

Coastal Medical Specialty Care Center


Click on the topic for a detailed description:

Cardiac Consultations I ECHO I Stress Testing I Dobutamine I TEE I Holter Monitors & Event Recording I 3D I Strain I ABI I Preventive Care I Acute Care I Immunization

Cardiac Consultations
Cardiologists are experts in the diagnosis, treatment and prevention of cardiovascular diseases, which generally include diseases of the heart and blood vessels throughout the body.   For many heart or blood vessel problems primary care physician may choose to  manage care, such as in the case of high blood pressure or high cholesterol.  Often times these conditions can be treated effectively with medication and diet only.  Sometimes, however,  the problems can be more complicated and may require a cardiology visit to discuss alternative treatment option or for the care of patients who are not showing the usual expected response. In theses cases the cardiologist and the primary care provider work together to achieve the optimal clinical response.

Heart ultrasound also known as echocardiography provides doctors with moving images of the  heart and takes excellent pictures that will help  doctors evaluate  heart health. The most common type of heart ultrasound is non-invasive and very easy on the patient. A specially trained technician, called a cardiac sonographer, uses a gel to slide a microphone-like device called a transducer over the chest area. This allows reflected sound waves to provide a live picture of your heart and valves. Heart Ultrasound uses the same technology that allows doctors to see an unborn baby inside a pregnant mother. No radiation is involved in heart ultrasound, and the technology can be used on people of all ages. There is no special preparation required for a heart ultrasound. Patients should come as they are and eat or drink as they normally do. If taking  medications, they should continue to take them as normal unless a doctor specifies otherwise. Patients should plan on being at the Echocardiography Lab for about forty-five minutes to one hour To learn more  see: http://www.asecho.org/i4a/pages/index.cfm?pageid=3286

Stress Testing
This specialized test combines the echo exam with a treadmill or an infusion of medication that shows the effect of exercise on the heart. Coastal Cardiac Imaging was the first private cardiology to perform this test in Rhode Island and has the longest ongoing experience in the state using this technique.  The cardiologist looks at the patient’s heart before after exercise. Patients should come to the office prepared to exercise so sneakers and a button down shirt work best. Most patients do not have a full stomach before the test.  Stress tests are used to diagnose the narrowing of the coronary arteries. Our experienced, well-trained staff will make the test easy for patients from start to finish.  The test will be performed by a board-certified cardiologist who has at least 20 years of experience and has personally performed more than 10,000 tests,  The cardiologist will give the patient  the results immediately after the test is completed and send them to the primary care  doctor on the same day.  Patients will know at the end of the test if there are any important findings and understand if they require further treatment. The test usually requires the patient to be in our office for 45 Minutes.

If exercise on a treadmill is not an option due to a patient’s medical condition, or the patient is unable to walk on a treadmill, our cardiologists use an intravenous medication called dobutamine to exercise the heart while the patient is lying comfortably on a bed.  A dobutamine stress echocardiogram is a diagnostic procedure that may be used when a physician wants to assess the heart muscle under stress independent of respiratory or muscular function.
The infused medication creates the same strains on the heart that would be seen if the patient was capable of walking on the treadmill.  The test has extra benefit in patients who have known underlying heart disease such as a prior heart attack or history of blocked arteries because it allows the evaluation for damaged but nonetheless, viable heart muscle. . Dobutamine causes the heart to beat faster and will mimic the effects of exercise on the heart and all healthy or potentially treatable parts of the heart contract more vigorously than what were seen at rest.  Diseased hearts or patients at risk for surgery will be detected and treated for heart disease with medicines of other interventions as needed before an unpredicted heart disorder or operative complication can occur.

Transesophageal echo is a form of echo where a miniature ultrasound probe  is carefully passed down the throat to look through the back of the heart using views that could never be obtained on a surface transthoracic echocardiogram. This allows the physician to obtain very high quality moving images in patients whose heart may not be readily imaged due to their body habitus or lung disease. The patients can be sedated during the procedure by experts in conscious sedation.  This procedure is usually performed in a hospital because of a need for anesthesia or conscious sedation.  Transesophageal echocardiograms are typically performed to evaluate serious heart conditions; thus must be performed by the highest level of cardiologists certified in this technique. The images are exquisite and provide detail not possible with other techniques.

