Chest pain may be a symptom of coronary heart disease, but a procedure known as cardiac catheterization is the best way to know for sure.
When catheterization reveals that a problem does exist, the next step is very often a procedure known as angioplasty, often involving a stent.
So what do these terms mean? Who is a candidate? And what is recovery like? These are important questions, since coronary heart disease is the No. 1 cause of death for both men and women in the U.S.
Here to explain it all is George J. Saviano, MD, an interventional cardiologist with Saint Peter’s Healthcare System in New Brunswick, New Jersey.
Selected Podcast
Cardiac Catheterization: Best Test for Heart Disease
Featured Speaker:
For more information about Saint Peter’s Healthcare System
George J. Saviano, MD
George J. Saviano, MD, is an interventional cardiologist with Saint Peter’s Healthcare System in New Brunswick, New Jersey. Dr. Saviano, a graduate of New York Medical College, owns the distinction of having performed the first cardiac stent in his part of New Jersey. And Dr. Saviano was a leader in expanding the use of low-risk catheterization.For more information about Saint Peter’s Healthcare System
Transcription:
Cardiac Catheterization: Best Test for Heart Disease
Bill Klaproth (Host): Coronary heart disease is the number one cause of death for both men and women in the US and chest pain maybe a symptom of coronary heart disease, but a procedure known as cardiac catheterization is the best way to know for sure. Here to explain it to us is Georgie Saviano, MD, an interventional cardiologist with Saint Peter’s Health Care System in New Brunswick, New Jersey. Dr. Saviano, thanks so much for being out with us today. So let’s jump right in, what is coronary heart disease and what are its causes?
Dr. Georgie Saviano (Guest): Okay. To begin with, I don't like the term “coronary heart disease” because blockages in the coronary arteries, which most people refer to as coronary heart disease, is no more unnatural than greying of the hair or wrinkling of the skin. It’s part of aging. No one gets through life without some element of blockage in the coronary arteries. The real issue is sometimes the blockages occur young and they’re substantial and actually jeopardize blood flow to the heart, so physicians and patients like to call it coronary heart disease, but it is natural in the population and the goal is to slow it down and recognize it.
Bill: So the build-up of plaque as you age is normal. All we need to worry about it is if it starts to happen really young and too fast and too much. Is that correct?
Dr. Saviano: Exactly right.
Bill: Okay. So when you look at this, how do you determine somebody has coronary heart disease or somebody doesn’t have coronary heart disease? How do you make that determination?
Dr. Saviano: Okay, well, it’s pretty straightforward. The reason why patients walk into my office, a cardiologist’s office, there are two major categories: they either have chest pain, they have some chest pain which either they or their referring doctor think might be coronary artery blockage—I’m going to use the term coronary artery disease which everyone else does—but either they recognized pain or their referring physician recognizes the pain, or simply they feel that they have a high likelihood of having coronary artery blockage. Why do they get that feeling? They go to their primary physician and their primary physician might tell them, “You have high cholesterol; your father had it, you have hypertension, you smoked.” There are generally five well-recognized risk factors, so a lot of people—I don’t call them patients yet—who have a lot of these risk factors either they or their referring physician get concerned. The five risk factors that are proven to be associated with the rapid build-up of blockage is hypertension, diabetes, high cholesterol, smoking and, of course, the family history. So those are the two paths why patients walk to the door: pain or the risk factors. Now, to talk about the pain, everyone gets chest pain. I don’t know anybody that I’ve ever met that never told me that they had chest pain. It could be a muscle ache or pain, they could have exercised too much the day before, it could be gastric reflux, esophageal reflux, and you don’t know for sure. But the pattern that one looks for, the pattern that I look for, is related to exertion. If there is a discomfort—either pain, pressure, squeezing—that occurs with exertion predictably and goes away with rest, that is the sine qua non, so to speak, of angina. Angina is chest pain that is due to coronary artery disease.
Bill: And where does this pain; this squeezing happen? I love the way you describe that, because you are saying, yes, chest pain – well, what that does mean? I love that you said it comes on with exertion, but where is the squeezing – in the centre of the chest, the whole upper body? What should we look out for?
Dr. Saviano: Okay. What the textbooks will tell you is, it begins in the chest and it radiates to the left shoulder and down the left arm. Rarely do you see a textbook case. Very often, it could be just in the chest. It could radiate to both shoulders. It could radiate to the right arm. It could be felt in the jaw or teeth as well. It’s not the quality is important. If patients say the word “squeezing” or if they say “tightening,” the red flag goes up, but more important to me is what the inciting action, which is either emotional or physical stress.
Bill: Okay. Now when you see those symptoms, does that always mean somebody is having a heart attack or has coronary artery disease?
