What Is the Heart?

Your heart is a muscular organ that acts like a pump to send blood throughout your body all the time. Your heart is at the center of your circulatory system, which delivers blood to all areas of your body. An electrical system regulates the heart and uses electrical signals to contract the hearts walls. When the walls contract, blood is pumped into your circulatory system. Your circulatory system is made up of a network of blood vessels, such as arteries, veins, and capillaries. The vessels in this network carry blood to and from all areas of your body. A system of inlet and outlet valves in your hearts chambers works to ensure that blood flows in the right direction. Your heart is vital to your health and nearly everything that goes on in your body. Without the hearts pumping action, blood cant circulate within your body. Your blood carries the oxygen and nutrients that your organs need to function normally. Blood also carries carbon dioxide, a waste product, to your lungs to be passed out of your body and into the air. A healthy heart supplies the areas of your body with the right amount of blood at the right rate needed to function normally. If disease or injury weakens your heart, your bodys organs wont receive enough blood to function normally.

Anatomy of the Heart

Your heart is located under the ribcage in the center of your chest between your right and left lung. Its shaped like an upside-down pear. Its muscular walls beat, or contract, pumping blood continuously to all parts of your body. The size of your heart can vary depending on your age, size, or the condition of your heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger. The Exterior of the Heart Below is a picture of the outside of a normal, healthy, human heart.

Heart Exterior

The illustration shows the front surface of the heart, including the coronary arteries and major blood vessels. The heart is the muscle in the lower half of the picture. The heart has four chambers. The right and left atria (AY-tree-uh) are shown in purple. The right and left ventricles (VEN-trihkuls) are shown in red. Connected to the heart are some of the main blood vesselsarteries and veinsthat make up your blood circulatory system. The ventricle on the right side of your heart pumps blood from the heart to your lungs. When you breathe air in, oxygen passes from your lungs through blood vessels where its added to your blood. Carbon dioxide, a waste product, is passed from your blood through blood vessels to your lungs and is removed from your body when you breathe air out. The atrium on the left side of your heart receives oxygen-rich blood from the lungs. The pumping action of your left ventricle sends this oxygen-rich blood through the aorta (a main artery) to the rest of your body. The Right Side of Your Heart The superior and inferior vena cavae are in blue to the left of the muscle as you look at the picture. These veins are the largest veins in your body. They carry used (oxygen-poor) blood to the right atrium of your heart. Used blood has had its oxygen removed and used by your bodys organs and tissues. The superior vena cava carries used blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries used blood from the lower parts of your body.

The used blood from the vena cavae flows into your hearts right atrium and then on to the right ventricle. From the right ventricle, the used blood is pumped through the pulmonary (PULL-mun-ary) arteries (in blue in the center of picture) to your lungs. Here, through many small, thin blood vessels called capillaries, your blood picks up oxygen needed by all the areas of your body. The oxygen-rich blood passes from your lungs back to your heart through the pulmonary veins (in red to the left of the right atrium in the picture). The Left Side of Your Heart Oxygen-rich blood from your lungs passes through the pulmonary veins (in red to the right of the left atrium in the picture). It enters the left atrium and is pumped into the left ventricle. From the left ventricle, your blood is pumped to the rest of your body through the aorta. Like all of your organs, your heart needs blood rich with oxygen. This oxygen is supplied through the coronary arteries as its pumped out of your hearts left ventricle. Your coronary arteries are located on your hearts surface at the beginning of the aorta. Your coronary arteries (shown in red in the drawing) carry oxygen-rich blood to all parts of your heart. The Interior of the Heart Below is a picture of the inside of a normal, healthy, human heart. Heart Interior

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which low-oxygen blood flows from the body to the lungs. The

red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body. The Septum The right and left sides of your heart are divided by an internal wall of tissue called the septum. The area of the septum that divides the two upper chambers (atria) of your heart is called the atrial or interatrial septum. The area of the septum that divides the two lower chambers (ventricles) of your heart is called the ventricular or interventricular septum. Heart Chambers The picture shows the inside of your heart and how its divided into four chambers. The two upper chambers of your heart are called atria. The atria receive and collect blood. The two lower chambers of your heart are called ventricles. The ventricles pump blood out of your heart into the circulatory system to other parts of your body. Heart Valves The picture shows your hearts four valves. Shown counterclockwise in the picture, the valves include the aortic (ay-OR-tik) valve, the tricuspid (tri-CUSS-pid) valve, the pulmonary valve, and the mitral (MI-trul) valve. Blood Flow The arrows in the drawing show the direction that blood flows through your heart. The light blue arrows show that blood enters the right atrium of your heart from the superior and inferior vena cavae. From the right atrium, blood is pumped into the right ventricle. From the right ventricle, blood is pumped to your lungs through the pulmonary arteries. The light red arrows show the oxygen-rich blood coming in from your lungs through the pulmonary veins into your hearts left atrium. From the left atrium, the blood is pumped into the left ventricle, where its pumped to the rest of your body through the aorta. For the heart to function properly, your blood flows in only one direction. Your hearts valves make this possible. Both of your hearts ventricles has an in (inlet) valve from the atria and an out (outlet) valve leading to your arteries. Healthy valves open and close in very exact coordination with the pumping action of your hearts atria and ventricles. Each valve has a set of flaps called leaflets or cusps, which seal or open the valves. This allows pumped blood to pass through the chambers and into your arteries without backing up or flowing backward.

Heart Contraction and Blood Flow

The animation below shows how your heart pumps blood. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame of the animation. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how blood flows through the heart as it contracts and relaxes. Heartbeat Almost everyone has heard the real or recorded sound of a heartbeat. When your heart beats, it makes a "lub-DUB" sound. Between the time you hear "lub" and "DUB," blood is pumped through your heart and circulatory system.

A heartbeat may seem like a simple event repeated over and over. A heartbeat actually is a complicated series of very precise and coordinated events that take place inside and around your heart. Each side of your heart uses an inlet valve to help move blood between the atrium and ventricle. The tricuspid valve does this between the right atrium and ventricle. The mitral valve does this between the left atrium and ventricle. The "lub" is the sound of the mitral and tricuspid valves closing. Each of your hearts ventricles has an outlet valve. The right ventricle uses the pulmonary valve to help move blood into the pulmonary arteries. The left ventricle uses the aortic valve to do the same for the aorta. The "DUB" is the sound of the aortic and pulmonary valves closing. Each heartbeat has two basic parts: diastole (di-AS-toe-lee, or relaxation) and atrial and ventricular systole (SIS-toe-lee, or contraction). During diastole, the atria and ventricles of your heart relax and begin to fill with blood. At the end of diastole, your hearts atria contract (an event called atrial systole) and pump blood into the ventricles. The atria then begin to relax. Next, your hearts ventricles contract (an event called ventricular systole) and pump blood out of your heart. Pumping Action Your heart uses the four valves to ensure your blood flows only in one direction. Healthy valves open and close in coordination with the pumping action of your hearts atria and ventricles. Each valve has a set of flaps called leaflets or cusps. These seal or open the valves. This allows pumped blood to pass through the chambers and into your blood vessels without backing up or flowing backward. Blood without oxygen from the two vena cavae fill your hearts right atrium. The atrium contracts (atrial systole). The tricuspid valve located between the right atrium and ventricle opens for a short time and then shuts. This allows blood to enter into the right ventricle without flowing back into the right atrium. When your hearts right ventricle fills with blood, it contracts (ventricular systole). The pulmonary valve located between your right ventricle and pulmonary artery opens and closes quickly. This allows blood to enter into your pulmonary artery without flowing back into the right ventricle. This is important because the right ventricle begins to refill with more blood through the tricuspid valve. Blood travels through the pulmonary arteries to your lungs to pick up oxygen. Oxygen-rich blood returns from the lungs to your hearts left atrium through the pulmonary veins. As your hearts left atrium fills with blood, it contracts. This event also is called atrial systole. The mitral valve located between the left atrium and left ventricle opens and closes quickly. This allows blood to pass from the left atrium into the left ventricle without flowing back into the left atrium. As the left ventricle fills with blood, it contracts. This event also is called ventricular systole. The aortic valve located between the left ventricle and aorta opens and closes quickly. This

allows blood to flow into the aorta. The aorta is the main artery that carries blood from your heart to the rest of your body. The aortic valve closes quickly to prevent blood from flowing back into the left ventricle, which is already filling up with new blood.

Circulation and Blood Vessels

Your heart and blood vessels make up your overall blood circulatory system. Your overall blood circulatory system is made up of four subsystems. Arterial Circulation Arterial circulation is that part of your overall blood circulatory system that involves arteries, like the aorta and pulmonary arteries. Arteries are blood vessels that carry blood away from your heart. Healthy arteries are strong and elastic. They become narrow between beats of the heart, and they help keep your blood pressure consistent. This helps blood circulate efficiently through your body. Arteries branch into smaller blood vessels called arterioles. Arteries and arterioles have strong, flexible walls that allow them to adjust the amount and rate of blood flowing to different parts of your body. Venous Circulation Venous circulation is the part of your overall blood circulatory system that involves veins, like the vena cavae and pulmonary veins. Veins are blood vessels that carry blood to your heart. Veins have thinner walls than arteries. Veins can increase in width as the amount of blood passing through them increases. Capillary Circulation Capillary circulation is the part of your circulatory system where oxygen, nutrients, and waste pass between your blood and parts of your body. Capillaries connect the arterial and venous circulatory subsystems. Capillaries are very small blood vessels. The importance of capillaries lies in their very thin walls. Unlike arteries and veins, capillary walls are thin enough that oxygen and nutrients in your blood can pass through the walls to the parts of your body that need them to function normally. Capillaries' thin walls also allow waste products like carbon dioxide to pass from your body's organs and tissues into the blood where it's taken away to your lungs. Pulmonary Circulation Pulmonary circulation is the movement of blood from the heart to the lungs and back to the heart again. Pulmonary circulation includes both arterial and venous circulation.

Blood without oxygen is pumped to the lungs from the heart (arterial circulation). Oxygen-rich blood moves from the lungs to the heart through the pulmonary veins (venous circulation). Pulmonary circulation also includes capillary circulation. Oxygen you breathe in from the air passes through your lungs into your blood through the many capillaries in the lungs. Oxygenrich blood moves through your pulmonary veins to the left side of your heart and out the aorta to the rest of your body. Capillaries in the lungs also remove carbon dioxide from your blood so that your lungs can breathe the carbon dioxide out into the air.

Your Hearts Electrical System

The animation below shows how your heart's electrical system works. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame of the animation. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how the heart's internal electrical conduction system causes the heart to pump blood. Your hearts electrical system controls all the events that occur when your heart pumps blood. The electrical system also is called the cardiac conduction system. If youve ever seen

the heart test called an EKG (electrocardiogram), youve seen a graphical picture of the electrical activity of your heart. Your hearts electrical system is made up of three main parts:

The sinoatrial (SA) node located in the right atrium of your heart The atrioventricular (AV) node located on the interatrial septum close to the tricuspid valve The His-Purkinje system located along the walls of your hearts ventricles

A heartbeat is a complicated series of events that take place in your heart. A heartbeat is a single cycle in which your hearts chambers relax and contract to pump blood. This cycle includes the opening and closing of the two inlet and outlet valves of the right and left ventricles of your heart. Each heartbeat has two basic parts: diastole, and atrial and ventricular systole. During diastole, the atria and ventricles of your heart relax and begin to fill with blood. At the end of diastole, your hearts atria contract (atrial systole), pumping blood into the ventricles, and then begin to relax. Your hearts ventricles then contract (ventricular systole), pumping blood out of your heart. Each beat of your heart is set in motion by an electrical signal from within your heart muscle. In a normal, healthy heart, each beat begins with a signal from the SA node. This is why the SA node is sometimes called your hearts natural pacemaker. Your pulse, or heart rate, is the number of signals the SA node produces per minute. The signal is generated as the two vena cavae fill your hearts right atrium with blood from other parts of your body. The signal spreads across the cells of your hearts right and left atria. This signal causes the atria to contract. This action pushes blood through the open valves from the atria into both ventricles. The signal arrives at the AV node near the ventricles (see red burst on picture), where it slows for an instant to allow your hearts right and left ventricles to fill with blood. The signal is released and moves to the His bundle located in the walls of your hearts ventricles. From the His bundle, the signal fibers divide into left and right bundle branches through the Purkinje fibers that connect directly to the cells in the walls of your hearts left and right ventricles (see yellow on the picture). As the signal spreads across the cells of your hearts ventricle walls, both ventricles contract, but not at exactly the same moment. The left ventricle contracts an instant before the right ventricle. This pushes blood through the pulmonary valve (for the right ventricle) to your lungs, and through the aortic valve (for the left ventricle) to the rest of your body. As the signal passes, the walls of the ventricles relax and await the next signal. This process continues over and over as the atria refill with blood and other electrical signals come from the SA node.

Heart Disease
Your heart is made up of many parts working together to pump blood. In a healthy heart, all the parts work well so that your heart pumps blood normally. Then all parts of your body that depend on the heart to deliver blood also stay healthy. Heart disease can disrupt a heart's normal electrical system and pumping functions. Diseases and conditions of the heart's muscle make it difficult for your heart to pump blood normally. Damaged or diseased blood vessels make the heart work harder than normal. Problems with the heart's electrical system, called arrhythmias, can make it difficult for the heart to pump blood efficiently. The National Heart, Lung, and Blood Institute's Diseases and Conditions Index has information on the most common diseases and conditions of the heart.

What Is Coronary Artery Disease?

Coronary artery disease (CAD) is a condition in which plaque (plak) builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. Plaque is made up of fat, cholesterol (ko-LES-ter-ol), calcium, and other substances found in the blood. When plaque builds up in the arteries, the condition is called atherosclerosis (ATH-er-o-skler-O-sis).

Atherosclerosis

Figure A shows a normal artery with normal blood flow. Figure B shows an artery with plaque buildup. Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow. Overview When your coronary arteries are narrowed or blocked, oxygen-rich blood can't reach your heart muscle. This can cause angina (an-JI-nuh or AN-juh-nuh) or a heart attack. Angina is chest pain or discomfort that occurs when not enough oxygen-rich blood is flowing to an area of your heart muscle. Angina may feel like pressure or squeezing in your chest. The pain also may occur in your shoulders, arms, neck, jaw, or back. A heart attack occurs when blood flow to an area of your heart muscle is completely blocked. This prevents oxygen-rich blood from reaching that area of heart muscle and causes it to die. Without quick treatment, a heart attack can lead to serious problems and even death.

Over time, CAD can weaken the heart muscle and lead to heart failure and arrhythmias (ahRITH-me-ahs). Heart failure is a condition in which your heart can't pump enough blood throughout your body. Arrhythmias are problems with the speed or rhythm of your heartbeat. Outlook CAD is the most common type of heart disease. It's the leading cause of death in the United States for both men and women. Lifestyle changes, medicines, and/or medical procedures can effectively prevent or treat CAD in most people.

Other Names for Coronary Artery Disease

Atherosclerosis Coronary heart disease Hardening of the arteries Heart disease Ischemic (is-KE-mik) heart disease Narrowing of the arteries

What Causes Coronary Artery Disease?

Research suggests that coronary artery disease (CAD) starts when certain factors damage the inner layers of the coronary arteries. These factors include:

Smoking High amounts of certain fats and cholesterol in the blood High blood pressure High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Excess fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged. Over time, the plaque may crack. Blood cells called platelets (PLATE-lets) clump together to form blood clots where the cracks are. This narrows the arteries more and worsens angina or causes a heart attack. The buildup of plaque in the coronary arteries may start in childhood. Over time, this buildup can narrow or completely block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle.

Who Is At Risk for Coronary Artery Disease?

Coronary artery disease (CAD) is the leading cause of death in the United States for both men and women. Each year, more than half a million Americans die from CAD.

Certain traits, conditions, or habits may raise your chance of developing CAD. These conditions are known as risk factors. You can control most risk factors and help prevent or delay CAD. Other risk factors can't be controlled.

Major Risk Factors

Many factors raise the risk of developing CAD. The more risk factors you have, the greater chance you have of developing CAD.

Unhealthy blood cholesterol levels. This includes high LDL cholesterol (sometimes called bad cholesterol) and low HDL cholesterol (sometimes called good cholesterol). High blood pressure. Blood pressure is considered high if it stays at or above 140/90 mmHg over a period of time. Smoking. This can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn't allow enough oxygen to reach the body's tissues. Insulin resistance. This condition occurs when the body can't use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it's used. Diabetes. This is a disease in which the body's blood sugar level is high because the body doesn't make enough insulin or doesn't use its insulin properly. Overweight or obesity. Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat. Metabolic syndrome. Metabolic syndrome is the name for a group of risk factors linked to overweight and obesity that raise your chance for heart disease and other health problems, such as diabetes and stroke. Lack of physical activity. Lack of activity can worsen other risk factors for CAD. Age. As you get older, your risk for CAD increases. Genetic or lifestyle factors cause plaque to build in your arteries as you age. By the time you're middle-aged or older, enough plaque has built up to cause signs or symptoms.
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In men, the risk for CAD increases after age 45. In women, the risk for CAD risk increases after age 55.

Family history of early heart disease. Your risk increases if your father or a brother was diagnosed with CAD before 55 years of age, or if your mother or a sister was diagnosed with CAD before 65 years of age.

Although age and a family history of early heart disease are risk factors, it doesn't mean that you will develop CAD if you have one or both. Making lifestyle changes and/or taking medicines to treat other risk factors can often lessen genetic influences and prevent CAD from developing, even in older adults.

Emerging Risk Factors

Scientists continue to study other possible risk factors for CAD. High levels of a protein called C-reactive protein (CRP) in the blood may raise the risk for CAD and heart attack. High levels of CRP are proof of inflammation in the body. Inflammation is the body's response to injury or infection. Damage to the arteries' inner walls seems to trigger inflammation and help plaque grow. Research is under way to find out whether reducing inflammation and lowering CRP levels also can reduce the risk of developing CAD and having a heart attack. High levels of fats called triglycerides in the blood also may raise the risk of CAD, particularly in women.

Other Factors That Affect Coronary Artery Disease

Other factors also may contribute to CAD. These include:

Sleep apnea. Sleep apnea is a disorder in which your breathing stops or gets very shallow while you're sleeping. Untreated sleep apnea can raise your chances of having high blood pressure, diabetes, and even a heart attack or stroke. Stress. Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Alcohol. Heavy drinking can damage the heart muscle and worsen other risk factors for heart disease. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day.

What Are the Signs and Symptoms of Coronary Artery Disease?

A common symptom of coronary artery disease (CAD) is angina. Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get worse with activity and go away when you rest. Emotional stress also can trigger the pain. Another common symptom of CAD is shortness of breath. This symptom happens if CAD causes heart failure. When you have heart failure, your heart can't pump enough blood throughout your body. Fluid builds up in your lungs, making it hard to breathe. The severity of these symptoms varies. The symptoms may get more severe as the buildup of plaque continues to narrow the coronary arteries. Signs and Symptoms of Heart Problems Linked to Coronary Artery Disease Some people who have CAD have no signs or symptoms. This is called silent CAD. It may not be diagnosed until a person show signs and symptoms of a heart attack, heart failure, or an arrhythmia (an irregular heartbeat).

Heart Attack A heart attack happens when an area of plaque in a coronary artery breaks apart, causing a blood clot to form. The blood clot cuts off most or all blood to the part of the heart muscle that's fed by that artery. Cells in the heart muscle die because they don't receive enough oxygen-rich blood. This can cause lasting damage to your heart. For more information, see the animation in "What Causes a Heart Attack?" Heart With Muscle Damage and a Blocked Artery

Figure A is an overview of a heart and coronary artery showing damage (dead heart muscle) caused by a heart attack. Figure B is a cross-section of the coronary artery with plaque buildup and a blood clot. The most common symptom of heart attack is chest pain or discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. The discomfort can feel like pressure, squeezing, fullness, or pain. It can be mild or severe. Heart attack pain can sometimes feel like indigestion or heartburn. Heart attacks also can cause upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath or fatigue (tiredness) often may occur with or before chest discomfort. Other symptoms of heart attack are nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, and breaking out in a cold sweat.

Heart Failure Heart failure is a condition in which your heart can't pump enough blood to your body. Heart failure doesn't mean that your heart has stopped or is about to stop working. It means that your heart can't fill with enough blood or pump with enough force, or both. This causes you to have shortness of breath and fatigue that tends to increase with activity. Heart failure also can cause swelling in your feet, ankles, legs, and abdomen. Arrhythmia An arrhythmia is a problem with the speed or rhythm of the heartbeat. When you have an arrhythmia, you may notice that your heart is skipping beats or beating too fast. Some people describe arrhythmias as a fluttering feeling in their chests. These feelings are called palpitations. Some arrhythmias can cause your heart to suddenly stop beating. This condition is called sudden cardiac arrest (SCA). SCA can make you faint and it can cause death if its not treated right away. For more information, see the animations in "Types of Arrhythmia."

How Is Coronary Artery Disease Diagnosed?

Your doctor will diagnose coronary artery disease (CAD) based on:

Your medical and family histories Your risk factors The results of a physical exam and diagnostic tests and procedures

Diagnostic Tests and Procedures No single test can diagnose CAD. If your doctor thinks you have CAD, he or she will probably do one or more of the following tests. EKG (Electrocardiogram) An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack.

Stress Testing During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate. When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:

Abnormal changes in your heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in your heart rhythm or your heart's electrical activity

During the stress test, if you can't exercise for as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness). Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it's working hard and when it's at rest. These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats. Echocardiography This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow. Chest X Ray A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure, as well as lung disorders and other causes of symptoms that aren't due to CAD. Blood Tests Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for CAD.

Electron-Beam Computed Tomography Your doctor may recommend electron-beam computed tomography (EBCT). This test finds and measures calcium deposits (called calcifications) in and around the coronary arteries. The more calcium detected, the more likely you are to have CAD. EBCT isn't used routinely to diagnose CAD, because its accuracy isn't yet known. Coronary Angiography and Cardiac Catheterization Your doctor may ask you to have coronary angiography (an-jee-OG-ra-fee) if other tests or factors show that you're likely to have CAD. This test uses dye and special x rays to show the insides of your coronary arteries. To get the dye into your coronary arteries, your doctor will use a procedure called cardiac catheterization (KATH-e-ter-i-ZA-shun). A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. The tube is then threaded into your coronary arteries, and the dye is released into your bloodstream. Special x rays are taken while the dye is flowing through your coronary arteries. Cardiac catheterization is usually done in a hospital. You're awake during the procedure. It usually causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter.

How Is Coronary Artery Disease Treated?

Treatment for coronary artery disease (CAD) may include lifestyle changes, medicines, and medical procedures. The goals of treatments are to:

Relieve symptoms Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque Lower the risk of blood clots forming, which can cause a heart attack Widen or bypass clogged arteries Prevent complications of CAD

Lifestyle Changes Making lifestyle changes can often help prevent or treat CAD. For some people, these changes may be the only treatment needed:

Follow a heart healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you. Lose weight, if you're overweight or obese. Quit smoking, if you smoke. Avoid exposure to secondhand smoke.

Learn to cope with and reduce stress.

Follow a Heart Healthy Eating Plan For a heart healthy eating plan, go to the National Heart, Lung, and Blood Institute's (NHLBI's) Aim for a Healthy Weight Web site. This site provides practical tips on healthy eating, physical activity, and controlling your weight.

Therapeutic Lifestyle Changes (TLC).

Your doctor may recommend TLC if you have high cholesterol. TLC is a three-part program that includes a healthy diet, physical activity, and weight management. With the TLC diet, less than 7 percent of your daily calories should come from saturated fat. This kind of fat is mainly found in meat and poultry, including dairy products. No more than 25 to 35 percent of your daily calories should come from all fats, including saturated, trans, monounsaturated, and polyunsaturated fats. You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label. Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

Whole grain cereals such as oatmeal and oat bran Fruits such as apples, bananas, oranges, pears, and prunes Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber. Fish are an important part of a heart healthy diet. They're a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (canned or fresh), and mackerel. You also should try to limit the amount of sodium (salt) that you eat. This means choosing low-sodium and low-salt foods and "no added salt" foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item. Try to limit alcoholic drinks. Too much alcohol will raise your blood pressure and triglyceride level. (Triglycerides are a type of fat found in the blood.) Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two alcoholic drinks a day. Women should have no more than one alcoholic drink a day. See the NHLBI's "Your Guide to Lowering Your Cholesterol With TLC" for more information.

Dietary Approaches to Stop Hypertension (DASH) eating plan.

Your doctor may recommend the DASH eating plan if you have high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in salt/sodium. This eating plan is low in fat and cholesterol. It also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meat (including lean red meat), sweets, added sugars, and sugar-containing beverages. It's rich in nutrients, protein, and fiber. The DASH eating plan is a good heart healthy eating plan, even for those who don't have high blood pressure. See the NHLBI's "Your Guide to Lowering Your Blood Pressure With DASH" for more information. Increase Physical Activity Regular physical activity can lower many CAD risk factors, including LDL ("bad") cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol (the "good" cholesterol that helps prevent CAD). Check with your doctor about how much and what kinds of physical activity are safe for you. Unless your doctor tells you otherwise, try to get at least 30 minutes of moderate-intensity activity on most or all days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each. Moderate-intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning. More intense activities, such as jogging, swimming, and various sports, also may be appropriate for shorter periods. See the NHLBI's "Your Guide to Physical Activity and Your Heart" for more information. Maintain a Healthy Weight Maintaining a healthy weight can decrease risk factors for CAD. If you're overweight, aim to reduce your weight by 7 to 10 percent during your first year of treatment. This amount of weight loss can lower your risk for CAD and other health problems. After the first year, you may have to continue to lose weight so you can lower your body mass index (BMI) to less than 25. BMI measures your weight in relation to your height and gives an estimate of your total body fat. A BMI between 25 and 29 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing and treating CAD.

You can calculate your BMI using the NHLBI's online calculator, or your health care provider can calculate your BMI. For more information on losing weight and maintaining your weight, see the Diseases and Conditions Index Overweight and Obesity article. Quit Smoking If you smoke or use tobacco, quit. Smoking can damage and tighten blood vessels and raise your risk for CAD. The U.S. Department of Health and Human Services has information on how to quit smoking. Reduce Stress Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Also, some of the ways people cope with stress, such as drinking, smoking, or overeating, aren't heart healthy. Physical activity can help relieve stress and reduce other CAD risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress. Medicines You may need medicines to treat CAD if lifestyle changes aren't enough. Medicines can:

Decrease the workload on your heart and relieve CAD symptoms Decrease your chance of having a heart attack or dying suddenly Lower your cholesterol and blood pressure Prevent blood clots Prevent or delay the need for a special procedure (for example, angioplasty or coronary artery bypass grafting (CABG))

Medicines used to treat CAD include anticoagulants (AN-te-ko-AG-u-lants), aspirin and other antiplatelet (an-ty-PLAYT-lit) medicines, ACE inhibitors, beta blockers, calcium channel blockers, nitroglycerin, glycoprotein IIb-IIIa, statins, and fish oil and other supplements high in omega-3 fatty acids. Medical Procedures You may need a medical procedure to treat CAD. Both angioplasty and CABG are used as treatments. Angioplasty opens blocked or narrowed coronary arteries. During angioplasty, a thin tube with a balloon or other device on the end is threaded through a blood vessel to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque outward against the wall of the artery. This widens the artery and restores the flow of blood.

Angioplasty can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure. In CABG, arteries or veins from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. You and your doctor can discuss which treatment is right for you. Cardiac Rehabilitation Your doctor may prescribe cardiac rehabilitation (rehab) for angina or after CABG, angioplasty, or a heart attack. Cardiac rehab, when combined with medicine and surgical treatments, can help you recover faster, feel better, and develop a healthier lifestyle. Almost everyone with CAD can benefit from cardiac rehab. The cardiac rehab team may include doctors, nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists. Rehab has two parts:

Exercise training. This part helps you learn how to exercise safely, strengthen your muscles, and improve your stamina. Your exercise plan will be based on your individual abilities, needs, and interests. Education, counseling, and training. This part of rehab helps you understand your heart condition and find ways to reduce your risk for future heart problems. The cardiac rehab team will help you learn how to cope with the stress of adjusting to a new lifestyle and with your fears about the future.

For more information on cardiac rehab, see the Diseases and Conditions Index Cardiac Rehabilitation article.

How Can Coronary Artery Disease Be Prevented or Delayed?

Taking action to control your risk factors can help prevent or delay coronary artery disease (CAD). Your chance of developing CAD goes up with the number of risk factors you have. Making lifestyle changes and taking prescribed medicines are important steps. See "How Is Coronary Artery Disease Treated?" for information on heart healthy eating plans, physical activity, maintaining a healthy weight, and medicines. Know your family history of health problems related to CAD. If you or someone in your family has CAD, be sure to tell your doctor. Also, let your doctor know if you smoke.

Living With Coronary Artery Disease

Coronary artery disease (CAD) can cause serious complications. However, if you follow your doctor's advice and change your habits, you can prevent or reduce the chances of:

Dying suddenly from heart problems Having a heart attack and permanently damaging your heart muscle Damaging your heart because of reduced oxygen supply Having arrhythmias (irregular heartbeats)

Ongoing Health Care Needs

Doing physical activity regularly, taking prescribed medicines, following a heart healthy eating plan, and watching your weight can help control CAD. (See "How Is Coronary Artery Disease Treated?" for more information). See your doctor regularly to keep track of your blood pressure and blood cholesterol and blood sugar levels. A cholesterol blood test will show your levels of LDL ("bad") cholesterol, HDL ("good") cholesterol, and triglycerides. A fasting blood glucose test will check your blood sugar level and show if you're at risk for or have diabetes. These tests will show whether you need more treatments for your CAD. Talk to your doctor about how often you should schedule office visits or blood tests. Between those visits, call your doctor if you develop any new symptoms or if your symptoms worsen. CAD raises your risk for heart attack. Learn the symptoms of heart attack and arrhythmia. Call 911 if you have any of these symptoms for more than 5 minutes:

Chest discomfort or painuncomfortable pressure, squeezing, fullness, or pain in the center of the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back. Upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath, which may occur with or before chest discomfort.

It's important to know the difference between angina and a heart attack. During a heart attack, the pain is usually more severe than angina, and it doesn't go away when you rest or take medicine. If you don't know whether your chest pain is angina or a heart attack, call 9 11. Let the people you see regularly know you're at risk for a heart attack. They can seek emergency care if you suddenly faint, collapse, or develop other severe symptoms. You may feel depressed or anxious if you've been diagnosed with CAD and/or had a heart attack. You may worry about heart problems or making lifestyle changes that are necessary for your health. Your doctor may recommend medicine, professional counseling, or relaxation therapy if you have depression or anxiety.

Physical activity can improve mental well-being, but you should talk to your doctor before starting any fitness activities. It's important to treat any anxiety or depression that develops because it raises your risk of having a heart attack.

What To Expect During Coronary Angioplasty

Coronary angioplasty is performed in a special part of the hospital called the cardiac catheterization (kath-eh-ter-ih-ZA-shun) laboratory. The "cath lab" has special video screens and x-ray machines. Your doctor uses this equipment to see enlarged pictures of the blocked areas in your coronary arteries.

Preparation
In the cath lab, you will lie on a table. An intravenous (IV) line will be placed in your arm to give you fluids and medicines. The medicines will relax you and prevent blood clots from forming. These medicines may make you feel sleepy or as though you're floating or numb. To prepare for the procedure:

The area where the catheter will be inserted, usually the arm or groin (upper thigh), will be shaved. The shaved area will be cleaned to make it germ free and then numbed. The numbing medicine may sting as it's going in.

Steps in Angioplasty
When you're comfortable, the doctor will begin the procedure. You will be awake but sleepy. A small cut is made in your arm or groin into which a tube called a sheath is put. The doctor then threads a very thin guide wire through the artery in your arm or groin toward the area of the coronary artery that's blocked. Your doctor puts a long, thin, flexible tube called a catheter through the sheath and slides it over the guide wire and up to the heart. Your doctor moves the catheter into the coronary artery to the blockage. He or she takes out the guide wire once the catheter is in the right spot. A small amount of dye may be injected through the catheter into the bloodstream to help show the blockage on x ray. This x-ray picture of the heart is called an angiogram. Next, your doctor slides a tube with a small deflated balloon inside it through the catheter and into the coronary artery where the blockage is.

When the tube reaches the blockage, the balloon is inflated. The balloon pushes the plaque against the wall of the artery and widens it. This helps to increase the flow of blood to the heart. The balloon is then deflated. Sometimes the balloon is inflated and deflated more than once to widen the artery. Afterward, the balloon and tube are removed. In some cases, plaque is removed during angioplasty. A catheter with a rotating shaver on its tip is inserted into the artery to cut away hard plaque. Lasers also may be used to dissolve or break up the plaque. The animation below shows the process of coronary angioplasty. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how a doctor inserts a tube called a balloon catheter into a coronary artery narrowed by plaque. The balloon catheter compresses the plaque and widens the artery to restore blood flow. If your doctor needs to put a stent (small mesh tube) in your artery, another tube with a balloon will be threaded through your artery. A stent is wrapped around the balloon. Your doctor will inflate the balloon, which will cause the stent to expand against the wall of the artery. The balloon is then deflated and pulled out of the artery with the tube. The stent stays in the artery. After the angioplasty is done, your doctor pulls back the catheter and removes it and the sheath. The hole in the artery is either sealed with a special device, or pressure is put on it until the blood vessel seals. The animation below shows the process of coronary angioplasty and stent placement. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how a doctor inserts a tube called a balloon catheter into a coronary artery narrowed by plaque. The balloon catheter compresses the plaque, widens the artery, and restores blood flow. Through the catheter, a stent is placed in the artery to help maintain the restored blood flow. During angioplasty, strong antiplatelet medicines are given through the IV to prevent blood clots from forming in the artery or on the stent. These medicines help thin your blood. They're usually started just before the angioplasty and may continue for 1224 hours afterward.

What To Expect After Coronary Angioplasty

After coronary angioplasty, you will be moved to a special care unit, where you will stay for a few hours or overnight. While you recover in this area, you must lie still for a few hours to allow the blood vessels in your arm or groin (upper thigh) to seal completely. While you recover, nurses will check your heart rate and blood pressure. They also will check your arm or groin for bleeding. After a few hours, you will be able to walk with help. The place where the tube was inserted may feel sore or tender for about a week. Going Home Most people go home 1 to 2 days after the procedure. When your doctor thinks you're ready to leave the hospital, you will get instructions to follow at home, including:

How much activity or exercise you can do. When you should follow up with your doctor. What medicines you should take.

What you should look for daily when checking for signs of infection around the area where the tube was inserted. Signs of infection may include redness, swelling, or drainage. When you should call your doctor. For example, you may need to call if you have a fever or signs of infection, pain or bleeding where the catheter was inserted, or shortness of breath. When you should call 911 (for example, if you have any chest pain).

Your doctor will prescribe medicine to prevent blood clots from forming. Taking your medicine as directed is very important. If a stent was inserted, the medicine reduces the risk that blood clots will form in the stent. Blood clots in the stent can block blood flow and cause a heart attack. Recovery and Recuperation Most people recover from angioplasty and return to work about 1 week after being sent home. Your doctor will want to check your progress after you leave the hospital. During the followup visit, your doctor will examine you, make changes to your medicines if needed, do any necessary tests, and check your overall recovery. Use this time to ask questions you may have about activities, medicines, or lifestyle changes, or to talk about any other issues that concern you. Lifestyle Changes Although angioplasty can reduce the symptoms of coronary artery disease (CAD), it isn't a cure for CAD or the risk factors that led to it. Making healthy lifestyle changes can help treat CAD and maintain the good results from angioplasty. Talk with your doctor about your risk factors for CAD and the lifestyle changes you'll need to make. For some people, these changes may be the only treatment needed.

Follow a healthy diet to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight. Quit smoking if you smoke. Be physically active. Lose weight if you're overweight or obese. Reduce stress. Take medicines as your doctor directs to lower high blood pressure or high blood cholesterol.

"Your Guide to Living Well With Heart Disease," from the National Heart, Lung, and Blood Institute, will give you more detailed information about making healthy lifestyle changes.

Cardiac Rehabilitation Your doctor may want you to take part in a cardiac rehabilitation (rehab) program. Cardiac rehab helps people with heart disease recover faster and return to work or daily activities. Cardiac rehab includes supervised physical activity, education on heart healthy living, and counseling to cut down on stress and help you return to an active life. Your doctor can tell you where to find a cardiac rehab program near your home. "Your Guide to Living Well With Heart Disease," will give you more information on cardiac rehab.

What Are the Risks of Coronary Angioplasty?

Coronary angioplasty is a common medical procedure. Although angioplasty is normally safe, there is a small risk of serious complications, such as:

Bleeding from the blood vessel where the catheter was placed. Damage to blood vessels from the catheter. An allergic reaction to the dye given during the angioplasty. An arrhythmia (irregular heartbeat). The need for emergency coronary artery bypass grafting during the procedure (24 percent of people). This may occur when an artery closes down, instead of opening up. Damage to the kidneys caused by the dye used. Heart attack (35 percent of people). Stroke (less than 1 percent of people).

