Different Diagnostic Techniques

Submitted by: Jeddalyn M. Emperador IV-A1 BS BIOLOGY

Submitted to: Prof. Domingo S. Pantaleon

Mammography A screening mammogram is an X-ray used to detect breast changes in women who display no signs or symptoms of breast cancer. It is currently the best available tool for detecting breast cancer; however, women must be aware of its capabilities and limitations. Breast Cancer Network of Strength suggests the following: • •

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Women should discuss the benefits and risks of screening with their health care providers. Screening should occur every 1-2 years for women 40-49 years of age and annually for those 50-69. For those 70 and older, screening should continue as long as women maintain good health and have no other prohibitive medical conditions. Women who are younger than 40 should consider, in consultation with their healthcare provider, to have regular screening mammograms if they: o have an extensive family history of breast or ovarian cancer; o had irradiation at a young age in the area of the breast; o carry the BRCA1 or BRCA2 gene mutation; and/or are planning breast reduction surgery Any abnormality found on a screening mammogram should be discussed with a physician and followed up appropriately. Women—and men—of any age who have unusual changes in their breasts (e.g., lump, dimpling, skin irritation and nipple discharge) should consult a healthcare provider and together consider having a diagnostic mammogram. o

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The following table presents recommendations of other national organizations. Organization American Cancer Society American Medical Association American College of Radiology US Preventive Service Task Force National Cancer Institute

Age: 40-49 Annual Annual Annual 1-2 yrs. 1-2 yrs.

Age: 50-69 Annual Annual Annual 1-2 yrs. 1-2 yrs.

Age: <70 Annual Annual Annual 1-2 yrs. 1-2 yrs.

Adapted from Loyola University Health System, Care System, Cardinal Bernardin Cancer Center recommendations. Given the lack of clear evidence on the timing of screening mammograms, women should consult with their physicians to determine a schedule best for themselves.

Ultrasound Ultrasound is a painless procedure that produces a picture of the internal structures of the breast. Images are captured in real time to show structure, movement and blood flow to help your doctor diagnose breast abnormalities found on a physical exam and/or learn more about potential abnormalities seen on a mammogram. They can provide information to help determine whether an abnormality is solid (which may be a non-cancerous lump of tissue or a cancerous tumor) or fluid-filled (a benign cyst). No X-rays are involved. Women who benefit from ultrasound when abnormalities are not found on physical exam or mammogram include those who (a) have dense breasts, (b) are at high risk for breast cancer based on family history, (c) are pregnant and should not be exposed to X-rays, and (d) have silicone breast implants and very little tissue can be included on the mammogram.

Oncotype DX Research shows that the Oncotype DX™ 21-gene assay is effective in predicting the likelihood of disease recurrence within ten years and the magnitude of chemotherapy response in patients with node-negative, estrogen-receptorpositive, early-stage (I or II) breast cancer. In the chemotherapy benefit study conducted by the National Surgical Adjuvant Breast and Bowel Project B-20, patients with a high risk of breast cancer recurrence, as determined by the Oncotype DX™ assay, derived a large benefit from chemotherapy. Those with a low risk of recurrence derived only a small (if any) benefit from chemotherapy. Those at high risk represented about 25% of patients with node-negative, estrogen-receptor-positive, early-stage breast cancer. Those at low risk represented about 50% of such patients. The Oncotype DX test is included in the National Comprehensive Cancer Network (NCCN) Breast Cancer Treatment Guidelines, which outlines for physicians recommended methods of treatment and care. Needle Biopsy or Aspiration The only way to be sure that a breast lump or other abnormality is cancer is by having a biopsy. A biopsy is performed by a surgeon who removes some of the breast tissue. A pathologist then examines the tissue under a microscope to determine whether cancer is present.. A biopsy is often recommended when a breast lump or abnormality is detected by a mammogram or other diagnostic tool.