Dr. Saviano: No, absolutely not. We get fooled many times because in the population, people watch television, they listen to their neighbour’s friends, they were doctors, and they’re sort of pre-programmed to think in terms of chest pain and the arm. Sometimes patients will come in with pain that’s obviously a muscle strain. It’s in their left arm, but it’s not exertional, and if they move their arm, it hurts. That’s definitely not chest pain due to coronary artery disease.
Bill: Okay, so if we determine somebody has coronary artery disease and you need to go and treat it. Let’s talk about cardiac catheterization. Is that the same thing as angioplasty?
Dr. Saviano: No. A catheter is a tube, so cardiac catheterization has to be done before taking pictures which is called coronary angiography, before fixing a vessel which is called coronary angioplasty, that’s inflating a balloon. It has to be done before coronary stenting and it has to be done before coronary atherectomy where you remove plaque. So cardiac catheterization just means you put a catheter from the groin or the arm and locate the tip in the coronary artery and inject dye – that’s angiography. So if the catheter is used and coronary angiography is done and then the determination is made, does anything need to be done about blockages?
Bill: So cardiac catheterization is the first step before. You are determining whether or not somebody needs angioplasty or a stent.
Dr. Saviano: Exactly. It really goes back before. I don’t know how much time we have, but I could tell you that if you think of this in terms of flow, this is how I like to think of it. The first step is usually you listen to symptoms and look at risk factors, but don’t go into cardiac catheterization right away. You look for evidence. When you walk into the room, if your patient is going to do a cardiac catheterization you want to be pretty sure it’s there. You don’t want to subject them to that risk. So generally before cardiac catheterization, stress testing with perfusion imaging is done. The way I can liken it to make people understand it is if they’re going to buy a house they go into the house and open up faucets and they look at the water pressure. They look at what the flow is like, and if there is a bathroom or a kitchen, they turn on the faucet, it’s trickling out, there’s low pressure, low flow, then there’s a good likelihood that they have a problem with the pipe leading to that faucet. Then they call a plumber who goes down and dismantles and looks at the pipe. Well, the flow information is got in the doctor’s office from stress testing with perfusion imaging. We look at how the flow goes to various areas of the heart, and if we see an abnormality, if that bathroom, the trickle is slow, then we go in and do some plumbing.
Bill: So, hence, the cardiac catheterization then.
Dr. Saviano: Yeah, catheterization follows.
Bill: Are there any risk factors involved in this?
Dr. Saviano: Yes, there are. The risk factors are numerous, but they are fortunately rare. The risk factors stem from actually having to enter a blood vessel, so that blood vessel naturally can be damaged. You insert a catheter—let’s use the groin for example—you can damage the blood vessel and there could be some local bleeding in the groin area where you are doing the catheterization. That’s a minor problem. Then these catheters actually have to be threaded up and around the arch of the aorta right to the arteries that lead to the heart. Now you have to go past the blood vessels to the head and neck and the brain, so any kind of damage or clot coming from these catheters can embolize and go and cause a stroke, or if any clot is caused, it can go anywhere in the body and cause damage where ever it may go. When you inject dye into a coronary artery, the heart knows that this is not blood, that this is something different, and it might react unfavourably with a bad rhythm. So there could be life-threatening rhythms that are set up and that could result in passing out or even death. Of course, when you are working on the arteries, they could be disrupted and cause a heart attack. So, death is generally about one in a thousand. That’s why we never want to put a patient on the table without a very good reason to put that patient on the table. We have to be reasonably convinced that we’re going to find something to fix because we don’t want to subject them to catheterization without a pretty good indication that we’re going to find the problem.
Bill: And I’m sure you have procedures that minimize risk as well when doing the procedure?
Dr. Saviano: Absolutely. The way the catheters are inserted, a very soft guide wire is passed up into the vessels and the catheter is passed over the guide wire, and that minimizes trauma to the vessel. The other thing that we do before a patient ever goes in for catheterization is we draw what’s called pre-admission blood testing. We want to make sure that they are not anemic. We want to make sure they don’t have any kidney disease, because the dye we use in imaging the coronary arteries can be toxic to the kidneys. So I always check that very carefully and actually have a nephrologist, a kidney specialist, see my patient to help manage his fluids with the catheterization to minimize this risk. The patient’s heart is monitored throughout the entire procedure, pacemakers are available in the room –there are a multitude of things that we do to maintain safety.
Bill: And in our final minute here, Dr. Saviano, is there a type of post-operative care patients should undertake to minimize future problems?