As with any procedure involving the heart, complications can sometimes, though rarely, cause death. Less than 2 percent of people die during angioplasty. Sometimes chest pain can occur during angioplasty because the balloon briefly blocks off the blood supply to the heart. The risk of complications is higher in:

People aged 75 and older People who have kidney disease or diabetes Women People who have poor pumping function in their hearts People who have extensive heart disease and blockages

Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people. Complications From Stents

Restenosis There is a chance that the artery will become narrowed or blocked again in time, often within 6 months of angioplasty. This is called restenosis. Stent Restenosis

The illustration shows the restenosis of a stent-widened coronary artery. The coronary artery is located on the surface of the heart. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, the plaque grows (over time) through and around the stent, causing a partial blockage and abnormal blood flow. The inset image on figure B shows a cross-section of the growth of the plaque around the stent. When a stent isn't used, 4 out of 10 people have restenosis. When a nonmedicine-coated stent is used, 2 out of 10 people have restenosis. The growth of scar tissue in and around the stent also can cause restenosis. Medicinecoated stents reduce the growth of scar tissue around the stent and lower the chance of

restenosis. When medicine-coated stents are used, the chance of restenosis is lowered even more, to around 1 in 10 people. Other treatments, such as radiation, can help prevent tissue growth within a stent. For this procedure, the doctor puts a wire through a catheter to where the stent is placed. The wire releases radiation to stop any tissue growth that may block the artery. Blood Clots Recent studies suggest that there is a higher risk of blood clots forming in medicine-coated stents compared to bare metal stents (nonmedicine-coated). The Food and Drug Administration (FDA) reports that medicine-coated stents usually don't cause complications due to blood clots when used as recommended. When medicine-coated stents are used in people with advanced CAD, there is a higher risk of blood clots, heart attack, and death. The FDA is working with researchers to study medicine-coated stents, including their use in people with advanced CAD. Taking medicine as prescribed by your doctor can lower the risk of blood clots. People with medicine-coated stents are usually advised to take an anticlotting drug, such as clopidogrel and aspirin, for months to years to lower the risk of blood clots. As with all procedures, it's important to talk to your doctor about your treatment options, including the risks and benefits to you.

Key Points

Coronary angioplasty is a medical procedure in which a balloon is used to open a blockage in a coronary (heart) artery narrowed by atherosclerosis. This procedure improves blood flow to the heart. Atherosclerosis is a condition in which a material called plaque builds up on the inner walls of the arteries. When atherosclerosis affects the coronary arteries, the condition is called coronary artery disease (CAD). Angioplasty can improve some of the symptoms of CAD, such as angina (chest pain) and shortness of breath. It also can reduce damage to the heart muscle from a heart attack and reduce the risk of death in some patients. You may need angioplasty if medicines and lifestyle changes haven't improved your symptoms of CAD. You also may need angioplasty as emergency treatment during a heart attack. Angioplasty is less invasive than surgery. General anesthesia isn't needed. You will be given medicines to help you relax, but you will be awake during the procedure. Angioplasty is performed in a special part of the hospital called the cardiac catheterization laboratory. Before angioplasty is done, your doctor will need to know whether your coronary arteries are blocked. To find out, he or she will do an angiogram and take an x-ray

picture of your arteries to show any blockages and where they're located. Once your doctor has this information, the angioplasty can proceed.

During angioplasty, your doctor will use a small tube called a catheter with a balloon at the end. He or she will thread the balloon through an artery to the blockage. The balloon is blown up (inflated), pushing the plaque outward against the artery wall. This opens the artery more and improves blood flow through it. During angioplasty, a stent (mesh tube) is often placed in the artery that has been opened. The stent reduces the chance that the artery will become blocked again in the future. The stent remains in place after the procedure. Most people go home 1 to 2 days after having angioplasty. Full recovery from the procedure is usually 1 week or less. Lifestyles changes are recommended after angioplasty to improve CAD and to prevent the arteries from becoming narrowed or blocked again. Lifestyle changes include a healthy diet, weight control, medicines to lower high blood pressure and high blood cholesterol, regular physical activity, and quitting smoking. Angioplasty is a common medical procedure and is generally safe, but there is a small risk of serious complications. Renarrowing of the treated artery and growth of scar tissue within a stent can occur. The use of medicine-coated stents can lower the chance of this happening, but these stents aren't without risk. In some cases, blood clots can form in the medicine-coated stents. Research on angioplasty is ongoing to make it safer and more effective, to prevent treated arteries from closing again, and to make the procedure an option for more people.

What Is a Heart Attack?

A heart attack occurs when blood flow to a section of heart muscle becomes blocked. If the flow of blood isnt restored quickly, the section of heart muscle becomes damaged from lack of oxygen and begins to die. Heart attack is a leading killer of both men and women in the United States. But fortunately, today there are excellent treatments for heart attack that can save lives and prevent disabilities. Treatment is most effective when started within 1 hour of the beginning of symptoms. If you think you or someone youre with is having a heart attack, call 911 right away. Overview Heart attacks occur most often as a result of a condition called coronary artery disease (CAD). In CAD, a fatty material called plaque (plak) builds up over many years on the inside walls of the coronary arteries (the arteries that supply blood and oxygen to your heart). Eventually, an area of plaque can rupture, causing a blood clot to form on the surface of the plaque. If the clot becomes large enough, it can mostly or completely block the flow of oxygen-rich blood to the part of the heart muscle fed by the artery.

Heart With Muscle Damage and a Blocked Artery

Figure A is an overview of a heart and coronary artery showing damage (dead heart muscle) caused by a heart attack. Figure B is a cross-section of the coronary artery with plaque buildup and a blood clot. During a heart attack, if the blockage in the coronary artery isnt treated quickly, the heart muscle will begin to die and be replaced by scar tissue. This heart damage may not be obvious, or it may cause severe or long-lasting problems. Severe problems linked to heart attack can include heart failure and life-threatening arrhythmias (irregular heartbeats). Heart failure is a condition in which the heart cant pump enough blood throughout the body. Ventricular fibrillation is a serious arrhythmia that can cause death if not treated quickly. Get Help Quickly Acting fast at the first sign of heart attack symptoms can save your life and limit damage to your heart. Treatment is most effective when started within 1 hour of the beginning of symptoms. The most common heart attack signs and symptoms are:

Chest discomfort or painuncomfortable pressure, squeezing, fullness, or pain in the center of the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back. Upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath may occur with or before chest discomfort.

Other signs include nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, or breaking out in a cold sweat.

If you think you or someone you know may be having a heart attack:

Call 911 within a few minutes5 at the mostof the start of symptoms. If your symptoms stop completely in less than 5 minutes, still call your doctor. Only take an ambulance to the hospital. Going in a private car can delay treatment. Take a nitroglycerin pill if your doctor has prescribed this type of medicine. Put an aspirin under your tongue. Aspirin reduces blood clotting and can help keep a heart attack from getting worse. But dont delay calling 911 to take an aspirin.

Outlook Each year, about 1.1 million people in the United States have heart attacks, and almost half of them die. CAD, which often results in a heart attack, is the leading killer of both men and women in the United States. Many more people could recover from heart attacks if they got help faster. Of the people who die from heart attacks, about half die within an hour of the first symptoms and before they reach the hospital. May 2007

Other Names for a Heart Attack

Myocardial infarction or MI Acute myocardial infarction or AMI Acute coronary syndrome Coronary thrombosis Coronary occlusion

What Causes a Heart Attack?

Most heart attacks occur as a result of coronary artery disease (CAD). CAD is the buildup over time of a material called plaque on the inner walls of the coronary arteries. Eventually, a section of plaque can break open, causing a blood clot to form at the site. A heart attack occurs if the clot becomes large enough to cut off most or all of the blood flow through the artery.

Coronary Artery With Plaque Buildup

The illustration shows a normal artery with normal blood flow (figure A) and an artery containing plaque buildup (figure B). The blocked blood flow prevents oxygen-rich blood from reaching the part of the heart muscle fed by the artery. The lack of oxygen damages the heart muscle. If the blockage isnt treated quickly, the damaged heart muscle begins to die. Heart attack also can occur due to problems with the very small, microscopic blood vessels of the heart. This condition is called microvascular disease. Its believed to be more common in women than in men. Another less common cause of heart attack is a severe spasm (tightening) of a coronary artery that cuts off blood flow through the artery. These spasms can occur in coronary arteries that dont have CAD. Its not always clear what causes a coronary artery spasm, but sometimes it can be related to:

Taking certain drugs, such as cocaine Emotional stress or pain Exposure to extreme cold Cigarette smoking

The animation below shows how a heart attack occurs. Click the start button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

Who Is At Risk for a Heart Attack?

Certain risk factors make it more likely that you will develop coronary artery disease (CAD) and have a heart attack. Some risk factors for heart attack can be controlled, while others can't.

Major risk factors for heart attack that you can control include:

Smoking High blood pressure High blood cholesterol Overweight and obesity Physical inactivity Diabetes (high blood sugar)

Risk factors that you can't change include:

Age. Risk increases for men older than 45 years and for women older than 55 years (or after menopause). Family history of early CAD. Your risk increases if your father or a brother was diagnosed with CAD before 55 years of age, or if your mother or a sister was diagnosed with CAD before 65 years of age.

Certain CAD risk factors tend to occur together. When they do, its called metabolic syndrome. In general, a person with metabolic syndrome is twice as likely to develop heart disease and five times as likely to develop diabetes as someone without metabolic syndrome.

What Are the Signs and Symptoms of a Heart Attack?

Not all heart attacks begin with a sudden, crushing pain that is often shown on TV or in the movies. The warning signs and symptoms of a heart attack arent the same for everyone. Many heart attacks start slowly as mild pain or discomfort. Some people dont have symptoms at all (this is called a silent heart attack).

Chest Pain or Discomfort

The most common symptom of heart attack is chest pain or discomfort. Most heart attacks involve discomfort in the center of the chest that lasts for more than a few minutes or goes away and comes back. The discomfort can feel like uncomfortable pressure, squeezing, fullness, or pain. It can be mild or severe. Heart attack pain can sometimes feel like indigestion or heartburn. The symptoms of angina can be similar to the symptoms of a heart attack. Angina is pain in the chest that occurs in people with coronary artery disease, usually when theyre active. Angina pain usually lasts for only a few minutes and goes away with rest. Angina that doesnt go away or that changes from its usual pattern (occurs more frequently or occurs at rest) can be a sign of the beginning of a heart attack and should be checked by a doctor right away.

Other Common Signs and Symptoms

Other common signs and symptoms that a person can have during a heart attack include:

Upper body discomfort in one or both arms, the back, neck, jaw, or stomach Shortness of breath may often occur with or before chest discomfort Nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, or breaking out in a cold sweat

Not everyone having a heart attack experiences the typical symptoms. If youve already had a heart attack, your symptoms may not be the same for another one. The more signs and symptoms you have, the more likely it is that youre having a heart attack.

Act Fast
Sometimes the signs and symptoms of a heart attack happen suddenly, but they can also develop slowly, over hours, days, and even weeks before a heart attack occurs. Know the warning signs of a heart attack so you can act fast to get treatment for yourself or someone else. The sooner you get emergency help, the less damage there will be to your heart. Call 911 for help within 5 minutes if you think you may be having a heart attack or if your chest pain doesnt go away as it usually does when you take prescribed medicine. Dont drive yourself or anyone else to the hospital. Call an ambulance so that medical personnel can begin life-saving treatment on the way to the emergency room.

How Is a Heart Attack Diagnosed?

The diagnosis of heart attack is based on your symptoms, your personal and family medical history, and the results of diagnostic tests. EKG (Electrocardiogram) This test detects and records the electrical activity of the heart. Certain changes in the appearance of the electrical waves on an EKG are strong evidence of a heart attack. An EKG also can show if youre having arrhythmias (abnormal heartbeats), which a heart attack (and other conditions) can cause. Blood Tests During a heart attack, heart muscle cells die and burst open, letting certain proteins out in the bloodstream. Blood tests can measure the amount of these proteins in the bloodstream. Higher than normal levels of these proteins in the bloodstream is evidence of a heart attack. Commonly used blood tests include troponin tests, CK or CKMB tests, and serum myoglobin tests. Blood tests are often repeated to check for changes over time.

Coronary Angiography Coronary angiography is a special x-ray exam of the heart and blood vessels. It's often done during a heart attack to help pinpoint blockages in the coronary arteries. The doctor passes a catheter (a thin, flexible tube) through an artery in your arm or groin (upper thigh) and threads it to your heart. This procedurecalled cardiac catheterizationis part of coronary angiography. A dye that can be seen on x ray is injected into the bloodstream through the tip of the catheter. The dye lets the doctor study the flow of blood through the heart and blood vessels. If a blockage is found, another procedure, called angioplasty, may be used to restore blood flow through the artery. Sometimes during angioplasty, the doctor will place a stent (a small mesh tube) in the artery to help keep the artery open.

How Is a Heart Attack Treated?

Early treatment can prevent or limit damage to the heart muscle. Acting fast, at the first symptoms of heart attack, can save your life. Medical personnel can begin diagnosis and treatment even before you get to the hospital. Certain treatments are usually started right away if a heart attack is suspected, even before the diagnosis is confirmed. These include:

Oxygen Aspirin to prevent further blood clotting Nitroglycerin, to reduce the workload on the heart and improve blood flow through the coronary arteries Treatment for chest pain

Once the diagnosis of heart attack is confirmed or strongly suspected, treatments to try to restore blood flow to the heart are started as soon as possible. Treatments include medicines and medical procedures. Medicines A number of different kinds of medicines may be used to treat heart attack. They include the following. Thrombolytic Medicines These medicines (also called clot busters) are used to dissolve blood clots that are blocking the coronary arteries. To be most effective, these medicines must be given within 1 hour after the start of heart attack symptoms.

Beta Blockers These medicines decrease the workload on your heart. Beta blockers also are used to relieve chest pain or discomfort and to help prevent additional heart attacks. Beta blockers also are used to correct arrhythmias (irregular heartbeats). Angiotensin-Converting Enzyme (ACE) Inhibitors These medicines lower blood pressure and reduce the strain on your heart. They also help slow down further weakening of the heart muscle. Anticoagulants These medicines thin the blood and prevent clots from forming in your arteries. Antiplatelet Medicines These medicines (such as aspirin and clopidogrel) stop platelets (a type of blood cell) from clumping together and forming unwanted clots. Other Medicines Medicines may also be given to relieve pain and anxiety, and to treat arrhythmias, which often occur during a heart attack. Medical Procedures If medicines cant stop a heart attack, medical proceduressurgical or nonsurgicalmay be used. These procedures include the following. Angioplasty This nonsurgical procedure can be used to open coronary arteries that are blocked by a blood clot. During angioplasty, a catheter (a thin, flexible tube) with a balloon on the end is threaded through a blood vessel to the blocked coronary artery. Then, the balloon is inflated to push the plaque against the wall of the artery. This widens the inside of the artery, restoring blood flow. During angioplasty, a small mesh tube called a stent may be put in the artery to help keep it open. Some stents are coated with medicines that help prevent the artery from becoming blocked again. Coronary Artery Bypass Grafting Coronary artery bypass grafting is a surgery in which arteries or veins are taken from other areas of your body and sewn in place to bypass (that is, go around) blocked coronary arteries. This provides a new route for blood flow to the heart muscle.

Treatment After You Leave the Hospital Most people spend several days in the hospital after a heart attack. When you leave the hospital, treatment doesnt stop. At home, your treatment may include daily medicines and cardiac rehabilitation (rehab). Your doctor may recommend lifestyle changes, including quitting smoking, losing weight, changing your diet, and increasing your physical activity, to lower your chances of having another heart attack. Cardiac Rehabilitation Your doctor may prescribe cardiac rehab to help you recover from a heart attack and to help prevent another heart attack. Almost everyone who has had a heart attack can benefit from rehab. The heart is a muscle, and the right exercise will strengthen it. But cardiac rehab isnt only about exercise. It also includes education, counseling, and learning about reducing your risk factors. Rehab will help you learn the best way to take care of yourself after having a heart attack and how to prevent having another one. The cardiac rehab team may include doctors (your family doctor, a cardiologist, and/or a surgeon), nurses, exercise specialists, physical and occupational therapists, dietitians, and psychologists or other behavioral therapists. How Can a Heart Attack Be Prevented? Lowering your risk factors for coronary artery disease (CAD) can help you prevent a heart attack. (See "Who Is At Risk for a Heart Attack?") Even if you already have CAD, you can still take steps to lower your risk of heart attack. Reducing the risk of heart attack usually means making healthy lifestyle choices. You also may need treatment for medical conditions that raise your risk. Healthy Lifestyle Choices Healthy lifestyle choices to help prevent heart attack include:

Following a low-fat diet rich in fruits and vegetables. Pay careful attention to the amounts and types of fat in your diet. Lower your salt intake. These changes can help lower high blood pressure and high blood cholesterol. Losing weight if you're overweight or obese. Quitting smoking. Doing physical activity to improve heart fitness. Ask your doctor how much and what kinds of physical activity are safe for you.

Treat Related Conditions In addition to making lifestyle changes, you can help prevent heart attacks by treating conditions you have that make a heart attack more likely:

High blood cholesterol. You may need medicine to lower your cholesterol if diet and exercise aren't enough. High blood pressure. You may need medicine to keep your blood pressure under control. Diabetes (high blood sugar). If you have diabetes, control your blood sugar levels through diet and physical activity (as your doctor recommends). If needed, take medicine as prescribed.

Have an Emergency Action Plan Make sure that you have an emergency action plan in case you or someone else in your family has a heart attack. This is especially important if you're at high risk or have already had a heart attack. Talk with your doctor about the signs and symptoms of heart attack, when you should call 9 11, and steps you can take while waiting for medical help to arrive Life After a Heart Attack Many people survive heart attacks and live active and full lives. If you get help quickly, treatment can limit the damage to your heart muscle. Less heart damage improves your chances for a better quality of life after a heart attack. Medical Followup After a heart attack, you will need treatment for coronary artery disease to prevent another heart attack. Your doctor may recommend:

Lifestyle changes, such as quitting smoking, following a healthy diet, increasing your physical activity, and losing weight, if needed Medicines to control chest pain or discomfort, blood pressure, blood cholesterol, and your hearts workload Participation in a cardiac rehabilitation program

Returning to Normal Activities After a heart attack, most people without chest pain or discomfort or other complications can safely return to most of their normal activities within a few weeks. Most can begin walking immediately. Sexual activity also can begin within a few weeks for most patients. Discuss with your doctor a safe schedule for returning to your normal activities. If allowed by State law, driving can usually begin within a week for most patients who dont have chest pain or discomfort or other complications. Each State has rules about driving a motor vehicle following a serious illness. People with complications shouldnt drive until their symptoms have been stable for a few weeks. Anxiety and Depression After a Heart Attack

After a heart attack, many people worry about having another heart attack. Sometimes they feel depressed and have trouble adjusting to the new lifestyle thats needed to limit further heart trouble. Your doctor may recommend medicine or professional counseling if you have depression or anxiety. Physical activity can improve mental well-being, but you should consult with your doctor before starting any fitness activities. Risk of a Repeat Heart Attack Once youve had a heart attack, youre at higher risk for another one. Its important to know the difference between angina and a heart attack. The pain of angina usually occurs after exertion and goes away in a few minutes when you rest or take medicine as directed. During a heart attack, the pain is usually more severe than angina, and it doesnt go away when you rest or take medicine. If you dont know whether your chest pain is angina or a heart attack, call 911. Remember, the symptoms of a second heart attack may not be the same as those of a first heart attack. Dont take a chance if youre in doubt. Always call 911 within 5 minutes if you or someone youre with has symptoms of a heart attack. Unfortunately, most heart attack victims wait 2 hours or more after their symptoms begin before they seek medical help. This delay can result in lasting heart damage or death. Key Points

A heart attack occurs when blood flow to a section of heart muscle becomes blocked. If the flow of blood isnt restored quickly, the section of heart muscle becomes damaged from lack of oxygen and begins to die. Heart attack is a leading killer of both men and women in the United States. Today there are excellent treatments for heart attack that can save lives and prevent disabilities. Treatment is most effective when started within 1 hour of the beginning of symptoms. Unfortunately, many heart attack victims wait 2 hours or more after their symptoms begin before they seek medical help. This delay can result in lasting heart damage or death. If you think you or someone with you is having a heart attack, call 911 right away. Heart attacks occur most often as a result of a condition called coronary artery disease (CAD). Heart attack also can be caused by a condition called microvascular disease, which involves the microscopic blood vessels of the heart. Less commonly, a spasm (tightening) of a coronary artery can cause a heart attack. Certain risk factors increase the changes of developing CAD and having a heart attack (for example, age, a family history of CAD, smoking, and being overweight or obese). Some risk factors cant be controlled, while others can.

The warning signs of heart attack arent the same for everyone. However, common signs and symptoms of a heart attack are:
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Chest discomfort or painuncomfortable pressure, squeezing, fullness, or pain in the center or the chest that can be mild or strong. This discomfort or pain lasts more than a few minutes or goes away and comes back. Upper body discomfort in one or both arms, the back, neck, jaw, or stomach. Shortness of breath may occur with or before chest discomfort. Other signs include nausea (feeling sick to your stomach), vomiting, lightheadedness or fainting, or breaking out in a cold sweat.

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Treatments for heart attack include medicines and procedures to open blocked arteries (such as angioplasty). Lowering your risk for CAD can decrease your chances of having a heart attack (or second heart attack). This usually involves making healthy lifestyle choices and treating conditions related to CAD such as high cholesterol, high blood pressure, overweight and obesity, and diabetes. Most people are able to return to their normal activities after a heart attack. Ask your doctor when you can resume daily activities such as driving, exercise, work, sexual activity, strenuous activities (for example, running or heavy lifting), and travel. Many people survive heart attacks and live active and full lives.

What Are Congenital Heart Defects?

Congenital (kon-JEN-i-tal) heart defects are problems with the hearts structure that are present at birth. These defects can involve the interior walls of the heart, valves inside the heart, or the arteries and veins that carry blood to the heart or out to the body. Congenital heart defects change the normal flow of blood through the heart. There are many different types of congenital heart defects. They range from simple defects with no symptoms to complex defects with severe, life-threatening symptoms. Congenital heart defects are the most common type of birth defect, affecting 8 of every 1,000 newborns. Each year, more than 35,000 babies in the United States are born with congenital heart defects. Most of these defects are simple conditions that are easily fixed or need no treatment. A small number of babies are born with complex congenital heart defects that need special medical attention soon after birth. Over the past few decades, the diagnosis and treatment of these complex defects has greatly improved. As a result, almost all children with complex heart defects grow to adulthood and can live active, productive lives because their heart defects have been effectively treated.

Most people with complex heart defects continue to need special heart care throughout their lives. They may need to pay special attention to certain issues that their condition could affect, such as health insurance, employment, pregnancy and contraception, and preventing infection during routine health procedures. Today in the United States, about 1 million adults are living with congenital heart defects. How the Heart Works To understand congenital heart defects, its helpful to know how the normal heart works. Your childs heart is a muscle about the size of his or her fist. It works like a pump and beats 100,000 times a day. The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. Then, oxygen-rich blood returns from the lungs to the left side of the heart, and the left side pumps it to the body. The heart has four chambers and four valves and is connected to various blood vessels. Veins are the blood vessels that carry blood from the body to the heart. Arteries are the blood vessels that carry blood away from the heart to the body. A Healthy Heart Cross-Section

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body. Heart Chambers

The heart has four chambers or "rooms."

The atria (AY-tree-uh) are the two upper chambers that collect blood as it comes into the heart. The ventricles (VEN-trih-kuls) are the two lower chambers that pump blood out of the heart to the lungs or other parts of the body.

Heart Valves Four valves control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart.

The tricuspid (tri-CUSS-pid) valve is in the right side of the heart, between the right atrium and the right ventricle. The pulmonary (PULL-mun-ary) valve is in the right side of the heart, between the right ventricle and the entrance to the pulmonary artery, which carries blood to the lungs. The mitral (MI-trul) valve is in the left side of the heart, between the left atrium and the left ventricle. The aortic (ay-OR-tik) valve is in the left side of the heart, between the left ventricle and the entrance to the aorta, the artery that carries blood to the body.

Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries, and then they shut to keep blood from flowing backward. When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope.

The first soundthe lubis made by the mitral and tricuspid valves closing at the beginning of systole (SIS-toe-lee). Systole is when the ventricles contract, or squeeze, and pump blood out of the heart. The second soundthe DUBis made by the aortic and pulmonary valves closing at beginning of diastole (di-AS-toe-lee). Diastole is when the ventricles relax and fill with blood pumped into them by the atria.

Arteries The arteries are major blood vessels connected to your heart.

The pulmonary artery carries blood pumped from the right side of the heart to the lungs to pick up a fresh supply of oxygen. The aorta is the main artery that carries oxygen-rich blood pumped from the left side of the heart out to the body.

The coronary arteries are the other important arteries attached to the heart. They carry oxygen-rich blood from the aorta to the heart muscle, which must have its own blood supply to function.

Veins The veins are also major blood vessels connected to your heart.

The pulmonary veins carry oxygen-rich blood from the lungs to the left side of the heart so it can be pumped out to the body. The vena cava is a large vein that carries oxygen-poor blood from the body back to the heart.

For more information on how a healthy heart works, see the Diseases and Conditions Index article on How the Heart Works. This article contains animations that show how your heart pumps blood and how your hearts electrical system works. Types of Congenital Heart Defects Congenital heart defects change the normal flow of blood through the heart because some part of the heart didnt develop properly before birth. There are many types of congenital heart defects. They include simple ones such as a hole in the interior walls of the heart that allows blood from the left and right sides of the heart to mix, or a narrowed valve that blocks the flow of blood to the lungs or other parts of the body. Other defects are more complex. These include combinations of simple defects, problems with where the blood vessels leading to and from the heart are located, and more serious abnormalities in how the heart develops. Examples of Simple Congenital Heart Defects Holes in the Heart (Septal Defects) The septum is the wall that separates the chambers on the left side of the heart from those on the right. It prevents mixing of blood between the two sides of the heart. Sometimes, a baby is born with a hole in the septum. When that occurs, blood can mix between the two sides of the heart. Atrial septal defect (ASD). An ASD is a hole in the part of the septum that separates the atriathe upper chambers of the heart. This heart defect allows oxygen-rich blood from the left atrium to flow into the right atrium instead of flowing to the left ventricle as it should. Many children who have ASDs have few, if any, symptoms. Normal Heart and Heart With Atrial Septal Defect

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows a heart with an atrial septal defect, which allows oxygen-rich blood from the left atrium to mix with oxygen-poor blood from the right atrium. An ASD can be small or large. Small ASDs allow only a little blood to leak from one atrium to the other. Very small ASDs dont affect the way the heart works and therefore dont need any special treatment. Many small ASDs close on their own as the heart grows during childhood. Medium to large ASDs allow more blood to leak from one atrium to the other, and theyre less likely to close on their own. Half of all ASDs close on their own or are so small that no treatment is needed. Medium to large ASDs that need treatment can usually be repaired using a catheter procedure. (See How Are Congenital Heart Defects Treated?) Ventricular septal defect (VSD). A VSD is a hole in the part of the septum that separates the ventriclesthe lower chambers of the heart. The hole allows oxygen rich blood to flow from the left ventricle into the right ventricle instead of flowing into the aorta and out to the body as it should. Normal Heart and Heart With Ventricular Septal Defect

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows two common locations for a ventricular septal defect. The defect allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood in the right ventricle. A VSD can be small or large. A small VSD doesnt cause problems and may often close on its own. Large VSDs cause the left side of the heart to work too hard and increase blood pressure in the right side of the heart and the lungs because of the extra blood flow. The increased work of the heart can cause heart failure and poor growth. If the hole isnt closed, the high blood pressure in the lungs can cause the delicate arteries in the lungs to scar, a condition called pulmonary arterial hypertension. Open-heart surgery is used to repair VSDs. Narrowed Valves Simple congenital heart defects also can involve the hearts valves, which control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart (the aorta and the pulmonary artery). Valves can have the following types of defects:

Stenosis. This is when the valve doesnt open completely, and the heart has to work harder to pump the blood through the valve. Atresia. This is when the valve doesnt form correctly, so there is no opening for blood to pass through. Regurgitation (re-GUR-ji-TA-shun). This is when the valve doesnt close completely, so blood leaks back through the valve.

The most common valve defect is called pulmonary valve stenosis, which is a narrowing of the pulmonary valve. This valve allows blood to flow from the right ventricle into the pulmonary arteries and out to the lungs to pick up oxygen. Pulmonary valve stenosis can range from mild to severe. Most children with this defect have no signs or symptoms other than a heart murmur. Treatment isnt needed if the stenosis is mild. In a baby with severe pulmonary valve stenosis, the right ventricle can get very overworked trying to pump blood to the pulmonary arteries. Oxygen-poor blood can back up from the right side of the heart into the left side, causing cyanosis. Cyanosis is a bluish tint to the skin, lips, and fingernails. It occurs because the oxygen level in the blood leaving the heart is below normal. Older children with severe pulmonary valve stenosis may have symptoms such as fatigue (tiredness) when exercising. Severe pulmonary valve stenosis is treated with a catheter procedure. Example of a Complex Congenital Heart Defect Complex congenital heart defects need to be repaired with surgery. Because of advances in diagnosis and treatment, doctors can now successfully repair even very complex congenital heart defects. The most common complex heart defect is tetralogy of Fallot (teh-TRALL-o-gee of fall-O), a combination of four defects:

Pulmonary valve stenosis. A large VSD. An overriding aorta. The aorta sits above both the left and right ventricles over the VSD, rather than just over the left ventricle. As a result, oxygen poor blood from the right ventricle can flow directly into the aorta instead of into the pulmonary artery to the lungs. Right ventricular hypertrophy. The muscle of the right ventricle is thicker than usual because of having to work harder than normal.

These defects prevent enough blood from flowing to the lungs to get oxygen, while oxygenpoor blood flows directly out to the body. Normal Heart and Heart With Tetralogy of Fallot

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows a heart with the four defects of tetralogy of Fallot. Babies and children with tetralogy of Fallot have episodes of cyanosis, which can sometimes be severe. In the past, when this condition wasnt treated in infancy, older children would get very tired during exercise and could have fainting spells. Tetralogy of Fallot is now repaired in infancy to prevent these types of symptoms. Tetralogy of Fallot must be repaired with open heart surgery, either soon after birth or later in infancy, depending on how severely the pulmonary artery is narrowed. Children who have had this heart defect repaired need lifelong medical care from a specialist to make sure they stay as healthy as possible. Other Names for Congenital Heart Defects

Congenital heart disease Cyanotic heart disease Heart defects Congenital cardiovascular malformations What Causes Congenital Heart Defects? If you have a child with a congenital heart defect, you may think you did something wrong during your pregnancy to cause the problem. However, most of the time doctors dont know why congenital heart defects develop. Heredity may play a role in some heart defects. For example, a parent who has a congenital heart defect may be more likely than other people to have a child with the condition. In rare cases, more than one child in a family is born with a heart defect. Children with genetic defects often have congenital heart defects. An example of this

is Down syndromehalf of all babies with Down syndrome have congenital heart defects. Scientists continue to search for the causes of congenital heart defects.

What Are the Signs and Symptoms of Congenital Heart Defects? Many congenital heart defects have few or no symptoms. A doctor may not even detect signs of a heart defect during a physical exam. Some heart defects do have symptoms. These depend on the number and type of defects and how severe the defects are. Severe defects can cause symptoms, usually in newborn babies. These symptoms can include:

Rapid breathing Cyanosis (a bluish tint to the skin, lips, and fingernails) Fatigue (tiredness) Poor blood circulation

Congenital heart defects dont cause chest pain or other painful symptoms. Abnormal blood flow through the heart caused by a heart defect will make a certain sound. Your doctor can hear this sound, called a heart murmur, with a stethoscope. However, not all murmurs are a sign of a congenital heart defect. Many healthy children have heart murmurs. Normal growth and development depend on a normal workload for the heart and normal flow of oxygen-rich blood to all parts of the body. Babies with congenital heart defects may have cyanosis or tire easily when feeding. Sometimes they have both problems. As a result, they may not gain weight or grow as they should. Older children may get tired easily or short of breath during exercise or activity. Many types of congenital heart defects cause the heart to work harder than it should. In severe defects, this can lead to heart failure, a condition in which the heart cant pump blood strongly throughout the body. Symptoms of heart failure include:

Fatigue with exercise Shortness of breath A buildup of blood and fluid in the lungs A buildup of fluid in the feet, ankles, and legs

How Are Congenital Heart Defects Diagnosed? Serious congenital heart defects are generally identified during pregnancy or soon after birth. Less severe defects arent diagnosed until children are older. Minor defects often have no symptoms and are diagnosed based on results from a physical exam and special tests done for another reason.

Specialists Involved Doctors who specialize in the care of babies and children who have heart problems are called pediatric cardiologists. Other specialists who treat heart defects in children include cardiac surgeons (doctors who repair heart defects using surgery). Physical Exam During a physical exam, the doctor:

Listens to your childs heart and lungs with a stethoscope Looks for other signs of a heart defect, such as cyanosis (a bluish tint to the skin, lips, or fingernails), shortness of breath, rapid breathing, delayed growth, or signs of heart failure

Tests Commonly Used To Diagnosis Congenital Heart Defects Echocardiogram This test, which is harmless and painless, uses sound waves to create a moving picture of your childs heart. During an echocardiogram, reflected sound waves show the structure of the heart. The test allows the doctor to clearly see any problem with the way the heart is formed or the way its working. An echocardiogram is an important test for both diagnosing a heart problem and following the problem over time. In children with congenital heart defects, an echocardiogram will outline the problems with the hearts structure and show how the heart is reacting to these problems. The echocardiogram will help your childs cardiologist decide if and when treatment is needed. During pregnancy, if your doctor suspects that your baby has a congenital heart defect, a special test called a fetal echocardiogram can be done. This test uses sound waves to create a picture of the baby's heart while the baby is still in the womb. The test is usually done during the fourth or fifth month of pregnancy. If your child is diagnosed with a congenital heart defect before birth, your doctor can plan treatment before the baby is born. EKG (Electrocardiogram) An EKG detects and records the electrical activity of the heart. An EKG shows how fast the heart is beating and whether the hearts rhythm is steady or irregular. It can also detect if one of the hearts chambers is enlarged, which can help diagnose a heart problem. Chest X Ray A chest x ray takes a picture of the heart and lungs. It can show whether the heart is enlarged or whether the lungs have extra blood or fluid, which can be a sign of heart failure.

Pulse Oximetry Pulse oximetry shows how much oxygen is in the blood. A sensor is placed on the childs fingertip or toe (like an adhesive bandage). The sensor is attached to a small computer unit, which displays a number that indicates how much oxygen is in the blood. Cardiac Catheterization During cardiac catheterization (KATH-e-ter-i-ZA-shun), a thin, flexible tube called a catheter is passed through a vein in the arm, groin (upper thigh), or neck to reach the heart. A dye that can be seen on an x ray is injected through the catheter into a blood vessel or a chamber of the heart. This allows the doctor to see the flow of blood through the heart and blood vessels. Cardiac catheterization also can be used to measure the pressure inside the heart and blood vessels and to determine whether blood is mixing between the two sides of the heart. Its also used to repair some heart defects. How Are Congenital Heart Defects Treated? Although many children with congenital heart defects dont need treatment, some do. Doctors treat congenital heart defects with:

Procedures using catheters to repair the defect Surgery to repair the defect

The treatment your child receives depends on the type and severity of his or her heart defect. Other factors include your childs age, size, and general health. Treatment can be simple or very complex. Some children with complex congenital heart defects may need several catheter or surgical procedures over a period of years, or may need to take medicines for years. Procedures Using Catheters Catheter procedures are much easier than surgery on patients because they involve only a needle puncture in the skin where the catheter is inserted into a vein or an artery. Doctors dont have to surgically open the chest or operate directly on the heart to repair the defect. This means that recovery can be much easier and quicker. The use of catheter procedures has grown a lot in the past 20 years. They have become the preferred way to repair many simple heart defects, such as:

Atrial septal defect. The doctor inserts the catheter through a vein and threads it up into the heart to the septum. The catheter has a tiny umbrella-like device folded up inside it. When the catheter reaches the septum, the device is pushed out of the catheter and positioned so that it plugs the hole between the atria. The device is secured in place and the catheter is then withdrawn from the body.

Pulmonary valve stenosis. The doctor inserts the catheter through a vein and threads it into the heart to the pulmonary valve. A tiny balloon at the end of the catheter is quickly inflated to push apart the leaflets, or doors, of the valve. The balloon is then deflated and the catheter is withdrawn. Procedures like this can be used to repair any narrowed valve in the heart.