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Excisional: Surgical removal of the abnormal tissue. This is similar to a lumpectomy. It is usually done on small tumors in the outpatient department of a hospital while the patient is under local anesthesia. Incisional: Surgical removal of part of the abnormal tissue The procedure is done under local anesthesia on tumors that are larger. Fine needle aspiration: A very thin needle samples fluids and cells. Core Needle: A large needle collects small pieces of breast tissue. Stereotactic: Three-dimensional X-ray guides a needle to collect small cores of an abnormality that cannot be felt. Needle localization: A thin wire is inserted into the breast under X-ray guidance to aid the surgeon in locating an abnormality that cannot be felt. It can be used with surgical biopsy, fine needle aspiration or core needle biopsy.

Waiting for Pathology Results Waiting for pathology results can be stressful. To alleviate your concerns, ask your surgeon when you can expect to receive results and how the results will be provided (By phone? Who will call?). Be sure to request a copy of the pathology report for your records. Consider calling the YourShoesTM 24/7 Breast Cancer Support Center anytime at 1-800-221-2141 to talk about how you’re feeling during this time. What to Expect from a Needle Biopsy When a needle biopsy (or aspiration) is performed, the physician first anesthetizes (numb) the skin over the lump and then inserts a needle with a syringe on the end. .The physician draws back the syringe, which in some cases fills with breast fluid. This does not mean that you have cancer. The first step in analyzing a breast lump is to determine whether it is fluid filled. If a lump is entirely filled with fluid, it is called a cyst, and the needle aspiration drains it. There is no lump left and usually no other treatment is necessary. If there is no fluid in the lump, or a lump remains after a needle aspiration, two events occur. First, any cells that were removed are sent to a lab for analysis. Second, the patient will likely be recommended for an additional biopsy procedure. What to Expect from a Stereotactic Biopsy The patient lies on her stomach on a stereotactic table that has a hole where the breast is suspended. The table is raised before the breast is compressed and digital X-rays taken. The doctor works under the patient and views the X-rays on

a computer monitor to see the abnormality in three dimensions. The computer can then help guide a biopsy needle exactly to the suspicious spot to remove several cores, usually 6-10. Stereotactic biopsies are highly accurate, cause less patient discomfort and decreased scarring, and cost less. What to Expect from a Needle—or Wire— Localization Mammography is used to locate the abnormality and a needle, under local anesthesia, is inserted into it. The needle is removed after it is properly placed, leaving a wire sticking out of the breast. Another mammogram is taken to ensure that the needle properly identifies the area to be removed. The surgeon then uses the needle as a guide to remove the abnormality, including a margin of good tissue. The margin of good tissue allows the pathologist to determine whether the entire suspicious area was removed. Computed Tomography (CT or CAT) Scan A CT or CAT scan is a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, organs, and blood vessels. CT scans are more detailed than standard x-rays. In standard x-rays, a beam of energy is aimed at the body part being studied. A plate behind the body part captures the variations of the energy beam after it passes through skin, bone, muscle, and other tissue. While much information can be obtained from a regular x-ray, a lot of detail about internal organs and other structures is not available. In computed tomography, the x-ray beam moves in a circle around the body. This allows many different views of the same organ or structure, and provides much greater detail. The x-ray information is sent to a computer that interprets the x-ray data and displays it in 2-dimensional form on a monitor. Newer technology and computer software makes three-dimensional (3-D) images possible. CT scans may be done with or without contrast. "Contrast" refers to a substance taken by mouth or injected into an intravenous (IV) line that causes the particular organ or tissue under study to be seen more clearly. Contrast examinations may require you to fast for a certain period of time before the procedure. Your physician will notify you of this prior to the procedure. CT scans may be performed to help diagnose tumors, investigate internal bleeding, or check for other internal injuries or damage. You may want to ask your physician about the amount of radiation used during the CT procedure and the risks related to your particular situation. It is a good

idea to keep a record of your past history of radiation exposure, such as previous CT scans and other types of x-rays, so that you can inform your physician. Risks associated with radiation exposure may be related to the cumulative number of xray examinations and/or treatments over a long period of time. Advances in computed tomography technology include the following: •

