
Matthew DeVane, DO FACC: Yeah. So the EKG electrocardiogram will be looking at the electrical system. Your heart pump is looked at best with an echocardiogram. Your heart valves are also best looked at with an echocardiogram. And your heart arteries require a different test. And that's done through stress testing.
Carolyn Lacey, MD FACC: And all of these tests. These are these are our office tests. So we do them in the office. They're noninvasive. There's no IVs. We don't need any needle sticks. And and the tests themselves are performed by our staff. So it's either our medical assistants or our certified echo technicians. We call them sonographers. And for the most part, there's not a lot of preparation. You just show up and have these tests done.
Matthew DeVane, DO FACC: Yeah. During the stress test, we'll ask you to bring some comfy shoes that you can walk on treadmill on, but other than that, you just show up. And these tests, you know, EKG takes just a few seconds to do an echo or stress test will usually ask you to give us about an hour or so to get the test done, and then your cardiologist won't be there while you have the test done. But be sure that they'll be looking at it and getting a hold of you either the next visit or in some way to communicate with you the results.
Carolyn Lacey, MD FACC: So the EKG is the fundamental test. This is the test that has the squiggly lines on the pink paper. And, you know, there's only really 1 or 2 guarantees in life. But I think that we should add that if you're seeing a cardiologist, you're pretty much guaranteed that you're going to have an EKG.
Matthew DeVane, DO FACC: Yeah, as part of the visit.
Carolyn Lacey, MD FACC: It's part of the visit. Yeah. We joke about this, but we we do this test, the EKG test for so many reasons symptoms, monitoring of medications or screening for new heart. Heart issues.
Matthew DeVane, DO FACC: Yeah. And the EKG has been around for a long time. Uh, EKG was invented in 1901, just in case you're wondering, there, uh, the first EKG machine weighed about £600. That's a lot. Yeah. And then think about. Today I'm wearing an EKG on my wrist and they're completely portable, and we do them in the office. And every, every place does them so crazy.
Carolyn Lacey, MD FACC: It's it is very, very portable. And we order them like, I need an EKG. I need an EKG. Exactly. Right. So when you're actually having an EKG, you're going to have electrodes placed on your arms and legs and chest wall. And these are, these electrodes are sort of like sticky. Um, this records the electrical signals of your heart for 10s of activity. And then that generates the squiggly lines that come out and print out on the paper. It actually creates a pattern that your doctor interprets as a starting point for the health of your heart.
Matthew DeVane, DO FACC: Yeah. And I it's kind of hard to think about how these things work and can tell you about the heart, but let me give you a big overview. So there's a little electrical component in the top chamber of your heart that is called the sinoatrial node or the sinus node. And that's the little area that generates a little spark about every second that makes your heart beat. So the spark comes from there. And then it travels down. This a little electrical highway. And then when your heart muscle, your pumps or your ventricles see this spark, that's when they contract. So that's how you get a heartbeat is starting from this electrical point. And that's what the EKG is looking at, is looking at how this electrical muscle interaction looks like. And so the EKG portion is going to tell us what that map looks like, or it's going to give us a pattern that we recognize related to certain heart conditions. So a normal heart looks one way. If you've had a heart attack in the past, the EKG is going to look another way. And if you have some heart thickening or other issues, it's going to look another way. So for us, it's just about pattern recognition to know how your heart's doing.
Carolyn Lacey, MD FACC: And we I don't think we have time to get into all of the findings on the EKG. There's a lot. Um, but will you comment on the heart rate and rhythm a little bit?
Matthew DeVane, DO FACC: I think the main thing patients, our patients should be looking at when they hear about the EKG is what's my rhythm and what's my heart rate? That's the big thing the EKG does. So a normal sinus rhythm is a rhythm that's coming from that sinus node that I just talked about. And a normal sinus rhythm means that your heart rate is between 60 and 100 beats a minute. If your heart rate is slower than that, we call that sinus bradycardia. And that's a heart rate less than 60 could be perfectly normal for you. But it's got a name sinus bradycardia. If your heart rate is faster than 100 beats a minute, we call it sinus. Tachycardia just means a fast heart rate coming from that sinus node. Now there's all sorts of different extra beats that can be coming in your heart. Premature atrial beats, premature ventricular beats, abnormal rhythms like atrial fibrillation that many of you heard about. But the main thing is looking at the heart rate and the heart rhythm. And so the very first line that you're going to see on your EKG is that rhythm. So just thought we should cover at least the basics there.
Carolyn Lacey, MD FACC: Thanks. There's a lot of things though that this test doesn't show us. And so we often need to pair it with other tests. It doesn't tell us about blockages or valve problems or the pump function of the heart. And do you do you? I get asked this a lot, but do you also did I pass my EKG test?
Matthew DeVane, DO FACC: That is a pretty common question, and people want to know if they have a test if they passed or not, right? Yeah, right. Did I pass? This is not a pass or fail test. Fortunately, it's just giving us data to show us the basics about your heart's doing. So don't even worry about that. Not a pass or fail, right?