Doctors often use an echocardiogram or a transesophageal (trans-e-SOF-ah-ge-al) echocardiogram (TEE) as well as an angiogram to guide them in threading the catheter and doing the repair. A TEE is a special type of echocardiogram that takes pictures of the back of the heart through the esophagus (the tube leading from the mouth to the stomach). TEE also is often used to define complex heart defects. Catheter procedures also are sometimes used during surgery to help repair complex defects. Surgery A child may need open-heart surgery if his or her heart defect cant be fixed using a catheter procedure. Sometimes, one surgery can repair the defect completely. If thats not possible, a child may need more than one surgery over a period of months or years to fix the problem. Open-heart surgery may be done to:

Close holes in the heart with stitches or with a patch Repair or replace heart valves Widen arteries or openings to heart valves Repair complex defects, such as problems with where the blood vessels near the heart are located and how they develop

Rarely, babies are born with multiple defects that are too complex to repair. These babies may need a heart transplant. In this procedure, the childs heart is replaced with a healthy heart from a deceased child that has been donated by that childs family. Living With a Congenital Heart Defect The outlook for a child with a congenital heart defect is much better today than in past years. Advances in testing and treatment mean that most children with heart defects grow into adulthood and are able to live active, productive lives. Many need no special care or only occasional checkups with a cardiologist as they grow up and go through adult life. The small number of children who have complex heart defects need long-term, special care by trained specialists to stay as healthy as possible and maintain a good quality of life. Children and Teens With Congenital Heart Defects Routine Medical Care Ongoing medical care is important for your childs health. This includes:

Checkups with your childs heart specialist as directed Checkups with your childs pediatrician or family doctor for routine exams Taking medicines as prescribed

Most children with severe heart defects are at increased risk for bacterial endocarditis, a serious infection of the heart valves or lining of the heart. Your child's doctor or dentist may give your child antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria into the bloodstream. Talk to your child's doctor about whether your child needs to take antibiotics before such procedures. As children with heart defects grow up and become teens, its important that they understand what kind of defect they have, how it was treated, and what kind of care may still be needed. This understanding will help the teen take responsibility for his or her health. It also will help ensure a smooth transition from care by a pediatric cardiologist to care by an adult cardiologist. Young adults with complex congenital heart defects require ongoing care by doctors who specialize in adult congenital heart defects. You may want to work with your health care providers to put together a packet with medical records and information that covers all aspects of your childs heart defect, including:

Diagnosis Procedures or surgeries Prescribed medicines Recommendations about medical followup and how to prevent complications Health insurance

Keeping your health insurance current is important. For example, if your child is covered under health insurance through your employer and you plan to change jobs, find out if health insurance through your new employer will cover care for your childs congenital heart defect. Some health insurance plans may not cover medical conditions that you or your family member had before joining the new plan. Its also very important for your child to have health insurance as adulthood approaches. Review your current health insurance plan. Find out how coverage can be extended to your child beyond the age of 18. Some policies may allow you to keep your child on your plan if he or she remains in school or is disabled. Feeding and Nutrition Some babies and children with congenital heart defects dont grow and develop as fast as other children who are the same age. If your childs heart has to pump harder than normal because of the defect, he or she may tire quickly when feeding or eating and not be able to eat enough.

As a result, your child may be smaller and thinner than other children. Your child also may start activities such as rolling over, sitting, and walking later than other children. After treatments and surgery, growth and development often improve. To help your baby get enough calories, discuss with his or her doctor the best feeding schedule and any supplements your baby may need. Make sure your child has nutritious meals and snacks as he or she grows to help with growth and development. Exercise and Physical Activity Exercise helps children strengthen their muscles and stay healthy. Discuss with your childs doctor how much and what kinds of physical activities are best for your child. Some children and teens with congenital heart defects may need to limit the amount or type of exercise they do. Remember to ask the doctor for a note for school and other organizations describing any limits on your childs exercise or physical activities. Emotional Issues Its common for children and teens with serious conditions or illnesses to have a hard time emotionally or to feel isolated if they have to be in the hospital a lot. Some feel sad or frustrated with their body image and their inability to be a normal kid. Sometimes brothers or sisters are jealous of a child who needs a lot of attention for medical problems. If you have concerns about your childs emotional health, talk to his or her doctor. Adults With Congenital Heart Defects Adults with congenital heart defects who needed regular medical checkups in their youth may need to keep seeing a specialist who can care for their health. They will need to pay attention to the following issues. Medical History Sometimes people mistakenly believe that the surgery they had in childhood for their congenital heart defect was a cure. They dont realize that regular medical followup may be needed in adulthood to maintain good health. Some adults may not know what kind of heart defect they had (or still have) or how it was repaired. They should learn about their medical history and know as much as possible about any medicines theyre taking. Preventing Bacterial Endocarditis Some people may need antibiotics before medical or dental procedures that could allow bacteria to enter the bloodstream. Talk to your doctor about whether you need to take

antibiotics before such procedures. Regular brushing, flossing, and visits to the dentist also can help prevent bacterial endocarditis. Contraception and Pregnancy Women who have heart defects should talk with their doctors about the safest type of birth control. Many women can safely use most methods, but some women should avoid certain types of birth control, such as birth control pills or intrauterine devices (IUDs). Many women with simple heart defects can have a normal pregnancy and delivery. Women with congenital heart defects who want to become pregnant (or who are pregnant) should talk with their doctor about the health risks. They also may want to consult with specialists who help pregnant women with congenital heart defects. Health Insurance and Employment When thinking about changing jobs, adults with congenital heart defects should carefully consider the impact on their health insurance coverage. Some health plans have waiting periods or clauses to exclude some kinds of coverage. Before making any job changes, find out whether the change will affect your health insurance coverage. Several laws protect the employment rights of people who have congenital heart defects. The Americans with Disabilities Act and the Work Incentives Improvement Act try to ensure fairness in hiring for all people, including those with health conditions such as heart defects. Key Points

Congenital heart defects are problems with the hearts structure that are present at birth. Congenital heart defects change the normal flow of blood through the heart. Congenital heart defects are the most common type of birth defect, affecting 8 out of every 1,000 newborns. Each year, more than 35,000 babies in the United States are born with congenital heart defects. There are many types of congenital heart defects ranging from simple to very complex. Doctors dont know what causes most congenital heart defects. Heredity may play a role. Although many heart defects have few or no symptoms, some do. Severe defects can cause symptoms such as:
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Rapid breathing. A bluish tint to skin, lips, and fingernails. This is called cyanosis. Fatigue (tiredness). Poor blood circulation.

Serious heart defects are usually diagnosed while a baby is still in the womb or soon after birth. Some defects arent diagnosed until later in childhood, or even in adulthood. An echocardiogram is an important test for both diagnosing a heart problem and following the problem over time. This test helps diagnose problems with how the heart is formed and how well its working. Other tests include EKG (electrocardiogram), chest x ray, pulse oximetry, and cardiac catheterization. Doctors treat congenital heart defects with catheter procedures and surgery. Treatment depends on the type and severity of the defect. With new advances in testing and treatment, most children with congenital heart defects grow into adulthood and can live healthy, productive lives. Some need special care all though their lives to maintain a good quality of life.

What Is an Electrocardiogram?
An electrocardiogram, also called an EKG or ECG, is a simple test that detects and records the electrical activity of the heart. It is used to detect and locate the source of heart problems. Electrical signals in the heart trigger heartbeats. These signals start at the top of the heart in an area called the right atrium. The electrical signals travel from the top of the heart to the bottom. They cause the heart muscle to contract as they travel through the heart. As the heart contracts, it pumps blood out to the rest of the body. An EKG shows how fast the heart is beating. It shows the hearts rhythm (steady or irregular) and where in the body the heartbeat is being recorded. It also records the strength and timing of the electrical signals as they pass through each part of the heart. An EKG is sometimes called a 12-lead EKG (or 12-lead ECG) because the electrical activity of the heart is most often recorded from 12 different places on the body at the same time. See the How the Heart Works section for more details on the way the heart works. What EKG Reveals Many heart problems change the electrical signature of the heart in distinct ways. EKG recordings of this electrical activity can help reveal a number of heart problems, including:

Heart attack Lack of blood flow to the heart muscle A heart that is beating irregularly, or too fast or too slow A heart that does not pump forcefully enough

EKG recordings can help doctors diagnose a heart attack that is happening now or has happened in the past. This is especially true if doctors can compare a current EKG recording to an older one. EKG recordings can also reveal:

Heart muscle that is too thick or parts of the heart that are too big Birth defects in the heart Disease in the heart valves between the different heart chambers

An EKG also reveals whether the heartbeat starts at the top right part of the heart like it should. It shows how long it takes for the electrical signals to travel through the heart. March 2007 How the Heart Works The heart is a muscle about the size of your fist. It works like a pump and beats 100,000 times a day. The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. Then, oxygen-rich blood returns from the lungs to the left side of the heart, and the left side pumps it to the body. The heart has four chambers and four valves and is connected to various blood vessels. Veins are the blood vessels that carry blood from the body to the heart. Arteries are the blood vessels that carry blood away from the heart to the body. A Healthy Heart Cross-Section

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body. Heart Chambers The heart has four chambers or "rooms."

The atria (AY-tree-uh) are the two upper chambers that collect blood as it comes into the heart. The ventricles (VEN-trih-kuls) are the two lower chambers that pump blood out of the heart to the lungs or other parts of the body.

Heart Valves Four valves control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart.

The tricuspid (tri-CUSS-pid) valve is in the right side of the heart, between the right atrium and the right ventricle. The pulmonary (PULL-mun-ary) valve is in the right side of the heart, between the right ventricle and the entrance to the pulmonary artery, which carries blood to the lungs. The mitral (MI-trul) valve is in the left side of the heart, between the left atrium and the left ventricle. The aortic (ay-OR-tik) valve is in the left side of the heart, between the left ventricle and the entrance to the aorta, the artery that carries blood to the body.

Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries, and then they shut to keep blood from flowing backward. When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope.

The first sound-the "lub"-is made by the mitral and tricuspid valves closing at the beginning of systole (SIS-toe-lee). Systole is when the ventricles contract, or squeeze, and pump blood out of the heart. The second sound-the "DUB"-is made by the aortic and pulmonary valves closing at beginning of diastole (di-AS-toe-lee). Diastole is when the ventricles relax and fill with blood pumped into them by the atria.

Arteries The arteries are major blood vessels connected to your heart.

The pulmonary artery carries blood pumped from the right side of the heart to the lungs to pick up a fresh supply of oxygen. The aorta is the main artery that carries oxygen-rich blood pumped from the left side of the heart out to the body. The coronary arteries are the other important arteries attached to the heart. They carry oxygen-rich blood from the aorta to the heart muscle, which must have its own blood supply to function.

Veins The veins are also major blood vessels connected to your heart.

The pulmonary veins carry oxygen-rich blood from the lungs to the left side of the heart so it can be pumped out to the body. The vena cava is a large vein that carries oxygen-poor blood from the body back to the heart.

For more information on how a healthy heart works, see the Diseases and Conditions Index article on How the Heart Works. This article contains animations that show how your heart pumps blood and how your heart's electrical system works. Why Is an Electrocardiogram Done? An electrocardiogram (EKG) is done to evaluate signs and symptoms that could indicate heart problems. Some of the signs and symptoms that might be evaluated with an EKG include:

Chest pain Heart pounding, racing, or fluttering, or the sense that your heart is beating unevenly Difficulty breathing Feeling tired and weak (fatigue) Unusual heart sounds when the doctor listens to your heartbeat

When an adultusually someone who is older than 40 or 50 years of agehas a routine health exam, the doctor may order an EKG to screen for early heart disease that has no symptoms. The doctor is more likely to look for early heart disease if the person has a family history of heart disease in a mother, father, brother, or sisterespecially if the heart disease developed early in those family members lives. Doctors also use EKGs to check how well heart treatments, such as drugs or medical devices, are working. What Happens During an Electrocardiogram?

An electrocardiogram (EKG) is painless and harmless. A technician first attaches 12 soft patches called electrodes to the skin of the chest, arms, and legs. These electrodes are about the size of a quarter. To help an electrode stick to the skin, the technician may have to shave a patch of hair where the electrode will be attached. After the electrodes are placed on the skin, the patient lies still on a table for a few minutes while the electrodes detect the electrical signals of the heart. A machine then records these signals on graph paper or displays them on a screen. The entire test takes about 10 minutes. After the test, the electrodes are removed from the skin and discarded. Special EKGs The common EKG described above, called a resting 12-lead EKG, records only a few minutes of heart signals at a time. It will show a heart problem only if the problem is present during the few minutes that the test is being run. Many heart problems are present all the time and will be found by a resting 12-lead EKG. But some heart problems, like those related to irregular heartbeat, can come and go. They may be present for only a few minutes out of the day or only while exercising. Special types of EKGs are used to help diagnose those kinds of problems. Three of these special EKGs are:

Stress test Holter monitor Event monitor

Stress Test Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it's at rest. During stress testing, you exercise (or are given medicine if you are unable to exercise) to make your heart work harder and beat faster while heart tests are performed. During exercise stress testing, your blood pressure and EKG readings are monitored while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time. These would be ordered if your doctor needs more information than the exercise stress test can provide about how well your heart is working. If you are unable to exercise, a medicine can be injected through an intravenous line (IV) into your bloodstream to make your heart work harder and beat faster, as if you are exercising on a treadmill or bicycle. Nuclear heart scanning or echocardiography is then usually done. During nuclear heart scanning, radioactive tracer is injected into your bloodstream, and a special camera shows the flow of blood through your heart and arteries. Echocardiography

uses sound waves to show blood flow through the chambers and valves of your heart and to show the strength of your heart muscle. Your doctor also may order two newer tests along with stress testing if more information is needed about how well your heart works. These new tests are magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning of the heart. MRI shows detailed images of the structures and beating of your heart, which may help your doctor better assess if parts of your heart are weak or damaged. PET scanning shows the level of chemical activity in different areas of your heart. This can help your doctor determine if enough blood is flowing to the areas of your heart. A PET scan can show decreased blood flow caused by disease or damaged muscles that may not be detected by other scanning methods. Key Points

An electrocardiogram (EKG) is a test that detects and records the electrical activity of the heart. EKGs are used to evaluate signs and symptoms that could indicate heart problems. Many heart problems change the electrical signature of the heart in distinct ways. EKG recordings of this electrical signature can help reveal these heart problems. During an EKG, electrical signals in the heart are detected by electrodes placed on the skin. A machine records them on graph paper or displays them on a screen. An EKG is painless and harmless, and usually takes about 10 minutes to complete. Special EKG tests are done to detect certain kinds of heart symptoms, such as those that are present for only a few minutes out of the day, or that happen only while a person is exercising.

What Is Echocardiography?
Echocardiography (EK-o-kar-de-OG-ra-fee) is a painless test that uses sound waves to create images of your heart. It provides your doctor with information about the size and shape of your heart and how well your hearts chambers and valves are working. The test also can identify areas of heart muscle that arent contracting normally due to poor blood flow or injury from previous heart attack(s). In addition, a type of echocardiography called Doppler ultrasound shows how well blood flows through the chambers and valves of your heart. Echocardiography can detect possible blood clots inside the heart, fluid buildup in the sac around the heart (pericardium), and problems with the aorta (the main artery that carries oxygen-rich blood out of the heart). Who Needs Echocardiography? Your doctor may recommend echocardiography if youre suffering from signs and symptoms of heart problems. For example, symptoms such as shortness of breath and swelling in the

legs can be due to weakness of the heart (heart failure), which can be seen on an echocardiogram. Doctors also use echocardiography to provide information on:

The size of your heart. An enlarged heart can be the result of high blood pressure, leaky heart valves, or heart failure. Heart muscles that are weak and arent moving (pumping) properly. Weakened areas of heart muscle can be due to damage from a heart attack. Or weakening could mean that the area isnt getting enough blood supply, which can be due to coronary artery disease. Problems with your hearts valves. Echocardiography can show whether any of the valves of your heart dont open normally or dont form a complete seal when closed. Abnormalities in the structure of your heart. Echocardiography can detect a variety of heart abnormalities, such as a hole in the septum (the wall that separates the two chambers on the left side of the heart from the two chambers on the right side) and other congenital heart defects (structural problems present at birth). The aorta. Echocardiography is commonly used to assess and detect problems with the aorta such as aneurysm (abnormal bulge or ballooning in the wall of an artery). Blood clots or tumors. If you have had a stroke, echocardiography might be done to check for blood clots or tumors that may have caused it.

Doctors also use echocardiography to see how well your heart responds to certain heart treatments, such as treatment for heart failure. March 2007 Types of Echocardiography There are several different types of echocardiography-all use sound waves to create images your heart. This is the same technology that allows doctors to see an unborn baby inside a pregnant mother. Unlike x rays and some other tests, echocardiography doesn't involve radiation. Transthoracic Echocardiography Transthoracic (tranz-thor-AS-ik) echocardiography is the most common type of echocardiogram test. It's painless and noninvasive. "Noninvasive" means that no surgery is done and no instruments are inserted into your body. This type of echocardiography involves placing a device called a transducer on your chest that sends special sound waves, called ultrasound, through your chest wall to your heart. Ultrasound waves can't be heard by the human ear. As the ultrasound waves bounce off the structures of your heart, a computer in the echocardiography machine converts them into pictures on a screen.

Stress Echocardiography This is an echocardiography test that's done as part of a cardiac stress test. During a cardiac stress test, you exercise or take medicine (given by your doctor) to make your heart pump harder and beat faster. Some heart problems, such as coronary artery disease, are easier to diagnose when the heart is beating fast and pumping hard. Transesophageal Echocardiography With standard transthoracic echocardiography, it can be difficult to see the aorta and certain other parts of your heart. If your doctor needs a better look at these areas, he or she may recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echocardiography. In this test, the transducer is attached to the end of a flexible tube that's guided down your throat and into your esophagus (the tube leading from your mouth to your stomach) to get a more detailed image of your heart. Fetal Echocardiography This type of echocardiography is used to look at an unborn baby's heart. A doctor may recommend this test to check the baby for heart problems. Fetal echocardiography is commonly performed during pregnancy at about 18 to 22 weeks. Other Names for Echocardiography

Ultrasound of the heart Echo Surface echo

What To Expect Before Echocardiography Echocardiography can be performed in a doctor's office or a hospital. No special preparations are needed for most types of echocardiography. Usually you can eat, drink, and take any medicines as you normally would. The exception is if you're having a transesophageal echocardiography. This test usually requires that you don't eat or drink for 8 hours prior to the test. If you're having a stress echocardiography, there may be special preparations. Your doctor will advise you on how to prepare for your echocardiography test. What To Expect During Echocardiography Echocardiography is painless and usually takes less than an hour to perform. For some tests, the doctor will need to inject saline or a special dye into your vein that makes your heart show up more clearly on the test images. This special dye is different from the dye used during an angiogram test.

For most types of echocardiography, you will be asked to remove your clothing from the waist up. Women will be given a gown to wear during the procedure. You will lay on your back or left side on an exam table or stretcher. EKG electrodes will be attached to your chest to allow an EKG to be done. A doctor or sonographer (a person specially trained to do ultrasounds) will apply a gel to your chest that helps the sound waves reach your heart. A wand-like device called a transducer will then be moved around on your chest. The transducer transmits ultrasound waves into your chest. Echoes from the sound waves will be converted into pictures of your heart on a computer screen. During the test, the lights in the room are dimmed so the computer screen is easier to see. The sonographer will make several recordings of the images to show different locations in your heart. The recordings will be put on a computer disc or videotape for the cardiologist (a doctor who specializes in treating people who have heart problems) to review. During the test, you may be asked to change positions or hold your breath for a short time so that the sonographer can get good pictures of your heart. At times, the sonographer may apply a bit of pressure to your chest with the transducer. This pressure can be a little uncomfortable, but it helps the sonographer get the best picture of your heart. You should let him or her know if you feel too uncomfortable. Echocardiography is similar for fetal echocardiography, except in that test the transducer is placed over the location of the developing babys heart. Transesophageal Echocardiography Transesophageal echocardiography (TEE) is used when the doctor needs a more detailed view of your heart. This may be necessary to look for blood clots in the heart or if transthoracic echocardiography doesnt provide a good enough view of certain parts of the heart. A doctor, not a sonographer, performs this type of echocardiography. The test uses the same technology as transthoracic echocardiography, but the transducer is attached to the end of a flexible tube. The tube is guided down your throat and into your esophagus (the tube leading from your mouth to your stomach) to get a more detailed image of the heart and major blood vessels leading to and from the heart. For TEE, you will probably be given medicine through a needle inserted in one of your veins to help you relax during the test. Your blood pressure, the oxygen content of your blood, and other vital signs will be monitored during the test. You will be given oxygen through a tube to your nose. If you wear dentures or partials, you will have to remove them. The back of your mouth is numbed with a gel or a spray so that you dont gag when the transducer is put down your throat. The tube with the transducer on the end is gently placed in your throat and guided down until its in place behind the heart. The images of your heart are then recorded as the doctor moves the transducer around in your esophagus and

stomach. You shouldnt feel any discomfort as this happens. Although the imaging usually takes less than an hour, you may be monitored for a few hours at the doctors office or hospital after the test. Stress Echocardiography Stress echocardiography is a transthoracic echocardiogram combined with either an exercise or chemical stress test. For an exercise stress test, you walk or run on a treadmill or pedal a stationary bicycle to make your heart beat fast and pump hard. For a chemical stress test, youre given medicine to make your heart beat fast and pump hard. The Diseases and Conditions Index Stress Testing article provides additional information on what to expect during a cardiac stress test. What You May See and Hear During Echocardiography As the doctor or sonographer moves the transducer around, different views of your heart can be seen on the screen of the echocardiography machine. The structures of the heart will appear as white objects, while any fluid or blood will appear black on the screen. Doppler ultrasound techniques are often used during echocardiography tests. Doppler ultrasound is a special ultrasound that shows how blood is flowing through the blood vessels. This allows the sonographer to see the blood flowing in different speeds and directions. The speeds and directions appear as different colors moving within the black and white images. The human ear is unable to hear the sound waves used in echocardiography. If Doppler ultrasound is used, however, you may be able to hear a whooshing sound as the echocardiography machine converts the echoes into sounds that can be heard and which the doctor can use as information about the flow of blood through your heart. What To Expect After Echocardiography You usually can go back to your normal activities immediately after the test. You may not be able to drive after a transesophageal echocardiography. Your doctor will let you know whether you need to arrange for someone to take you home. What Does Echocardiography Show? An echocardiography shows the size, structure, and movement of the different parts of your heart, including the valves, the septum (the wall separating the chambers on the right and left sides of the heart), and the walls of the heart chambers. The Doppler ultrasound technique shows the movement of blood through the heart. Echocardiography can be used to:

Diagnose heart problems Guide or determine next steps for treatment

Monitor changes and improvement Determine the need for additional tests

Echocardiography can detect many different types of heart problems. Some of these can be minor and pose no risk to you. Others can be signs of serious heart disease or other heart problems. An echocardiography can provide information on:

The size of your heart. An enlarged heart can be the result of high blood pressure, leaky heart valves, or heart failure. Heart muscles that are weak and arent moving (pumping) properly. Weakened areas of heart muscle can be due to damage from a heart attack. Or weakening could mean that the area isnt getting enough blood supply, which can be due to coronary artery disease. Problems with your hearts valves. Echocardiography can show whether any of the valves of your heart dont open normally or dont form a complete seal when closed. Abnormalities in the structure of your heart. Echocardiography can detect a variety of heart abnormalities, such as a hole in the septum (the wall that separates the two chambers on the left side of the heart from the two chambers on the right side) and other congenital heart defects (structural problems present at birth). The aorta. Echocardiography is commonly used to assess and detect problems with the aorta such as aneurysm (abnormal bulge or ballooning in the wall of an artery). Blood clots or tumors. If you have had a stroke, echocardiography might be done to check for blood clots or tumors that may have caused it.

What Are the Risks of Echocardiography?

There are no risks associated with transthoracic or fetal echocardiography. If you have a transesophageal echocardiography, there are some risks associated with medicine given to help you relax. These include a bad reaction to the medicine, difficulty breathing, or nausea. Your throat also might be sore for a few hours after the test. On rare occasions, the tube can cause a minor throat injury. There are risks associated with stress echocardiography, but these are related to the exercise or medicine used to raise your heart rate, not to the echocardiography part of the test. Serious complications from cardiac stress tests are very uncommon. See the Diseases and Conditions Index Stress Testing article for more information about the risks of that test.

Key Points

Echocardiography is a painless test that uses sound waves to create images of your heart. This test provides your doctor with information about the size and shape of your heart and how well your heart's chambers and valves are working. In addition, a type of echocardiography called Doppler ultrasound shows how well blood flows through the chambers and valves of your heart.

Your doctor may recommend echocardiography if you're suffering from signs and symptoms that heart problems could cause. The test can be used to confirm a diagnosis, determine the status of an existing problem, or help guide treatment. There are different types of echocardiography. Transthoracic and stress echocardiographies are standard types of the test. Transesophageal echocardiography (TEE) is used if the standard tests don't produce clear results. A fetal echocardiography is used to look at an unborn baby's heart. Echocardiography takes place in a doctor's office or hospital. The test usually takes up to 1 hour. A standard echocardiography doesn't require any special preparations or followup. If you're having a TEE, you usually shouldn't eat or drink for 8 hours prior to the test. During a standard echocardiography, the doctor or sonographer will move a wandlike device called a transducer around on your chest to get images of your heart. During a TEE, the transducer will be put down your throat to get a better view of your heart. A cardiologist will analyze the results from your echocardiography. You usually can go back to your normal activities immediately after having an echocardiography. There are no risks associated with transthoracic or fetal echocardiography. If you have TEE, there are some risks associated with the medicine given to help you relax. On rare occasions, the tube used in TEE can cause minor throat injury. The risks for stress echocardiography are related to the exercise or medicine used to raise your heart rate. Serious complications from a stress echocardiography are rare.

What Is Cholesterol?
To understand high blood cholesterol (ko-LES-ter-ol), it is important to know more about cholesterol.

Cholesterol is a waxy, fat-like substance that is found in all cells of the body. Your body needs some cholesterol to work the right way. Your body makes all the cholesterol it needs. Cholesterol is also found in some of the foods you eat. Your body uses cholesterol to make hormones, vitamin D, and substances that help you digest foods.

Blood is watery, and cholesterol is fatty. Just like oil and water, the two do not mix. To travel in the bloodstream, cholesterol is carried in small packages called lipoproteins (lip-o-PROteens). The small packages are made of fat (lipid) on the inside and proteins on the outside. Two kinds of lipoproteins carry cholesterol throughout your body. It is important to have healthy levels of both:

Low-density lipoprotein (LDL) cholesterol is sometimes called bad cholesterol.

High LDL cholesterol leads to a buildup of cholesterol in arteries. The higher the LDL level in your blood, the greater chance you have of getting heart disease. HDL carries cholesterol from other parts of your body back to your liver. The liver removes the cholesterol from your body. The higher your HDL cholesterol level, the lower your chance of getting heart disease.

High-density lipoprotein (HDL) cholesterol is sometimes called good cholesterol.

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What Is High Blood Cholesterol? Too much cholesterol in the blood, or high blood cholesterol, can be serious. People with high blood cholesterol have a greater chance of getting heart disease. High blood cholesterol on its own does not cause symptoms, so many people are unaware that their cholesterol level is too high. Cholesterol can build up on the walls of your arteries (blood vessels that carry blood from the heart to other parts of the body). This buildup of cholesterol is called plaque (plak). Over time, plaque can cause narrowing of the arteries. This is called atherosclerosis (ath-er-oskler-O-sis), or hardening of the arteries.

The illustration shows a normal artery with normal blood flow (Figure A) and an artery containing plaque buildup (Figure B).

Special arteries, called coronary arteries, bring blood to the heart. Narrowing of your coronary arteries due to plaque can stop or slow down the flow of blood to your heart. When the arteries narrow, the amount of oxygen-rich blood is decreased. This is called coronary artery disease (CAD). Large plaque areas can lead to chest pain called angina (an-JI-nuh or AN-juh-nuh). Angina happens when the heart does not receive enough oxygen-rich blood. Angina is a common symptom of CAD. Some plaques have a thin covering and burst (rupture), releasing fat and cholesterol into the bloodstream. The release of fat and cholesterol may cause your blood to clot. A clot can block the flow of blood. This blockage can cause angina or a heart attack. Lowering your cholesterol level decreases your chance for having a plaque burst and cause a heart attack. Lowering cholesterol may also slow down, reduce, or even stop plaque from building up. Plaque and resulting health problems can also occur in arteries elsewhere in the body. February 2006 Other Names Other Names for High Blood Cholesterol

Hypercholesterolemia (HI-per-ko-LES-ter-ol-E-me-a) Hyperlipidemia (HI-per-lip-i-DE-me-a)

What Causes High Blood Cholesterol? A variety of things can affect the cholesterol levels in your blood. Some of these things you can control and others you cannot. You can control:

What you eat. Certain foods have types of fat that raise your cholesterol level.
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Saturated fat raises your low-density lipoprotein (LDL) cholesterol level more than anything else in your diet. Trans fatty acids (trans fats) are made when vegetable oil is hydrogenated to harden it. Trans fatty acids also raise cholesterol levels. Cholesterol is found in foods that come from animal sources, for example, egg yolks, meat, and cheese.

Your weight. Being overweight tends to increase your LDL level, lower your highdensity lipoprotein (HDL) level, and increase your total cholesterol level.

Your activity. Lack of regular exercise can lead to weight gain, which could raise your LDL cholesterol level. Regular exercise can help you lose weight and lower your LDL level. It can also help you raise your HDL level.

You cannot control:

Heredity. High blood cholesterol can run in families. An inherited genetic condition (familial hypercholesterolemia) results in very high LDL cholesterol levels. It begins at birth, and may result in a heart attack at an early age. Age and sex. Starting at puberty, men have lower levels of HDL than women. As women and men get older, their LDL cholesterol levels rise. Younger women have lower LDL cholesterol levels than men, but after age 55, women have higher levels than men.

What Are the Signs and Symptoms of High Blood Cholesterol?

There are usually no signs or symptoms of high blood cholesterol. Many people don't know that their cholesterol level is too high. Everyone age 20 and older should have their cholesterol levels checked at least once every 5 years. You and your doctor can discuss how often you should be tested.

How Is High Blood Cholesterol Diagnosed? High blood cholesterol is diagnosed by checking levels of cholesterol in your blood. It is best to have a blood test called a lipoprotein profile to measure your cholesterol levels. Most people will need to not eat or drink anything (fast) for 9 to 12 hours before taking the test. The lipoprotein profile will give information about your:

Total cholesterol Low-density lipoprotein (LDL) bad cholesterol: the main source of cholesterol buildup and blockage in the arteries High-density lipoprotein (HDL) good cholesterol: the good cholesterol that helps keep cholesterol from building up in arteries Triglycerides: another form of fat in your blood

If it is not possible to get a lipoprotein profile done, knowing your total cholesterol and HDL cholesterol can give you a general idea about your cholesterol levels. Testing for total and HDL cholesterol does not require fasting. If your total cholesterol is 200 mg/dL or more, or if your HDL is less than 40 mg/dL, you will need to have a lipoprotein profile done. Cholesterol levels are measured in milligrams (mg) of cholesterol per deciliter (dL) of blood. See how your cholesterol numbers compare to the tables below. Total Cholesterol Level Less than 200 mg/dL Total Cholesterol Category Desirable

200239 mg/dL 240 mg/dL and above LDL Cholesterol Level Less than 100 mg/dL 100129 mg/dL 130159 mg/dL 160189 mg/dL 190 mg/dL and above HDL Cholesterol Level Less than 40 mg/dL 4059 mg/dL 60 mg/dL and above

Borderline high High LDL Cholesterol Category Optimal Near optimal/above optimal Borderline high High Very high HDL Cholesterol Category A major risk factor for heart disease The higher, the better Considered protective against heart disease

Triglycerides can also raise your risk for heart disease. If you have levels that are borderline high (150199 mg/dL) or high (200 mg/dL or more), you may need treatment. Things that can increase triglyceride levels include:

Overweight Physical inactivity Cigarette smoking Excessive alcohol use Very high carbohydrate diet Certain diseases and drugs Genetic disorders

How Is High Blood Cholesterol Treated? The main goal of cholesterol-lowering treatment is to lower your low-density lipoprotein (LDL) level enough to reduce your risk of having a heart attack or diseases caused by hardening of the arteries. In general, the higher your LDL level and the more risk factors you have, the greater your chances of developing heart disease or having a heart attack. (A risk factor is a condition that increases your chance of getting a disease.) Some people are at high risk for heart attack because they already have heart disease. Other people are at high risk for developing heart disease because they have diabetes or a combination of risk factors for heart disease. Follow the steps below to find out your risk for getting heart disease. Check the list to see how many of the risk factors you have. These are the risk factors that affect your LDL goal:

Cigarette smoking High blood pressure (140/90 mg/dL or higher), or if you are on blood pressure medicine Low high-density lipoprotein (HDL) cholesterol (less than 40 mg/dL)1 Family history of early heart disease (heart disease in father or brother before age 55; heart disease in mother or sister before age 65) Age (men 45 years or older; women 55 years or older)

If you have two or more of the risk factors in the list above, use the NHLBI 10-Year Risk Calculator to find your risk score. Risk scores refer to the chance of having a heart attack in the next 10 years, given as a percentage. Use your medical history, number of risk factors, and risk score to find your risk of developing heart disease or having a heart attack according to the table below. If You Have Heart disease, diabetes, or a risk score higher than 20% You Are in Category I. Highest risk And Your LDL Goal Is Less than 100 mg/dL Less than 130 mg/dL Less than 130 mg/dL Less than 160 mg/dL

Two or more risk factors and a II. Next highest risk risk score 1020% Two or more risk factors and a III. Moderate risk risk score lower than 10% One or no risk factors IV. Low to moderate risk

After following the above steps, you should have an idea about your risk for getting heart disease or having a heart attack. The higher your risk is, the lower your LDL goal will be. There are two main ways to lower your cholesterol:

Therapeutic Lifestyle Changes (TLC)includes a cholesterol-lowering diet (called the TLC Diet), physical activity, and weight management. TLC is for anyone whose LDL is above goal. Drug Treatmentif cholesterol-lowering drugs are needed, they are used together with TLC treatment to help lower your LDL.

The higher your risk for heart disease, the lower your LDL goal will be. Your doctor will set your LDL goal. Using the following guide, you and your doctor can develop a possible plan for treating your high blood cholesterol. Category I, highest risk, your LDL goal is less than 100 mg/dL. Your LDL Level Treatment

If your LDL is 100 or above Even if your LDL is below 100

You will need to begin the TLC Diet together with drug treatment. You should follow the TLC Diet on your own to keep your LDL as low as possible.

Category II, next highest risk, your LDL goal is less than 130 mg/dL. Your LDL Level If your LDL is 130 mg/dL or above If your LDL is 130 mg/dL or more after 3 months on the TLC Diet If your LDL is less than 130 mg/dL Treatment You will need to begin the TLC Diet. You may need drug treatment along with the TLC Diet. You will need to follow the Heart Healthy Diet.

Category III, moderate risk, your LDL goal is less than 130 mg/dL. Your LDL Level If your LDL is 130 mg/dL or above Treatment You will need to begin treatment with the TLC Diet.

If your LDL is 160 mg/dL or more after You may need drug treatment along with you have tried the TLC Diet for 3 months the TLC Diet. If your LDL is less than 130 mg/dL You will need to follow the Heart Healthy Diet.

Category IV, low to moderate risk, your LDL goal is less than 160 mg/dL. Your LDL Level If your LDL is 160 mg/dL or above If your LDL is still 160 mg/dL or more after 3 months on the TLC Diet If your LDL is less than 160 mg/dL Treatment You will need to begin the TLC Diet. You may need drug treatment along with the TLC Diet. You will need to follow the Heart Healthy Diet.

Lowering Cholesterol With TLC TLC is a set of lifestyle changes you can make to help lower your LDL cholesterol. The main parts of TLC are:

The TLC Diet, which recommends:

o o o o

Limiting the amount of saturated fat and cholesterol you eat. Eating only enough calories to achieve or maintain a healthy weight. Increasing the soluble fiber in your diet. For example, oatmeal, kidney beans, and apples are good sources of soluble fiber. Adding cholesterol-lowering food, such as margarines that contain plant sterol or stanol esters that lower cholesterol for some people. Losing weight if you are overweight can help lower LDL. Weight management is especially important for those with a group of risk factors that includes high triglyceride and/or low HDL levels and being overweight with a large waist measurement (more than 40 inches for men and more than 35 inches for women). Regular physical activity is recommended for everyone. It can help raise HDL levels and lower LDL levels, and is especially important for those with high triglyceride and/or low HDL levels who are overweight with a large waist measurement.

Weight management:
o

Physical activity:
o

Cholesterol-Lowering Medicines Along with suggesting that you change the way you eat and exercise regularly, your doctor may prescribe medicines to help lower your cholesterol. Even if you begin drug treatment, you will need to continue TLC. Drug treatment controls but does not "cure" high blood cholesterol. Therefore, you must continue taking your medicine to keep your cholesterol level in the recommended range. The five major types of cholesterol-lowering medicines are:

Statins
o o o

Very effective in lowering LDL (bad) cholesterol levels Safe for most people Rare side effects to watch for are liver and muscle problems Help lower LDL cholesterol levels Sometimes prescribed with statins Not usually prescribed as the only medicine to lower cholesterol Lowers LDL cholesterol and triglycerides, and raises HDL (good) cholesterol Should only be used under a doctor's supervision

Bile Acid Sequestrants (seh-KWES-trants)

o o o

Nicotinic (Nick-o-TIN-ick) Acid

o o

Fibrates

o o o

Lower triglycerides May increase HDL (good) cholesterol levels When used with a statin, may increase the chance of muscle problems Lowers LDL cholesterol May be used with statins or alone Acts within the intestine to block cholesterol absorption

Ezetimibe
o o o

When you are under treatment, you will be checked regularly to:

Make sure your cholesterol level is controlled Check for other health problems

You may take medicines for other health problems. It is important that you take ALL medicines as your doctor prescribes. The combination of medicines may lower your risk for heart disease or heart attack. When trying to lower your cholesterol or keep it low, it is important to remember to follow your treatments for other conditions you may have, such as high blood pressure. Get help with quitting smoking and losing weight if they are risk factors for you. ____________ 1 If your HDL cholesterol is 60 mg/dL or higher, subtract 1 from your total count. Key Points

Cholesterol is a fat-like substance that is made in your body. Cholesterol is also in some foods that you eat. Your body needs some cholesterol to work the right way. Your body makes all the cholesterol it needs. Too much cholesterol in the blood is hypercholesterolemia. called high blood cholesterol or

High blood cholesterol increases the chance of having a heart attack or some other symptom of heart disease, like chest pain (angina). Lowering cholesterol is important for everyoneyoung, middle-aged, and older adults, and both men and women. Eating too much saturated fat and cholesterol raises the level of cholesterol in your blood. Too much cholesterol in your blood can build up in the walls of arteries. This is called plaque. There are no signs or symptoms of high blood cholesterol. Many people don't know that their cholesterol level is too high. High blood cholesterol is diagnosed by checking cholesterol levels in your blood.