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high-resolution computed tomography This type of CT scan uses very thin slices (less than one-tenth of an inch), which are effective in providing greater detail in certain conditions such as lung disease. helical or spiral computed tomography During this type of CT scan, both the patient and the x-ray beam move continuously, with the x-ray beam circling the patient. The images are obtained much more quickly than with standard CT scans. The resulting images have greater resolution and contrast, thus providing more detailed information. ultrafast computed tomography (also called electron beam computed tomography) This type of CT scan produces images very rapidly, thus creating a type of "movie" of moving parts of the body, such as the chambers and valves of the heart. This scan may be used to obtain information about calcium build-up inside the coronary arteries of the heart. computed tomographic angiography (CTA) Angiography (or arteriography) is an x-ray image of the blood vessels. A CT angiogram uses CT technology rather than standard x-rays or fluoroscopy to obtain images of blood vessels, for example, the coronary arteries of the heart. combined computed tomography and positron emission tomography (PET/CT) The combination of computed tomography and positron emission tomography technologies into a single machine is referred to as PET/CT. PET/CT combines the ability of CT to provide detailed anatomy with the ability of PET to show cell function and metabolism to offer greater accuracy in the diagnosis and treatment of certain types of diseases, particularly cancer. PET/CT may also be used to evaluate epilepsy, Alzheimer's disease, and coronary artery disease.

You will need to let your physician know if you have ever had a reaction to any contrast dye, or if you are allergic to iodine or seafood. If you are pregnant or think you may be pregnant, you should notify your physician. If you are claustrophobic or tend to become anxious easily, tell your physician ahead of time, as he/she may prescribe a mild sedative for you before the procedure to make you more comfortable. It will be necessary for you to remain still and quiet during the procedure, which may last 10 to 20 minutes, on average.

Reminders Before the Examination Tell the radiologist if you are allergic to iodine or other materials, if you are pregnant, or if you are claustrophobic and think you will be unable to lie still while inside the scanning machine. How is a CT or CAT scan performed? CT scans can be performed on an outpatient basis, unless they are part of a patient's inpatient care. Although each facility may have specific protocols in place, generally, CT scans follow this process: 1. When the patient arrives for the CT scan, he/she will be asked to remove any clothing, jewelry, or other objects that may interfere with the scan. 2. If the patient will be having a procedure done with contrast, an intravenous (IV) line will be started in the hand or arm for injection of the contrast medication. For oral contrast, the patient will be given medication to swallow. 3. The patient will lie on a scan table that slides into a large, circular opening of the scanning machine. 4. The CT staff will be in another room where the scanner controls are located. However, the patient will be in constant sight of the staff through a window. Speakers inside the scanner will enable the staff to communicate with and hear the patient. The patient will have a call bell so that he/she can let the staff know if he/she has any problems during the procedure. 5. As the scanner begins to rotate around the patient, x-rays will pass through the body for short amounts of time. 6. The x-rays absorbed by the body's tissues will be detected by the scanner and transmitted to the computer. 7. The computer will transform the information into an image to be interpreted by the radiologist. 8. It is very important that the patient remain very still during the procedure. You may be asked to hold your breath at various times during the procedure. 9. The technologist will be watching the patient at all times and will be in constant communication. 10. The patient may be asked to wait for a short period of time while the radiologist examines the scans to make sure they are clear. If the scans are not clear enough to obtain adequate information, the patient may need to have additional scans performed.

