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THE CARDIOLOGY UNIT: THE STRESS TEST AND THE HOLTER MONITOR
April 2, 2009
A stress test is done on a treadmill or stationary bike. The treadmill is a moving walkway, the speed and incline of which can be altered. The faster it moves and the steeper the incline, the more work it forces your heart to do. While you walk on the treadmill, your heart is monitored by EKG, which will show when the demand for oxygen by the heart is beginning to outstrip the supply through the coronary arteries. This is usually well before you feel any pain.
The EKG can show how much of the heart is affected, and which part of the heart. This helps to pinpoint which coronary artery is affected, and roughly where. It is a start on the road to defining what exactly your problem is, but it is too inaccurate to use as the sole basis of treatment.
As a rough rule of thumb, if angina or ischemic changes on the EKG start within two minutes of beginning the treadmill exercise, there is enough coronary disease for serious note to be taken. If you can go ten minutes without pain, and there is no silent ischemia on the EKG, there is little to worry about. However, many people fall in between these limits.
The Holter monitor is a portable computerized EKG machine that can be strapped to your chest for twenty-four or forty-eight hours. You wear it as you perform your everyday tasks and even when you sleep (some angina may occur when you sleep).
The Holter monitor records a continuous trace of your heartbeats throughout the whole time you are wearing it, and is programmed to pick up every abnormality during that time, from episodes of ischemia to bursts of abnormal rhythm, to the odd missed beat. It can compare the episodes of ischemia with your count of episodes of pain. The difference gives the numbers of attacks of silent ischemia, and gives an idea of the whole burden of ischemia your heart is carrying, day and night.
Treadmill testing and Holter monitoring can detect people who are at relatively high risk of a serious heart attack. Cardiologists now recommend that everyone with angina under the age of sixty-five years, regardless of whether their symptoms are mild or severe (remember they often bear no relationship to the severity of your blockage), should be offered these tests. For those aged over sixty-five, the decision to put them to such discomfort depends on their general fitness and on how much their angina is interfering with their quality of life.
*86\86\8*
HELP YOUR ANGINA/EXERCISE: THE IMPORTANCE OF REST
Daily exercise is all very well, but rest is important, too. Some people find that exercise helps them to relax and reduce their stress, because they always feel good after vigorous physical activity. However, they must not exercise vigorously every day.
For muscles, including the heart muscle, to get the best out of exercise you should take two days of rest from it every week. Plan your week accordingly for two separate “do little” days between exercises. Professional athletes know this—and it is even more important if you have angina.
Rest is important at certain times in your exercise days, too. Don’t, for example, exercise vigorously for at least two hours after a main meal, or until an hour after a snack. Don’t exercise after drinking alcohol.
If you are ill, don’t try to keep up the exercise schedule, especially if you have a virus infection such as the flu or a cold. As you begin to recover, start with a few easy exercises at home—they will help your muscles to recover faster.
Don’t stick to just one exercise either. Mix your exercises with walking, swimming, cycling, running, golfing, tennis, badminton, or whatever you most enjoy. Keep it moderate, and not too competitive, and learn how to relax.
*62\86\8*
REDUCING THE RISK FACTORS/TACKLING CHOLESTEROL:SUMMARIZING THE TRIALS
All the trials aiming to reduce the heart attack rate by lowering cholesterol levels have met with some success, but in most the success has been less spectacular than expected. The limitations have been partly caused by the design of the trials, that is, the control groups have often taken to healthier lifestyles as the news of the good effects started to spread.
A main problem with the cholesterol-lowering trials, however, has been their concentration on cholesterol only, and not on all the circumstances that contribute to heart attacks, such as high blood pressure, obesity, lack of exercise, smoking, and alcohol. In any doctor/patient discussion, all the risks would be put before the patient, and then doctor and patient would work together to reduce or abolish them. This was deliberately not done in many of the trials, as their aim was specifically to measure the effect of cholesterol lowering.
*42\86\8*
RATES OF HEART DISEASE IN DIFFERENT COUNTRIES
Countries vary enormously in the proportion of their populations with coronary heart disease. In 1986, Professor Hugh Tunstall-Pedoe of Dundee, Scotland, compared mortality rates from coronary heart disease in men aged forty to sixty-nine years from thirty countries. At the top of the list were Northern Ireland, Finland, and Scotland, with six hundred deaths per one hundred thousand men of that age range per year. England and Wales were next, followed by, in the middle, the United States, Norway, Canada, and Israel, with three hundred to four hundred deaths per one hundred thousand. Countries with much lower rates—around one hundred to two hundred deaths per one hundred thousand—were Italy, Yugoslavia, Greece, Spain, and France. Lowest of all, by far, was Japan, with a death rate of around fifty per one hundred thousand—less than one-tenth of the death rates of the three top countries.
The variations are not just between countries, but within them. Within lowland Scotland, coronary deaths are high in the west and low in the east—a twofold difference in populations living only forty or so miles apart. Districts within western Scotland vary by as much as twofold in their heart disease death rates.
Such regional and local variations in coronary disease have given the clues to its causes. One clue was given in the 1960s by the International Atherosclerosis Project, when investigators from fourteen countries in North, South, and Central America, the Philippines, Jamaica, South Africa, and Norway collected specimens of arteries from postmortem examinations of 22,509 people aged from ten to sixty-nine years.
They showed that atheroma was present in the arteries of all people, regardless of age, race, and geography. It was more common and more extensive as they aged. However, the severe form of the disease—in which there were raised plaques with roughened surfaces projecting into the bloodstream—was closely linked to death rates from heart attacks in the countries concerned. The environment was much more important than race or gender. The severity of the atheromatous changes was directly associated with average blood cholesterol levels in the various populations.
*22\86\8*