A blood test called a lipoprotein profile measures the cholesterol levels in your blood and is the recommended test. It is important that everyone age 20 and older get their cholesterol checked at least once every 5 years. Many people are able to lower their cholesterol levels by eating a low saturated fat and low cholesterol diet, exercising, and losing weight if needed. Some people will need to take medicines prescribed by their doctor to lower their cholesterol in addition to eating a low saturated fat and low cholesterol diet, exercising, and losing weight if needed.

What Is a Stent?
A stent is a small mesh tube thats used to treat narrowed or weakened arteries in the body. You may have a stent placed in an artery as part of a procedure called angioplasty (AN-jeeoh-plas-tee). Angioplasty can restore blood flow through narrowed or blocked arteries. Stents help prevent arteries from becoming narrowed or blocked again in the months or years after treatment with angioplasty. You may also have a stent placed in a weakened artery to improve blood flow and to help prevent the artery from bursting. Stents are usually made of metal mesh, but sometimes theyre made of fabric. Fabric stents, also called stent grafts, are used in larger arteries. Some stents are coated with medicines that are slowly and continuously released into the artery. These medicines help prevent the artery from becoming blocked again. May 2007 How Are Stents Used? Stents for Arteries in the Heart With age and some health conditions, the inside openings of the coronary arteries (arteries of the heart) tend to narrow due to deposits of a fatty substance called plaque (plak). High cholesterol, diabetes, and smoking can cause the arteries to narrow. This narrowing of the coronary arteries can cause angina (chest pain) or lead to heart attack. During angioplasty, doctors use an expanding balloon inside the artery to compress the plaque and widen the passageway. The result is improved blood flow to the heart and a decreased chance of heart attack. Unless an artery is too small, doctors usually place a stent in the treated portion of the artery during angioplasty. The stent supports the inner artery wall and reduces the chance of the artery closing up again. A stent also can keep an artery open that was torn or injured during angioplasty.

When stents are placed in coronary arteries, there's a 1 in 5 chance that the arteries will close in the first 6 months after angioplasty. When stents aren't used, the risk of the arteries closing can be twice as high. Stents for the Carotid Arteries in the Neck Both the right and left sides of your neck have blood vessels called carotid (ka-ROT-id) arteries. These arteries carry blood from the heart to the brain. Carotid arteries can become narrowed by plaque. These plaque deposits limit blood flow to the brain and increase your risk for stroke. Your chance of developing plaque in your carotid arteries increases with age, and may increase if you smoke. A new procedure uses stents to help keep the carotid arteries fully open after they're widened with angioplasty. Not all hospitals offer this procedure. How effective it is long term is still not known. The National Institute of Neurological Disorders and Stroke supports clinical studies to explore the risks and benefits of angioplasty and stenting of carotid arteries. Stents for Other Arteries The arteries in the kidneys also can become narrowed. This reduces blood flow to the kidneys, which can affect their ability to control blood pressure. This can cause severe high blood pressure. The arteries in the arms and legs also can narrow with plaque over time. This narrowing can cause pain and cramping in the affected limbs. If the narrowing is severe, it can completely cut off the blood flow to a limb, which could require surgical treatment. To relieve these problems, doctors may perform angioplasty on the narrowed kidney, arm, or leg arteries. This procedure often is followed by placing a stent in the treated artery. The stent helps keep the artery fully open. Stents for the Aorta in the Abdomen or Chest The major artery coming out of the heart and supplying blood to the body is called the aorta. The aorta travels through the chest and then down into the abdomen. Over time, some areas of the walls of the aorta can become weak. These weakened areas can cause a bulge in the artery called an aneurysm. An aorta with an aneurysm can burst, leading to potentially deadly internal bleeding. When aneurysms occur, they're usually in the part of the aorta in the abdomen. To help avoid a burst, doctors place a fabric stent in the weakened area of the abdominal aorta. The stent creates a stronger inner lining for the artery. Aneurysms also can develop in the part of the aorta in the chest. These aneurysms also can be treated with stents. But this new use of stents is not offered by all hospitals, and how effective it is long term is still not known.

Stents To Close Off Aortic Tears Another problem that can develop in the aorta is a tear in the inside wall. Blood can be forced into this tear, causing it to widen and eventually block blood flow through the artery or burst. When this occurs, it's usually in the part of the aorta that's in the chest. Fabric stents are being developed and used experimentally to prevent aortic dissection by stopping blood from flowing into the tear. Tears in the aorta reduce blood flow to the tissues the aorta serves. A fabric stent placed within the torn area of the artery can help restore normal blood flow and reduce the risk of a burst aorta. Stents to treat aortic tears are still being researched. Only a few hospitals offer this procedure. How Are Stents Placed? To place a stent, your doctor will make a small opening in a blood vessel in your groin (upper thigh), arm, or neck. Through this opening, your doctor will thread a flexible, plastic tube (catheter) with a deflated balloon on the end. A stent may be placed around the deflated balloon. The tip of the catheter is threaded up to the narrowed artery section or to the aneurysm or aortic tear site. Special x-ray movies are taken of the tube as it is threaded up into your blood vessel. These movies help your doctor position the catheter. For Arteries Narrowed by Plaque Once the tube is in the area of the artery that needs treatment:

Your doctor uses a special dye to help see narrowed areas of the blood vessel. Your doctor inflates the balloon. It pushes against the plaque and compresses it against the artery wall. The fully extended balloon also expands the surrounding stent, pushing it into place in the artery. The balloon is deflated and taken out along with the catheter. The stent remains in your artery. Cells in your artery eventually grow to cover the mesh of the stent and create an inner layer that resembles what is normally seen inside a blood vessel.

Coronary Artery Stent Placement

The illustration shows the placement of a stent in a coronary artery with plaque buildup. The coronary artery is located on the surface of the heart. Figure A shows the deflated balloon catheter and closed stent inserted into the narrowed coronary artery. The insert image on figure A shows a cross-section of the artery with the inserted balloon catheter and closed stent. In figure B, the balloon is inflated, expanding the stent and compressing the plaque to restore the size of the artery. Figure C shows normal blood flow restored in the stent-widened artery. The insert image on figure C shows a cross-section of the compressed plaque and stent-widened artery. The animation below shows coronary angioplasty and stent placement. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows how a doctor inserts a tube called a balloon catheter into a coronary artery narrowed by plaque. The balloon catheter compresses the plaque, widens the artery, and restores blood flow. Through the catheter, a stent is placed in the artery to help maintain the restored blood flow. A very narrow artery, or one that is difficult to reach with the catheter, may require more steps to place a stent. This type of artery usually is first expanded by inflating a small balloon. The balloon is then removed and replaced by another larger balloon with the collapsed stent around it. At this point, your doctor can follow the standard practice of compressing the plaque and placing the stent. When angioplasty and stent placement are performed on carotid arteries, a special filter device is used. The filter helps keep blood clots and loose pieces of plaque from passing into the bloodstream and brain during the procedure. For Aortic Aneurysms Placing a stent to treat an aneurysm in an artery is slightly different than treating an artery narrowed by plaque. The stent used to treat an aneurysm is made out of pleated fabric, often with one or more tiny hooks. Once the catheter is positioned at the aneurysm site, the stent is threaded through the tube to the area that needs treatment. Then, your doctor places a balloon inside the stent. The balloon is inflated to expand the stent and have it fit tight against the artery wall. The hooks on the stent latch on to the artery wall to anchor the stent. Your doctor then removes the balloon and catheter, leaving the fabric stent behind.

The stent creates a new inner lining for that portion of the artery. Cells in the artery eventually grow to cover the fabric and create an inner layer that resembles whats normally seen inside a blood vessel. What To Expect Before a Stent Procedure Most stent procedures require an overnight stay in the hospital and someone to take you home. Discuss with your doctor:

When to stop eating and drinking before coming to the hospital What medicines you should or shouldn't take on the day of the procedure When to come to the hospital and where to go

You also should let your doctor know if you have diabetes, kidney disease, or other conditions that may require taking extra steps during or after the procedure to avoid complications. What To Expect During a Stent Procedure For Arteries Narrowed by Plaque This procedure usually takes a few hours. Before the procedure starts, you will get medicine to help you relax. You will be on your back and awake during the procedure so you can follow the doctor's instructions. The area where the catheter is inserted will be numbed and you won't feel the doctor threading the catheter, balloon, or stent inside the artery. You may feel some pain when the balloon is expanded to push the stent into place. For Aortic Aneurysms This procedure takes a few hours. It usually requires a 2- to 3-day stay in the hospital. Before the procedure, you will be given medicine to help you relax. If a stent is placed in the abdominal portion of the aorta, your doctor may give you a regional anesthetic. This will make you numb from the area of the stent placement down, but it will allow you to be awake during the procedure. If a stent is placed in the chest portion of the aorta, usually a general anesthetic will be used, which will make you sleep through the procedure. Once you're numbed or asleep, your doctor will make a small cut in your groin (upper thigh). The doctor will insert a catheter into the blood vessel through this cut. Sometimes, two cuts (one above each leg) are needed to place fabric stents that come in two parts. You will not feel the doctor threading the catheter, balloon, or stent into the artery. What To Expect After a Stent Procedure Recovery

After either type of stent procedure (for arteries narrowed by plaque or aortic aneurysm), once the stent has been placed and the balloon and catheter have been removed, the tube insertion site will be bandaged. A small sandbag or other type of weight may be put on top of the bandage to apply pressure to help prevent bleeding. You will recover in a special care area where your movement will be limited. While you're in recovery, a nurse will check your heart rate and blood pressure regularly. The nurse also will see if there's any bleeding from the insertion site. Eventually, a small bruise and sometimes a small, hard "knot" will appear at the insertion site. This area may feel sore or tender for about a week. You should let your doctor know if:

You have a constant or large amount of bleeding at the site that can't be stopped with a small bandage. You have any unusual pain, swelling, redness, or other signs of infection at or near the insertion site.

Common Precautions After a Stent Procedure After a stent procedure, your doctor may have you take blood-thinning or anticlotting medicines for at least a few months. These medicines help prevent the development of blood clots in the stent. If your stent is coated with medicine, your doctor may advise you to take aspirin and an anticlotting medicine for months to years to lower the risk of blood clots. You should avoid vigorous exercise and heavy lifting for a short time after the procedure. Your doctor will discuss with you when you can resume normal activities. If you have a metal stent placed, you shouldn't have a magnetic resonance imaging (MRI) test within the first couple of months after the procedure. Metal detectors used in airports and other screening areas don't affect stents. If you have an aortic fabric stent, your doctor will probably recommend that you have followup imaging tests (for example, x ray) within the first year of having the procedure, and yearly imaging tests after that. What Are the Risks of Having a Stent? Risks Related to Angioplasty Any medical procedure has risks, but major complications from angioplasty are rare. The most common risks from angioplasty include:

Bleeding from the site where the catheter was inserted into the skin Damage to the blood vessel from the catheter Infection

Allergic reaction to the dye used during the procedure

Another common problem after angioplasty is too much tissue growth within the treated portion of the artery. This can cause the artery to narrow or close again, which is called restenosis. This problem is often avoided with the use of newer stents coated with medicines that help prevent too much tissue growth. Treating the tissue around the stent with radiation also can prevent tissue growth. For this procedure, the doctor puts a wire through a catheter to where the stent is placed. The wire releases radiation and stops cells around the stent from growing and blocking the artery. Restenosis of a Stent-Widened Coronary Artery

The illustration shows the restenosis of a stent-widened coronary artery. The coronary artery is located on the surface of the heart. In figure A, the expanded stent compresses plaque, allowing normal blood flow. The inset image on figure A shows a cross-section of the compressed plaque and stent-widened artery. In figure B, over time, the plaque grows through and around the stent, causing a partial blockage and abnormal blood flow. The inset image on figure B shows a cross-section of the growth of the plaque around the stent. Risks Related to Stent

About 1 to 2 percent of people with a stented artery develop a blood clot at the stent site. Blood clots can cause heart attacks, strokes, or other serious problems. The risk of blood clots is greatest during the first few months after the stent is placed in the artery. Your doctor will probably have you take blood-thinning or anticlotting medicines for at least a few months after having a stent procedure to prevent blood clots. Stents coated with medicine (drug-releasing stents), which are often used to keep clogged heart arteries open, may increase your risk for potentially dangerous blood clots. But an expert Food and Drug Administration panel found no conclusive evidence that these stents increase the chances of having a heart attack or dying, if used as recommended. Patients with drug-releasing stents are usually advised to take aspirin and an anticlotting drug, such as clopidogrel, for months to years to lower the risk of blood clots. Risks Related to Aortic Stents in the Abdomen Whenever an aneurysm in the abdomen region of the aorta is repaired with either surgery or with a fabric stent, few rare but serious complications can occur, including:

A burst artery (aneurysm rupture). Blocked blood flow to the stomach or lower body. Paralysis in the legs due to interruption of blood flow to the spinal cord. This is an especially rare complication.

Another possible complication is the fabric stent moving further down the aorta. This sometimes happens years after the stent is first placed. Such stent movement may require a doctor to place another fabric stent in the area of the aneurysm. Key Points

A stent is a small mesh tube thats used to treat narrowed or weakened arteries in the body. A stent is usually placed in an artery after it has been widened with a procedure called angioplasty. Angioplasty and stents are often used to relieve chest pain and minimize damage to the heart due to narrowed or blocked heart arteries. They also are used in other arteries in the body to prevent loss of blood flow to the limbs, and to prevent weakened arteries from bursting. Stents are usually made of metal mesh, but sometimes theyre made of fabric. Fabric stents, also called stent grafts, are used in larger arteries. Stents can be placed in the carotid arteries or the aorta, and in leg, arm, or kidney arteries to prevent stroke or loss of a limb, or to relieve high blood pressure. Stents are used to repair aortic arteries that have bulges called aneurysms. To place a stent, your doctor makes a small opening in a blood vessel in your groin (upper thigh), arm, or neck. Through this opening, a flexible, plastic tube (catheter) with a collapsed balloon and stent on the end is threaded up to the area of the artery

that needs treatment. The balloon is then expanded, which widens the narrowed artery and pushes the stent into place.

The placement of a stent only takes a few hours. You may have to stay in the hospital for up to 3 days, depending on which artery was treated. You may feel some pain when the balloon is expanded to push a stent into place. To prevent blood clots, you will probably take blood-thinning medicines for at least a few months after having a stent placed. Vigorous exercise and heavy lifting should be avoided for a short time after a stent procedure. Your doctor will discuss with you when you can resume normal activities. Developing a blood clot at the stent site is the main risk of having a stent. Blood clots can cause heart attack, stroke, and other serious problems. This risk is greatest during the first few months after the stent is placed in the artery. Taking bloodthinning or anticlotting medicines can decrease the risk for a blood clot. There also are risks related to angioplasty and to the placement of the stent. Patients with drug-releasing stents are usually advised to take aspirin and an anticlotting drug, such as clopidogrel, for months to years to lower the risk of blood clots.

What Is an Aneurysm?
An aneurysm (AN-u-rism) is an abnormal bulge or ballooning in the wall of an artery. Arteries are blood vessels that carry oxygen-rich blood from the heart to other parts of the body. An aneurysm that grows and becomes large enough can burst, causing dangerous, often fatal, bleeding inside the body. Most aneurysms occur in the aorta. The aorta is the main artery that carries blood from the heart to the rest of the body. The aorta comes out from the left ventricle (VEN-trih-kul) of the heart and travels through the chest and abdomen. An aneurysm that occurs in the aorta in the chest is called a thoracic (tho-RAS-ik) aortic aneurysm. An aneurysm that occurs in the aorta in the abdomen is called an abdominal aortic aneurysm. Aneurysms also can occur in arteries in the brain, heart, intestine, neck, spleen, back of the knees and thighs, and in other parts of the body. If an aneurysm in the brain bursts, it causes a stroke. About 15,000 Americans die each year from ruptured aortic aneurysms. Ruptured aortic aneurysm is the 10th leading cause of death in men over age 50 in the United States. Many cases of ruptured aneurysm can be prevented with early diagnosis and medical treatment. Because aneurysms can develop and become large before causing any symptoms, it is important to look for them in people who are at the highest risk. Experts recommend that men who are 65 to 75 years old and have ever smoked (at least 100 cigarettes in their lifetime) should be checked for abdominal aortic aneurysms.

When found in time, aneurysms can usually be treated successfully with medicines or surgery. If an aortic aneurysm is found, the doctor may prescribe medicine to reduce the heart rate and blood pressure. This can reduce the risk of rupture. Large aortic aneurysms, if found in time, can often be repaired with surgery to replace the diseased portion of the aorta. The outlook is usually excellent. August 2006 Types of Aneurysm Types of aneurysm include aortic aneurysms, cerebral aneurysms, and peripheral aneurysms. Aortic Aneurysm Most aneurysms occur in the aorta. The aorta is the main artery that carries blood from the heart to the rest of the body. The aorta comes out from the left ventricle of the heart and travels through the chest and abdomen. The two types of aortic aneurysm are thoracic aortic aneurysm (TAA) and abdominal aortic aneurysm (AAA). Thoracic Aortic Aneurysm An aortic aneurysm that occurs in the part of the aorta running through the thorax (chest) is a thoracic aortic aneurysm. One in four aortic aneurysms is a TAA. Most TAAs do not produce symptoms, even when they are large. Only half of all people with TAAs notice any symptoms. TAAs are identified more often now than in the past because of chest computed tomography (CT) scans performed for other medical problems. In a common type of TAA, the walls of the aorta become weak and a section nearest to the heart enlarges. Then the valve between the heart and the aorta cannot close properly and blood leaks backward into the heart. Less commonly, a TAA can develop in the upper back away from the heart. A TAA in this location can result from and injury to the chest such as from an auto crash. Abdominal Aortic Aneurysm An aortic aneurysm that occurs in the part of the aorta running through the abdomen is an abdominal aortic aneurysm. Three in four aortic aneurysms are AAAs. An AAA can grow very large without producing symptoms. About 1 in 5 AAAs rupture.

Figure A shows a normal aorta. Figure B shows a thoracic aortic aneurysm located behind the heart. Figure C shows an abdominal aortic aneurysm located below the arteries that supply the kidneys. Cerebral Aneurysm Aneurysms that occur in an artery in the brain are called cerebral aneurysms. They are sometimes called berry aneurysms because they are often the size of a small berry. Most cerebral aneurysms produce no symptoms until they become large, begin to leak blood, or rupture.

The illustration shows a typical location of a cerebral (berry) aneurysm in the arteries supplying blood to the brain. The inset image shows a closeup of the sac-like aneurysm. A ruptured cerebral aneurysm causes a stroke. Signs and symptoms can include a sudden, extremely severe headache, nausea, vomiting, stiff neck, sudden weakness in an area of the body, sudden difficulty speaking, and even loss of consciousness, coma, or death. The danger of a cerebral aneurysm depends on its size and location in the brain, whether it leaks or ruptures, and the persons age and overall health. Peripheral Aneurysm Aneurysms that occur in arteries other than the aorta (and not in the brain) are called peripheral aneurysms. Common locations for peripheral aneurysms include the artery that runs down the back of the thigh behind the knee (popliteal artery), the main artery in the groin (femoral artery), and the main artery in the neck (carotid artery). Peripheral aneurysms are not as likely to rupture as aortic aneurysms, but blood clots can form in peripheral aneurysms. If a blood clot breaks away from the aneurysm, it can block blood flow through the artery. If a peripheral aneurysm is large, it can press on a nearby nerve or vein and cause pain, numbness, or swelling. Other Names for Aneurysm

Aortic aneurysm
o o

Abdominal aortic aneurysm, or AAA Thoracic aortic aneurysm, or TAA

Cerebral aneurysm

Peripheral aneurysm

What Causes an Aneurysm? An aneurysm can result from atherosclerosis (hardening and narrowing of the inside of arteries). As atherosclerosis develops, the artery walls become thick and damaged and lose their normal inner lining. This damaged area of artery can stretch or "balloon" from the pressure of blood flow inside the artery, resulting in an aneurysm. An aneurysm also can develop from constant high blood pressure inside an artery. A thoracic aortic aneurysm can result from an injury to the chest (for example, an injury that occurs from an auto crash). Certain medical conditions, such as Marfan syndrome, that weaken the body's connective tissues, also can cause aneurysms. In rare cases, infections such as untreated syphilis (a sexually transmitted infection) can cause aortic aneurysms. Aortic aneurysms also can occur as a result of diseases that cause inflammation of blood vessels, such as vasculitis. Who Is At Risk for an Aneurysm? Populations Affected Men are 5 to 10 times more likely than women to have an abdominal aortic aneurysm (AAA)the most common type of aneurysm. The risk of AAA increases as you get older, and it is more likely to occur in people between the ages of 60 to 80. A peripheral aneurysm also is more likely to affect people ages 60 to 80. Cerebral (brain) aneurysms, though rare, are more likely to occur in people ages 35 to 60. Risk Factors Factors that increase your risk for aneurysm include:

Atherosclerosis, a buildup of fatty deposits in the arteries. Smoking. You are eight times more likely to develop an aneurysm if you smoke. Overweight or obesity. A family history of aortic aneurysm, heart disease, or other diseases of the arteries. Certain diseases that can weaken the wall of the aorta, such as:
o o o

Marfan syndrome (an inherited disease in which tissues don't develop normally) Untreated syphilis (a very rare cause today) Tuberculosis (also a very rare cause today)

Trauma such as a blow to the chest in a car accident.

Severe and persistent high blood pressure between the ages of 35 and 60. This increases the risk for a cerebral aneurysm. Use of stimulant drugs such as cocaine.

What Are the Signs and Symptoms of an Aneurysm? The signs and symptoms of an aneurysm depend on its type, location, and whether it has ruptured or is interfering with other structures in the body. Aneurysms can develop and grow for years without causing any signs or symptoms. It is often not until an aneurysm ruptures or grows large enough to press on nearby parts of the body or block blood flow that it produces any signs or symptoms. Abdominal Aortic Aneurysm Most abdominal aortic aneurysms (AAAs) develop slowly over years and have no signs or symptoms until (or if) they rupture. Sometimes, a doctor can feel a pulsating mass while examining a patient's abdomen. When symptoms are present, they can include:

Deep penetrating pain in your back or the side of your abdomen Steady gnawing pain in your abdomen that lasts for hours or days at a time Coldness, numbness, or tingling in your feet due to blocked blood flow in your legs

If an AAA ruptures, symptoms can include sudden, severe pain in your lower abdomen and back; nausea and vomiting; clammy, sweaty skin; lightheadedness; and a rapid heart rate when standing up. Internal bleeding from a ruptured AAA can send you into shock. Shock is a life-threatening condition in which the organs of the body do not get enough blood flow. Thoracic Aortic Aneurysm A thoracic (chest) aortic aneurysm may have no symptoms until the aneurysm begins to leak or grow. Signs or symptoms may include:

Pain in your jaw, neck, upper back (or other part of your back), or chest Coughing, hoarseness, or trouble breathing

Cerebral Aneurysm If a cerebral (brain) aneurysm presses on nerves in your brain, it can cause signs and symptoms. These can include:

A droopy eyelid Double vision or other changes in vision Pain above or behind the eye A dilated pupil Numbness or weakness on one side of the face or body

If a cerebral aneurysm ruptures, symptoms can include a sudden, severe headache, nausea and vomiting, stiff neck, loss of consciousness, and signs of a stroke. Signs of a stroke are similar to those listed above for cerebral aneurysm, but they usually come on suddenly and are more severe. Any of these symptoms require immediate medical attention. Peripheral Aneurysm Signs and symptoms of peripheral aneurysm may include:

A pulsating lump that can be felt in your neck, arm, or leg Leg or arm pain, or cramping with exercise Painful sores on toes or fingers Gangrene (tissue death) from severely blocked blood flow in your limbs

An aneurysm in the popliteal artery (behind the knee) can compress nerves and cause pain, weakness, and numbness in your knee and leg. Blood clots can form in peripheral aneurysms. If a clot breaks loose and travels through the bloodstream, it can lodge in your arm, leg, or brain and block the artery. An aneurysm in your neck can block the artery to the brain and cause a stroke. How Is an Aneurysm Diagnosed? An aneurysm may be found by chance during a routine physical exam. More often, an aneurysm is found by chance during an x ray, ultrasound, or computed tomography (CT) scan performed for another reason, such as chest or abdominal pain. If you have an abdominal aortic aneurysm (AAA), the doctor may feel a pulsating mass in your abdomen. A rapidly growing aneurysm about to rupture can be tender and very painful when pressed. If you are overweight or obese, it may be difficult for your doctor to feel even a large abdominal aneurysm. If you have an AAA, your doctor may hear rushing blood flow instead of the normal whooshing sound when listening to your abdomen with a stethoscope. Specialists Involved You may be referred to a cardiothoracic surgeon, vascular surgeon, or neurosurgeon for diagnosis and treatment of an aneurysm. A cardiothoracic surgeon performs surgery on the heart, lungs, and other organs and structures in the chest, including the aorta. A vascular surgeon performs surgery on the abdominal aorta and on the peripheral arteries. A neurosurgeon performs surgery on the brain, including the arteries in the head, and on the spine and nerves. Diagnostic Tests and Procedures

To diagnose and evaluate an aneurysm, one or more of the following tests or procedures may be performed:

Chest x ray. A chest x ray provides a picture of the organs and structures inside the chest, including the heart, lungs, and blood vessels. Ultrasound. This simple and painless test uses sound waves to create a picture of the inside of the body. It shows the size of an aneurysm, if one is detected. The ultrasound scan may be repeated every few months to see how quickly an aneurysm is growing. CT scan. A CT scan provides computer-generated, x-ray images of the internal organs. A CT scan may be performed if the doctor suspects a TAA or AAA. A liquid dye that can be seen on an x ray is injected into an arm vein to outline the aorta or artery on the CT scan. The CT scan images can be used to determine the size and shape of an abdominal aneurysm more accurately than an ultrasound. MRI. MRI uses magnets and radio waves to create images of the inside of the body. It is very accurate in detecting aneurysms and determining their size and exact location. Angiography. Angiography also uses a special dye injected into the blood stream to make the insides of arteries show up on x-ray pictures. An angiogram shows the amount of damage and blockage in blood vessels. Aortogram. An aortogram is an angiogram of the aorta. It may show the location and size of an aortic aneurysm, and the arteries of the aorta that are involved.

How Is an Aneurysm Treated? Goals of Treatment Some aneurysms, mainly small ones that are not causing pain, can be treated with "watchful waiting." Others need to be treated to prevent growth and complications. The goals of treatment are to prevent the aneurysm from growing, prevent or reverse damage to other body structures, prevent or treat a rupture, and to allow you to continue to participate in normal daily activities. Treatment Options Medicine and surgery are the two types of treatment for an aneurysm. Medicines may be prescribed before surgery or instead of surgery. Medicines are used to reduce pressure, relax blood vessels, and reduce the risk of rupture. Beta blockers and calcium channel blockers are the medicines most commonly used. Surgery may be recommended if an aneurysm is large and likely to rupture. Treatment by Type of Aneurysm

Aortic Aneurysm Experts recommend that men who have ever smoked (at least 100 cigarettes in their lifetime) and are between the ages of 65 and 75 should have an ultrasound screening to check for abdominal aortic aneurysms. Treatment recommendations for aortic aneurysms are based on the size of the aneurysm. Small aneurysms found early can be treated with "watchful waiting."

If the diameter of the aorta is small-less than 3 centimeters (cm)-and there are no symptoms, "watchful waiting" and a followup screening in 5 to 10 years may be all that is needed, as determined by the doctor. If the aorta is between 3 and 4 cm in diameter, the patient should return to the doctor every year for an ultrasound to see if the aneurysm has grown. If the aorta is between 4 and 4.5 cm, testing should be repeated every 6 months. If the aorta is larger than 5 cm (2 inches around or about the size of a lemon) or growing more than 1 cm per year, surgery should be considered as soon as possible.

Two main types of surgery to repair aortic aneurysms are open abdominal or open chest repair and endovascular repair. The traditional and most common type of surgery for aortic aneurysms is open abdominal or open chest repair. It involves a major incision in the abdomen or chest. General anesthesia is needed with this procedure. The aneurysm is removed and the section of aorta is replaced with an artificial graft made of material such as Dacron or Teflon. The surgery takes 3 to 6 hours, and the patient remains in the hospital for 5 to 8 days. It often takes a month to recover from open abdominal or open chest surgery and return to full activity. Open abdominal and chest surgeries have been performed for 50 years. More than 90 percent of patients make a full recovery. In endovascular repair, the aneurysm is not removed, but a graft is inserted into the aorta to strengthen it. This type of surgery is performed through catheters (tubes) inserted into the arteries; it does not require surgically opening the chest or abdomen. To perform endovascular repair, the doctor first inserts a catheter into an artery in the groin (upper thigh) and threads it up to the area of the aneurysm. Then, watching on x ray, the surgeon threads the graft (also called a stent graft) into the aorta to the aneurysm. The graft is then expanded inside the aorta and fastened in place to form a stable channel for blood flow. The graft reinforces the weakened section of the aorta to prevent the aneurysm from rupturing.

The illustration shows the placement of an endovascular stent graft in an aortic aneurysm. In figure A, a catheter is inserted into an artery in the groin (upper thigh). It is then threaded up to the abdominal aorta, and the stent graft is released from the catheter. In figure B, the stent graft allows blood to flow through the aneurysm. Endovascular repair surgery reduces recovery time to a few days and greatly reduces time in the hospital. The procedure has been used since 1999. Not all aortic aneurysms can be repaired with this procedure. The exact location or size of the aneurysm may prevent the stent graft from being safely or reliably positioned inside the aneurysm. Cerebral Aneurysm Treatment for cerebral (brain) aneurysms depends on the size and location of the aneurysm, whether it is infected, and whether it has ruptured. A small cerebral aneurysm that hasn't burst may not need treatment. A large cerebral aneurysm may press against brain tissue, causing a severe headache or impaired vision, and is likely to burst. If the aneurysm ruptures, there will be bleeding into the brain which will cause a stroke. If a cerebral aneurysm becomes infected, it requires immediate medical treatment. Treatment of many cerebral aneurysms, especially large or growing ones, involves surgery, which can be risky depending on the location of the aneurysm. Peripheral Aneurysm Most peripheral aneurysms have no symptoms, especially if they are small. They seldom rupture.

Treatment of peripheral aneurysms depends on the presence of symptoms, the location of the aneurysm, and whether the blood flow through the artery is blocked. Blood clots can form in a peripheral aneurysm, break loose, and block the artery. An aneurysm in the back of the knee that is larger than 1 inch in diameter usually requires surgery. An aneurysm in the thigh also is usually repaired with surgery. How Can an Aneurysm Be Prevented? The best way to prevent an aneurysm is to avoid the risk factors that increase the changes of developing one. To do this, you can:

Quit smoking. Eat a low-fat, low-cholesterol diet to reduce the buildup of plaque in the arteries. Plaque is a fatty buildup that narrows the arteries. Control high blood pressure (eating a low-salt diet helps). Control high cholesterol. Get regular physical activity.

Key Points

An aneurysm is an abnormal bulge or "ballooning" in the wall of an artery. Arteries are blood vessels that carry oxygen-rich blood from the heart to other parts of the body. An aneurysm that grows and becomes large enough can rupture, causing dangerous bleeding inside the body. Most aneurysms occur in the aorta. The aorta is the main artery that carries blood from the heart to the rest of the body. Most aneurysms (3 out of 4) are found by chance when a diagnostic test, such as x ray or ultrasound, is performed for a different reason. Many cases of ruptured aneurysm can be prevented with early diagnosis and medical treatment. Because aneurysms can develop and become large before causing any symptoms, it is important to look for them in people who are at the highest risk. Ultrasound screening for abdominal aortic aneurysms is recommended for men who have ever smoked and are between the ages of 65 and 75. Medicines and surgery are the two main treatments for aneurysms. Medicines may be prescribed before surgery or instead of surgery. To prevent an aneurysm and keep blood vessels healthy, quit smoking, eat a low-fat, low-cholesterol diet, get regular physical activity, and control high blood pressure and high cholesterol.

What Is Sudden Cardiac Arrest?

Sudden cardiac arrest (SCA), also known as sudden cardiac death, is when the heart suddenly and unexpectedly stops beating. When this occurs, blood stops flowing to the brain and other vital organs. SCA usually causes death if not treated in minutes. The heart has an internal electrical system that controls the rhythm of the heartbeat. Problems with the electrical system can cause abnormal heart rhythms, called arrhythmias (ah-RITH-me-ahs). There are many types of arrhythmia. During an arrhythmia, the heart can beat too fast, too slow, or it can stop beating. SCA occurs when the heart develops an arrhythmia that causes it to stop beating. SCA is not the same thing as a heart attack. A heart attack is a problem with blocked blood flow to a part of the heart muscle. In a heart attack, the heart usually does not suddenly stop beating. SCA, however, may happen during recovery from a heart attack. People with heart disease have a higher chance of having SCA. But most SCAs happen in people who appear healthy and have no known heart disease or other risk factors for SCA. Outlook Ninety-five percent of people who have SCA die from it, most within minutes. Rapid treatment of SCA with a device that sends an electrical shock to the heart (called a defibrillator) can be lifesaving. Automated external defibrillators (AEDs), which are often found in public places like airports and office buildings, can be used to save the lives of people having SCAs. August 2006 Other Names for Sudden Cardiac Arrest The term "sudden cardiac death" is sometimes used to describe the sudden loss of heart function, even if the person is resuscitated and survives. This is the term that doctors most often use when gathering information on the number of people who have suffered sudden cardiac arrest. What Causes Sudden Cardiac Arrest? Most cases of sudden cardiac arrest (SCA) are due to an arrhythmia called ventricular fibrillation (v-fib). In v-fib, the ventricles (the large pumping chambers of the heart) quiver very rapidly and irregularly instead of beating normally. When this happens, the heart pumps little or no blood to the body. Death results if the arrhythmia is not treated within a few minutes. Other electrical problems that can cause SCA are extreme slowing of the rate of the heart's electrical signals or when heart muscle stops responding to the electrical signals. Several factors can cause the electrical problems that lead to SCA. These factors include:

Coronary artery disease (CAD)

Severe physical stress Inherited disorders Structural changes in the heart

Coronary Artery Disease CAD occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed, causing less blood to flow to the muscle. The arteries harden and narrow because a material called plaque (plak) builds up on their inner walls. As the plaque increases in size, the insides of the coronary arteries narrow, and less blood flows through them to the heart muscle. Eventually, the heart muscle is not able to receive the amount of blood and oxygen that it needs. Reduced blood flow or no blood flow to the heart muscle can result in a heart attack. During a heart attack, some heart tissue dies and turns into scar tissue. This can damage the heart's electrical system, increasing the risk for dangerous arrhythmias and SCA. Physical Stress Certain physical stresses can cause the heart's electrical system to fail. The physical stresses that cause this to happen include:

Major blood loss. Severe lack of oxygen. Very low blood levels of potassium or magnesium. Intense exercise. The hormone adrenaline released during intense exercise can trigger SCA in people who have other heart problems.

Inherited Disorders A tendency to develop arrhythmias runs in some families. This tendency is inherited, which means it is passed from parents to children. Members of these families might have an increased chance of having SCA. Other people are born with inherited structural defects in their hearts that may increase their chance of having SCA. Structural Changes in the Heart Changes in the heart's normal size or structure can affect its electrical system. Such changes include a heart enlarged by blood pressure or advanced heart disease. Heart infections also can cause structural changes in the heart. Several research studies are under way to try to understand these possible causes of SCA and to find other causes. Who Is At Risk for Sudden Cardiac Arrest? Populations Affected

Each year, between 250,000 and 450,000 Americans have sudden cardiac arrest (SCA). Ninety-five percent of these people die within minutes. SCA occurs most often in adults in their mid-thirties to mid-forties. It affects men twice as often as women. SCA rarely occurs in children unless they have inherited problems that make them likely to have SCA. Only 1 to 2 out of every 100,000 children experiences SCA each year. Major Risk Factors The major risk factor for SCA is having coronary artery disease (CAD). Most people who have SCA have some degree of CAD. But most of these people don't know they have CAD until SCA occurs. Their CAD is "silent" (that is, it has no symptoms), and doctors and nurses have not previously found it. Because of this, most cases of SCA happen in people with silent CAD who have no known heart disease at the time of the event. Many people with SCA had a silent heart attack before the SCA happened. These people have no obvious signs of having a heart attack, and they don't even realize that they've had one. The chances for having SCA are higher during the first 6 months after a heart attack. The risk factors for developing CAD include:

Smoking A family history of early cardiovascular disease (that is, heart disease diagnosed before age 55 in your father or a brother, or heart disease diagnosed before age 65 in your mother or a sister) High blood cholesterol Diabetes Increasing age (risk increases for men after age 45 and for women after age 55) High blood pressure Overweight and obesity Lack of physical activity

Other Risk Factors Other risk factors for SCA include:

A personal or family history of SCA Abnormal heart rhythms (arrhythmias) Birth defects of the heart or blood vessels, or an enlarged heart Heart failure Recreational drug abuse

What Are the Signs and Symptoms of Sudden Cardiac Arrest?