Fluoroscopy Fluoroscopy is a study of moving body structures - similar to an x-ray "movie." A continuous x-ray beam is passed through the body part being examined, and is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail. Fluoroscopy, as an imaging tool, enables physicians to look at many body systems, including the skeletal, digestive, urinary, respiratory, and reproductive systems. Fluoroscopy may be performed to evaluate specific areas of the body, including the bones, muscles, and joints, as well as solid organs such as the heart, lung, or kidneys. Fluoroscopy is used in many types of examinations and procedures, such as barium x-rays, cardiac catheterization, arthrography (visualization of a joint or joints), lumbar puncture, placement of intravenous (IV) catheters (hollow tubes inserted into veins or arteries), intravenous pyelogram, hysterosalpingogram, and biopsies. Fluoroscopy may be used alone as a diagnostic procedure, or may be used in conjunction with other diagnostic or therapeutic media or procedures. In barium x-rays, fluoroscopy used alone allows the physician to see the movement of the intestines as the barium moves through them. In cardiac catheterization, fluoroscopy is added to enable the physician to see the flow of blood through the coronary arteries in order to evaluate the presence of arterial blockages. For intravenous catheter insertion, fluoroscopy assists the physician in guiding the catheter into a specific location inside the body. Other uses of fluoroscopy include, but are not limited to, the following: • •

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locating foreign bodies viscosupplementation injections of the knees - a procedure in which a liquid substance that acts as a cartilage replacement or supplement is injected into the knee joint image-guided anesthetic injections into joints or the spine percutaneous vertebroplasty - a minimally invasive procedure used to treat compression fractures of the vertebrae of the spine

How is fluoroscopy performed? Fluoroscopy may be part of an examination or procedure that is done on either an outpatient or inpatient basis. The specific type of procedure or examination being done will determine whether any preparation prior to the procedure is required. Your physician should notify you of any pre-procedure instructions.

Although each facility may have specific protocols in place and specific examinations and procedures may differ, fluoroscopy procedures generally follow this process: 1. An intravenous (IV) line will be inserted in the patient's hand or arm. 2. The patient will be positioned on the x-ray table. 3. For procedures that require catheter insertion, such as cardiac catheterization or catheter placement, an additional line insertion site may be used in the groin, elbow, or other site. 4. A special x-ray scanner will be used to produce the fluoroscopic images of the body structure being examined or treated. 5. A dye or contrast substance may be injected into the IV line in order to better visualize the structure being studied. 6. The type of care required after the procedure will depend on the type of procedure done. Certain procedures, such as cardiac catheterization, will require a recovery period of several hours with immobilization of the leg or arm where the cardiac catheter was inserted. Other procedures may require less time for recovery. The physician will give more specific instructions related to care after the examination or procedure.

Intravenous Pyelogram (IVP) An intravenous pyelogram, also called intravenous urography, is a diagnostic xray of the kidneys, ureters, and bladder. When a contrast dye is injected intravenously (IV), the urinary tract will show up very clearly, which is not seen on regular x-rays. An intravenous pyelogram may be done for many reasons, including the following: • • • • •

to detect kidney tumors to identify blockages or obstructions of the normal flow of urine to detect kidney or bladder stones to establish if the prostate gland is enlarged to detect injuries to the urinary tract

As the contrast dye moves into and through the kidneys, ureters, and bladder, xrays taken at short intervals can capture its movement. A delay in the contrast dye moving through the urinary system may indicate an obstruction (blockage) in the kidney's blood flow or poor kidney function. A radiologist can then assess the function and detect abnormalities of the urinary system. This test is usually ordered as one of the first tests in cases of suspected kidney disease or urinary tract disorders.