Holter Monitors and Event Recording
Holter and event monitors are medical devices that record the heart's electrical activity. Doctors most often use these monitors to diagnose irregularities in the heart rhythm. Arrhythmias are problems with the speed or rhythm of the heartbeat. During an arrhythmia, the heart can beat too fast, too slow, or with an irregular rhythm.
Holter and event monitors also are used to detect silent drops in the blood flow to the heart muscle. In this condition known as myocardial ischemia not enough oxygen-rich blood reaches the heart muscle. "Silent" means that no symptoms occur. These monitors also can check whether treatments for arrhythmia and silent myocardial ischemia are working.
Holter and event monitors are similar to an EKG (electrocardiogram). An EKG is a simple test that detects and records the heart's electrical activity. It's the most common test for diagnosing a heart rhythm problem. However, a standard EKG only records the heartbeat for a few seconds. It won't detect heart rhythm problems that don't occur during the test.
Holter and event monitors are small, portable devices. Patients  can wear one while doing your normal daily activities. This allows the monitor to record the  heart beat for a longer time than an EKG.  Some people have heart rhythm problems that only occur during certain activities, such as sleep or physical exertion. Using a Holter or event monitor increases the chance of recording these problems.
Although similar, Holter and event monitors are not the same. A Holter monitor records heart's electrical activity the entire time you're wearing it. This is best used to detect silent rhythm disturbances. . An event monitor only records your heart's electrical activity at certain times while you're wearing it so it is best used for “non silent” events because it is triggered only when the patient senses that something is wrong. The cardiologists can see if the heart rhythm is what is causing the unusual awareness of the heart beat.

One of the most significant developments of the last decade in ultrasound imaging of the heart was the evolution of 3-dimensional (3D) imaging from slow and labor-intense offline reconstruction to real-time volumetric imaging. This imaging modality provides valuable clinical information that empowers echocardiographers with new levels of confidence in the diagnosis of heart disease. The development of real-time 3D echocardiographic imaging and its major advantages over conventional 2-dimensional echocardiography were recognized at Coastal Cardiac Imaging in 2006 and the preliminary testing in this office supported the routine use of this new methodology in select patients in clinical practice.1 Since 2006, the growing availability of this  technology, its ease of use, and its multiple attractive features have sparked significant interest in the research community, resulting in a large number of publications, most of which have endorsed real time  3D  imaging for clinical use by demonstrating its unique capabilities in different scenarios. In parallel, the clinical acceptance of this new tool has broadened significantly. The spectacular imaging of the heart at the bedside led to miniaturization and development of esophageal probes that could be easily slid down the esophagus during anesthesia. The most recent clinically significant addition is matrix-array transesophageal echocardiography which provides images of unprecedented quality that aid surgeons and interventional cardiologists in planning and guiding procedures and evaluating their outcomes.

Two-dimensional echocardiography has become the procedure of choice for examining the status of the left ventricle, with direct real-time visualization of endocardial motion and wall thickening . The most commonly used parameter of systolic function from two-dimensional echocardiography is the ejection fraction (EF), which is now routinely requested from all echocardiographic studies and is used by the clinical cardiologist for diagnosis, prognosis, and to determine therapy. However, the EF itself has major limitations as a measurement of the status of the contractile properties of the left ventricle. The measurement itself is subject to error whether using a subjective visual estimate or quantitative analysis, the latter assuming that an accurate tracing of endocardial borders can be obtained. Also, EF is a global assessment of left ventricular performance and does not take into consideration regional contractile dysfunction, which is commonly seen in patients with coronary artery disease and primary myocardial disease.

At Coastal Cardiac Imaging we were aware of the limitation of this measure of contractility  so in 2008 working with Norwegian cardiologists we began to use a new method to measure both left and right ventricular function using a measurement of myocardial strain.    Heart “strain" is a dimensionless quantity that represented the percent change in dimension from a resting state to one achieved following application of a force.  Therefore, strain is the relative deformation of tissue from an applied force. Thus, negative strain would indicate compression or shortening; conversely, positive strain implies lengthening or expansion. Strain rate is the shortening velocity per fiber length and thus may be substituted for instantaneous force velocity length relations that are used to define the local contractile state in the basic muscle physiology.
Using this technique we have been able to measure longitudinal ventricular contractility and rotation torsion using either Doppler or tissue tracking in nearly all patients.  This allows the early detection of right heart dysfunction as well as early signs of cardiac dysfunction such as those seen as a complication of cancer chemotherapy.   These techniques are applied to all comprehensive echocardiograms performed here.

An ABI or Ankle-Brachial Index tests how good the large vessels that head down towards the foot are carrying the blood supply to the feet.   Cardiologists tend to take the blood pressure in both arms when seeing a patient.  Using this technique the patient's blood pressure is taken at each arm AND at each ankle, and the ratios are compared.  People with poor circulation in the vessels that head towards the foot will have altered ABI's.    For example, an ABI of .96 or above is normal.  An ABI of .31 to .95 will have pain with activity.   An ABI of .25-.3 will have pain at rest.  And an ABI under .3 will have a tendency towards gangrene. The test is done at the bedside, does not require specific preparation and can be part of a routine office visit.