Usually, the first sign of sudden cardiac arrest is loss of consciousness, which is similar to fainting. At the same time, breathing often stops and no heartbeat (or pulse) can be felt. Some people may first notice that they have a racing heartbeat or feel dizzy or lightheaded just before they faint. How Is Sudden Cardiac Arrest Diagnosed? Sudden cardiac arrest (SCA) happens without warning and requires immediate treatment. Rarely is there a chance to diagnose it with medical tests as it is happening. Instead, SCA is often diagnosed after it happens, by ruling out other causes of the patient's sudden collapse. Specialists Involved People who may be at high risk for SCA can see a cardiologist (heart specialist) who can decide whether they need preventive treatments. Some cardiologists specialize in recognizing and treating problems with the electrical system of the heart. These specialists are called electrophysiologists (e-LEK-tro-FIH-ze-ah-low-jists). Diagnostic Tests and Procedures Doctors use several tests to help detect the factors that put people at risk for SCA. These tests include:

EKG (electrocardiogram). This is a simple test that records the electrical activity of the heart from the body's surface. It's used to detect and locate the source of arrhythmias and other heart problems. It may show whether you have had a heart attack. Echocardiogram. This test uses sound waves to create a moving picture of your heart. Echocardiogram provides information about the size and shape of your heart and how well your heart chambers and valves are functioning. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that are not contracting normally, and previous injury to the heart muscle caused by poor blood flow. There are several different types of echocardiograms, including a stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine into your bloodstream that makes your heart beat faster and work harder. A stress echocardiogram is usually done to find out if you have decreased blood flow to your heart (coronary artery disease). MUGA test or magnetic resonance imaging (MRI) heart scans. These scans can detect whether the heart has a reduced ability to pump blood. Cardiac catheterization. In this procedure, a thin, flexible tube (called a catheter) is passed through an artery in the groin (upper thigh) or arm to reach the coronary arteries in the heart. Your doctor can use the catheter to determine pressure and blood flow in the heart's chambers, collect blood samples from the heart, and examine the coronary arteries by x ray.

Electrophysiology study. For this study, doctors also use cardiac catheterization to see how the heart's electrical system responds to certain medicines and electrical stimulation. The electrical stimulation helps to find where the heart's electrical system is damaged.

How Is Sudden Cardiac Arrest Treated?

Sudden cardiac arrest (SCA) requires immediate treatment with a defibrillator, a device that sends an electrical shock to the heart. Defibrillation can restore a normal rhythm to a heart that is beating irregularly. To be effective, defibrillation must be provided within minutes of cardiac arrest. With every minute of delay in providing defibrillation, the chances of surviving SCA drop rapidly. Police, emergency medical technicians, and other first responders are usually trained and equipped to use a defibrillator. The sooner 911 is called after a person experiences SCA, the sooner potentially lifesaving defibrillation can be provided. Special defibrillators that untrained bystanders can use in an emergency are becoming more available in some public places, like airports, office buildings, and shopping centers. These devices are called automated external defibrillators (AEDs). To prevent delivering a shock to someone who may have fainted but is not having a SCA, AEDs are programmed to deliver a shock only if the computer detects a dangerously abnormal heart rhythm, such as ventricular fibrillation. Cardiopulmonary resuscitation (CPR) should be given to a person having SCA until defibrillation can be provided. A person who survives SCA is usually admitted to the hospital for observation and treatment. In the hospital, the heart is monitored closely, medicines may be given to try to reduce the chance of another SCA, and tests are performed to identify the cause of the SCA. If coronary artery disease is detected, the person may undergo a procedure called angioplasty to restore blood flow through blocked coronary arteries. Often, a device called an implantable cardioverter defibrillator (ICD) will be surgically placed under the skin. An ICD continuously monitors the heart for dangerous rhythms. If SCA or another dangerous rhythm is detected, the ICD immediately delivers an electric shock to restore a normal rhythm.

How Can Death Due to Sudden Cardiac Arrest Be Prevented?

Ways to prevent death due to sudden cardiac arrest (SCA) differ depending on whether a person has already had SCA; has never had SCA but is at high risk; or has never had SCA and has no known risk factors for it.

For People Who Have Survived Sudden Cardiac Arrest

People who have already had SCA are at high risk of having it again. For these people, research shows that an implantable cardioverter defibrillator (ICD) reduces the chances of dying from a second SCA. An ICD is surgically implanted under the skin. It continually monitors the heartbeat and delivers a shock to the heart when it detects a dangerous rhythm. The shocks can be painful, like a kick in the chest. Medicines can be given to try to reduce

how often the person experiences the irregular heartbeats that trigger the device to deliver a shock.

The illustration shows the location of an implantable cardioverter defibrillator in the upper chest. The electrodes are inserted into the heart through a vein. An ICD is not the same as a pacemaker. Doctors mainly use pacemakers to treat hearts that beat too slowly. However, some ICDs also can function as pacemakers. For People at Increased Risk of a First Sudden Cardiac Arrest People with severe coronary artery disease (CAD) are at increased risk for SCA. This is especially true if they have recently had a heart attack. For these people, a type of medicine called a beta blocker can help reduce the chances of dying from SCA. For People With No Known Risk Factors for Sudden Cardiac Arrest The underlying cause of most SCAs seems to be CAD. CAD also is a major risk factor for angina and heart attack, and it contributes to other heart problems. Heart-healthy lifestyle choices can help you reduce your chances of CAD, SCA, and other heart problems. These lifestyle choices include:

Eating a diet low in cholesterol and saturated fats and high in omega-3 fatty acids (see the National Heart, Lung, and Blood Institute's Aim for a Healthy Weight Web site). Participating in physical activity Not smoking

Maintaining a healthy weight

Treatments for high blood pressure, diabetes, and high blood cholesterol also help lower the risk for SCA. Key Points

Sudden cardiac arrest (SCA) is when the heart suddenly and unexpectedly stops beating. This is often because of a problem with the heart's electrical system. SCA is not the same thing as a heart attack, although it may happen during recovery from a heart attack. The first sign of SCA is usually sudden loss of consciousness. Ninety-five percent of people who have SCA die from it, most within minutes. Several factors can cause electrical problems that trigger SCA, including coronary artery disease, physical stress, inherited disorders, and structural changes in the heart. People with heart disease have a greater chance of having SCA. But most cases occur in people who appear healthy and have no known heart disease or other risk factors for SCA. SCA occurs most often in adults in their mid-thirties to mid-forties. It affects men twice as often as women. SCA rarely occurs in children (although children with certain inherited heart conditions are at increased risk). Several tests can help show if people have a greater chance for having SCA. These tests are EKG, echocardiogram, MUGA test, magnetic resonance imaging (MRI) heart scan, cardiac catheterization, and electrophysiology study. SCA requires immediate treatment with a device called a defibrillator, which delivers an electrical shock to the heart. Successful defibrillation restores normal rhythm to the heart. Defibrillation must be provided within minutes after SCA to avoid permanent damage to the body and brain and to prevent death. With every minute of delay in providing defibrillation, the chances of surviving SCA drop rapidly. People experiencing SCA should be given cardiopulmonary resuscitation (CPR) until they can be treated with a defibrillator. Special defibrillators called automated external defibrillators (AEDs) can be used by untrained bystanders in an emergency. AEDs are becoming increasingly available at public places, such as airports, office building, and shopping centers. People who survive SCA may need an implantable cardioverter defibrillator to help prevent death if another SCA happens. Beta blocker drugs also help reduce the chance of death from SCA in people with known heart disease. Heart healthy lifestyle choices may lower people's chances for SCA.

What Is Cardiac Catheterization?

Cardiac catheterization (KATH-e-ter-i-ZA-shun) is a medical procedure used to diagnose and treat certain heart conditions. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Through the catheter, doctors can perform diagnostic tests and treatments on your heart. Sometimes a special dye is put into the catheter to make the insides of your heart and blood vessels show up on x rays. The dye can show whether a material called plaque (plak) has narrowed or blocked any of your hearts arteries (called coronary arteries). Plaque is made up of fat, cholesterol, calcium, and other substances found in your blood. The buildup of plaque narrows the inside of the arteries and, in time, may restrict blood flow to your heart. When this happens, its called coronary artery disease (CAD). Blockages in the arteries also can be seen using ultrasound during cardiac catheterization. Ultrasound uses sound waves to create detailed pictures of the hearts blood vessels. Doctors may take samples of blood and heart muscle during cardiac catheterization, as well as do minor heart surgery. Cardiologists (doctors who specialize in treating people who have heart problems) usually perform cardiac catheterization in a hospital. Youre awake during the procedure, and it causes little to no pain, although you may feel some soreness in the blood vessel where your doctor put the catheter. Cardiac catheterization rarely causes serious complications. Who Needs Cardiac Catheterization? Cardiac catheterization is used to diagnose and/or treat various heart conditions. Doctors may recommend this procedure for a number of different reasons. The most common reason is to evaluate chest pain. Chest pain can be a symptom of coronary artery disease (CAD), and cardiac catheterization can show whether plaque is narrowing or blocking your hearts arteries. CAD can be treated during cardiac catheterization with a procedure called angioplasty (ANjee-oh-plas-tee). During angioplasty, a tiny balloon is put through the catheter and into the blocked artery. When the balloon is inflated, it compresses the plaque that has built up inside the artery. This creates a wider pathway for blood to flow to the heart. Sometimes a stent is placed in the artery during angioplasty. A stent is a small mesh tube thats used to treat narrowed or weakened arteries in the body. Most people who have heart attacks have partially or completely blocked coronary arteries. Thus, cardiac catheterization may be done on an emergency basis while youre having a heart attack. When used with angioplasty, the procedure allows the doctor to open up blocked arteries and prevent more damage to your heart.

You also may have cardiac catheterization to help your doctor figure out the best treatment for your CAD if you:

Recently recovered from a heart attack, but are having chest pain Had a heart attack that caused major damage to your heart Had an EKG (electrocardiogram), stress test, or other test with results that suggested heart disease

You also may need cardiac catheterization if your doctor suspects you have a heart defect or if youre about to have heart surgery. The procedure shows the overall shape of your heart and the four large spaces (heart chambers) inside it. This inside view of the heart will show certain heart defects and help your doctor plan your heart surgery. Sometimes your doctor may do a cardiac catheterization to see how well the valves at the openings and exits of the heart chambers are working. Valves control the flow of blood in the heart. To evaluate the valves, your doctor will measure blood flow and oxygen levels in different parts of your heart. Cardiac catheterization also can check how well an artificial heart valve is working or how well your heart is pumping blood. If your doctor thinks you have a heart infection or tumor, he or she may take samples of your heart muscle through the catheter. With the help of cardiac catheterization, doctors can even do minor heart surgery, such as repair certain heart defects. What To Expect Before Cardiac Catheterization Before having a cardiac catheterization, discuss with your doctor:

How to prepare for the procedure Any medicines youre taking, and whether you should stop taking them before the procedure Whether you have diabetes, kidney disease, or other conditions that may require taking extra steps during or after the procedure to avoid complications

It may not be safe to drive right after having cardiac catheterization. If your doctor says you can go home the same day as the procedure, you should arrange for a ride home from the hospital. What To Expect During Cardiac Catheterization During a cardiac catheterization, youre kept on your back and awake. That way you can follow your doctors instructions during the procedure. Youre given medicine to help you relax, which may make you sleepy.

Your doctor will numb the area on the arm, groin (upper thigh), or neck where the small plastic tube (catheter) will enter your blood vessel. A needle is used to make a small hole in the blood vessel. Through this hole your doctor will put a tapered tube called a sheath. Next, your doctor will put a thin, flexible wire through the sheath and into your blood vessel. This guide wire is then threaded through your blood vessel to your heart. The wire helps your doctor position the catheter correctly. Your doctor then puts a catheter through the sheath and slides it over the guide wire and into the coronary arteries. Special x-ray movies are taken of the guide wire and the catheter as theyre moved into the heart. The movies help your doctor see where to position the tip of the catheter. When the catheter reaches the right spot, your doctor then uses it to conduct tests or treatments. For example, your doctor may perform angioplasty and stenting. The animation below shows the process of cardiac catheterization. Click the "start" button to play the animation. Written and spoken explanations are provided with each frame. Use the buttons in the lower right corner to pause, restart, or replay the animation, or use the scroll bar below the buttons to move through the frames.

The animation shows the step-by-step process your doctor will follow to perform cardiac catheterization. During the procedure, your doctor may put a special dye in the catheter. This dye will flow through your bloodstream to your heart. Once the dye reaches your heart, it will make the inside of your hearts arteries show up on an x ray called an angiogram. The test is called coronary angiography. Coronary angiography can show how well blood is being pumped out of the hearts main pumping chambers, which are called ventricles (VEN-trih-kuls). An x ray taken when the dye is in the hearts ventricles is called a ventriculogram. (The procedure is called ventriculography.) When the catheter is inside your heart, your doctor may use it to take blood samples from different parts of the heart or to do minor heart surgery. To get a more detailed view of a blocked coronary artery, your doctor may do intracoronary ultrasound. For this, your doctor will thread a tiny ultrasound device through the catheter and into the artery. This device gives off ultrasound waves that bounce off the artery wall (and its blockage) to make an image of the inside of the artery. If the angiogram or intracoronary ultrasound shows blockages or other possible problems in the hearts arteries, your doctor may use angioplasty to open up the blocked arteries. After your doctor does all of the needed tests or treatments, he or she will pull back the catheter and take it out along with the sheath. The opening left in the blood vessel will then be closed up and bandaged. A small weight may be put on top of the bandage for a few hours to apply more pressure. This will help prevent major bleeding from the site.

What To Expect After Cardiac Catheterization After a cardiac catheterization, you will be moved to a special care area, where you will rest for several hours or overnight. During that time, your movement will be limited to avoid bleeding from the site where the catheter was inserted. While you recover in this area, nurses will check your heart rate and blood pressure regularly and see whether there is any bleeding from the catheter insertion site. A small bruise may develop on your arm, groin (upper thigh), or neck at the site where the catheter was inserted. That area may feel sore or tender for about a week. Be sure to let your doctor know if you develop problems such as:

A constant or large amount of bleeding at the insertion site that cant be stopped with a small bandage Unusual pain, swelling, redness, or other signs of infection at or near the insertion site

Talk to your doctor about whether you should avoid certain activities, such as heavy lifting, for a short time after the procedure. What Are the Risks of Cardiac Catheterization? Cardiac catheterization is a common medical procedure that rarely causes serious problems. But complications can include:

Bleeding, infection, and pain where the catheter was inserted. Damage to blood vessels. This is a very rare complication caused by the catheter scraping or poking a hole in a blood vessel as its threaded to the heart. An allergic reaction to the dye used.

Other less common complications of the procedure include:

An arrhythmia (irregular heartbeat), which often goes away on its own, but may need treatment if it persists. Damage to the kidneys caused by the dye used. Blood clots that can trigger strokes, heart attacks, or other serious problems. Low blood pressure. A buildup of blood or fluid in the sac that surrounds the heart. This fluid can prevent the heart from beating properly.

As with any procedure involving the heart, complications can sometimes, although rarely, be fatal. The risk of complications with cardiac catheterization is higher if you have diabetes or kidney disease, or if youre 75 years old or older. The risk of complications also is greater in women and people having cardiac catheterization on an emergency basis. Key Points

Cardiac catheterization is a medical procedure used to diagnose and treat certain heart conditions. A long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart to do tests or treatments on the heart. Cardiac catheterization is most often used to evaluate chest pain. It may also be done during a heart attack to identify narrowed or blocked coronary arteries. You also may need this procedure if other tests suggest you have coronary artery disease. Before having cardiac catheterization, discuss with your doctor how to prepare for the test and any special instructions you need to follow. It may not be safe to drive right after the procedure. If your doctor says you can go home the same day, you should arrange for a ride home from the hospital. During cardiac catheterization, youre kept on your back and awake. That way you can follow your doctors instructions during the procedure. Youre given medicine to help you relax. After the procedure, you will be moved to a special care area, where you will rest for several hours or overnight. During this time, your movement will be limited to avoid bleeding from the site where the catheter was inserted. A small bruise may develop at the site where the catheter was inserted. That area may feel sore or tender for about a week. You need to let your doctor know if you have a lot of bleeding from that area or signs of infection. You may have to avoid doing certain activities, such as heavy lifting, for a short time after the procedure. Cardiac catheterization is a common medical procedure that rarely causes serious complications. The risk of complications is higher in people with diabetes and kidney disease, and in older people and women.

What Is Heart Valve Disease?

Heart valve disease is a condition in which one or more of your heart valves don't work properly. The heart has four valves: the tricuspid (tri-CUSS-pid), pulmonary (PULL-mun-ary), mitral (MI-trul), and aortic (ay-OR-tik) valves. These valves have tissue flaps that open and close with each heartbeat. The flaps make sure blood flows in the right direction through your heart's four chambers and to the rest of your body.

Healthy Heart Cross-Section

The illustration shows a cross-section of a healthy heart, including the four heart valves. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body. Birth defects, age-related changes, infections, or other conditions can cause one or more of your heart valves to not open fully or to let blood leak back into the heart chambers. This can make your heart work harder and affect its ability to pump blood. Overview How the Heart Valves Work At the start of each heartbeat, blood returning from the body and the lungs fills the heart's two upper chambers. The mitral and tricuspid valves are located at the bottom of these chambers. As the blood builds up in the upper chambers, these valves open to allow blood to flow into the lower chambers of your heart. After a brief delay, as the lower chambers begin to contract, the mitral and tricuspid valves shut tightly. This stops blood from flowing backward. As the lower chambers contract, they pump blood through the pulmonary and aortic valves. The pulmonary valve opens to allow blood to flow from the right lower chamber into the pulmonary artery. This artery carries blood to the lungs to get oxygen. At the same time, the aortic valve opens to allow blood to flow from the left lower chamber into the aorta. This aorta carries oxygen-rich blood to the body. As the contraction ends, the

pulmonary and aortic valves shut tightly. This stops blood from flowing backward into the lower chambers. For more information on how the heart pumps blood, see the animation in the "Heart Contraction and Blood Flow" section of the Diseases and Conditions Index article on How the Heart Works. Heart Valve Problems Heart valves can have three basic kinds of problems:

Regurgitation (re-GUR-ji-TA-shun), or backflow, occurs when a valve doesnt close tightly. Blood leaks back into the chamber rather than flowing forward through the heart or into an artery. In the United States, backflow is most often due to prolapse. "Prolapse" is when the flaps of the valve flop or bulge back into an upper heart chamber during a heartbeat. Prolapse mainly affects the mitral valve, but it can affect the other valves as well. Stenosis (ste-NO-sis) occurs when the flaps of a valve thicken, stiffen, or fuse together. This prevents the heart valve from fully opening, and not enough blood flows through the valve. Some valves can have both stenosis and backflow problems. Atresia (a-TRE-ze-AH) occurs when a heart valve lacks an opening for blood to pass through.

You can be born with heart valve disease or you can acquire it later in life. Heart valve disease that develops before birth is called a congenital (kon-JEN-i-tal) valve disease. Congenital heart valve disease can occur alone or with other congenital heart defects. Congenital heart valve disease usually involves pulmonary or aortic valves that don't form properly. These valves may not have enough tissue flaps, they may be the wrong size or shape, or they may lack an opening through which blood can flow properly. Acquired heart valve disease usually involves the aortic or mitral valves. Although the valve is normal at first, disease can cause problems to develop over time. Both congenital and acquired heart valve disease can cause stenosis or backflow. Outlook Many people have heart valve defects or disease but don't have symptoms. For some people, the condition will stay largely the same over their lifetime and not cause any problems. For other people, the condition will worsen slowly over time until symptoms develop. If not treated, advanced heart valve disease can cause heart failure, stroke, blood clots, or sudden death due to sudden cardiac arrest.

Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines can relieve many of the symptoms and problems linked to heart valve disease. They also can lower your risk of developing a life-threatening condition, such as stroke or sudden cardiac arrest. Eventually, you may need to have your faulty heart valve repaired or replaced. Some types of congenital heart valve disease are so severe that the valve is repaired or replaced during infancy or childhood or even before birth. Other types may not cause problems until you're middle-aged or older, if at all. December 2007 Other Names for Heart Valve Disease

Aortic regurgitation Aortic stenosis Aortic sclerosis Aortic valve disease Bicuspid aortic valve Congenital heart defect Congenital valve disease Mitral regurgitation Mitral stenosis Mitral valve disease Mitral valve prolapse Pulmonic regurgitation Pulmonic stenosis Pulmonic valve disease Tricuspid regurgitation Tricuspid stenosis Tricuspid valve disease

What Causes Heart Valve Disease? Heart conditions and other disorders, age-related changes, rheumatic fever, and infections can cause acquired heart valve disease. These factors change the shape or flexibility of once-normal valves. The cause of congenital heart valve defects isn't known. These defects occur before birth as the heart is forming. Congenital heart valve defects can occur alone or with other types of congenital heart defects.

Heart Conditions and Other Disorders Heart valves can be stretched and distorted by:

Damage and scar tissue due to a heart attack or injury to the heart. Advanced high blood pressure and heart failure. These conditions can enlarge the heart or the main arteries. Narrowing of the aorta due to the buildup of a fatty material called plaque (plak) inside the artery. The aorta is the main artery that carries oxygen-rich blood to the body. The buildup of plaque inside an artery is called atherosclerosis (ath-er-o-skler-O-sis).

Age-Related Changes Men older than 65 and women older than 75 are prone to developing calcium and other deposits on their heart valves. These deposits stiffen and thicken the valve flaps and limit blood flow (stenosis). The aortic valve is especially prone to this problem. The deposits resemble those seen in the narrowed and hardened blood vessels of people who have atherosclerosis. Some of the same processes may cause both atherosclerosis and heart valve disease. Rheumatic Fever Some people have heart valve disease due to untreated strep throat or other infections with strep bacteria, which progress to rheumatic fever. When the body tries to fight the strep infection, one or more heart valves may be damaged or scarred in the process. The aortic and mitral valves are most often affected. Symptoms due to heart valve damage often don't appear until many years after recovery from rheumatic fever. Today, most people with strep infections are treated with antibiotics before rheumatic fever develops. It's very important to take the entire amount of antibiotics your doctor prescribes for strep throat, even if you feel better. Heart valve disease due to rheumatic fever mainly affects older people who had strep infections before antibiotics were available. It also affects people from developing countries, where rheumatic fever is more common. Infections Common germs that enter through the bloodstream and get carried to the heart can sometimes infect the inner surface of the heart, including the heart valves. This rare, but sometimes life-threatening infection is called endocarditis (EN-do-kar-DI-tis).

The germs can enter the bloodstream through needles, syringes, or other medical devices and through breaks in the skin or gums. Usually the body's defenses fight off the germs and no infection occurs. Sometimes these defenses fail, which leads to endocarditis. Endocarditis can develop in people who already have abnormal blood flow through a heart valve due to congenital or acquired heart valve disease. The abnormal blood flow causes blood clots to form on the surface of the valve. The blood clots make it easier for germs to attach to and infect the valve. Endocarditis can worsen existing heart valve disease. Other Conditions and Factors Linked To Heart Valve Disease A number of other conditions and factors are sometimes linked to heart valve disease. However, it's often unknown how these conditions actually cause heart valve disease.

Systemic lupus erythmatosis (SLE). SLE and other immune diseases can affect the aortic and mitral valves. Carcinoid syndrome. Tumors in the digestive tract that spread to the liver or lymph nodes can affect the tricuspid and pulmonary valves. Metabolic disorders. Relatively uncommon diseases, such as Fabry disease and hyperlipidemia, can affect the heart valves. Diet medicines. The use of fenfluramine and phentermine ("fen-phen") has sometimes been linked to heart valve problems. These problems typically stabilize or improve after the medicine is stopped. Radiation therapy. Radiation therapy to the chest area can cause heart valve disease. This therapy is used to treat cancer. Heart valve disease due to radiation therapy may not cause symptoms for as many as 20 years after the therapy ends. Marfan syndrome. Congenital disorders, such as Marfan syndrome, and other connective tissue disorders mainly affect the structure of the body's main arteries. However, these conditions also can also affect the heart valves.

Who Is At Risk for Heart Valve Disease? Populations Affected Older people are more likely to develop heart valve disease. It's estimated that 1 in 8 people age 75 or older have at least moderate heart valve disease. People who have a history of endocarditis, rheumatic fever, heart attack, or heart failureor previous heart valve diseaseare more likely to develop heart valve disease. About 1 to 2 percent of people are born with an aortic valve that has two flaps instead of three. Sometimes an aortic valve may have three flaps, but two flaps are fused together and act as one flap. This is called a bicuspid or bicommissural aortic valve. People who have this congenital condition are more likely to develop aortic heart valve disease.

Major Risk Factors The major risk factors for acquired heart valve disease are:

Age Heart disease risk factors, such as unhealthy blood cholesterol levels, high blood pressure, smoking, insulin resistance, diabetes, overweight or obesity, lack of physical activity, and a family history of early heart disease Risk factors for endocarditis, such as intravenous drug use

What Are the Signs and Symptoms of Heart Valve Disease? Major Signs and Symptoms The main sign of heart valve disease is an unusual heart sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope. However, many people have heart murmurs without having heart valve disease or any other heart problems. Others may have heart murmurs due to heart valve disease, but have no other signs or symptoms. Heart valve disease often worsens over time, so signs and symptoms may develop years after a heart murmur is first heard. Many people who have heart valve disease don't have any symptoms until they're middle-aged or older. Other common signs and symptoms of heart valve disease relate to heart failure, which heart valve disease can eventually cause. These symptoms include:

Unusual fatigue (tiredness) Shortness of breath, especially when you exert yourself or when you're lying down Swelling of your ankles, feet, or sometimes the abdomen

Other Signs and Symptoms Heart valve disease can cause chest pain that may only happen when you exert yourself. You also may notice a fluttering, racing, or irregular heartbeat. Some types of heart valve disease, such as aortic or mitral valve stenosis, can cause dizziness or fainting. How Is Heart Valve Disease Diagnosed? Your primary care provider may detect a heart murmur or other signs of heart valve disease. However, a cardiologist will usually diagnose the condition. A cardiologist is a doctor who specializes in treating heart problems. To diagnose heart valve disease, your doctor will ask about your symptoms. (See "What Are the Signs and Symptoms of Heart Valve Disease?")

He or she also will do a physical exam and look at the results of medical tests and imaging. Physical Exam Your doctor will listen to your heart with a stethoscope to find out if you have a heart murmur that's likely caused by a heart valve problem. Your doctor also will listen to your lungs as you breathe to check for fluid buildup. He or she will check for swollen ankles and other signs that your body is keeping in water. Tests and Procedures The main test for diagnosing heart valve disease is echocardiography. But an EKG (electrocardiogram) or chest x ray is commonly used to reveal certain signs of the condition. If these signs are present, echocardiography usually is done to confirm the diagnosis. Your doctor also may have you undergo other tests, such as cardiac catheterization, stress testing, or cardiac MRI (magnetic resonance imaging), if you're diagnosed with heart valve disease. These tests and procedures can help your doctor better assess how severe your condition is and plan treatment. Electrocardiogram This is a simple test that detects and records the electrical activity of your heart. It can detect an irregular heartbeat and signs of a previous heart attack. It can also show whether certain chambers of your heart are enlarged. An EKG usually is done in your doctor's office. Chest X Ray This test can show whether certain sections of your heart are enlarged, whether you have fluid in your lungs, or whether there are calcium deposits in your heart. This test helps your doctor learn which type of valve defect you have, how severe it is, and whether you have any other heart problems. Echocardiography The test uses sound waves to create a moving picture of your heart as it beats. A wand that's placed on the surface of your chest transmits the sound waves. Echoes from the sound waves are converted into pictures of your heart on a computer screen. An echocardiogram can show:

The size and shape of your heart valves and chambers How well your heart is pumping blood

Whether a valve is narrowed or has backflow

Your doctor may recommend a transesophageal (tranz-ih-sof-uh-JEE-ul) echocardiogram, or TEE, to get a better image. For a TEE, the sound wave wand is put on the end of a special tube. The tube is passed down your throat and into your esophagus (the tube leading from your mouth to your stomach). You will be given medicine to relax you during this procedure. Cardiac Catheterization For this procedure, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, upper thigh (groin), or neck and threaded into your heart. Your doctor uses x-ray images to guide the catheter. Through the catheter, your doctor does diagnostic tests and imaging that show whether backflow is occurring through a valve and how fully the valve opens. You're given medicine to help you relax, but you're awake during the procedure. Your doctor may order a cardiac catheterization if your signs and symptoms of heart valve disease aren't in line with your echocardiography results. The procedure also can help your doctor assess whether your symptoms are due to specific valve problems or coronary artery disease. All of this information helps your doctor decide the best way to treat you. Stress Test During stress testing, you exercise to make your heart work hard and beat fast while heart tests and imaging are done. If you can't exercise, you'll be given medicine to make your heart work hard and beat fast. A stress test can show whether you have signs and symptoms of heart valve disease when your heart is working hard. It can help your doctor assess the severity of your heart valve disease. Cardiac MRI Cardiac MRI uses a powerful magnet and radio waves to make detailed images of your heart. A cardiac MRI image can confirm information about valve defects or provide more detailed information. This information can help your doctor plan your treatment. An MRI also may be done before heart valve surgery to help your surgeon plan for the surgery. How Is Heart Valve Disease Treated? The goals of heart valve disease treatment are to:

Prevent, treat, or relieve the symptoms of other related heart conditions. Protect your valve from further damage. Repair or replace faulty valves when they cause severe symptoms or become life threatening. Man-made or biological valves are used as replacements.

Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines often can successfully treat symptoms and delay complications for many years. Eventually, though, you may need surgery to repair or replace a faulty heart valve. Prevent, Treat, or Relieve the Symptoms of Other Related Heart Conditions To relieve the symptoms of heart conditions related to heart valve disease, your doctor may ask you to quit smoking and follow a healthy eating plan low in salt, cholesterol, and fat. Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) and Dietary Approaches to Stop Hypertension (DASH) eating plans. TLC is for people who have high blood cholesterol. DASH is for people who have high blood pressure (or for anyone who wants to follow a healthy eating plan). Your doctor also may ask you to limit physical activities that make you unusually short of breath and fatigued (tired). He or she also may ask that you limit competitive athletic activity, even if the activity doesn't leave you unusually short of breath or fatigued. Your doctor may prescribe medicines to help prevent or treat other related heart conditions, such as heart failure, high blood pressure, irregular heartbeats, coronary artery disease (CAD), and life-threatening blood clots. Heart valve disease can cause these conditions or worsen them. People who have heart valve disease are commonly prescribed medicines to:

Treat heart failure. Heart failure medicines widen blood vessels and rid the body of too much fluid. Lower blood pressure or blood cholesterol levels. Prevent irregular heartbeats. Thin the blood and prevent clots (for people who have man-made valves). These medicines also are prescribed for mitral stenosis or other valve defects that make you prone to developing blood clots.

Protect Your Valve From Further Damage If you've had previous heart valve disease and now have a man-made valve, you may be at increased risk for a heart infection called endocarditis. This infection can worsen your heart valve disease. Even if you don't yet have symptoms of a valve problem, you're at increased risk for this infection.

To help prevent this serious infection, floss and brush your teeth and see a dentist regularly. Gum infections and tooth decay can cause endocarditis. Let your doctors and dentists know if you have a man-made valve or if you've had endocarditis before. They may give you antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter your bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures. Repair or Replace Heart Valves Your doctor may recommend repairing or replacing your heart valve(s), even if you do not yet have symptoms of heart valve disease. This can prevent lasting damage to your heart and sudden death. Having heart valve repair or replacement depends on a number of factors, including:

How severe your valve disease is. Your age and general health. Whether you need heart surgery for other conditions, such as bypass surgery to treat CAD. Bypass surgery and valve surgery can be done at the same time.

When possible, heart valve repair is preferred over heart valve replacement. Valve repair preserves the strength and function of the heart muscle. People who have valve repair also have a lower risk for endocarditis after the surgery, and they don't need to take bloodthinning medicines for the rest of their lives. However, heart valve repair surgery is harder to do than valve replacement. Also, not all valves can be repaired. Mitral valves often can be repaired. Aortic or pulmonary valves often have to be replaced. Repairing Heart Valves Heart valves can be repaired by:

Separating fused valve flaps Removing or reshaping tissue so the valve can close tighter Adding tissue to patch holes or tears or to increase the support at the base of the valve

Heart surgeons do most heart valve repair surgeries. Cardiologists do some repair surgeries using cardiac catheterization. Although catheterization procedures are less invasive, they also may not work as well for some patients. You and your doctor will decide whether repair is appropriate and the best procedure for doing it.

Balloon valvuloplasty. Heart valves that don't open fully (stenosis) can be repaired with surgery or with a less invasive catheter procedure called balloon valvuloplasty (VAL-vyu-loplas-tee). This procedure also is called balloon valvotomy. During the procedure, a balloon-tipped tube is threaded through your blood vessels and into the faulty valve in your heart. The balloon is inflated to help widen the opening of the valve. Your doctor then deflates the balloon and removes both it and the tube. You're awake during the procedure, which usually requires an overnight stay in the hospital. Balloon valvuloplasty relieves many of the symptoms of heart valve disease, but it may not cure it. The condition can still worsen over time. You may need medicines to help with symptoms or surgery to repair or replace the faulty valve. Balloon valvuloplasty has a shorter recovery time than surgery. For some patients who have mitral valve stenosis, it may work as well as surgical repair or replacement. For these reasons, balloon valvuloplasty usually is preferred over surgical repair or replacement for these people. Balloon valvuloplasty doesn't work as well as surgical treatment for adults who have aortic valve stenosis. Balloon valvuloplasty often is used in infants and children. In these patients, valve stenosis is caused by a congenital defect that can be repaired by a one-time procedure. Replacing Heart Valves Sometimes heart valves can't be repaired and must be replaced. This surgery involves removing the faulty valve and replacing it with a man-made valve or a biologic valve. Biologic valves are made from pig, cow, or human heart tissue and may have man-made parts as well. These valves are specially treated, so no medicines are needed to stop the body from rejecting the valve. Man-made valves are more durable than biologic valves and usually don't have to be replaced. Biologic valves usually have to be replaced after about 10 years, although newer biologic valves may last 15 years or longer. Unlike biologic valves, however, man-made valves require you to take blood-thinning medicines for the rest of your life. These medicines prevent blood clots from forming on the valve. Blood clots can cause a heart attack or stroke. Man-made valves also raise your risk for endocarditis. You and your doctor will decide together whether you should have a man-made or biologic replacement valve. If you're a woman of childbearing age or if you're athletic, you may prefer a biologic valve so you don't have to take blood-thinning medicines. If you're elderly, you also may prefer a biologic valve, as it will likely last for the rest of your life. Other Approaches for Repairing and Replacing Heart Valves

Some newer forms of heart valve repair or replacement surgery are less invasive than traditional surgery. These procedures use smaller incisions (cuts) to reach the heart valves. Hospital stays for these newer types of surgery are usually 3 to 5 days, compared to 5 day stays for traditional heart valve surgery. New surgeries tend to cause less pain and have a lower risk of infection. Recovery time also tends to be shorter2 to 4 weeks versus 6 to 8 weeks for traditional surgery. Some cardiologists and surgeons are exploring procedures that use cardiac catheterization to thread clips or other devices in a tube through your blood vessels and into the faulty valve in your heart. The clips or devices are used to reshape the valve and stop the backflow of blood. It's not yet known how effective these procedures are. The Ross operation is a surgical procedure to treat faulty aortic valves. During this operation, your doctor removes your faulty aortic valve and replaces it with your pulmonary valve. The pulmonary valve is then replaced with a pulmonary valve from a deceased human donor. This is more involved surgery than typical valve replacement, and it has a greater risk of complications. The Ross operation may be especially useful for children because the surgically replaced valves continue to grow with the child. Also, lifelong treatment with blood-thinning medicines isn't required. But in some patients, one or both valves fail to work properly within a few years of the surgery. Experts continue to debate the usefulness of this procedure. Serious risks from all types of heart valve surgery vary according to your age, health, the type of valve defect(s) you have, and the surgical procedure(s) performed. How Can Heart Valve Disease Be Prevented To prevent heart valve disease caused by rheumatic fever, see your doctor if you have signs of a strep infection. These signs include a red and painful sore throat, fever, and white spots on your tonsils. If you do have a strep infection, be sure to take all medicines prescribed to treat it. Prompt treatment of strep infections can prevent rheumatic fever, which damages heart valves. It's possible that exercise, diet, and medicines that lower cholesterol also might prevent aortic stenosis (thickening and stiffening of the aortic valve). Researchers continue to study this possibility. A heart healthy eating plan, physical activity, other lifestyle measures, or medicines aimed at preventing a heart attack, high blood pressure, or heart failure also might help prevent heart valve disease.