What is an x-ray? X-rays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film or digital media. X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body structures onto specially-treated plates (similar to camera film) or digital media and a "negative" type picture is made (the more solid a structure is, the whiter it appears on the film). IVP may be performed at the same time as a computed tomography (CT) scan of the kidneys (also called nephrotomography). This test, like the IVP, is performed after contrast dye has been injected, but unlike a standard x-ray, provides images of layers or "slices" of the kidney. As newer technologies are developed, other procedures such as CT, MRI, and ultrasound (high-frequency sound waves) are often used instead of IVP. How are intravenous pyelograms performed? Intravenous pyelograms are usually performed on an outpatient basis, although they can be part of inpatient care. The patient may be asked to take a laxative to cleanse the bowel before the examination. Although each facility may have specific protocols in place, generally, an intravenous pyelogram procedure follows this process: 1. The patient will be positioned on the x-ray table. 2. A preliminary x-ray will be taken. 3. An intravenous (IV) line will be started in the hand or arm for injection of the contrast dye. 4. The radiologist will inject the contrast dye into the vein in the arm. 5. During the injection of the contrast dye, the patient may feel warm and become flushed, only for a minute or so. This reaction is normal. 6. X-rays will be taken at intervals after the dye has been injected. 7. At times the patient may have to change positions as the x-rays are taken. 8. The patient will be asked to empty the bladder. 9. A final x-ray will be taken after urination to determine the amount of contrast dye remaining in the urinary tract. Angiography Angiography is a test that uses an injection of a liquid dye to make the arteries easily visible on X-rays.

When is angiography used? An angiogram was once commonly used to check the condition of blood vessels. Nowadays, non-invasive tests provide the same information with less discomfort and risk to the patient. These include: Doppler, digital subtraction angiography (from venous dye injection), ultrasound, CT scans and MRI scans. • • •

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Angiography may be used if the doctor is considering surgery, because it shows a clear picture of the blood vessels. Angiography may reveal aneurysms (a bulge on an artery caused by a blood vessel wall becoming weaker). An angiogram can also be used to give a good view of the carotid artery and its branches in the neck and head. This is generally done to investigate a bleed in the brain (cerebral bleed) or identify the blood supply to a tumour. The angiogram can be used to show if an operation is necessary or possible. Angiography is used to look at the coronary arteries that send blood to the heart. The test is used to show if the arteries of the heart have narrowed. Angiography is used to look at the arteries in the legs and kidneys, as well as the aorta (the body's largest artery). Angiography is used to look at the liver to localise abnormalities, including tumours. This can be particularly useful when planning surgery.

How is angiography done? Before taking an X-ray, a liquid dye is injected into the blood vessels. When the test is on the arteries of the heart, the carotid artery, or the major arteries coming from the aorta, the catheter is inserted into the groin, or occasionally the arm. • •

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Before a catheter can be inserted into an artery, the surrounding area has to be numbed with a local anaesthetic. A short, thin wire with a rounded tip is then carefully inserted into the artery using a needle. It is guided with the help of fluoroscopy (X-ray images) to the spot where the dye is needed. The needle is then removed and a vascular sheath inserted around the wire. A catheter may then be inserted along the guide wire. When the catheter is in the correct position, the wire is pulled out and dye is inserted through the catheter. The patient may experience a feeling of warmth in the area, but this will disappear after a few seconds. Now the blood vessels can be checked on a screen, or on a series of rapidly recorded X-rays.

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A small minority of patients are allergic to the liquid dye, mainly due to the iodine content of the dye. Anyone who has previously experienced such reactions should mention this to the doctor. There is a small risk of the catheter damaging the blood vessels that it was inserted through. Cerebral angiography carries a small but significant risk of a serious adverse outcome. Pregnant women should enquire about the risks of the fluoroscopy (X-ray screening) harming their baby. Patients suffering from severe liver, heart or kidney diseases may be at greater risk, and should seek advice from the specialist. The risk of X-rays being harmful is very small. Modern X-ray machines are designed to take high quality pictures using the minimum radiation dose.