Dr. Saviano: Sure. Immediately when they leave, they should walk easily on their leg. They shouldn’t bend too much on the groin because that can cause cause bleeding. Now cases are done through the arm or even the wrist, and that minimizes it even further. That’s the short-term risk. And then the long-term risk, of course, whether or not we find blockage, we tell them all: Treat diabetes, hypertension and high cholesterol, avoid smoking. Of course, they can’t change their family history, but live a healthy life basically.
Bill: Terrific. Dr. Saviano, thank you so much for spending time with us today. We really appreciate it. And for more information on cardiac catheterization, please visit saintpetershcs.com. This is Saint Peter’s Better Health Update. Thanks for listening.
Cardiac Catheterization: Best Test for Heart Disease
Bill Klaproth (Host): Coronary heart disease is the number one cause of death for both men and women in the US and chest pain maybe a symptom of coronary heart disease, but a procedure known as cardiac catheterization is the best way to know for sure. Here to explain it to us is Georgie Saviano, MD, an interventional cardiologist with Saint Peter’s Health Care System in New Brunswick, New Jersey. Dr. Saviano, thanks so much for being out with us today. So let’s jump right in, what is coronary heart disease and what are its causes?
Dr. Georgie Saviano (Guest): Okay. To begin with, I don't like the term “coronary heart disease” because blockages in the coronary arteries, which most people refer to as coronary heart disease, is no more unnatural than greying of the hair or wrinkling of the skin. It’s part of aging. No one gets through life without some element of blockage in the coronary arteries. The real issue is sometimes the blockages occur young and they’re substantial and actually jeopardize blood flow to the heart, so physicians and patients like to call it coronary heart disease, but it is natural in the population and the goal is to slow it down and recognize it.
Bill: So the build-up of plaque as you age is normal. All we need to worry about it is if it starts to happen really young and too fast and too much. Is that correct?
Dr. Saviano: Exactly right.
Bill: Okay. So when you look at this, how do you determine somebody has coronary heart disease or somebody doesn’t have coronary heart disease? How do you make that determination?
Dr. Saviano: Okay, well, it’s pretty straightforward. The reason why patients walk into my office, a cardiologist’s office, there are two major categories: they either have chest pain, they have some chest pain which either they or their referring doctor think might be coronary artery blockage—I’m going to use the term coronary artery disease which everyone else does—but either they recognized pain or their referring physician recognizes the pain, or simply they feel that they have a high likelihood of having coronary artery blockage. Why do they get that feeling? They go to their primary physician and their primary physician might tell them, “You have high cholesterol; your father had it, you have hypertension, you smoked.” There are generally five well-recognized risk factors, so a lot of people—I don’t call them patients yet—who have a lot of these risk factors either they or their referring physician get concerned. The five risk factors that are proven to be associated with the rapid build-up of blockage is hypertension, diabetes, high cholesterol, smoking and, of course, the family history. So those are the two paths why patients walk to the door: pain or the risk factors. Now, to talk about the pain, everyone gets chest pain. I don’t know anybody that I’ve ever met that never told me that they had chest pain. It could be a muscle ache or pain, they could have exercised too much the day before, it could be gastric reflux, esophageal reflux, and you don’t know for sure. But the pattern that one looks for, the pattern that I look for, is related to exertion. If there is a discomfort—either pain, pressure, squeezing—that occurs with exertion predictably and goes away with rest, that is the sine qua non, so to speak, of angina. Angina is chest pain that is due to coronary artery disease.
Bill: And where does this pain; this squeezing happen? I love the way you describe that, because you are saying, yes, chest pain – well, what that does mean? I love that you said it comes on with exertion, but where is the squeezing – in the centre of the chest, the whole upper body? What should we look out for?
Dr. Saviano: Okay. What the textbooks will tell you is, it begins in the chest and it radiates to the left shoulder and down the left arm. Rarely do you see a textbook case. Very often, it could be just in the chest. It could radiate to both shoulders. It could radiate to the right arm. It could be felt in the jaw or teeth as well. It’s not the quality is important. If patients say the word “squeezing” or if they say “tightening,” the red flag goes up, but more important to me is what the inciting action, which is either emotional or physical stress.
Bill: Okay. Now when you see those symptoms, does that always mean somebody is having a heart attack or has coronary artery disease?
Dr. Saviano: No, absolutely not. We get fooled many times because in the population, people watch television, they listen to their neighbour’s friends, they were doctors, and they’re sort of pre-programmed to think in terms of chest pain and the arm. Sometimes patients will come in with pain that’s obviously a muscle strain. It’s in their left arm, but it’s not exertional, and if they move their arm, it hurts. That’s definitely not chest pain due to coronary artery disease.
Bill: Okay, so if we determine somebody has coronary artery disease and you need to go and treat it. Let’s talk about cardiac catheterization. Is that the same thing as angioplasty?