If you've had previous heart valve disease and now have a man-made valve, you may be at higher risk for a heart infection called endocarditis. Floss and brush your teeth regularly. Gum infections and tooth decay can cause endocarditis. Let your doctors and dentists know if you have a man-made valve or if you've had endocarditis before. They may give you antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter your bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures. Living With Heart Valve Disease Heart valve disease is a lifelong condition. However, many people with the condition don't have any symptoms until they're middle-aged or older. Over time, heart valve disease may worsen and can cause heart failure or other life-threatening conditions. Eventually, you may need your faulty heart valve(s) repaired or replaced. After repair or replacement, you will still need certain medicines and regular checkups with your doctor. Ongoing Health Care Needs

See your doctor regularly for checkups and for echocardiography or other tests. This will allow your doctor to check the progress of your heart valve disease. Ask your doctor what physical activities are appropriate for you. Call your doctor if your heart valve disease symptoms worsen or you develop new symptoms. (See "What Are the Signs and Symptoms of Heart Valve Disease?") Call your doctor if you develop symptoms of endocarditis. Symptoms of this heart infection include fever, chills, muscle aches, night sweats, difficulty breathing, fatigue (tiredness), weakness, red spots on the palms and soles, and swelling of the feet, legs, and belly. Let your doctors and dentists know if you have a man-made valve or if you've had endocarditis before. They may give you antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter your bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures. Take all your prescribed medicines.

Pregnancy and Heart Valve Disease Mild to moderate heart valve disease during pregnancy usually can be managed with medicines or bed rest without posing heightened risks to the mother or fetus. Most heart valve conditions can be treated with medicines that are safe to take during pregnancy. Your doctor can advise you on which medicines are safe for you. Severe heart valve disease can make pregnancy or labor and delivery riskier. If you have severe heart valve disease and/or its symptoms, consider having your heart valves repaired

or replaced before getting pregnant. Such repair or replacement also can be done during pregnancy, if needed. But this surgery poses danger to both the mother and fetus. Key Points

Heart valve disease is a condition in which one or more of your heart valves don't work properly. The heart has four valves: the tricuspid, pulmonary, mitral, and aortic valves. These valves have tissue flaps that open and close with each heartbeat. These flaps make sure blood flows in the right direction through your heart's four chambers and to the rest of your body. Heart valves can have three basic kinds of problems:
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Regurgitation, or backflow, occurs when a valve doesn't close tightly. Blood leaks back into the heart chamber rather than flowing forward through the heart or into an artery. Stenosis occurs when the flaps of a valve thicken, stiffen, or fuse together. This prevents the heart valve from fully opening, and not enough blood flows through the valve. Atresia occurs when a valve lacks an opening for blood to pass through.

Heart valve disease can make your heart work harder and affect its ability to pump blood. If not treated, advanced heart valve disease can cause heart failure, stroke, blood clots, or sudden death due to sudden cardiac arrest. You can be born with heart valve disease or develop it later in life. It's not known what causes the type of valve disease that people are born with. Heart conditions and other disorders, age-related changes, rheumatic fever, and infections can cause heart valve disease that develops later in life. The major risk factors for acquired heart valve disease are age, having risk factors for heart disease, and having risk factors for the heart infection endocarditis. Many people don't have signs or symptoms of heart valve disease until they're middle-aged or older. The main sign of heart valve disease is a heart murmur (an unusual heart sound). Other common signs and symptoms are unusual fatigue (tiredness), shortness of breath, and swelling of your ankles, feet, or abdomen. Heart valve disease is diagnosed based on your symptoms, a physical exam, and the results from tests and procedures. Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines often can successfully treat symptoms and delay complications for many years. Eventually, you may need to have your faulty valve repaired or replaced with a man-made or biological valve. When possible, heart valve repair is preferred over heart valve replacement. Valve repair preserves the strength and function of the heart muscle. People who have valve repair also have a lower risk for endocarditis after the surgery, and they don't need to take blood-thinning medicines for the rest of their lives.

To prevent heart valve disease caused by rheumatic fever, see your doctor if you have signs of a strep infection. This infection can cause rheumatic fever, which can damage the heart valves. If you do have a strep infection, take all medicines as prescribed. Heart valve disease is a lifelong condition. If you have the condition, it's important to have ongoing medical care. See your doctor regularly. Call your doctor if your signs or symptoms worsen or if you have signs or symptoms of endocarditis. Take all your medicines as prescribed. Mild to moderate heart valve disease during pregnancy usually can be managed with medicines or bed rest without posing heightened risks to the mother or fetus. Your doctor can advise you on which medicines are appropriate during pregnancy. Severe heart valve disease can make pregnancy or labor and delivery riskier. If you have severe valve disease and/or its symptoms, consider having your heart valves repaired or replaced before getting pregnant. Such repair or replacement also can be done during pregnancy, if needed. But this surgery poses danger to both the mother and fetus.

What Is Atherosclerosis?
Atherosclerosis (ath-er-o-skler-O-sis) is a disease in which plaque (plak) builds up on the insides of your arteries. Arteries are blood vessels that carry oxygen-rich blood to your heart and other parts of your body. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. The flow of oxygen-rich blood to your organs and other parts of your body is reduced. This can lead to serious problems, including heart attack, stroke, or even death.

Atherosclerosis

Figure A shows a normal artery with normal blood flow. Figure B shows an artery with plaque buildup. Overview Atherosclerosis can affect any artery in the body, including arteries in the heart, brain, arms, legs, and pelvis. As a result, different diseases may develop based on which arteries are affected.

Coronary artery disease (CAD). This is when plaque builds up in the coronary arteries. These arteries supply oxygen-rich blood to your heart. When blood flow to your heart is reduced or blocked, it can lead to chest pain and heart attack. CAD also is called heart disease, and it's the leading cause of death in the United States. Carotid (ka-ROT-id) artery disease. This happens when plaque builds up in the carotid arteries. These arteries supply oxygen-rich blood to your brain. When blood flow to your brain is reduced or blocked, it can lead to stroke. Peripheral arterial disease (PAD). This occurs when plaque builds up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis. When blood flow to these parts of your body is reduced or blocked, it can lead to numbness, pain, and sometimes dangerous infections.

Some people with atherosclerosis have no signs or symptoms. They may not be diagnosed until after a heart attack or stroke. The main treatment for atherosclerosis is lifestyle changes. You also may need medicines and medical procedures. These, along with ongoing medical care, can help you live a healthier life. The cause of atherosclerosis isnt known. However, certain conditions may raise your chances of developing it. These conditions are known as risk factors. You can control some risk factors, such as lack of physical activity, smoking, and unhealthy eating. Others you cant control, such as age and family history of heart disease. Outlook Better treatments have reduced the number of deaths from atherosclerosis-related diseases. These treatments also have improved the quality of life for people with these diseases. Still, the number of people diagnosed with atherosclerosis remains high. You may be able to prevent or delay atherosclerosis and the diseases it can cause, mainly by maintaining a healthy lifestyle. This, along with ongoing medical care, can help you avoid the problems of atherosclerosis and live a long, healthy life. Other Names for Atherosclerosis

Arteriosclerosis (ar-TER-e-o-skler-o-sis) Hardening of the arteries

What Causes Atherosclerosis? The exact cause of atherosclerosis isn't known. However, studies show that atherosclerosis is a slow, complex disease that may start in childhood. It develops faster as you age. Atherosclerosis may start when certain factors damage the inner layers of the arteries. These factors include:

Smoking High amounts of certain fats and cholesterol in the blood High blood pressure High amounts of sugar in the blood due to insulin resistance or diabetes

When damage occurs, your body starts a healing process. Fatty tissues release compounds that promote this process. This healing causes plaque to build up where the arteries are damaged.

Over time, the plaque may crack. Blood cells called platelets (PLATE-lets) clump together to form blood clots where the cracks are. This narrows the arteries more and worsens angina (chest pain) or causes a heart attack. Researchers continue to look at why atherosclerosis develops. They hope to find answers to such questions as:

Why and how do the arteries become damaged? How does plaque develop and change over time? Why does plaque break open and lead to clots?

Who Is At Risk for Atherosclerosis? Coronary artery disease (atherosclerosis of the coronary arteries) is the leading cause of death in the United States. The exact cause of atherosclerosis isn't known. However, certain traits, conditions, or habits may raise your chance of developing it. These conditions are known as risk factors. Your chances of developing atherosclerosis increase with the number of risk factors you have. You can control most risk factors and help prevent or delay atherosclerosis. Other risk factors can't be controlled. Major Risk Factors

Unhealthy blood cholesterol levels. This includes high LDL cholesterol (sometimes called bad cholesterol) and low HDL cholesterol (sometimes called good cholesterol). High blood pressure. Blood pressure is considered high if it stays at or above 140/90 mmHg over a period of time. Smoking. This can damage and tighten blood vessels, raise cholesterol levels, and raise blood pressure. Smoking also doesn't allow enough oxygen to reach the body's tissues. Insulin resistance. This condition occurs when the body can't use its own insulin properly. Insulin is a hormone that helps move blood sugar into cells where it's used. Diabetes. This is a disease in which the bodys blood sugar level is high because the body doesnt make enough insulin or doesnt use its insulin properly. Overweight or obesity. Overweight is having extra body weight from muscle, bone, fat, and/or water. Obesity is having a high amount of extra body fat. Lack of physical activity. Lack of activity can worsen other risk factors for atherosclerosis. Age. As you get older, your risk for atherosclerosis increases. Genetic or lifestyle factors cause plaque to build in your arteries as you age. By the time you're middleaged or older, enough plaque has built up to cause signs or symptoms.
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In men, the risk increases after age 45.

In women, the risk increases after age 55.

Family history of early heart disease. Your risk for atherosclerosis increases if your father or a brother was diagnosed with heart disease before 55 years of age, or if your mother or a sister was diagnosed with heart disease before 65 years of age.

Although age and a family history of early heart disease are risk factors, it doesn't mean that you will develop atherosclerosis if you have one or both. Making lifestyle changes and/or taking medicines to treat other risk factors can often lessen genetic influences and prevent atherosclerosis from developing, even in older adults. Emerging Risk Factors Scientists continue to study other possible risk factors for atherosclerosis. High levels of a protein called C-reactive protein (CRP) in the blood may raise the risk for atherosclerosis and heart attack. High levels of CRP are proof of inflammation in the body. Inflammation is the body's response to injury or infection. Damage to the arteries' inner walls seems to trigger inflammation and help plaque grow. People with low CRP levels may get atherosclerosis at a slower rate than people with high CRP levels. Research is under way to find out whether reducing inflammation and lowering CRP levels also can reduce the risk of atherosclerosis. High levels of fats called triglycerides in the blood also may raise the risk of atherosclerosis, particularly in women. Other Factors That Affect Atherosclerosis Other risk factors also may raise your risk for developing atherosclerosis. These include:

Sleep apnea. Sleep apnea is a disorder in which your breathing stops or gets very shallow while you're sleeping. Untreated sleep apnea can raise your chances of having high blood pressure, diabetes, and even a heart attack or stroke. Stress. Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Alcohol. Heavy drinking can damage the heart muscle and worsen other risk factors for atherosclerosis. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day. What Are the Signs and Symptoms of Atherosclerosis? Atherosclerosis usually doesn't cause signs and symptoms until it severely narrows or totally blocks an artery. Many people don't know they have the disease until they have a medical emergency, such as a heart attack or stroke. Some people may have other signs and symptoms of the disease. These depend on which arteries are severely narrowed or blocked.

The coronary arteries supply oxygen-rich blood to your heart. When plaque narrows or blocks these arteries (a condition called coronary artery disease, or CAD), a common symptom is angina (AN-ji-na or an-JI-na). Angina is chest pain or discomfort that occurs when your heart muscle doesn't get enough oxygen-rich blood. Angina may feel like pressure or a squeezing pain in your chest. You also may feel it in your shoulders, arms, neck, jaw, or back. This pain tends to get worse with activity and go away when you rest. Emotional stress also can trigger the pain. Other symptoms of CAD are shortness of breath and arrhythmias (irregular heartbeats). The carotid arteries supply oxygen-rich blood to your brain. When plaque narrows or blocks these arteries (a condition called carotid artery disease), you may have symptoms of a stroke. These symptoms include sudden numbness, weakness, and dizziness. Plaque also can build up in the major arteries that supply oxygen-rich blood to the legs, arms, and pelvis (a condition called peripheral arterial disease). When these arteries are narrowed or blocked, it can lead to numbness, pain, and sometimes dangerous infections.

How Is Atherosclerosis Diagnosed? Your doctor will diagnose atherosclerosis based on:

Your medical and family histories Your risk factors The results of a physical exam and diagnostic tests

Specialists Involved If you have atherosclerosis, a doctor, internist, or general practitioner may handle your care. Your doctor may send you to other health care specialists if you need expert care. These specialists may include:

A cardiologist (a doctor who specializes in treating people with heart problems). You may see a cardiologist if you have coronary artery disease (CAD). A vascular specialist (a doctor who specializes in treating people with blood vessel problems). You may see a vascular specialist if you have peripheral arterial disease (PAD). A neurologist (a doctor who specializes in treating people with disorders of the nervous system). You may see a neurologist if you've had a stroke due to carotid artery disease.

Physical Exam

During the physical exam, your doctor may listen to your arteries for an abnormal whooshing sound called a bruit (broo-E). Your doctor can hear a bruit when placing a stethoscope over an affected artery. A bruit may indicate poor blood flow due to plaque. Your doctor also may check to see whether any of your pulses (for example, in the leg or foot) are weak or absent. A weak or absent pulse can be a sign of a blocked artery. Diagnostic Tests and Procedures Your doctor may order one or more tests to diagnose atherosclerosis. These tests also can help your doctor learn the extent of your disease and plan the best treatment. Blood Tests Blood tests check the levels of certain fats, cholesterol, sugar, and proteins in your blood. Abnormal levels may show that you have risk factors for atherosclerosis. EKG (Electrocardiogram) An EKG is a simple test that detects and records the electrical activity of your heart. An EKG shows how fast your heart is beating and whether it has a regular rhythm. It also shows the strength and timing of electrical signals as they pass through each part of your heart. Certain electrical patterns that the EKG detects can suggest whether CAD is likely. An EKG also can show signs of a previous or current heart attack. Chest X Ray A chest x ray takes a picture of the organs and structures inside the chest, including your heart, lungs, and blood vessels. A chest x ray can reveal signs of heart failure. Ankle/Brachial Index This test compares the blood pressure in your ankle with the blood pressure in your arm to see how well your blood is flowing. This test can help diagnose PAD. Echocardiography This test uses sound waves to create a moving picture of your heart. Echocardiography provides information about the size and shape of your heart and how well your heart chambers and valves are working. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that aren't contracting normally, and previous injury to the heart muscle caused by poor blood flow.

Computed Tomography Scan A computed tomography, or CT, scan creates computer-generated images of the heart, brain, or other areas of the body. The test can often show hardening and narrowing of large arteries. Stress Testing During stress testing, you exercise to make your heart work hard and beat fast while heart tests are performed. If you can't exercise, you're given medicine to speed up your heart rate. When your heart is beating fast and working hard, it needs more blood and oxygen. Arteries narrowed by plaque can't supply enough oxygen-rich blood to meet your heart's needs. A stress test can show possible signs of CAD, such as:

Abnormal changes in your heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in your heart rhythm or your heart's electrical activity

During the stress test, if you can't exercise for as long as what's considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness). Some stress tests use a radioactive dye, sound waves, positron emission tomography (PET), or cardiac magnetic resonance imaging (MRI) to take pictures of your heart when it's working hard and when it's at rest. These imaging stress tests can show how well blood is flowing in the different parts of your heart. They also can show how well your heart pumps blood when it beats. Angiography Angiography (an-jee-OG-ra-fee) is a test that uses dye and special x rays to show the insides of your arteries. This test can show whether plaque is blocking your arteries and how severe the plaque is. A thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck. A dye that can be seen on x ray is then injected into the arteries. By looking at the x-ray picture, your doctor can see the flow of blood through your arteries. How Is Atherosclerosis Treated? Treatments for atherosclerosis may include lifestyle changes, medicines, and medical procedures or surgery. Goals of Treatment

The goals of treatment are to:

Relieve symptoms Reduce risk factors in an effort to slow, stop, or reverse the buildup of plaque Lower the risk of blood clots forming Widen or bypass clogged arteries Prevent diseases related to atherosclerosis

Lifestyle Changes Making lifestyle changes can often help prevent or treat atherosclerosis. For some people, these changes may be the only treatment needed.

Follow a healthy eating plan to prevent or reduce high blood pressure and high blood cholesterol and to maintain a healthy weight. Increase your physical activity. Check with your doctor first to find out how much and what kinds of activity are safe for you. Lose weight, if you're overweight or obese. Quit smoking, if you smoke. Avoid exposure to secondhand smoke. Reduce stress.

Follow a Healthy Eating Plan For a healthy eating plan, go to the National Heart, Lung, and Blood Institutes (NHLBIs) Aim for a Healthy Weight Web site. This site provides practical tips on healthy eating, physical activity, and controlling your weight. Therapeutic Lifestyle Changes (TLC). Your doctor may recommend TLC if you have high cholesterol. TLC is a three-part program that includes a healthy diet, physical activity, and weight management. With the TLC diet, less than 7 percent of your daily calories should come from saturated fat. This kind of fat is mainly found in meat and poultry, including dairy products. No more than 25 to 35 percent of your daily calories should come from all fats, including saturated, trans, monounsaturated, and polyunsaturated fats. You also should have less than 200 mg a day of cholesterol. The amounts of cholesterol and the different kinds of fat in prepared foods can be found on the Nutrition Facts label. Foods high in soluble fiber also are part of a healthy eating plan. They help block the digestive track from absorbing cholesterol. These foods include:

Whole grain cereals such as oatmeal and oat bran Fruits such as apples, bananas, oranges, pears, and prunes

Legumes such as kidney beans, lentils, chick peas, black-eyed peas, and lima beans

A diet high in fruits and vegetables can increase important cholesterol-lowering compounds in your diet. These compounds, called plant stanols or sterols, work like soluble fiber. Fish are an important part of a heart healthy diet. They're a good source of omega-3 fatty acids, which may help protect the heart from blood clots and inflammation and reduce the risk for heart attack. Try to have about two fish meals every week. Fish high in omega-3 fats are salmon, tuna (canned or fresh), and mackerel. You also should try to limit the amount of sodium (salt) that you eat. This means choosing low-sodium and low-salt foods and "no added salt" foods and seasonings at the table or when cooking. The Nutrition Facts label on food packaging shows the amount of sodium in the item. Try to limit drinks with alcohol. Too much alcohol will raise your blood pressure and triglyceride level. (Triglycerides are a type of fat found in the blood.) Alcohol also adds extra calories, which will cause weight gain. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day. See the NHLBIs "Your Guide to Lowering Your Cholesterol With TLC" for more information. Dietary Approaches to Stop Hypertension (DASH) eating plan. Your doctor may recommend the DASH eating plan if you have high blood pressure. The DASH eating plan focuses on fruits, vegetables, whole grains, and other foods that are heart healthy and lower in salt/sodium. This eating plan is low in fat and cholesterol. It also focuses on fat-free or low-fat milk and dairy products, fish, poultry, and nuts. The DASH eating plan is reduced in red meats (including lean red meat), sweets, added sugars, and sugar-containing beverages. It's rich in nutrients, protein, and fiber. The DASH eating plan is a good heart healthy eating plan, even for those who dont have high blood pressure. See the NHLBIs "Your Guide to Lowering Your Blood Pressure With DASH" for more information. Increase Physical Activity Regular physical activity can lower many atherosclerosis risk factors, including LDL ("bad") cholesterol, high blood pressure, and excess weight. Physical activity also can lower your risk for diabetes and raise your levels of HDL cholesterol (the "good" cholesterol that helps prevent atherosclerosis). Check with your doctor about how much and what kinds of physical activity are safe for you. Unless your doctor tells you otherwise, try to get at least 30 minutes of moderate-intensity activity on most or all days of the week. You can do the activity all at once or break it up into shorter periods of at least 10 minutes each.

Moderate-intensity activities include brisk walking, dancing, bowling, bicycling, gardening, and housecleaning. More intense activities, such as jogging, swimming, and various sports, also may be appropriate for shorter periods. See the NHLBIs "Your Guide to Physical Activity and Your Heart" for more information. Maintain a Healthy Weight Maintaining a healthy weight can decrease your risk factors for atherosclerosis. A general goal to aim for is a body mass index (BMI) of less than 25. BMI measures your weight in relation to your height and gives an estimate of your total body fat. You can calculate your BMI using the NHLBI's online calculator, or your health care provider can calculate your BMI. A BMI between 25 and 29 is considered overweight. A BMI of 30 or more is considered obese. A BMI of less than 25 is the goal for preventing and treating atherosclerosis. Your doctor or other health care provider can help you determine an appropriate goal for you. For more information on losing weight and maintaining your weight, see the Diseases and Conditions Index Overweight and Obesity article. Quit Smoking If you smoke or use tobacco, quit. Smoking can damage and tighten blood vessels and raise your risk for atherosclerosis. The U.S. Department of Health and Human Services has information on how to quit smoking. Reduce Stress Research shows that the most commonly reported "trigger" for a heart attack is an emotionally upsetting eventparticularly one involving anger. Also, some of the ways people cope with stress, such as drinking, smoking, or overeating, aren't heart healthy. Physical activity can help relieve stress and reduce other atherosclerosis risk factors. Many people also find that meditation or relaxation therapy helps them reduce stress. Medicines To help slow or reverse atherosclerosis, your doctor may prescribe medicines to help lower your cholesterol or blood pressure or prevent blood clots from forming. For successful treatment, take all medicines as your doctor prescribes. Medical Procedures and Surgery

If you have severe atherosclerosis, your doctor may recommend one of several procedures or surgeries. Angioplasty is a procedure to open blocked or narrowed coronary (heart) arteries. Angioplasty can improve blood flow to the heart, relieve chest pain, and possibly prevent a heart attack. Sometimes a small mesh tube called a stent is placed in the artery to keep it open after the procedure. Coronary artery bypass grafting (CABG) is a type of surgery. In CABG, arteries or veins from other areas in your body are used to bypass (that is, go around) your narrowed coronary arteries. CABG can improve blood flow to your heart, relieve chest pain, and possibly prevent a heart attack. Bypass grafting also can be used for leg arteries. In this surgery, a healthy blood vessel is used to bypass a narrowed or blocked blood vessel in one of your legs. The healthy blood vessel redirects blood around the artery, improving blood flow to the leg. Carotid artery surgery removes plaque buildup from the carotid arteries in the neck. This opens the arteries and improves blood flow to the brain. Carotid artery surgery can help prevent a stroke. How Can Atherosclerosis Be Prevented or Delayed? Taking action to control your risk factors can help prevent or delay atherosclerosis and its related diseases. Your chance of developing atherosclerosis goes up with the number of risk factors you have. Making lifestyle changes and taking prescribed medicines are important steps. See "How Is Atherosclerosis Treated?" for information on healthy eating plans, physical activity, maintaining a healthy weight, and medicines. Know your family history of health problems related to atherosclerosis. If you or someone in your family has this disease, be sure to tell your doctor. Also, let your doctor know if you smoke. Living With Atherosclerosis Improved treatments have reduced deaths from atherosclerosis-related diseases. These treatments also have improved the quality of life for people with these diseases. You may be able to prevent or delay atherosclerosis and the problems it can cause, mainly by maintaining a healthy lifestyle. This, along with ongoing medical care, can help you avoid the problems of atherosclerosis and live a long, healthy life. Research continues look for ways to improve the health of people who have atherosclerosis or may get it. The goals of research are to:

Find more effective medicines Identify people at greatest risk earlier Find out how well alternative treatments work

Ongoing Health Care Needs If you have atherosclerosis, work closely with your doctor and other health care providers to avoid serious problems, like heart attack and stroke. Talk to your doctor about how often you should schedule office visits or blood tests. Be sure to let your doctor know if you develop new symptoms or if your symptoms worsen. Support Groups Community resources are available to help you learn more about atherosclerosis. Contact your local public health departments, hospitals, and local chapters of national health organizations to learn more about available resources in your area. Talk about your lifestyle changes with your spouse, family, or friendswhoever can provide support or needs to understand why you're changing your habits. They may be able to help you make lifestyle changes, like helping you plan healthier meals. Because atherosclerosis tends to run in families, your lifestyle changes may help many of your family members too. Key Points

Atherosclerosis is a disease in which plaque builds up on the insides of your arteries. Over time, plaque hardens and narrows your arteries. The flow of oxygen-rich blood to your organs and other parts of your body is reduced. This can lead to serious problems, including heart attack, stroke, or even death. Atherosclerosis can affect any artery in the body.
o o o

Coronary artery disease (CAD) occurs when plaque builds up in the coronary (heart) arteries. CAD is a leading cause of death in the United States. Carotid artery disease happens when plaque builds up in the carotid arteries (the arteries that supply blood and oxygen to your brain). Peripheral arterial disease (PAD) occurs when plaque builds up in the major arteries of the legs, arms, and pelvis.

The exact cause of atherosclerosis isnt known. It may start when certain factors damage the inner layers of arteries. When damage occurs, your body starts a healing process. This healing causes plaque to build up where the arteries are damaged. Over time, the plaque may crack and causes blood clots to form in the arteries. This can worsen angina (chest pain) or cause a heart attack. Many factors raise your risk for atherosclerosis. Major risk factors include unhealthy cholesterol levels, high blood pressure, smoking, insulin resistance, diabetes,

overweight or obesity, lack of physical activity, age, and a family history of early heart disease.

Atherosclerosis usually doesn't cause signs and symptoms until it severely narrows or totally blocks an artery. Many people don't know they have the disease until they have a medical emergency, such as a heart attack or stroke. Other signs and symptoms depend on which arteries are narrowed or blocked. Your doctor will diagnose atherosclerosis based on your medical and family histories, your risk factors, and the results of a physical exam and diagnostic tests. Treatments for atherosclerosis may include lifestyle changes, medicines, and medical procedures and surgery. Lifestyle changes include following a healthy eating plan, increasing physical activity, maintaining a healthy weight, quitting smoking, and reducing stress. Taking steps to control your risk factors can help prevent or delay atherosclerosis and its related diseases. These steps include making lifestyle changes and/or taking medicines as prescribed by your doctor. Improved treatments have helped reduce deaths from atherosclerosis-related diseases. However, the number of people diagnosed with atherosclerosis remains high. If you've been diagnosed with atherosclerosis, you can control the disease with lifestyle changes and/or medicines. See your doctor regularly, and call him or her if you develop any new symptoms or your symptoms worsen.

What Is a Coronary Calcium Scan?

A coronary calcium scan is a test that can help show whether you have coronary artery disease (CAD). In CAD, a fatty material called plaque (plak) narrows your coronary (heart) arteries and limits blood flow to your heart. CAD is the most common type of heart disease in both men and women. It can lead to angina, heart attack, heart failure, and arrhythmia. Coronary calcium scanning looks for specks of calcium (called calcifications) in the walls of the coronary arteries. Calcifications are an early sign of heart disease. The test can show, before other signs and symptoms occur, whether youre at increased risk for a heart attack or other heart problems. A coronary calcium scan is most useful for people who are at moderate risk for a heart attack. You or your doctor can calculate your 10-year risk using the Risk Assessment Tool from the National Cholesterol Education Program. People at moderate risk have a 10 to 20 percent chance of having a heart attack within the next 10 years. The coronary calcium scan helps doctors decide who within this group needs treatment. Two machines can show calcium in the coronary arterieselectron beam computed tomography (EBCT) and multidetector computed tomography (MDCT). Both use an x-ray

machine to make detailed pictures of your heart. Doctors study the pictures to see whether youre at risk for heart problems in the next 2 to 10 years. A coronary calcium scan is simple and easy for the patient, who lies quietly in the scanner machine for about 10 minutes. Pictures of the heart are taken that show whether the coronary arteries have calcifications. (For more information, see What To Expect During a Coronary Calcium Scan.) Coronary Calcium Scan

Figure A shows the position of the heart in the body and the location and angle of the coronary calcium scan image. Figure B is the coronary calcium scan image showing calcification in a coronary artery. Other Names for Coronary Calcium Scans

Calcium scan test Cardiac CT for calcium scoring

Sometimes people refer to a coronary calcium scan by the name of the machine used to take pictures of the heart:

Electron-beam computed tomography (EBCT) or electron-beam tomography (EBT) Multidetector computed tomography (MDCT)

What To Expect Before a Coronary Calcium Scan

No special preparation is needed. You may be asked to avoid caffeine and smoking for 4 hours before the test. For the scan, you will remove your clothes above the waist and wear a hospital gown. You also will remove any jewelry from around your neck or chest. What To Expect During a Coronary Calcium Scan Coronary calcium scans are done in a hospital or outpatient office. The x-ray machine thats used is called a computed tomography (CT) scanner. The technician who operates the scanner will clean areas of your chest and apply small sticky patches called electrodes. The electrodes are attached to an EKG (electrocardiogram) monitor. The EKG measures the electrical activity of your heart during the scan. This makes it possible to take pictures of your heart when its relaxed, between beats. The CT scanner is a large machine that has a hollow, circular tube in the center. You will lie on your back on a sliding table. The table can move up and down and goes inside the tunnellike machine. The table will slowly slide into the opening in the machine. Inside the scanner, an x-ray tube moves around your body to take pictures of your heart. You may be asked to hold your breath for 10 to 20 seconds while the pictures are taken. This prevents movement in the image. During the test, the technician will be in a nearby room with the computer that controls the CT scanner. The technician can see you through a window and talk to you through an intercom system. You may be given medicine to slow down a fast heart rate. This helps the machine take better pictures of your heart. The medicine will be given by mouth or injected into a vein. A coronary calcium scan takes about 5 to 10 minutes. During the test, the machine makes clicking and whirring sounds as it takes pictures. It causes no discomfort, but the exam room may be chilly to keep the machine working properly. If you become nervous in enclosed spaces, you may need to take medicine to stay calm. This isnt a problem for most people, because your head will remain outside the opening in the machine. What To Expect After a Coronary Calcium Scan You're able to return to your normal activities after the coronary calcium scan is done. A doctor who is trained in reading these scans will discuss the results with you. What Does the Coronary Calcium Scan Show? After the coronary calcium scan, you will get a calcium score called an Agatston score. The score is based on the amount of calcium found in your coronary arteries. You may get an Agatston score for each major artery and a total score.

The test is negative if no sign of calcium deposits (calcifications) is found in your arteries. This means your chance of having a heart attack in the next 2 to 5 years is low. The test is positive if calcifications are found in your arteries. Calcifications are a sign of atherosclerosis (ATH-er-o-skler-O-sis) and coronary artery disease. (Atherosclerosis is when the arteries harden and narrow due to plaque buildup.) The higher your Agatston score, the greater the amount of atherosclerosis. Use this calculator (from the National Heart, Lung, and Blood Institute) to see whether your score is high. If it is, your doctor may prescribe medicines or order more tests. What Are the Risks of a Coronary Calcium Scan? Coronary calcium scanning has very few risks. The test isnt invasive, which means that no surgery is done and no instruments are inserted into your body. Coronary calcium scanning doesnt require an injection of contrast dye to make your heart or arteries visible on the x-ray images. Because an x-ray machine is involved, you will be exposed to a small amount of radiation. Electron-beam computed tomography (EBCT) uses less radiation than multidetector computed tomography (MDCT). In either case, the amount of radiation is less than or equal to the amount of radiation youre naturally exposed to in a single year.

Key Points

A coronary calcium scan is a test that can help show whether you have coronary artery disease (CAD). Coronary calcium scanning looks for specks of calcium (called calcifications) in the walls of the coronary arteries. Calcifications are an early sign of heart disease. This test is most useful for people who are at moderate risk for a heart attack. You or your doctor can calculate your 10-year risk using the Risk Assessment Tool from the National Cholesterol Education Program. People at moderate risk have a 10 to 20 percent chance of having a heart attack within the next 10 years. The coronary calcium scan helps doctors decide who within the moderate risk group needs treatment. No special preparation is needed before a coronary calcium scan. Coronary calcium scans are done in a hospital or outpatient office. The x-ray machine thats used is called a computed tomography (CT) scanner. A coronary calcium scan takes about 5 to 10 minutes. During the scan, you will lie quietly on your back, while the CT scanner takes pictures of your heart. Youre able to return to your normal activities after the scan is done. The test is negative if there are no calcifications in your coronary arteries. This means your chance of having a heart attack in the next 2 to 5 years is low.

The test is positive if calcifications are found in your coronary arteries. Calcifications are a sign of atherosclerosis and CAD. After the scan, you will receive a calcium score called an Agatston score. The higher the score, the greater the amount of atherosclerosis or plaque buildup. Use this calculator (from the National Heart, Lung, and Blood Institute) to see whether your Agatston score is high. Coronary calcium scanning has very few risks. The test usually isnt invasive, which means that no surgery is done and no instruments are inserted into your body. Coronary calcium scan doesnt require the injection of contrast dye to make your heart or arteries visible on the x-ray images. If you need medicine to slow down your heartbeat during the scan, it may be injected into a vein. Because an x-ray machine is involved, you will be exposed to a small amount of radiation. The amount of radiation is less than or equal to the amount of radiation youre naturally exposed to in a single year.

What Is Heart Failure?

Heart failure is a condition in which the heart cant pump blood the way it should. In some cases, the heart cant fill with enough blood. In other cases, the heart cant send blood to the rest of the body with enough force. Some people have both problems. Heart failure doesnt mean that your heart has stopped or is about to stop working. However, its a serious condition that requires medical care. Overview Heart failure develops over time as the pumping of the heart grows weaker. It can affect the right side of the heart only or both the left and right sides of the heart. Most cases involve both sides of the heart. Right-side heart failure occurs when the heart cant pump blood to the lungs, where it picks up oxygen. Left-side heart failure occurs when the heart cant pump enough oxygen-rich blood to the rest of the body. Right-side heart failure may cause fluid to build up in the feet, ankles, legs, liver, abdomen, and, rarely, the veins in the neck. Right-side and left-side heart failure also cause shortness of breath and fatigue (tiredness). The leading causes of heart failure are diseases that damage the heart. These include coronary artery disease (CAD), high blood pressure, and diabetes. Outlook

Heart failure is a very common condition. About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year. Both children and adults can have heart failure, although the symptoms and treatments differ. This article focuses on heart failure in adults. Taking steps to prevent CAD can help prevent heart failure. These steps include following a heart healthy diet, not smoking, doing physical activity, and losing weight if youre overweight or obese. Working with your doctor to control high blood pressure and diabetes also can help prevent heart failure. People who have heart failure can live longer and more active lives if its diagnosed early and they follow their treatment plans. For most, treatment includes medicines and lifestyle measures. Currently, theres no cure for heart failure. However, researchers are finding and testing new treatments. These treatments offer hope for better ways to delay heart failure and its complications. Other Names for Heart Failure

Dropsy. Left-side, or systolic, heart failure. This is when the heart can't pump enough oxygenrich blood to the body. Right-side, or diastolic, heart failure. This is when the heart can't fill with enough blood.

Some people have only right-side heart failure. But all people who have left-side heart failure also have right-side heart failure. Treatments for right-side heart failure alone differ from treatments for both right-side and left-side heart failure. Your doctor will plan your treatment based on your type of heart failure and your unique needs. What Causes Heart Failure? Conditions that damage the heart muscle or make it work too hard can cause heart failure. Over time, the heart weakens. It isn't able to fill with and/or pump blood as well as it should. As the heart weakens, certain proteins and other substances may be released into the blood. They have a toxic effect on the heart and blood flow, and they cause heart failure to worsen. Major Causes The most common causes of heart failure are coronary artery disease (CAD), high blood pressure, and diabetes. Treating these problems can prevent or improve heart failure.

Coronary Artery Disease CAD occurs when a fatty material called plaque (plak) builds up in your coronary arteries. These arteries supply oxygen-rich blood to your heart. Plaque narrows the arteries, causing less blood to flow to your heart muscle. This can lead to chest pain, heart attack, and heart damage. High Blood Pressure Blood pressure is the force of blood pushing against the walls of the arteries. Blood pressure is high if it stays at or above 140/90 mmHg over a period of time. High blood pressure stiffens blood vessels and makes the heart work harder. Without treatment, the heart may be damaged. Diabetes This disease occurs when the level of sugar in the blood is high. The body doesn't make enough insulin or doesn't use its insulin properly. Insulin is a hormone that helps convert food to energy. High sugar levels can damage blood vessels around the heart. Other Causes Other diseases and conditions that can lead to heart failure are:

Heart muscle diseases. These diseases may be present at birth or due to injury or infection. Heart valve disorders. These problems may be present at birth or due to infections, heart attacks, or damage from heart disease. Arrhythmias (ah-RITH-me-ahs), or irregular heartbeats. These heart problems may be present at birth or due to heart disease or heart defects. Congenital heart defects. These heart problems are present at birth.

