HEALTH SERVICES PROVIDED

OFFICE CARDIAC CONSULTATION

We can offer consultations at your request or a referral from your physician. When you come for the consultation we will review the details of your current complaints and questions. We will want to know the pertinent details of your past medical history, a list of any medications and food supplements that you take, any allergies,your family medical history, and your social environment. Prior records from your physicians would be very helpful, and will avoid duplicated tests. A complete physical examination will be done, and we will then discuss our findings and recommendations for further treatment and/or testing.
Please print and fill out our health questionnaire which appears on this website under "New Patient Forms". Please write down in advance any questions you would like to ask, so that we can be sure to address them.

HOSPITAL CONSULTATIONS
We have arranged our schedules so that one of our physicians is available 24-hours a day to see you at the Yale-New Haven Hospital or the Hospital of Saint Raphael if you need urgent care. We respond directly to requests from your physician, from you or a family member for either consultations or "second opinions".

NON-INVASIVE TESTING AVAILABLE IN OUR OFFICES:

1. EKG or electrocardiogram. The electrocardiogram amplifies and records the tiny electrical signal which your heart makes with each beat. It is a simple and very useful test.
2. Echocardiogram. This "sonar" study is a safe and painless test which uses a handheld ultrasound probe which is applied to your chest to make pictures of the heart valves and chambers, identifying abnormal structures and function.  We offer the very best equipment, skilled technologists, and expert physician readers who have access to your chart and are therefore looking for the special details that are important in your case.
3. Stress Testing. We offer a variety of stress tests. The specific type ordered for you will depend on your physical condition and a number of other medical factors.
• The EKG monitored treadmill test ("standard EKG stress test")- In this test you will walk on a treadmill with gradually increasing speed and elevation until you want to stop or we find a reason to stop you. We look at how far you can go, whether you develop any discomfort, what happens to your heart rate, rhythm, and blood pressure, and whether there are any abnormalities on the electrocardiogram. The test, including set up and cool down, usually takes about 45 minutes. There is a copy of our consent form listed under the heading of "New Patient Forms". 
• Echocardiographic treadmill test- To the EKG monitored test described above, we add the additional dimension of echocardiography. This tells how your heart walls are contracting before exercise and immediately afterwards. Abnormal contractions after exercise would indicate poor coronary blood flow to the area involved. This test provides information about heart muscle function and gives an accurate indication of the presence or absence of coronary narrowing.
• Nuclear treadmill Test.- Like the Echocardiographic treadmill test, the nuclear test adds an additional level of information to the standard stress test. An intravenous line is placed before patients begin exercise. Then, a tiny amount of radioisotope is injected at the peak of exercise. The isotope travels to the heart muscle with the blood flow and an area of diminished blood flow shows up as "a cold spot" on the scan. Two scans are obtained- at rest and exercise. This series of tests takes approximately 21/2 hours to complete. The test provides accurate information about blood flow to the heart muscle and heart muscle function. This is particularly helpful in individuals who have complicated cardiac histories or abnormal electrocardiograms.
• Pharmacologic stress testing. - A pharmacologic, "chemical stress test" is prescribed for individuals who can't or shouldn't walk on the treadmill. 
• Adenosine Nuclear Stress Test - We obtain nuclear scan images of the heart at rest and after the infusion of a medication which mimics exercise. The scans are then compared for evidence of poor coronary blood flow. 
• Dobutamine Echocardiographic Stress Test.- For certain individuals who cannot do treadmill walking, but have severe lung disease which may be worsened by Adenosine, stress testing is done with the infusion of Dobutamine which mimics exercise. The heart is studied by echocardiograms before and after the infusion to evaluate heart function and look for poor coronary blood flow. 
4. Holter monitor. - Three EKG leads are placed on your chest and connected to a small tape recorder which can be carried with a belt or shoulder strap. Every heart beat is recorded for 24 hours. If you feel anything unusual, there is a button that you can push to mark the time on the recording. We ask you to keep a diary of your activities while you are wearing the unit. It is very helpful in determining the cause for palpitations, lightheadedness, or fainting spells, and for evaluating response to medication. 
5. Event Recorder. - We have several styles of small recorders which can be kept for up to a month. Recordings can be made at the time of infrequent spells of lightheadedness, palpitation, or fainting. You can transmit your EKG by telephone to our office, or a central monitoring station.
6. MUGA Scan. - An isotope is injected and a scan performed which shows how well your heart muscle is contracting. 
7. Pacemaker monitoring. - For those who have an implanted pacemaker we offer a convenient and accurate way to check your pacemaker function by telephone on a regular basis.
8. Microvolt T-Wave Alternans Testing (In Our Orange Office)
   This simple test helps prevent sudden cardiac death – which is estimated to occur 300,000 times annually in the United States. It has been difficult to precisely determine which patients are at high risk for this condition. This new test is now available to help assess the risk of sudden cardiac death.
   Cardiology Associates is currently the only medical practice in greater New Haven to offer this test. It is a noninvasive test which takes about 30 minutes. During the test, patients walk gently on a treadmill, while certain aspects of their heart rhythm are monitored with a special EKG machine. Unlike a standard stress test, there is no running involved. The information provided by the test can help physicians determine who is at risk for this condition.
    