Carolyn Lacey, MD FACC: It's just really one piece of the puzzle. And using between your symptoms and your physical exam, the EKG may lead to more testing. Sometimes it doesn't, though, but a lot of times it does. And so knowing that we're probably going to need some more testing after the EKG. The test that I move on to most frequently is is the echocardiogram.
Matthew DeVane, DO FACC: Yeah. I think the echo would be the second most common test that we do is cardiologist. And one of our partners put a very well recently when we were having a little discussion after work, he called the echocardiogram the single best bang for the buck procedure that you can get from your heart. And I thought that was a pretty well said. So you get a lot of information from a simple, non-invasive test. So I just also want to say one thing. A lot of my patients get echocardiogram mixed up with electrocardiogram that we just talked about. So an electrocardiogram is the EKG that's looking at the electrical impulses of your heart. The echocardiogram is an ultrasound looking at your heart and pump two different tests.
Carolyn Lacey, MD FACC: Two different tests.
Matthew DeVane, DO FACC: So an echocardiogram is a completely noninvasive test. Takes about 45 minutes to do. Like we said, there's no IVs, there's no fasting. You just show up and we'll get the test done. Our echo technicians or Sonographers will use a transducer, which they'll rub across your chest wall and sometimes the upper part of your abdomen to take pictures of your heart. And this technology is using high frequency ultrasound waves to bounce off. Your heart goes back to our machine and creates these. Beautiful pictures of the heart and we can actually see the heart beating, moving. We can see the valves beating, moving. And so it gives a really nice overview of how the heart looks as it beats.
Carolyn Lacey, MD FACC: And and while you're having your test done, you're going to hear swooshing sounds and see color images. And these images and the sounds are giving us information about the direction and the speed of the blood flow through your heart. But they're not actually the sounds that your heart makes.
Matthew DeVane, DO FACC: Yeah, those are just all computer generated noises, but patients tend to love it. And so it's kind of just expected during the study doesn't mean anything. So it's not good or bad when you hear those noises.
Carolyn Lacey, MD FACC: What are some of the reasons that we may need to check your heart with an echocardiogram?
Matthew DeVane, DO FACC: There are a lot of reasons we need to look at your heart with an echo. I'd say number one would be symptoms, right? So someone comes to us and consultation. They come to us with chest pain or shortness of breath or palpitations or racing heart. So an echocardiogram is always going to just help us understand the structure and function of the heart, which will direct our treatment. Another common reason that people come see us for an echo they will need an echo is because someone heard a heart murmur. Now, a heart murmur just means that your physician can hear some swishing when they listen to your heart with their stethoscope. It doesn't mean there's a problem with your heart. I tell patients that I hear heart murmurs on 90% of people I listen to, so oftentimes that's just normal blood going through the heart. But it could be a sign of something else. So an echo is going to clarify that for us. There are a lot of other reasons we may need an echocardiogram. Other heart conditions like high blood pressure, coronary artery disease, and of course heart valve disease are truly best managed with intermittent echos just so we can track your heart health and progress over time. We do look at your whole heart with the echo, but there are few key components to focus on.
Carolyn Lacey, MD FACC: The first component that I look at is the function of your heart. And as a basic anatomy lesson, we have two ventricles, the right and the left, and our ventricles pump blood out of our heart. Our right ventricle sends blood to the lungs to pick up oxygen, and our left ventricle delivers this blood oxygen nutrients to the rest of our body. And since our left ventricle delivers blood flow over a further distance, this is the ventricle with a higher pressure compared to the right ventricle. And your left ventricle is the one we're mostly referring to. When we talk about the function of your heart. The terme we use is ejection fraction. This is a measurement of the strength of your pump. We also call it the left ventricular ejection fraction. We call it the Lvef. And a normal ejection fraction is actually 55 to 70%. So if you fall in that range normal's normal, it doesn't mean that if you have 55 it's better to be 70 or vice versa.
Matthew DeVane, DO FACC: Yeah. And also I want to be very clear, a lot of people that get this test done, they assume 100% is normal and it's not. So 55 to 70% is in the normal range. Think of it, if your heart is squeezing and pumping blood forward, it doesn't squeeze every single drop out. Each time that it pumps, it pumps out about 60% of what's in there.
Carolyn Lacey, MD FACC: I get asked that question a lot too. The other part we really look at are the valves, which I describe our valves as locks in a canal. It keeps blood flowing in one direction through your heart. And we have four total valves. We have two around our right ventricle and two around our left ventricle. They're named tricuspid, pulmonic, mitral and aortic valves. And because the mitral and the aortic valves surround your left ventricle, we tend to focus more on these valves. Some degree of wear and tear is expected on your valves throughout our life. But there are a couple specific problems we look for on your echo. One problem is called stenosis, which is a narrowing of the opening of your valve. The other problem is regurgitation, which is leaking or backwards flow of blood in your heart across that valve. They're pretty common to see those problems.