Other factors also can injure the heart muscle and lead to heart failure. These include:

Treatments for cancer, such as radiation and chemotherapy Thyroid disorders (having either too much or too little thyroid hormone in the body) Alcohol abuse HIV/AIDS Cocaine and other illegal drug use Too much vitamin E

Heart damage from obstructive sleep apnea may cause heart failure to worsen. In obstructive sleep apnea, your breathing stops or gets very shallow while youre sleeping. This can deprive the heart of oxygen and increase its workload. Treating this sleep problem may improve heart failure.

Who Is At Risk for Heart Failure? About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year. The number of people who have heart failure is growing. Each year, another 550,000 people are diagnosed for the first time. Heart failure is more common in:

People who are 65 or older. Aging can weaken the heart muscle. Older people also may have had a disease for many years that causes heart failure. Heart failure is the #1 reason for hospital visits in this age group. African Americans. African Americans are more likely than people of other races to have heart failure and to suffer from more severe forms of it. Theyre also more likely than other groups to have symptoms at a younger age, get worse faster, have more hospital visits due to heart failure, and die from heart failure. People who are overweight or obese. Excess weight puts a greater strain on the heart. It also can lead to type II diabetes, which adds to the risk of heart failure.

Men have a higher rate of heart failure than women. But in actual numbers, more women have the condition. This is because many more women than men live into their seventies and eighties when its common. Children with congenital heart defects also can develop heart failure. Children are born with these defects when the heart, heart valves, and/or blood vessels near the heart dont form correctly. This can weaken the heart muscle and lead to heart failure. Children dont have the same symptoms or get the same treatment for heart failure as adults. This article focuses on heart failure in adults. What Are the Signs and Symptoms of Heart Failure? The most common signs and symptoms of heart failure are:

Shortness of breath or trouble breathing Fatigue (tiredness) Swelling in the ankles, feet, legs, abdomen, and, rarely, the veins in your neck

All of these symptoms are due to the buildup of fluid in your body. When symptoms start, you may feel tired and short of breath after routine physical effortlike climbing stairs. As the heart grows weaker, symptoms get worse. You may begin to feel tired and short of breath after getting dressed or walking across the room. Some people have shortness of breath while lying flat. Fluid buildup from heart failure also causes weight gain, frequent urination, and a cough that's worse at night and when you're lying down. This cough may be a sign of a condition called acute pulmonary (PULL-mun-ary) edema (e-DE-ma). This is when too much fluid is in your lungs. This severe condition requires emergency treatment.

Heart Failure Signs and Symptoms

The illustration shows the major signs and symptoms of heart failure. How Is Heart Failure Diagnosed? Your doctor will diagnose heart failure based on your medical and family histories, a physical exam, and tests. Because the symptoms of heart failure also are common in other conditions, your doctor must:

Find out whether you have a disease or condition that can cause heart failure, such as coronary artery disease (CAD), high blood pressure, or diabetes Rule out other causes of your symptoms Find any damage to your heart and measure how well your heart pumps blood

Early diagnosis and treatment can help people with heart failure live longer, more active lives. Medical and Family Histories

Your doctor will ask whether you or others in your family have or have had a disease or condition that can cause heart failure. Your doctor also will ask about your symptoms. He or she will want to know which symptoms you've have, when they occur, how long you've had them, and how severe they are. The answers will help show whether and how much your symptoms limit your daily routine. Physical Exam During the physical exam, your doctor will:

Listen to your heart for sounds that aren't normal Listen to your lungs for the sounds of extra fluid buildup Look for swelling in your ankles, feet, legs, abdomen, and the veins in your neck

Diagnostic Tests No one test shows whether you have heart failure. If you have signs and symptoms of heart failure, your doctor may order an EKG (electrocardiogram), a chest x ray, and a BNP blood test as initial tests. Initial Tests EKG. This simple test shows how fast your heart is beating and whether its rhythm is steady or irregular. An EKG may show whether you have had a heart attack or whether the walls in your heart's pumping chambers are thicker than normal. Thicker walls can make it harder for your heart to pump blood. Chest x ray. A chest x ray takes a picture of your heart and lungs. It can show whether your heart is enlarged, whether you have fluid in your lungs, or whether you have lung disease. BNP blood test. This new test checks the level of a hormone called BNP, which rises during heart failure. Followup Tests Your doctor may refer you to a cardiologist if your initial test results indicate heart failure. A cardiologist is a doctor who specializes in treating people with heart problems. The cardiologist will likely order one or more other tests to confirm the diagnosis. Echocardiography. Echocardiography uses sound waves to create a moving picture of your heart. It shows the size and shape of your heart and how well parts of your heart are working. The test also can show where blood flows poorly to the heart, where the heart muscle doesn't contract as it should, and damage to the heart muscle caused by poor blood flow.

Sometimes this test is done both before and after your heart is put through physical stress (see stress testing below). Testing under stress helps show whether there's a lack of blood flow to your heart (a sign of CAD). Doppler imaging. A Doppler test uses sound waves to measure the speed and direction of blood flow. It's often done with an echocardiogram to give a more complete picture of blood flow to the heart and lungs. Doppler is often used to find out whether you have right-side heart failure (this is when the heart can't fill with enough blood). Holter monitor. A Holter monitor is a small box that you carry in a pouch around your neck or clipped to your belt. It's attached to sticky patches called electrodes that are placed on your chest. The device records your heart rhythm for a full 24- or 48-hour period, while you do your normal daily activities. Nuclear heart scan. A nuclear heart scan is a test that shows how well blood is passing through your heart and how much blood is reaching your heart muscle. Your doctor will inject a radioactive substance into your bloodstream, which will make your heart chambers and vessels easy to see. Then, a special camera is used to show where the substance lights up (in healthy heart muscle) and where it doesn't (in damaged heart muscle). Your doctor may want to do this test while your heart is under physical stress (see stress testing below). Cardiac catheterization. During cardiac catheterization (KATH-e-ter-i-ZA-shun), a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. This allows your doctor to study the insides of your coronary arteries. Coronary arteries carry oxygen-rich blood to your heart. During this procedure, your doctor can check the pressure and blood flow in the heart's chambers, collect blood samples, and use x rays to look at the coronary arteries. Coronary angiography. Coronary angiography (an-jee-OG-ra-fee) is usually done with cardiac catheterization. A dye that can be seen on x ray is injected into the blood through the tip of the catheter. The dye allows your doctor to see the flow of blood to the heart muscle. This test also shows how well your heart is pumping. Stress test. Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it's at rest. During stress testing, you exercise (or are given medicine if you can't exercise) to make your heart work harder and beat faster. You may walk or run on a treadmill or pedal a bicycle. Heart tests, such as nuclear heart scanning and echocardiography, are done during stress testing.

Cardiac magnetic resonance imaging (MRI). A cardiac MRI scan shows, in detail, the structures and beating of your heart. An MRI scan can help your doctor see whether parts of your heart are damaged. Doctors also are using MRI in research studies to find early signs of heart failure, even before symptoms appear. Positron emission tomography (PET). PET scanning shows the level of chemical activity in areas of your heart. This scan can help your doctor see whether enough blood is flowing to these areas. It can show blood flow problems that other types of scans may not pick up. Thyroid function tests. Thyroid function tests show how well the thyroid is working. They include blood tests, imaging tests, and tests to stimulate the thyroid. These common tests are key in checking for heart failure. Having too much or too little thyroid hormone in the blood can cause heart failure. How Is Heart Failure Treated? Early diagnosis and treatment can help people with heart failure live longer, more active lives. How heart failure is treated will depend on your type and stage of heart failure (how severe it is). The goals of treatment for all stages of heart failure are to:

Treat the underlying cause of your heart failure, such as coronary artery disease (CAD), high blood pressure, or diabetes Reduce your symptoms Stop your heart failure from getting worse Increase your lifespan and improve your quality of life

For people with any stage of heart failure, treatment will include lifestyle measures, medicines, and ongoing care. People who have more severe heart failure also may need medical procedures and surgery. Lifestyle Measures You can take simple steps to help yourself feel better and control heart failure. The sooner you start these measures, the better off you're likely to be. Follow a Healthy Eating Plan A diet low in salt, fat, saturated fat, trans fat, and cholesterol can help you prevent or control heart failure. Salt can cause extra fluid to build up in your body, making heart failure worse. Fat and saturated fat can increase your blood cholesterol levels. Trans fat raises your LDL ("bad") cholesterol and lowers your HDL ("good") cholesterol. High blood cholesterol can cause heart disease, which in turn can cause heart failure.

A balanced diet with varied nutrients can help your heart work better. Getting enough potassium is key for people with heart failure. Some heart failure medicines deplete the potassium in your body. This can put people with heart failure in danger. Lack of potassium can cause very rapid heart rhythms that lead to sudden death. Potassium is found in foods like bananas, strawberries, raisins, beets, and greens. Talk to your health care team about getting the correct amount of potassium. If you have heart failure, you shouldn't drink alcohol. If you have severe heart failure, your doctor may advise you to limit the amount of fluids that you drink. Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) diet and the Dietary Approaches to Stop Hypertension (DASH) eating plan. The TLC diet is low in saturated fat and cholesterol to help lower blood cholesterol. The DASH eating plan contains less salt/sodium, sweets, added sugars, fats, and red meat than the typical American diet. Fruits, vegetables, fat-free or low-fat diary products, whole grains, fish, poultry, beans, seeds, and nuts are the focus of the plan. Adopt Healthy Habits Taking steps to control risk factors for CAD, high blood pressure, and diabetes also will help control heart failure.

Lose weight if you're overweight or obese. Work with your health care team to lose weight safely. Do physical activity as your doctor directs to become more fit and stay as active as possible. Quit smoking and avoid using illegal drugs. Avoid exposure to secondhand smoke. Smoking and drugs can worsen heart failure and harm your health. Get enough rest.

Medicines Your doctor will base your medicine treatment on the type of heart failure you have, how severe it is, and your response to certain medicines. The following are the main medicines for treating heart failure.

Diuretics (water or fluid pills) help reduce fluid buildup in your lungs and swelling in your feet and ankles. ACE inhibitors lower blood pressure and reduce strain on your heart. They also may reduce the risk of a future heart attack. Aldosterone antagonists trigger the body to get rid of salt and water through urine, which lowers the volume of blood that the heart must pump.

Angiotensin receptor blockers relax your blood vessels and lower blood pressure, so the heart doesn't have to work as hard. Beta blockers slow your heart rate and lower your blood pressure to decrease the workload on your heart. Isosorbide dinitrate/hydralazine hydrochloride helps relax your blood vessels, so your heart doesn't work as hard to pump blood. The Food and Drug Administration approved this medicine for use in African Americans after studies showed it worked well for this group. Digoxin makes the heart beat stronger and pump more blood.

Many people with severe heart failure must be treated in the hospital from time to time. In the hospital, you may receive new or special medicines, but you will keep taking your other medicines too. Some people with very severe heart failure are given intravenous (IV) medicines, which are injected into veins in their arms. Your doctor also will order extra oxygen if you take medicine but still have trouble breathing. The extra oxygen can be given in the hospital and at home. Ongoing Care It's important to watch for signs that heart failure is getting worse. Weigh yourself each day. Let your doctor know right away if you have a sudden weight gain or weight loss. Either one can signal a need to adjust your treatment. If your doctor advises you to limit your intake of fluids, carefully watch how much you drink during the day. It's also important to get medical care for other related conditions. If you have diabetes and/or high blood pressure, work with your health care team to control your condition(s). Have your blood sugar level and blood pressure checked. Your doctor will tell you how often to come in for tests and how often to take measurements at home. Medical Procedures and Surgery As heart failure worsens, lifestyle changes and medicines may no longer control heart failure symptoms. You may need a medical procedure or surgery. If you have heart damage and severe heart failure symptoms, you may need:

Cardiac resynchronization therapy. In heart failure, the right and left sides of the heart may no longer contract at the same time. This disrupts the heart's pumping. To correct this problem, doctors may implant a type of pacemaker near your heart. This device helps both sides of the heart contract at the same time, which may decrease heart failure symptoms. An implantable cardioverter defibrillator (ICD). Some people with heart failure have very rapid, irregular heartbeats. Without treatment, the problem can cause sudden cardiac arrest. Doctors implant ICDs to solve this problem. ICDs are similar to

pacemakers. The device checks your heart rate and corrects heart rhythms that are too fast. People who have heart failure symptoms at rest despite other treatments may need:

A mechanical heart pump, such as a left ventricular assist device. This device helps pump blood from the heart to the rest of the body. People may use pumps until they have surgery or as a long-term treatment. Heart transplant. When all other treatments fail to control symptoms, some people who have heart failure receive healthy hearts from deceased donors. Experimental treatments. Studies are under way to see whether open-heart surgery or angioplasty (a procedure used to unblock heart arteries and improve blood flow) can reduce heart failure symptoms.

Ongoing Research Researchers continue to learn more about heart failure and how to treat it. As a result, treatments are getting better. People with heart failure often can be treated in a research study. You get top care from heart failure experts and the chance to help advance heart failure knowledge and care. You also may want to take part in a heart failure registry, which tracks the course of disease and treatment in large numbers of people. These data help research move forward. You may help yourself and others by taking part. Talk to your health care team to learn more. How Can Heart Failure Be Prevented? You can take steps to prevent heart failure. The sooner you start, the better your chances to avoid it or to stay healthier longer. For People Who Have Healthy Hearts If you have a healthy heart, you can take action to prevent heart disease, which helps prevent heart failure. To prevent heart disease:

Follow a heart healthy diet that focuses on fruits, vegetables, whole grains, low-fat diary products, and lean meat. It also should be low in salt, fat, saturated fat, trans fat, and cholesterol. Examples of healthy eating plans are the National Heart, Lung, and Blood Institute's Therapeutic Lifestyle Changes (TLC) diet and the Dietary Approaches to Stop Hypertension (DASH) eating plan. Quit smoking if you smoke. Avoid exposure to secondhand smoke. Lose weight if you're overweight or obese. Get regular physical activity. Aim for at least 30 minutes on most, and preferably all, days of the week. Avoid using illegal drugs.

For People Who Are at High Risk for Heart Failure Even if you're at high risk for heart failure, you can take steps to reduce your risks. People at high risk include those who have high blood pressure, coronary artery disease, or diabetes, or people who are obese.

Follow all of the steps listed above. Treat and control any conditions that cause heart failure. Take medicines as your doctor prescribes. Avoid drinking alcohol. See your doctor for regular followup visits.

For People Who Have Heart Damage but No Signs of Heart Failure If you have heart damage but no signs of heart failure, you can still reduce your risks. In addition to taking the steps above, take all of the medicines your doctor prescribes to reduce your heart's workload. If you have side effects from a medicine, tell your doctor. You should never stop taking medicine without asking your doctor first. Living With Heart Failure Heart failure can't be cured. You will likely have to take medicine and follow a treatment plan for the rest of your life. Despite treatment, symptoms may get worse over time. You may not be able to do many of the things that you did before you had heart failure. However, if you take all the steps your doctor recommends, you can stay healthier longer. Researchers also may find new treatments that can help you in the future. Follow Your Treatment Plan Treatment can relieve your symptoms and make daily activities easier. It also can reduce the chance that you'll have to go to the hospital. For these reasons, it's vital that you follow your treatment plan.

Take all of your medicines as your doctor prescribes. If you have side effects from a medicine, tell your doctor. You should never stop taking medicine without asking your doctor first. Make all of the lifestyle changes that your doctor recommends. Get advice from your doctor about how active you can/should be. This includes advice on daily activities, work, leisure time, sex, and exercise. Your level of activity will depend on the stage of your heart failure (how severe it is). Studies show that aerobic exercise improves heart function; other types of exercise don't.

Keep all of your medical appointments, including visits to the doctor and appointments to get tests and lab work. Your doctor needs the results of these tests to adjust your medicine doses and help you avoid any harmful side effects.

Take Steps To Prevent Heart Failure From Getting Worse Certain factors can cause your heart failure to worsen. These include:

Forgetting to take your medicines Not following your diet (such as eating salty foods) Drinking alcohol

These factors can lead to a hospital stay. If you have trouble following your diet, talk to your doctor. Your doctor can help arrange for a dietitian to work with you. Avoid drinking alcohol. People with heart failure often have other serious conditions that require ongoing treatment. If you do, you're likely taking medicines for them as well as for heart failure. Taking more than one medicine raises the risk of side effects and other problems. Make sure your pharmacist has a complete list of all of the medicines and over-the-counter products that you're taking. Tell your doctor right away about any problems with your medicines. Also, talk with your doctor before taking any new medicine another doctor prescribes or any new over-thecounter medicines or herbal supplements. Try to avoid respiratory infections like the flu and pneumonia. Ask your doctor or nurse about getting flu and pneumonia vaccines. Coping with heart failure and changing your life to decrease symptoms can be hard. You may feel depressed. If so, talk to your doctor. He or she may recommend treatment for depression. This treatment can improve your outlook and help you enjoy life more. Plan Ahead Be ready to meet your health needs. Know:

When to seek help. Talk to your doctor about when to make an office visit or when to get urgent help. Phone numbers for your doctor and hospital. Directions to the doctor's office or hospital and people who can take you there. A list of medicines you're taking.

Key Points

Heart failure is a condition in which your heart can't pump blood the way it should. In some cases, the heart can't fill with enough blood. In other cases, the heart can't send blood to the rest of the body with enough force. Some people have both problems. "Heart failure" doesn't mean that your heart has stopped or is about to stop working. However, it's a serious condition that requires medical care. The leading causes of heart failure are diseases that damage the heart. These include coronary artery disease, high blood pressure, and diabetes. Heart failure develops over time as the pumping action of the heart grows weaker. Heart failure is a common condition. About 5 million people in the United States have heart failure, and it results in about 300,000 deaths each year. Heart failure is more common in people who are 65 or older, African American, or overweight or obese. Men have a higher rate of heart failure than women. Common signs and symptoms of heart failure are shortness of breath or trouble breathing, fatigue (feeling tired), and swelling in the ankles, feet, legs, abdomen, and, rarely, the veins in the neck. All of these symptoms are due to fluid buildup in your body. Your doctor will diagnose heart failure based on your medical and family histories, a physical exam, and tests. He or she must rule out other causes for symptoms and find out whether you have a disease or condition that's causing heart failure. He or she also will check whether your heart is damaged and how well it pumps blood. Heart failure treatment may include lifestyle measures, medicines, ongoing care, and using a medical device or having surgery. The sooner you start treatment, the better off you're likely to be. You can take steps to prevent heart failure by having a healthy lifestyle, preventing and treating conditions that can lead to heart failure, and taking medicines as your doctor prescribes. Heart failure can't be cured. You will likely need to take medicine and follow a treatment plan for the rest of your life. Despite treatment, your symptoms may get worse over time. Following your treatment plan, taking steps to prevent heart failure from getting worse, and planning ahead can help you stay healthier longer. Researchers are finding and testing new treatments for heart failure. These treatments offer hope for the future. Talk to your doctor about whether research studies may benefit you.

What Are Holes in the Heart?

A hole in the heart (also called an atrial septal defect (ASD) or ventricular septal defect (VSD)) is a type of simple congenital (kon-JEN-i-tal) heart defect. This is a problem with the heart's structure that's present at birth. Congenital heart defects change the normal flow of blood through the heart.

Your heart has two sides, separated by an inner wall called the septum. With each heartbeat, the right side of the heart receives oxygen-poor blood from the body and pumps it to the lungs. The left side of the heart receives oxygen-rich blood from the lungs and pumps it to the body. The septum prevents mixing of blood between the two sides of the heart. Some babies are born with a hole in the upper or lower septum. A hole in the septum between the heart's upper two chambers (the atria, pronounced AY-tree-uh) is an ASD. A hole in the septum between the heart's lower two chambers (the ventricles, pronounced VEN-trih-kuls) is a VSD. A hole in the septum can allow blood to pass from the left side of the heart to the right side. This means that oxygen-rich blood can mix with oxygen-poor blood, causing the oxygen-rich blood to be pumped to the lungs a second time. Over the past few decades, the diagnosis and treatment of ASDs and VSDs have greatly improved. As a result, a child with a simple heart defect can grow to adulthood and live a normal, active, and productive life because his or her heart defect closes on its own or has been repaired.
December 2007

How the Heart Works To understand holes in the heart, it's helpful to know how a healthy heart works. Your child's heart is a muscle about the size of his or her fist. The heart works like a pump and beats 100,000 times a day. The heart has two sides, separated by an inner wall called the septum. The right side of the heart pumps blood to the lungs to pick up oxygen. Then, oxygen-rich blood returns from the lungs to the left side of the heart, and the left side pumps it to the body. The heart has four chambers and four valves and is connected to various blood vessels. Veins are the blood vessels that carry blood from the body to the heart. Arteries are the blood vessels that carry blood away from the heart to the body.

A Healthy Heart Cross-Section

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body. Heart Chambers The heart has four chambers or "rooms."

The atria are the two upper chambers that collect blood as it comes into the

heart.

The ventricles are the two lower chambers that pump blood out of the heart to the lungs or other parts of the body. Heart Valves Four valves control the flow of blood from the atria to the ventricles and from the ventricles into the two large arteries connected to the heart.

The tricuspid (tri-CUSS-pid) valve is in the right side of the heart, between the right atrium and the right ventricle. The pulmonary (PULL-mun-ary) valve is in the right side of the heart, between the right ventricle and the entrance to the pulmonary artery, which carries blood to the lungs.

The mitral (MI-trul) valve is in the left side of the heart, between the left atrium and the left ventricle.

The aortic (ay-OR-tik) valve is in the left side of the heart, between the left ventricle and the entrance to the aorta, the artery that carries blood to the body. Valves are like doors that open and close. They open to allow blood to flow through to the next chamber or to one of the arteries, and then they shut to keep blood from flowing backward. When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope.

The first soundthe lubis made by the mitral and tricuspid valves closing at the beginning of systole (SIS-toe-lee). Systole is when the ventricles contract, or squeeze, and pump blood out of the heart.

The second soundthe DUBis made by the aortic and pulmonary valves closing at beginning of diastole (di-AS-toe-lee). Diastole is when the ventricles relax and fill with blood pumped into them by the atria. Arteries The arteries are major blood vessels connected to your heart.

The pulmonary artery carries blood pumped from the right side of the heart to the lungs to pick up a fresh supply of oxygen. The aorta is the main artery that carries oxygen-rich blood pumped from the left side of the heart out to the body. The coronary arteries are the other important arteries attached to the heart. They carry oxygen-rich blood from the aorta to the heart muscle, which must have its own blood supply to function. Veins The veins are also major blood vessels connected to your heart.

The pulmonary veins carry oxygen-rich blood from the lungs to the left side of the heart so it can be pumped out to the body. The vena cava is a large vein that carries oxygen-poor blood from the body back to the heart. For more information on how a healthy heart works, see the Diseases and Conditions Index article on How the Heart Works. This article contains animations that show how your heart pumps blood and how your hearts electrical system works. Types of Holes in the Heart Atrial Septal Defect

An atrial septal defect (ASD) is a hole in the part of the septum that separates the atria (upper chambers of the heart). This heart defect allows oxygen-rich blood from the left atrium to flow across the atrial septum into the right atrium instead of flowing down to the left ventricle as it should. This is inefficient because oxygen-rich blood gets pumped back to the lungs, where it has just been, instead of going to the body. Cross-Section of a Normal Heart and a Heart With Atrial Septal Defect

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows a heart with an atrial septal defect, which allows oxygen-rich blood from the left atrium to mix with oxygen-poor blood from the right atrium. An ASD can be small or large. Small ASDs allow only a little blood to flow from one atrium to the other. Small ASDs don't affect the way the heart works and therefore don't need any special treatment. Many small ASDs close on their own as the heart grows during childhood. Medium to large ASDs allow more blood to leak from one atrium to the other, and they are less likely to close on their own. Most children with ASDs have no symptoms, even if they have large ASDs. There are three major types of ASD:

Secundum. This defect is in the middle of the atrial septum. Its the most common form of ASD. About 8 out of every 10 babies born with ASD have secundum defects. At least half of all secundum ASDs close on their own. This is less likely if the defect is large. Primum. This defect is in the lower part of the atrial septum. It often occurs along with abnormalities in the heart valves that connect the upper and lower heart chambers. Primum defects arent very common. This type of defect doesnt close on its own. Sinus venosus. This defect is in the upper part of the atrial septum, near where a large vein (the superior vena cava) brings oxygen-poor blood from the upper body to

the right atrium. Sinus venosus is a rare defect. Sinus venosus defects dont close on their own. Long-Term Effects of Atrial Septal Defects That Arent Repaired Over time, the extra blood flow to the right side of the heart and the lungs may cause problems for a heart that has an ASD. Usually, most of these problems dont show up until adulthood, often around age 30 or later. They are rare in infants and children. These possible problems include:

Right heart failure. The right side of the heart has to work harder to pump extra blood to the lungs. Over time, the heart may become tired from this extra work and not pump efficiently. Arrhythmias (irregular heartbeats). Extra blood flowing into the right atrium through an ASD can cause the atrium to stretch and enlarge. Over time, this can lead to problems with the hearts rhythm. When this occurs, an arrhythmia can develop, with signs or symptoms such as palpitations (a feeling that your heart has skipped a beat or is beating too hard) or a rapid heartbeat. Stroke. Usually, the lungs filter out small clots that can form on the right side of the heart. Sometimes a blood clot formed on the right side of the heart can pass through an ASD to the left side and be pumped out to the body. A clot like this can travel to an artery in the brain, blocking blood flow through it and causing a stroke. This doesnt occur in childhood. Pulmonary arterial hypertension (PAH). PAH is high blood pressure in the arteries in the lungs. Over time, high blood pressure in the lungs can damage the arteries and the small blood vessels in the lungs. They thicken and become stiff, making it harder for blood to flow through them.

These problems develop over many years and dont occur in children. They also are rare in adults because most ASDs either close on their own or are repaired in early childhood. Ventricular Septal Defect A ventricular septal defect (VSD) is a hole in the part of the septum that separates the ventricles, the lower chambers of the heart. The hole allows oxygen-rich blood to flow from the left ventricle across the heart into the right ventricle instead of flowing up into the aorta and out to the body as it should.

Cross-Section of a Normal Heart and a Heart With Ventricular Septal Defect

Figure A shows the normal structure and blood flow in the interior of the heart. Figure B shows two common locations for a ventricular septal defect. The defect allows oxygen-rich blood from the left ventricle to mix with oxygen-poor blood in the right ventricle. An infant born with a VSD may have a single hole or more than one hole in the wall that separates the two ventricles. The defect also may occur by itself or with other congenital heart defects. Doctors classify VSDs based on the:

Size of the defect. Location of the defect. Number of defects. Presence or absence of a ventricular septal aneurysma thin flap of tissue on the septum. This tissue is harmless and can help a VSD close on its own.

VSDs can be small or large. A small VSD doesnt cause problems and may often close on its own. Because small VSDs allow only a small amount of blood to flow between the ventricles, theyre sometimes called restrictive VSDs. Small VSDs dont cause any symptoms. Medium VSDs are less likely than small defects to close on their own. They may require surgery to close and may cause symptoms during infancy and childhood.

Large VSDs allow a large amount of blood to flow from the left ventricle to the right ventricle and are sometimes called nonrestrictive VSDs. A large VSD is less likely to close completely on its own, but it may get smaller over time. Large VSDs often cause symptoms in infants and children, and surgery is usually needed to close them. VSDs are found in different parts of the septum.

Membranous VSDs are located near the heart valves. They can close at any time. Muscular VSDs are found in the lower part of the septum. Theyre surrounded by muscle, and most close on their own during early childhood. Inlet VSDs are located close to where blood enters the ventricles. Theyre less common than membranous and muscular VSDs. Outlet VSDs are found in the part of the ventricle where the blood leaves the heart. This is the rarest type of VSD.

Long-Term Effects of Large Ventricular Septal Defects That Arent Repaired A moderate to large VSD can cause:

Heart failure. Infants with large VSDs may develop heart failure because the left side of the heart pumps blood into the right ventricle in addition to its normal work of pumping blood to the body. The increased workload on the heart also increases the heart rate and the bodys demand for energy. Growth failure, especially in infancy. A baby may not be able to eat enough to keep up with his or her bodys increased energy demands. As a result, the baby may lose weight or fail to grow and develop normally. Arrhythmias (irregular heartbeats). The extra blood flowing through the heart can cause areas of the heart to stretch and enlarge. This can disturb the normal electrical activity of the heart, leading to fast and irregular heart rhythms. PAH. The high pressure and high volume of extra blood pumped through a large VSD into the lungs can cause scarring of the delicate arteries in the lungs. Today, PAH rarely develops because most large VSDs are repaired in infancy.

What Causes Holes in the Heart? Mothers of children born with an atrial septal defect (ASD), a ventricular septal defect (VSD), or another type of heart defect often think that they did something wrong during the pregnancy to cause the problem. However, most of the time, doctors don't know why these congenital heart defects develop. Heredity may play a role in some heart defects. For example, a parent who has a congenital heart defect is slightly more likely than other people to have a child with the problem. In very

rare cases, more than one child in a family is born with a heart defect. Children with genetic defects often have congenital heart defects. An example of this is Down syndromehalf of all babies with Down syndrome have congenital heart defects. Scientists continue to search for the causes of congenital heart defects. What Are the Signs and Symptoms of Holes in the Heart? Atrial Septal Defect A heart murmur (an extra flow sound associated with the heartbeat) is the most common sign of an atrial septal defect (ASD). Often, its the only sign. However, not all murmurs are a sign of a congenital heart defect. Many healthy children have heart murmurs, which are innocent, normal sounds of blood flow through the heart. A doctor can tell by listening whether a murmur is a normal flow sound or a sign of a heart problem. Many babies born with ASDs have no signs or symptoms. If a large ASD isnt repaired, the extra blood flow to the right side of the heart can eventually damage the heart and lungs, causing heart failure. This doesnt occur until adulthood. Signs and symptoms of heart failure can include:

Fatigue or tiring easily during exercise or activity Shortness of breath A buildup of blood and fluid in the lungs A buildup of fluid in the feet, ankles, and legs

Ventricular Septal Defect A heart murmur is usually present in ventricular septal defect (VSD) and may be the first and only sign of this defect. The heart murmur is often present right after birth in many infants, but it may not be heard until the baby is 6 to 8 weeks old. Most newborns who have VSDs dont have heart-related symptoms. However, a baby with a medium or large VSD can develop heart failure. Signs and symptoms of heart failure usually appear during the babys first 2 months of life. The signs and symptoms of heart failure from VSD are similar to those listed above for ASD, but they occur in infancy. The major sign of heart failure is difficulty feeding and poor growth. VSD symptoms are rare after infancy because the defect either decreases in size on its own or is repaired. How Are Holes in the Heart Diagnosed? Holes in the heart are usually diagnosed based on results from a physical exam and special tests. The exam findings for an atrial septal defect (ASD) often aren't obvious, so the diagnosis is sometimes not made until later childhood or even adulthood. A ventricular septal defect (VSD) has a very distinct heart murmur, so this diagnosis is usually made in infancy.

Specialists Involved Doctors who specialize in heart problems are called cardiologists. Pediatric cardiologists take care of babies and children who have heart problems. Other specialists who treat heart defects include cardiac surgeons (doctors who repair heart defects using surgery). Physical Exam During a physical exam, the doctor:

Listens to your child's heart and lungs with a stethoscope Looks for signs of a heart defect, such as a heart murmur or signs of heart failure

Diagnostic Tests and Procedures The doctor will order several tests to diagnose an ASD or VSD. These tests also will help the doctor determine the location and size of the defect. Echocardiography This test, which is harmless and painless, uses sound waves to create a moving picture of the heart. During echocardiography, ultrasound waves bounce off the structures of the heart, and then a computer converts them into pictures on a video screen. The test allows the doctor to clearly see any problem with the way the heart is formed or the way it's working. Echocardiography is an important test for diagnosing a hole in the heart and for following the problem over time. This test shows problems with the heart's structure and how the heart is reacting to these problems. Echocardiography helps the cardiologist decide whether and when treatment is needed. EKG An EKG (electrocardiogram) detects and records the electrical activity of the heart. This simple and painless test is used to assess the heart rhythm. An EKG shows how fast the heart is beating and whether the heart's rhythm is steady or irregular. It also can detect enlargement of one of the heart's chambers, which can help to diagnose a heart defect. Chest X Ray A chest x ray takes a picture of the heart and lungs. It can show whether the heart is enlarged or whether the lungs have extra blood flow or extra fluid, which can be a sign of heart failure.

Pulse Oximetry Pulse oximetry shows how much oxygen is in the blood. A sensor is placed on the fingertip or toe (like an adhesive bandage). The sensor is attached to a small computer unit, which displays a number that indicates how much oxygen is in the blood. Cardiac Catheterization During cardiac catheterization (KATH-e-ter-i-ZA-shun), a thin, flexible tube called a catheter is put into a vein in the arm, groin (upper thigh), or neck and threaded to the heart. A dye that can be seen on an x ray is injected through the catheter into a blood vessel or a chamber of the heart. This allows the doctor to see the flow of blood through the heart and blood vessels on the x-ray image. Cardiac catheterization also can be used to measure the pressure inside the heart chambers and blood vessels and can determine whether blood is mixing between the two sides of the heart. It's also used to repair some heart defects. (See How Are Holes in the Heart Treated?) How Are Holes in the Heart Treated? Although many holes in the heart don't need treatment, some do. These days, most holes in the heart that need treatment are repaired in infancy or early childhood. Sometimes, adults are treated for holes in the heart if problems develop. The treatment your child receives depends on the type, location, and size of the hole. Other factors include your child's age, size, and general health. Treating Atrial Septal Defect Periodic checkups are done to see whether the defect closes on its own. About half of all ASDs close on their own over time, and about 20 percent close within the first year of life. Your child's doctor will recommend how often your child should be checked. For an ASD, frequent checkups aren't needed. When treatment of an ASD is required, it involves catheter or surgical procedures to close the hole. Catheter or Surgical Procedures To Repair ASD Doctors often decide to close an ASD in children who still have medium to large holes by the time they are 2 to 5 years old. Catheter procedure. Until the early 1990s, surgery was the usual method for closing all ASDs. Now, thanks to medical advances, catheter procedures can be used to close secundum ASDs, which are the most common type of ASD. This procedure is done under general anesthesia, so the child sleeps throughout and doesn't feel any pain.

During the procedure, the doctor inserts a catheter (a thin, flexible tube) into a vein in the groin (upper thigh) and threads it to the heart's septum. The catheter has a tiny umbrella-like device folded up inside it. When the catheter reaches the septum, the device is pushed out of the catheter and positioned so that it plugs the hole between the atria. The device is secured in place and the catheter is withdrawn from the body. Within 6 months, normal tissue grows in and over the device. There is no need to replace the closure device as the child grows. Doctors often use echocardiography or a transesophageal (trans-e-SOF-ah-ge-al) echocardiography (TEE) as well as angiography to guide them in threading the catheter to the heart and closing the defect. A TEE is a special type of echocardiography that takes pictures of the heart through the esophagus (the tube leading from the mouth to the stomach). Catheter procedures are much easier than surgery on patients because they involve only a needle puncture in the skin where the catheter is inserted. This means that recovery is faster and easier. The outlook for children having this procedure is excellent. Closures are successful in more than 9 out of 10 patients, with no significant leakage. Rarely, a defect is too large for catheter closure, so surgery is needed. Surgery. Open-heart surgery is generally done to repair primum or sinus venosus ASDs. General anesthesia is used so the child will sleep through the operation and not feel any pain. During this procedure, the surgeon makes an incision in the chest to reach the ASD and repairs the defect with a special patch that covers the hole. The child is placed on a heartlung bypass machine so that the heart can be opened to perform the operation. The outlook for children after ASD surgery is excellent. On average, children spend 3 to 4 days in the hospital before going home. Complications, such as bleeding and infection, from ASD surgery are very rare. Some children may develop inflammation of the outer lining of the heart, causing fluid to collect around the heart in the weeks after surgery. This is a reaction to the heart operation and usually resolves with medicine. While in the hospital, the child is given medicines as needed to reduce pain or anxiety. The doctors and nurses at the hospital teach parents how to care for the child at home. They will talk about preventing blows to the chest as the incision heals, limiting activity while the child recovers, bathing, scheduling followup appointments with the doctor, and determining when the child can resume regular activities. Treating Ventricular Septal Defect The doctor may choose to monitor and observe a child with VSD who doesn't have symptoms of heart failure. This means regular checkups and tests to see whether the defect closes on it own or gets smaller. More than half of VSDs eventually close, usually by the time a child is in preschool. Your child's doctor will recommend how often your child should be checked, ranging from monthly checkups to checkups every 1 or 2 years.

When treatment for VSD is required, options include extra nutrition and surgery to close the VSD. Surgical treatment is needed if a child's VSD:

Is large Is causing your child to have symptoms Is medium-sized and is causing enlargement of the heart chambers Affects the aortic valve

Extra Nutrition Some infants with VSDs don't grow and develop or gain weight as they should. These infants usually:

Have large VSDs Are born prematurely Tire easily during feeding

Doctors usually recommend extra nutrition or special feedings for these infants. These feedings are high-calorie formulas or breast milk supplements that give the baby extra nourishment. In some cases, tube feeding is needed. Food is given through a small tube that is placed through the nose into the stomach. Tube feeding can add to or take the place of bottle feeding. This treatment is usually temporary, because a VSD that causes symptoms will likely need surgery. Surgery To Repair VSDs Today, most doctors recommend surgery to close a large VSD that's causing symptoms or hasn't closed by 1 year of age. Surgery may be required earlier if:

The child fails to gain weight Medicines are required to control the symptoms of heart failure

Rarely, a medium-sized VSD that's causing enlargement of the heart chambers is treated with surgery after infancy. However, most VSDs that need surgery are repaired in the first year of life. Living With Holes in the Heart The outlook for children with atrial septal defects (ASDs) and ventricular septal defects (VSDs) is excellent. Advances in treatment mean that most children with these heart defects have normal, active, and productive lives with no decrease in lifespan.