9. Anticoagulation Management. - Coumadin (Warfarin) is an effective medication which prevents blood clotting in patients for whom blood clots may cause injury. Patients with artificial heart valves, rhythm abnormalities such as atrial fibrillation and flutter and blood clots in large veins in the body are often managed with this medication. Our staff helps manage the safe dosing of Coumadin by closely following a blood test called the INR. By keeping the dosage controlled, we can safely prevent clotting while avoiding problems with bleeding. There are many other drugs and diet modifications which can influence the proper dose of anticoagulation. The INR must be done at least monthly and often more frequently for safety. Our Coumadin Center helps our patients take Coumadin safely. 

INVASIVE PROCEDURES

1. Cardiac catheterization is a diagnostic test where "we go inside to get the inside story". A thin plastic tube (catheter) approximately 1/16 inch in diameter is inserted into an artery or vein (usually at the groin) and is used to measure oxygen content, pressure, and blood flow inside the heart. This tube is then used to inject dye into arteries so that Xray pictures can be performed (Angiography).
2. Coronary angiography. - As part of a cardiac catheterization, Angiography of the arteries supplying the heart muscle is performed. This reveals any narrowings or blockages. Contrast injections may also be made into the cardiac chambers to assess how the heart is contracting and to look for valve leakage. Catheterization and angiography are invasive procedures but they definite, specific information which guides the treatment you receive.
3. Coronary Angioplasty. - Once a narrowing or blockage in a coronary artery is detected by Angiography, this can be treated by Angioplasty. A special guiding catheter is stabilized in or near a coronary or bypass graft vessel, a thin flexible wire is passed beyond the narrowed area and a special cylindrical balloon is delivered over the wire to the narrowed area where it is briefly inflated. A tiny metal coil (stent) is then placed in the dilated area and left in place to keep the vessel open. In special circumstances, a directional cutter, a high-speed drill, a clot removal device, or intracoronary radiation may be used as part of an angioplasty procedure. Angioplasty may be added on to an elective or emergency diagnostic angiogram procedure. It is a safe and effective procedure. There is a small but definite chance of renarrowing of the dilated areas in the coronary vessels. New techniques are being introduced to minimize this possibility.
   
   The risk of complications from a catheterization or an angioplasty is small but not zero. There can be bleeding, blood clots, injury to blood vessels, reaction to the x-ray dye- allergic or adverse kidney effects, and very rarely the complications of stroke, heart attack, the need for emergency surgery, or even death.. We recommend these procedures only when the benefits outweigh the risks. To see the hospital procedure consent forms please go to "New Patient Forms" .
    
4. Transesophageal Echocardiogram. - This is an ultra high quality ultrasound study of the heart which is performed as an outpatient at Saint Raphael's. You are given sedation and a flexible probe is positioned in the esophagus(the food pipe between the mouth and the stomach) just in back of the heart. This approach is particularly useful in looking for blood clots in the heart, problems with the aorta, and fine details of the valves.
5. Electrophysiologic Testing. (EP Study)- A EP study is a diagnostic test designed to evaluate an abnormal heart rhythm and look for its cause. The test, which is done on an outpatient basis, involves placing several thin wires into veins in the leg. The wires are then passed with the blood flow to the heart. The electrical patterns of the heart can then be studied. The risk of dangerous rhythms can be evaluated, medications tested, and some rhythms can even be cured by the technique known as ablation.
6. Catheter Ablation. - In certain patients with rapid heart rhythms a "short circuit" causes the problem and can be located by EP study. This short circuit can then be knocked out by application of a current through the wires placed at the time of an EP study.
7. Tilt Table Testing - A tilt table test is a non-invasive test used to evaluate people with dizziness or fainting spells. Your heart rate and blood pressure are monitored while you stand still for 30-45 minutes
8. Pacemaker. - A cardiac pacemaker is a small electrical device implanted underneath the skin connected to wires placed in the heart chambers.  Should your heart rate slow down too much the electronic pacemaker silently triggers your heart into action at the desired rate. Pacemaker insertion is a minor surgical procedure which is done under local anesthesia with infrequent complications. It requires one day of monitoring in the hospital after implantation. After initial adjustment we are able to follow your pacemaker conveniently by telephone monitoring as well as occasional office visits. 
9. Biventricular Pacemaker - A newly available technique, biventricular pacing, involves placing several pacing wires into a weakened heart, enabling it to pump more efficiently and improving the patient's energy level. The insertion of the device is much like a standard pacemaker, involving a minor surgical procedure and overnight hospitalization.
10. Implantable Cardioverter-Defibrillator. (ICD) - An ICD is a type of pacemaker used to treat patients with potentially dangerous rapid heart rhythms (not all rapid heart rhythms are dangerous). ICD's may be life saving for certain people. Like pacemakers, they are implanted in a minor surgical procedure and require a one-night hospitalization.