Matthew DeVane, DO FACC: Yeah. And we also like to quantify what that leakiness or stenosis is about. So we'll use a couple terms mild moderate or severe. So that is just to help us gauge how your heart valves are doing over time. A common question that I know we get a lot after an echocardiogram is how my arteries are doing. Well, the echocardiogram doesn't tell us information about your heart arteries. So that leads us to the last test in our trifecta of cardiology testing. And that's the stress test. And today we're just going to be talking about the stress echocardiogram. It's one of the type of stress tests that we do in our office. So when we talk about stress testing we're really talking about coronary artery disease. That's what we're looking for when we do a stress test and quick anatomy lesson there. You have three main coronary arteries of your heart. Each of those arteries does have some side branching and those arteries. Need to be open to get blood to your heart. Now, the stress echocardiogram doesn't actually look at the arteries of your heart. What it's looking at is your heart pump. And we're also watching the EKG to see if there are any changes there that suggest that it's not happy and it's not getting enough blood flow during your stress test.
Carolyn Lacey, MD FACC: This test is basically both the EKG and the echocardiogram that we just talked about coming together. We combine this test with you walking briskly on the treadmill. And it's a protocol of different speeds and inclines. This protocol has been in existence for almost 50 years, and it is meant for you to feel like you're working hard. We want to stress your heart to a good level most of the time, depending on your age. We expect people to walk about 6 to 10 minutes on the treadmill.
Matthew DeVane, DO FACC: Yeah, I think people have unrealistic expectations when they come in that this is a major, you know, 25 minute walk or something like that. This is a test that we're aiming for a certain heart rate to get you up to, to make the test adequate for us to interpret it. And typically that's going to take yeah. Like you said, Carolyn, five, ten minutes on the treadmill to get those numbers. Now, there are a number of reasons your doc may want you to do a stress test. Probably the most common one is some symptoms that you're having. Chest pain and shortness of breath are probably the most common symptoms that would suggest you might have some coronary artery disease. So that's what would lead you to this test. Sometimes if you've got a weakened heart muscle for other reasons, we'll want to check your arteries out. So you may need a stress test to do that. And sometimes this is a test that will be done before you're having an elective surgery, so that we can check your heart out in a controlled environment before it's checked out in the stressful environment of the operating room. So that may be another reason. Sometimes we'll do it too. If you haven't been very active for a while, but you want to start a new exercise program and you've got some risk, we'll check the heart out first to make sure it's safe.
Carolyn Lacey, MD FACC: And of all the three tests that we've just discussed, this is the test where the results kind of are pass or fail.
Matthew DeVane, DO FACC: This is the only one, and it's not truly a pass or fail. But there's kind of, I think of a Carolyn as three different results coming from a stress test. Okay, so you've had your stress test done. And there's really three major outcomes that I want to talk about. Number one is hey, you passed the test. And that kind of means you had no symptoms on the treadmill. Your EKG looked okay and your heart looked strong both before you exercise and afterwards. That's great news. Then there's the failing part of the test. And that just means that you had symptoms during the treadmill test, or there were some changes on the EKG or the echocardiogram that suggest you may have coronary artery disease, and you may need more testing. And the third outcome is not great, but we call it an indeterminate test where we need to hedge a little bit. It means the test didn't fully tell us exactly what we needed from the test, and we still have some concerns about your heart. We're always going to err on the side of safety, and sometimes when we get this unclear answer, you may need some more testing.
Carolyn Lacey, MD FACC: So we do have some alternatives to stress testing. The stress echo is just one type of stress test. It's a good choice if you can walk briskly on the treadmill, but if you have issues where it's really difficult to walk on the treadmill because of pain, or your you're afraid to walk on the treadmill, you're not used to walking on the treadmill. We have another type of stress test called the pharmacologic nuclear stress test, where we use medicine to make your heart think it's exercising. And we'll talk about that in another Cardiology 101 episode. I do want to talk to you all, though, about seeing your results immediately after the tests are interpreted and finalized by your doctor. This is a good thing, but I've also seen some real anxiety over all of the medical words. So I want to help you focus on the important parts of each of the three tests. So with the EKG, we look at the rhythm as a reminder. Sinus is normal. The echocardiogram the most important. Terme is the ejection fraction and normal is 55 to 70%. And for the stress echocardiogram, this is the one that's either positive or negative for ischemia. Ischemia signifies that there may be blockages in the arteries.
Matthew DeVane, DO FACC: And just remember, some of these test results may lead to further testing. Just work closely with your doctor about the results and taking the next steps.
Carolyn Lacey, MD FACC: So Matt calls these the cardiology testing trifecta. Just to be clear, nobody else calls it that. Just him. He's trying to make it work for now.
Matthew DeVane, DO FACC: I know you're going to be calling it the trifecta in the future.
Carolyn Lacey, MD FACC: I'm probably going to end up calling it the trifecta overnight. Yeah, but hopefully we shed some light on how the EKG, the echo, and the stress echo are really used together to help keep your heart happy and healthy. I think that's a wrap. Thanks for listening.
Matthew DeVane, DO FACC: Thank you. This is Doctor Matt DeVane and on behalf of my co-host, Doctor Carolyn Lacey, and our partners at John Muir Health, we hope that you enjoyed this show and we really hope that you keep living heart smart.
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