Dr. Saviano: No. A catheter is a tube, so cardiac catheterization has to be done before taking pictures which is called coronary angiography, before fixing a vessel which is called coronary angioplasty, that’s inflating a balloon. It has to be done before coronary stenting and it has to be done before coronary atherectomy where you remove plaque. So cardiac catheterization just means you put a catheter from the groin or the arm and locate the tip in the coronary artery and inject dye – that’s angiography. So if the catheter is used and coronary angiography is done and then the determination is made, does anything need to be done about blockages?
Bill: So cardiac catheterization is the first step before. You are determining whether or not somebody needs angioplasty or a stent.
Dr. Saviano: Exactly. It really goes back before. I don’t know how much time we have, but I could tell you that if you think of this in terms of flow, this is how I like to think of it. The first step is usually you listen to symptoms and look at risk factors, but don’t go into cardiac catheterization right away. You look for evidence. When you walk into the room, if your patient is going to do a cardiac catheterization you want to be pretty sure it’s there. You don’t want to subject them to that risk. So generally before cardiac catheterization, stress testing with perfusion imaging is done. The way I can liken it to make people understand it is if they’re going to buy a house they go into the house and open up faucets and they look at the water pressure. They look at what the flow is like, and if there is a bathroom or a kitchen, they turn on the faucet, it’s trickling out, there’s low pressure, low flow, then there’s a good likelihood that they have a problem with the pipe leading to that faucet. Then they call a plumber who goes down and dismantles and looks at the pipe. Well, the flow information is got in the doctor’s office from stress testing with perfusion imaging. We look at how the flow goes to various areas of the heart, and if we see an abnormality, if that bathroom, the trickle is slow, then we go in and do some plumbing.
Bill: So, hence, the cardiac catheterization then.
Dr. Saviano: Yeah, catheterization follows.
Bill: Are there any risk factors involved in this?
Dr. Saviano: Yes, there are. The risk factors are numerous, but they are fortunately rare. The risk factors stem from actually having to enter a blood vessel, so that blood vessel naturally can be damaged. You insert a catheter—let’s use the groin for example—you can damage the blood vessel and there could be some local bleeding in the groin area where you are doing the catheterization. That’s a minor problem. Then these catheters actually have to be threaded up and around the arch of the aorta right to the arteries that lead to the heart. Now you have to go past the blood vessels to the head and neck and the brain, so any kind of damage or clot coming from these catheters can embolize and go and cause a stroke, or if any clot is caused, it can go anywhere in the body and cause damage where ever it may go. When you inject dye into a coronary artery, the heart knows that this is not blood, that this is something different, and it might react unfavourably with a bad rhythm. So there could be life-threatening rhythms that are set up and that could result in passing out or even death. Of course, when you are working on the arteries, they could be disrupted and cause a heart attack. So, death is generally about one in a thousand. That’s why we never want to put a patient on the table without a very good reason to put that patient on the table. We have to be reasonably convinced that we’re going to find something to fix because we don’t want to subject them to catheterization without a pretty good indication that we’re going to find the problem.
Bill: And I’m sure you have procedures that minimize risk as well when doing the procedure?
Dr. Saviano: Absolutely. The way the catheters are inserted, a very soft guide wire is passed up into the vessels and the catheter is passed over the guide wire, and that minimizes trauma to the vessel. The other thing that we do before a patient ever goes in for catheterization is we draw what’s called pre-admission blood testing. We want to make sure that they are not anemic. We want to make sure they don’t have any kidney disease, because the dye we use in imaging the coronary arteries can be toxic to the kidneys. So I always check that very carefully and actually have a nephrologist, a kidney specialist, see my patient to help manage his fluids with the catheterization to minimize this risk. The patient’s heart is monitored throughout the entire procedure, pacemakers are available in the room –there are a multitude of things that we do to maintain safety.
Bill: And in our final minute here, Dr. Saviano, is there a type of post-operative care patients should undertake to minimize future problems?
Dr. Saviano: Sure. Immediately when they leave, they should walk easily on their leg. They shouldn’t bend too much on the groin because that can cause cause bleeding. Now cases are done through the arm or even the wrist, and that minimizes it even further. That’s the short-term risk. And then the long-term risk, of course, whether or not we find blockage, we tell them all: Treat diabetes, hypertension and high cholesterol, avoid smoking. Of course, they can’t change their family history, but live a healthy life basically.
Bill: Terrific. Dr. Saviano, thank you so much for spending time with us today. We really appreciate it. And for more information on cardiac catheterization, please visit saintpetershcs.com. This is Saint Peter’s Better Health Update. Thanks for listening.