Many children with these defects need no special care or only occasional checkups with a cardiologist (a doctor who specializes in heart problems) as they go through childhood and adult life. Living With an Atrial Septal Defect Small ASDs often close on their own, and children with these heart defects don't have any problems or need treatment. Children and adults with small ASDs that don't close and don't cause symptoms are healthy and don't need treatment. Many others with ASDs that don't close undergo procedures to close the hole and prevent possible long-term complications. Children recover well from these procedures and lead normal, healthy lives. Adults also do well after closure procedures. Medical Needs Arrhythmias. The risk of arrhythmias (irregular heartbeats) increases before and after surgery. Adults with ASDs who are older than 40 years are especially likely to have arrhythmias. People who had arrhythmias before surgery are more likely to have them after surgery. Followup care. Regular followup care into adult life is advised for those who have had:

An ASD repaired as an adult Arrhythmias before and after surgery An ASD repaired with a catheter procedure High blood pressure in the pulmonary artery at the time of surgery

Antibiotics. Some heart defects and their repairs can increase the risk of bacterial endocarditis, a serious infection of the heart valves or lining of the heart. You may need antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter your bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures. ASDs aren't associated with the risk of endocarditis, except in the 6 months after repair (for both catheter procedures and surgery). Special Considerations for Children and Teens Activity. Children with a repaired or closed ASD have no restrictions on their activity. Growth and development. Children with ASDs don't have growth or development problems. Regular health care. Your child should see his or her regular doctor for routine health care. Additional surgery or procedures. When a child has an ASD, but no other heart defect, additional surgery isn't needed.

Special Considerations for Adults Recovery from surgical repair of an ASD. When an ASD is repaired in adult life, the cardiologist or surgeon will explain what to expect during the recovery period and when to return to driving, working, exercising, and other activities. Living With a Ventricular Septal Defect Children with small VSDs have no symptoms and need only rare followup with a cardiologist. To protect these children from endocarditis, they may need antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter the bloodstream. Talk to your child's doctor about whether your child needs to take antibiotics before such procedures. Children and adults who have had successful repair of a VSD and have no other congenital heart defects can expect to lead normal, healthy, and active lives. Medical Needs Sometimes problems and risks remain after surgical closure. They include:

Arrhythmias (irregular heartbeats). Serious and frequent arrhythmias require regular medical followup. The risk of arrhythmia is greater if surgery is done later in life. Residual or remaining VSD. This is usually due to a leak at the edge of the patch used to close the hole. These VSDs tend to be very small and don't cause problems. They very rarely require another operation.

Antibiotics. People who have VSDs are at increased risk for bacterial endocarditis. Antibiotic treatment to prevent bacterial endocarditis may be recommended after VSD surgery. Residual VSDs or small VSDs that don't need surgery may require treatment with antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter the bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures. Special Considerations for Children and Teens Activity. There should be no activity restrictions on a child with a small VSD that doesn't need surgery, or after recovery from VSD repair. Be sure to check with your child's doctor about whether your child can take part in sports. Growth and development. Your pediatrician or family doctor checks your child for growth and development at each routine checkup. Babies with large VSDs may not grow as quickly as other infants. These babies usually catch up after the VSD is closed. Regular health care. Your child should see his or her regular doctor for routine health care.

Additional surgery or procedures. Teens and young adults rarely need additional surgery once a VSD closes or is repaired. Key Points

A hole in the heart is a type of simple congenital heart defect (a problem with the heart's structure that's present at birth). Congenital heart defects change the normal flow of blood through the heart. The heart has two sides, which are separated by an inner wall called the septum. An atrial septal defect (ASD) is a hole in the upper part of the septum, which separates the atria. A ventricular septal defect (VSD) is a hole in the lower part of the septum, which separates the ventricles. ASDs and VSDs allow oxygen-rich blood from the left side of the heart to mix with oxygen-poor blood from the right side of the heart, increasing the flow of blood out of the heart to the lungs. ASDs and VSDs can be small or large. Many small ASDs and VSDs close on their own as the heart grows during childhood. Large holes in the septum are less likely to close on their own over time. Doctors don't know what causes most holes in the heart. A heart murmur (an extra flow sound associated with the heartbeat) is the most common sign of both ASD and VSD. Sometimes, it's the only sign. Many babies born with ASDs have no signs or symptoms. Children with small VSDs also have no symptoms, but babies with large VSDs can have symptoms of heart failure. ASDs and VSDs are usually diagnosed based on results from a physical exam and special tests. Echocardiography is commonly used to diagnose ASD and VSD. Other tests include EKG (electrocardiogram), chest x ray, pulse oximetry, and cardiac catheterization. Depending on where the hole is located and how large it is, treatment may be needed. Catheter procedures and surgery are used to treat holes in the heart. With new advances in testing and treatment, most children with holes in the heart grow into adulthood and lead normal, healthy, and productive lives.

What Is Coronary Artery Bypass Grafting?

Coronary artery bypass grafting (CABG) is a type of surgery called revascularization (reVAS-kyu-lar-i-ZA-shun), used to improve blood flow to the heart in people with severe coronary artery disease (CAD). CAD occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become blocked due to the buildup of a material called plaque (plak) on the inside of the

blood vessels. If the blockage is severe, chest pain (also called angina), shortness of breath, and, in some cases, heart attack can occur. CABG is one treatment for CAD. During CABG, a healthy artery or vein from another part of the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein bypasses (that is, it goes around) the blocked portion of the coronary artery. This new passage routes oxygen-rich blood around the blockage to the heart muscle. As many as four major blocked coronary arteries can be bypassed during one surgery. Overview CABG is the most common type of open-heart surgery in the United States, with more than 500,000 surgeries performed each year. Doctors called cardiothoracic (KAR-de-o-tho-RASik) surgeons perform this surgery. CABG isnt used for everyone with CAD. Many people with CAD can be treated by other means, such as lifestyle changes, medicines, and another revascularization procedure called angioplasty. CABG may be an option if you have severe blockages in the large coronary arteries that supply a major part of the heart muscle with bloodespecially if the hearts pumping action has already been weakened. CABG may also be an option if you have blockages in the heart that cant be treated with angioplasty. In these situations, CABG is considered more effective than other types of treatment. If youre a candidate for CABG, the goals of having the surgery are to:

Improve your quality of life and decrease angina and other symptoms of CAD Resume a more active lifestyle Improve the pumping action of the heart if it has been damaged by a heart attack Lower the chances of a heart attack (in some patients, such as those with diabetes) Improve your chance of survival

Repeat surgery may be needed if grafted arteries or veins become blocked, or if new blockages develop in arteries that werent blocked before. Taking medicines as prescribed and making lifestyle changes that your doctor recommends can lower the chance of a graft becoming blocked. In people who are candidates for the surgery, the results are usually excellent, with 85 percent of people having significantly reduced symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years following the surgery. March 2007

Types of Coronary Artery Bypass Grafting Traditional Coronary Artery Bypass Grafting This is the most common type of coronary artery bypass grafting (CABG). It's used when at least one major artery needs to be bypassed. During the surgery, the chest bone is opened to access the heart. Medicines are given to stop the heart, and a heart-lung machine is used to keep blood and oxygen moving throughout the body during surgery. This allows the surgeon to operate on a still heart. After surgery, the heart is restarted using mild electric shocks. Off-Pump Coronary Artery Bypass Grafting This type of CABG is similar to traditional CABG in that the chest bone is opened to access the heart. However, the heart isn't stopped, and a heart-lung machine isn't used. Off-pump CABG is sometimes called beating heart bypass grafting. This type of surgery may reduce complications that can occur when a heart-lung machine is used, and it may speed up recovery time after surgery. Minimally Invasive Direct Coronary Artery Bypass Grafting This surgery is similar to off-pump, but instead of a large incision to open the chest bone, several small incisions are made on the left side of the chest between the ribs. This type of surgery is used mainly for bypassing the vessels in front of the heart. It's a fairly new procedure, which is performed less often than the other types. This type of surgery is not for everybody, especially if more than one or two coronary arteries need to be bypassed. Other Names for Coronary Artery Bypass Grafting

Bypass surgery Coronary artery bypass surgery Heart bypass surgery

Who Needs Coronary Artery Bypass Grafting? Coronary artery bypass grafting (CABG) is only used to treat people who have severe coronary artery disease (CAD) that could lead to a heart attack. Your doctor may recommend CABG if other treatments, such as lifestyle changes or medicines, haven't worked. He or she also may recommend CABG if you have severe blockages in the large coronary arteries that supply a major part of the heart muscle with blood-especially if your heart's pumping action has already been weakened. CABG also may be a treatment option if you have blockages in the heart that can't be treated with angioplasty.

Your doctor will determine if you're a candidate for CABG based on a number of factors. These include the presence and severity of CAD symptoms, the severity and location of blockages in your coronary arteries, your response to other treatments, your quality of life, and any other medical problems you may have. In some cases, CABG may be performed on an emergency basis, such as pending or during a heart attack. Physical Exam and Diagnostic Tests To determine if you're a candidate for CABG, your doctor will do a physical exam that involves checking your cardiovascular system, focusing on heart, lungs, and pulse. Your doctor also will ask you about any symptoms you have, such as chest pain or shortness of breath, and how long, how often, and how severe they are. Medical tests will be done to find out which arteries are clogged, how much they're clogged, and whether there's any heart damage. Tests may include:

EKG (electrocardiogram). An EKG is a simple test that detects and records the electrical activity of the heart. This test is used to help detect and locate the source of heart problems. An EKG shows how fast the heart is beating, whether the heart's rhythm is steady or irregular, where in the heart the electrical activity starts, and whether the electrical activity is traveling through the heart in a normal way. Stress test. Some heart problems are easier to diagnose when your heart is working harder and beating faster than when it's at rest. During stress testing, you exercise (or are given medicine if you're unable to exercise) to make your heart work harder and beat faster while heart tests are performed. During exercise stress testing, your blood pressure and EKG readings are monitored while you walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning or echocardiography, also can be done at the same time. These would be ordered if your doctor needs more detailed information on blood flow and the heart's pumping action than the exercise stress test can provide. If you are unable to exercise, a medicine can be injected through an intravenous line (IV) into your bloodstream to make your heart work harder and beat faster, as if you are exercising on a treadmill or bicycle. Nuclear heart scanning or echocardiography is then usually done. During nuclear heart scanning, radioactive tracer is injected into your bloodstream, and a special camera shows the flow of blood through your heart and arteries. Echocardiography uses sound waves to show blood flow through the chambers and valves of your heart and to show how well your heart pumps. Your doctor also may order two newer tests along with stress testing if more information is needed about how well your heart works. These new tests are magnetic resonance imaging (MRI) and positron emission tomography (PET) scanning of the heart. MRI shows detailed images of the structures and beating of your heart, which may help your doctor better assess if parts of your heart are weak or damaged. PET scanning shows the level of metabolic activity in different areas of

your heart. This can help your doctor determine if enough blood is flowing to the areas of your heart. A PET scan can show decreased blood flow caused by disease or damaged muscles that may not be detected by other scanning methods.

Echocardiogram. This test uses sound waves to create a moving picture of your heart. Echocardiogram provides information about the size and shape of your heart and how well your heart chambers and valves are functioning. The test also can identify areas of poor blood flow to the heart, areas of heart muscle that are not contracting normally, and previous injury to the heart muscle caused by poor blood flow. There are several different types of echocardiograms, including a stress echocardiogram. During this test, an echocardiogram is done both before and after your heart is stressed either by having you exercise or by injecting a medicine into your bloodstream that makes your heart beat faster and work harder. A stress echocardiogram is usually done to find out if you have decreased pumping action of your heart (CAD). Angiography. Angiography uses a special dye injected into the bloodstream to outline the insides of arteries on x-ray pictures. An angiogram shows the location and severity of blockages in blood vessels.

Other Considerations When deciding if you're a candidate for CABG, you doctor will also consider your:

History and past treatment of heart disease, including surgeries, procedures, or medicines History of other diseases and conditions Age and general health Family history of CAD, heart attack, or other heart diseases

Medicines and other medical procedures may be tried before CABG. Medicines that lower cholesterol levels and blood pressure and improve blood flow through the coronary arteries are often tried. A procedure called coronary angioplasty (also called balloon angioplasty) may be tried. During this procedure, a thin tube with a balloon or other device on the end is threaded through a blood vessel in your groin (upper thigh) or arm up to the narrowed or blocked coronary artery. Once in place, the balloon is inflated to push the plaque against the wall of the artery, widening the artery and restoring the flow of blood through it. In many cases, after the initial balloon angioplasty, a tiny mesh tube called a stent is inserted permanently in the area to keep the artery open. What To Expect Before Coronary Artery Bypass Grafting Tests may be done to prepare you for coronary artery bypass grafting, including blood tests, EKG, echocardiogram, chest x ray, cardiac catheterization, and angiography.

Your doctor will give you specific instructions about how to prepare for surgery. There will be instructions about what to eat or drink, what medicines to take, and what activities to stop (such as smoking). You will likely be admitted to the hospital on the same day as the surgery. What To Expect During Coronary Artery Bypass Grafting Coronary artery bypass grafting (CABG) requires a team of experts. A cardiothoracic surgeon performs the surgery with support from an anesthesiologist, perfusionist (heart-lung machine specialist), other surgeons, and nurses. There are several different types of CABG. They range from traditional surgery in which the chest is opened to reach the heart, to a nontraditional surgery in which small incisions are made to bypass the narrowed artery. Traditional Coronary Artery Bypass Grafting This type of surgery usually lasts 3 to 5 hours, depending on the number of arteries being bypassed. Numerous steps take place during traditional CABG. Anesthesia is given to put you to sleep. During the surgery, the anesthesiologist monitors your heartbeat, blood pressure, oxygen levels, and breathing. A breathing tube is placed in your lungs through your throat, and connected to a ventilator (breathing machine). An incision is made down the center of your chest. The chest bone is then cut and your ribcage is opened so that the surgeon can get to your heart. Medicines are used to stop your heart, which allows the surgeon to operate on it while it's not beating. A heart-lung machine keeps oxygen-rich blood moving throughout your body. An artery or vein is taken from a different part of your body, such as your chest or leg, and prepared to be used as a graft for the bypass. In surgery with several bypasses, a combination of both artery and vein grafts is commonly used.

Artery grafts. These grafts are much less likely than vein grafts to become blocked over time. The left internal mammary artery is most commonly used for an artery graft. It's located inside the chest close to the heart. Arteries from the arm or other places in the body are sometimes used as well. Vein grafts. Although veins are commonly used as grafts, they're more likely than artery grafts to develop plaque and become blocked over time. The saphenous vein-a long vein running along the inner side of the leg-is typically used.

After the grafting is complete, your heart is restarted using mild electric shocks. You're disconnected from the heart-lung machine. Tubes are inserted into your chest to drain fluid. The surgeon uses wires that stay in your body permanently to close your chest bone and stitches or staples to close the skin incision. The breathing tube is removed when you're able to breathe without it.

Nontraditional Coronary Artery Bypass Grafting Nontraditional CABG includes off-pump CABG and minimally invasive CABG. Off-Pump Coronary Artery Bypass Grafting This type of surgery can be used to bypass any of the coronary arteries. Off-pump CABG also is called beating heart bypass grafting because the heart isn't stopped and a heart-lung machine isn't used. Instead, the part of the heart where grafting is being done is steadied with a mechanical device. Off-pump CABG may reduce complications that can occur when a heart-lung machine is used, especially in people who have had a stroke or "mini-strokes" in the past, who are over age 70, and who have diabetes, lung disease, or kidney disease. Other advantages of this type of bypass surgery include:

Reduced bleeding during surgery and a lower chance of needing a blood transfusion A lower chance of infection, stroke, and kidney complications A lower chance of complications such as memory loss, difficulty concentrating, or difficulty thinking clearly Faster recovery from the surgery

Minimally Invasive Direct Coronary Artery Bypass Grafting There are several types of minimally invasive direct coronary artery bypass (MIDCAB) grafting. These types of surgery differ from traditional bypass surgery because they only require small incisions rather than opening the chest bone to get to the heart. These procedures sometimes use a heart-lung machine. MIDCAB procedure. This procedure is used when only one or two coronary arteries need to be bypassed. A series of small incisions is made between your ribs on the left side of your chest, directly over the artery to be bypassed. The incisions are usually about 3 inches long. (The incisions made in traditional CABG are at least 6 to 8 inches long.) The left internal mammary artery is most often used for the graft. A heart-lung machine isn't used during this procedure. Port-access coronary artery bypass procedure. This procedure is performed through small incisions (ports) made in your chest. Artery or vein grafts are used. The heart-lung machine is used during this procedure. Robot-assisted technique. This type of procedure allows for even smaller, keyhole-sized incisions. A small video camera is inserted in one incision to show the heart, while the surgeon uses remotely controlled surgical instruments to perform the surgery. The heart-lung machine is sometimes used during this procedure.

Advantages of minimally invasive CABG include smaller incisions, smaller scars, shorter recovery and hospital stay, less bleeding, less chance for infection, and less pain.

What To Expect After Coronary Artery Bypass Grafting Recovery in the Hospital After surgery, you will typically spend 1 or 2 days in an intensive care unit. Your heart rate and blood pressure will be continuously monitored during this time. Intravenous medicines (medicines injected through a vein) are often given to regulate blood circulation and blood pressure. You will then be moved to a less intensive care area of the hospital for 3 to 5 days before going home. Recovery at Home Your doctor will give you specific instructions for recovering at home, especially concerning:

How to care for your healing incisions How to recognize signs of infection or other complications When to call the doctor immediately When to make followup appointments

You may also receive instructions on how to deal with common after-effects from surgery. After-effects often go away within 4 to 6 weeks after surgery, but may include:

Discomfort or itching from healing incisions Swelling of the area where an artery or vein was taken for grafting Muscle pain or tightness in the shoulders and upper back Fatigue (tiredness), mood swings, or depression Difficulty sleeping or loss of appetite Constipation Chest pain around the site of the chest bone incision (more frequent with the traditional surgery)

Full recovery from traditional CABG may take 6 to 12 weeks or more. Less recovery time is needed for nontraditional CABG. Your doctor will provide instructions on resuming physical activity. This varies from person to person, but there are some typical timeframes. Most people can resume sexual activity within about 4 weeks and driving after 3 to 8 weeks.

Returning to work after 6 weeks is common unless the job involves specific and demanding physical activity. Some people may need to find less physically demanding types of work or work a reduced schedule at first. Ongoing Care Care after surgery may include periodic checkups with doctors. During these visits, tests may be done to see how the heart is working. Tests may include EKG, stress testing, and echocardiogram. CABG is not a cure for coronary artery disease (CAD). You and your doctor may develop a management plan that includes lifestyle changes to help you stay healthy and reduce the chances of CAD getting worse. Lifestyle changes may include quitting smoking, making changes in your diet, getting regular exercise, and lowering and managing stress. In some cases, your doctor may refer you to a cardiac rehabilitation (rehab) program. These programs can help you recover through supervised physical activity and education on how to make choices that reduce your risk for future heart problems and help you get back to your regular lifestyle after surgery. Doctors supervise these programs, which include counseling about lifestyle changes as well as exercise training to build strength and energy. Cardiac rehab programs may be offered in hospitals and other community facilities. Ask your doctor whether you're a candidate for cardiac rehab. Taking medicines as prescribed also is an important part of care after surgery. Medicines may be prescribed to manage pain during recovery; lower cholesterol, blood pressure, and the chance of developing blood clots; manage diabetes; or treat depression. What Are the Risks of Coronary Artery Bypass Grafting? Although complications from coronary artery bypass grafting (CABG) are uncommon, the risks include:

Wound infection and bleeding Anesthesia reactions Fever Pain Stroke, heart attack, or even death

Some patients can develop a fever associated with chest pain, irritability, and decreased appetite. This is due to inflammation involving the lung and heart sac, and is sometimes seen 1 to 6 weeks after surgeries that involve cutting through the pericardium (the outer covering of the heart). This reaction is usually a mild, self-limited illness, but some patients may develop fluid buildup around the heart that requires treatment.

Use of the heart-lung machine also can cause complications. Memory loss and other changes, such as difficulty concentrating or thinking clearly, may occur in some people. These changes are more likely to occur in people who are older, who have high blood pressure or lung disease, or who drink excessive amounts of alcohol. These side effects often improve several months after surgery. The heart-lung machine also increases the risk of blood clots forming in your blood vessels. Clots can travel to the brain or other parts of the body and block the flow of blood, which can cause stroke or other problems. Recent technical improvements in heart-lung machines are helping to reduce the risk of blood clots forming. In general, the chances of developing complications are higher when CABG is done in an emergency situation (for example, if performed during a heart attack), if you're over age 70, or if you have a history of smoking. Your risks also are higher if you have other diseases or conditions such as diabetes, kidney disease, lung disease, or peripheral vascular disease. Key Points

Coronary artery bypass grafting (CABG) is a type of surgery used to improve blood flow to the heart in people with severe coronary artery disease (CAD). During CABG, a healthy artery or vein from another part of the body is connected, or grafted, to a blocked coronary artery. The grafted artery or vein bypasses (that is, it goes around) the blocked portion of the coronary artery. This improves the flow of blood and oxygen to your heart muscle. CABG is one type of treatment for CAD. Not everyone with CAD needs CABG. In people who are candidates for the surgery, the results are usually excellent, with 85 percent of people having significantly reduced symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years following the surgery. Your doctor will determine if you're a candidate for CABG based on a number of factors, including the presence and severity of CAD. Often nonsurgical treatments, such as medicines and angioplasty, will be tried first. Although the surgery is usually done on an elective (scheduled) basis, it may need to be performed in an emergency, such as pending or during a heart attack. Although complications are rare, risks of CABG include infection at the incision site, bleeding, reactions to the anesthesia, fever and pain, stroke, heart attack, or even death. Recovery may take 6 to 12 weeks or more. Most people can get back to their normal activities about 6 weeks after the surgery. Care after surgery may include followup visits with doctors, lifestyle changes to prevent further progression of CAD, and taking medicines as prescribed.

What Is Stress Testing?

Stress testing provides your doctor with information about how your heart works during physical stress. Some heart problems are easier to diagnose when your heart is working hard and beating fast. During a stress test, you exercise (walk or run on a treadmill or pedal a bicycle) or are given a medicine to make your heart work harder while heart tests are performed. During these tests, your heart is monitored using images or through dime-sized electrodes attached to your chest, arms, or legs. You may be asked to breathe into a special tube during the test. This will allow your doctor to see how well youre breathing. You may have arthritis or another medical problem that prevents you from exercising during a stress test. If so, your doctor can give you a medicine that makes your heart work harder, as it would if you were exercising. This is called a pharmacological (FAR-ma-ko-LOJ-i-kal) stress test. Overview Doctors usually use stress testing to help diagnose coronary artery disease (CAD) or to see how serious this disease is in those who are known to have it. Its sometimes used to assess other problems such as heart valve abnormalities or heart failure. CAD occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed with a material called plaque (plak). Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Plaque builds up on the insides of the arteries, narrowing them and restricting blood flow to your heart. You may not have any signs or symptoms of CAD when your heart is at rest. But when your heart has to work harder during exercise, it needs more blood and oxygen, and narrowed arteries arent able to supply enough blood for your heart to work well. Thus, the signs and symptoms may occur only during exercise. A stress test can detect the following indications that your heart may not be getting enough blood during exercise.

Abnormal changes in your heart rate or blood pressure Symptoms such as shortness of breath or chest pain Abnormal changes in your heart rhythm or the electrical activity of your heart

During the stress test, if you cant exercise for as long as whats considered normal for someone your age, it may be a sign that not enough blood is flowing to your heart. But other factors besides CAD can prevent you from exercising long enough (for example, lung diseases, anemia, or poor general fitness).

Stress Testing Using Imaging Some stress tests take pictures of the heart when you exercise and when youre at rest. These imaging stress tests can show how well blood is flowing in the different parts of your heart and/or how well your heart squeezes out blood when it beats One type of imaging stress test involves echocardiography, which is a test that uses sound waves to create a moving picture of your heart. An echocardiogram stress test can show how well your hearts chambers and valves are working when your heart is under stress. The test can identify areas of poor blood flow to your heart, dead heart muscle tissue, and areas of the heart muscle wall that arent contracting normally. These areas may have been damaged during a heart attack or may be getting too little blood. Other imaging stress tests use a radioactive dye to create images of the blood flow to your heart. The dye is injected into your bloodstream before pictures are taken of your heart. The pictures show how much of the dye has reached various parts of your heart during exercise and at rest. Tests that use a radioactive dye include a thallium or sestamibi stress test and a positron emission tomography (PET) stress test. The amount of radiation in the dye is safe and not a danger to you or those around you. However, if youre pregnant, you shouldnt have this test because of risks it might pose to your unborn child. Some doctors may use magnetic resonance imaging (MRI) to take pictures of the heart when its working hard. This test doesnt use a radioactive dye or sound waves. Instead, it uses radio waves and magnetic fields to create images that show blood flow in the heart and whether all parts of the heart wall are contracting strongly. Imaging stress tests tend to be more accurate at detecting CAD than standard (nonimaging) stress tests. An imaging stress test may be done first if you:

Cant exercise for enough time to get your heart working its hardest. (Medical problems, such as arthritis or leg arteries clogged by plaque, may prevent you from exercising enough.) Have abnormal heartbeats or other problems that will cause a standard exercise stress test to be inaccurate. Are a woman. Standard stress tests are less accurate in women than in men. If youre a woman and live far from a testing facility, your doctor may want you to skip a standard stress test and get an imaging stress test instead. That way, you dont have to make a second trip for the imaging stress test if there are any questions about the results from the standard stress test. September 2007

Other Names for Stress Testing

Exercise test Treadmill test Exercise echocardiogram or exercise stress echo Thallium stress test Sestamibi stress test Stress EKG Myocardial perfusion imaging Pharmacological stress test MRI stress test PET stress test Nuclear stress test

Who Needs Stress Testing? You may need a stress test if you've had chest pains, shortness of breath, or other symptoms of limited blood flow to your heart. Imaging stress tests are particularly helpful in showing whether you have coronary artery disease (CAD) or a problem with one of the valves in your heart. (Heart valves are like doors that let blood flow between the heart's chambers and into the heart's arteries. So, like CAD, faulty heart valves can limit the amount of blood reaching your heart.) If you've been diagnosed with CAD or recently had a heart attack, you may need stress testing to see whether you can tolerate an exercise program. The testing also can show whether treatments designed to improve blood flow in the heart's arteries are necessary and likely to help you. These treatments include angioplasty (with or without stents) and coronary artery bypass grafting. After having one of these treatments, your doctor may want you to have a stress test to see how well the treatment relieves your signs or symptoms of CAD. You also may need a stress test if, during exercise, you feel faint, get a rapid heartbeat or a fluttering feeling in your chest, or have other symptoms of an arrhythmia (an irregular heartbeat). The stress test can detect an arrhythmia and show whether you need medicine or a pacemaker or implantable cardioverter defibrillator (ICD) to correct irregular heartbeats. It also can reveal the effectiveness of such devices. You may need a stress test even if you don't have chest pain when you exercise, but just get short of breath. The test can help show whether a heart problem, rather than a lung problem or being out of shape, is causing your breathing problems. For such testing, you breathe into a special tube so a technician can measure the gases you breathe out. Breathing into the special tube and monitoring of the heart as part of a stress test also is done to assess fitness before a heart transplant. Your doctor also may use this monitoring to figure out the best exercise plan for you after recovery from a heart attack.

Stress testing isn't routinely done to screen people for CAD. Usually you have to have symptoms of CAD before a doctor will recommend that you have a stress test. But your doctor may want to use a stress test to screen for CAD if you have diabetes, which increases your risk for developing CAD. What To Expect Before Stress Testing Standard stress testing can often be done in a doctor's office. But imaging stress testing is usually done at a hospital. Be sure to wear athletic or other shoes in which you can exercise comfortably. You may be asked to wear comfortable clothes in which you can easily exercise, or you may be given a gown to wear during the test. Your doctor may ask you not to eat or drink anything but water for a short time before the test. If you're diabetic, ask your doctor whether you need to adjust your medicines on the day of your test. For some stress tests, you can't drink coffee or other caffeinated drinks for a day before the test. Certain over-the-counter or prescribed medicines also may interfere with some stress tests. Ask your doctor whether you can take all your medicines as usual and whether you need to avoid certain drinks or foods. If you use an inhaler for asthma or other breathing problems, bring it to the test and be sure to let the doctor know that you use it. What To Expect During Stress Testing During all types of stress testing, a technician will always be with you to closely monitor your health status. Before you start the stress part of a stress test, a technician will put small sticky patches called electrodes on the skin of your chest, arms, and legs. To help an electrode stick to the skin, the technician may have to shave a patch of hair where the electrode will be attached. The electrodes are connected to a machine that records the electrical activity of your heart. This recording, which is called an EKG (electrocardiogram), shows how fast your heart is beating and the hearts rhythm (steady or irregular). The machine also records the strength and timing of electrical signals as they pass through each part of your heart. The technician will put a blood pressure cuff on your arm to monitor your blood pressure during the stress test. (The cuff will feel tight on your arm when it expands every few minutes.) In addition, you may be asked to breathe into a special tube so the gases you breathe out can be monitored. After these preparations, you will exercise on a treadmill or stationary bicycle. If such exercise poses a problem for you, you may instead turn a crank with your arms. During the test, the exercise level will get harder. But you can stop whenever you feel the exercise is too much for you.

Stress Testing

The illustration shows a patient having a stress test. Electrodes are attached to the patients chest and connected to an EKG (electrocardiogram) machine. The EKG records the hearts electrical activity. A blood pressure cuff is used to record the patients blood pressure while he walks on a treadmill. If you cant exercise, a technician will inject a medicine into a vein in your arm or hand. This medicine will increase the flow of blood through the coronary arteries and/or make your heart beat faster, as would exercise. This results in your heart working harder, so the stress test can be performed. The medicine may make you flushed and anxious, but the effects disappear as soon as the test is over. The medicine may also give you a headache. While youre exercising or receiving medicine to make your heart work harder, the technician will ask you frequently how youre feeling. You should tell him or her if you feel chest pain, shortness of breath, or dizzy. The exercise or medicine infusion will continue until you reach a target heart rate, or until you:

Feel moderate to severe chest pain Get too out of breath to continue Develop abnormally high or low blood pressure or an arrhythmia (an abnormal heartbeat) Become dizzy

The technician will continue to monitor your heart functions and blood pressure for a short time after you stop exercising or stop receiving the stress-creating medicine. The stress part of a stress test (when youre exercising or given a medicine that makes your heart work hard) usually lasts only about 15 minutes or less. But there is preparation time before the test and monitoring time afterward. Both extend the total test time to about an hour for a standard stress test, and up to 3 hours or more for some imaging stress tests. Exercise Stress Echocardiogram Test For an exercise stress echocardiogram test, the technician will take pictures of your heart using echocardiography before you exercise and after you finish. A sonographer (a person who specializes in using ultrasound techniques) will apply a gel to your chest and then will briefly put a wand-like device (called a transducer) against your chest and move it around. The transducer sends and receives high-pitched sounds that you usually cant hear. The echoes from the sound waves are converted into moving pictures of your heart on a screen. You may be asked to lie on your side on an examining table for this test. Some stress echocardiogram tests also use a dye to improve imaging. This dye is injected into your bloodstream while the test occurs. Sestamibi Stress Test or Other Imaging Stress Test Involving Radioactive Dye For a sestamibi or other imaging stress test that uses a radioactive dye, the technician will inject a small amount of the dye (such as sestamibi) into your bloodstream via a needle placed in a vein of your arm or hand. Youre usually given the dye about a half-hour before you start exercising or are given a medicine that makes your heart work hard. The amount of radiation in the dye is safe and not a danger to you or those around you. However, if youre pregnant, you shouldnt have this test because of risks it might pose to your unborn child. Pictures will be taken of your heart at least two timeswhen its at rest and when its working its hardest. For such imaging, you will lie down on a table and a special camera or scanner that can see the dye in your bloodstream will take pictures of your heart. Some pictures may not be taken until you lie quietly for a few hours after exercising or receiving the stresscreating medicine. Some patients may even be asked to return in a day or so for more pictures to be taken. Magnetic Resonance Imaging Stress Test A magnetic resonance imaging (MRI) stress test may use a medicine rather than exercise to get your heart to work harder. But some facilities have you exercise on a specially made bicycle or treadmill that allows you to exercise while lying on your back. For this test, you will be put inside a tunnel-like MRI machine that takes pictures of your heart when its working hard and when your body is at rest. What To Expect After Stress Testing

After stress testing, you're able to return to normal activities. If you had a test that involved radioactive dye, your doctor may ask you to drink plenty of fluids to flush it out of your body. You also shouldn't have certain other imaging tests until the dye is no longer in your body. Your doctor can advise you about this. What Does Stress Testing Show? Stress testing provides your doctor with information about how your heart works during physical stress (exercise) and how healthy your heart is. Standard exercise stress testing uses an EKG (electrocardiogram) to monitor changes in the electrical activity of your heart. Imaging stress tests take pictures of the blood flow to different parts of your heart. Both types of stress testing are used to look for signs that your heart isn't getting enough blood flow during exercise. Abnormal results on stress testing may be due to coronary artery disease (CAD), but also can be due to other factors such as a lack of physical fitness. If you have a standard exercise stress test and the results are normal, no further testing or treatment may be needed. But if your standard exercise stress test results are abnormal, or if you're physically unable to exercise, your doctor may want you to have an imaging stress test or undergo other testing. Even if your standard exercise stress test results are normal, your doctor may want you to have an imaging stress test if you continue having symptoms (such as shortness of breath or chest pain). Standard exercise stress testing isn't equally accurate in men and women. Normal results from a standard exercise stress test usually accurately rule out CAD in both men and women. But a standard exercise stress test can show abnormal results even when the patient doesn't have CAD (these results are called false positives). False positive exercise stress tests happen more often in women than in men. Imaging stress tests are more accurate than standard exercise stress tests (in men and women) because they directly show how well blood is flowing in heart muscle and reveal parts of the heart that aren't contracting strongly. But imaging stress tests are much more expensive than standard exercise stress tests. Imaging stress tests can show the parts of the heart not getting enough blood, as well as dead tissue in the heart, where no blood flows. (A heart attack can cause some tissue in the heart to die.) If your imaging stress test suggests significant CAD, your doctor may want you to have more testing and/or treatment.

What Are the Risks of Stress Testing? There's little risk of being seriously harmed from any type of stress testing. The chance of these tests causing a heart attack or death is about 1 in 5,000. More common but less serious side effects linked to stress testing include:

Arrhythmia (an irregular heartbeat). This often will go away quickly once you're at rest. But if it persists, you may need to go to the hospital and be monitored or get treatment. Low blood pressure, which can cause you to feel dizzy or faint. This will go away once your heart stops working hard; it doesn't usually require treatment. Jitteriness or discomfort while getting medicine to make your heart work harder (you will be given medicine if you can't exercise). These side effects usually disappear shortly after you stop getting the medicine, but in some cases may last a few hours.

Key Points

A stress test helps show whether enough blood flows to your heart when it's working hard. Doctors usually use stress testing to help them diagnose coronary artery disease (CAD) or to see how serious this disease is in those who are known to have it. During a stress test, your heart is monitored using images or through dime-sized electrodes attached to your chest, arms, or legs. You may be asked to breathe into a special tube during the test. This will allow your doctor to see how well you're breathing. Standard exercise stress tests use EKGs (electrocardiograms) and breathing and blood pressure monitoring to assess blood flow in the heart. Imaging stress tests, such as those that use echocardiography, radioactive dyes, or magnetic resonance imaging (MRI), show how well blood is flowing in heart muscle. Imaging stress tests tend to be more accurate than standard exercise tests. You may need a stress test if you have CAD symptoms, such as chest pain and shortness of breath. If you've been diagnosed with CAD or recently had a heart attack, you may have stress testing to see whether treatments aimed at improving blood flow in the heart's arteries are needed and likely to help you. Stress testing also is done on people who have signs of an arrhythmia (irregular heartbeat). Stress testing may be done at a doctor's office or at a hospital. It will usually take between 1 and 3 hours. You may have to restrict your diet or not take certain medicines before a stress test. Be sure to wear shoes in which you can exercise comfortably during the stress test. Your health status will always be closely monitored during a stress test, and you will not have to exercise more than you think you can handle. Stress tests are safe and have few side effects. The chance of a stress test causing a heart attack or death is only about 1 in 5,000. You're able to return to all your normal activities after a stress test. If test results are normal, no further testing or treatment is usually needed unless your CAD symptoms persist. If there are abnormal results on your standard exercise stress test, your doctor will probably want you to have an imaging stress test or undergo other testing. But imaging may not be needed if factors other than CAD

could explain the abnormal results. Abnormal results on an imaging stress test will require more testing and/or treatment.