How does a radionuclide scan work? A radionuclide (sometimes called a radioisotope or isotope) is a chemical which emits a type of radioactivity called gamma rays. A tiny amount of radionuclide is put into the body, usually by a injection into a vein. (Sometimes it is breathed in, or swallowed, depending on the test.) There are different types of radionuclides. Different ones tend to collect or concentrate in different organs or tissues. So, the radionuclide used depends on which part of the body is to be scanned. For example, if radioactive iodine is injected into a vein it is quickly taken up into the tissues of the thyroid gland. So, it is used to scan the thyroid gland. Cells which are most 'active' in the target tissue or organ will take up more of the radionuclide. So, active parts of the tissue will emit more gamma rays than less active or inactive parts. Gamma rays are similar to x-rays and are detected by a device called a gamma camera. The gamma rays which are emitted from inside the body are detected by the gamma camera, are converted into an electrical signal, and sent to a computer. The computer builds a picture by converting the differing intensities of radioactivity emitted into different colours or shades of grey. For example, areas of the target organ or tissue which emit lots of gamma rays may be shown as red spots ('hot spots') on the picture on the computer monitor. Areas which emit low levels of gamma rays may be shown as blue ('cold spots'). Various other colours may be used for 'in between' levels of gamma rays emitted.

What happens during a radionuclide scan? Depending on the type of scan you have, you either swallow a small quantity of radionuclide, or it is injected into a vein in your arm. It then takes some time, sometimes several hours (depending on what is being scanned) for the radionuclide to travel to the target organ or tissue, and to be 'taken' into the active cells. So, after receiving the radionuclide you may have a wait of a few hours. You may be able to go out and come back to the scanning room later in the day. When it is time to do the scanning, you lie on a couch while the gamma camera detects the gamma rays coming from your body. The computer turns the information into a picture. You need to lie as still as possible whilst each picture is taken (so it is not blurred). Some pictures can take 20 minutes or more to expose. The number of pictures taken, and the time interval between each picture, varies depending on what is being scanned. Sometimes only one picture is needed. However, for some scans (such as bone scans or heart scans), two or more pictures are needed. Each picture may be taken several hours apart. So, the whole process can take several hours. What is a radionuclide scan used for? A radionuclide scan may be done for all sorts of reasons. •

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A bone scan is a common type. A radionuclide is used which collects in areas where there is a lot of bone activity (where bone cells are breaking down or repairing parts of the bone). So a bone scan is used to detect areas of bone where there is cancer, infection, or damage. These areas of activity are seen as 'hot spots' on the scan picture. A kidney scan can assess how well a kidney is working (as the radionuclide chosen is taken up by kidney cells and passes into the urine). So, the scan can detect scars on the kidney, and how well urine drains from the kidney to the bladder. Lung Perfusion Scan ('VQ scan') can detect blood clots in the lungs (pulmonary embolus). A heart scan can assess blood flow to the heart muscle. Areas of poor blood flow to the heart muscle do not 'take up' the radionuclide very well and this will be shown in the picture. Thyroid scan may be done to assess cases of overactive thyroid (hyperthyroidism). For example, some nodules (small 'lumps') are sometimes a focus of overactivity, and will show as 'hot spots' on the picture.

ECG (Stress Test) An ECG, or electrocardiogram, is a graphic representation of the electrical activity of the heart muscle as it contracts and relaxes. When the ECG is obtained on a heart that is working harder due to exercise or medication-induced stress, the test is called an exercise ECG, or "stress test." This test is useful in detecting problems that may not be apparent while the heart is at rest. Is the Exercise ECG Safe? The exercise test is generally safe. A small amount of risk does exist since exercise stresses the heart. Extremely rare complications include abnormal heart rhythms and a heart attack. Experienced personnel are available to handle any emergency. What Does It Show? Doctors can see how well your heart functions during exertion by studying what happens during the exercise test. • •

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How long were you able to exercise? Generally, people with a healthy heart and in good physical condition are able to exercise longer? Did you have significant symptoms? It is normal to feel tired and short of breath during strenuous exercise. However, if you develop chest pain or become extremely short of breath, this may indicate a heart problem. What happened to your heart rate and blood pressure? The heart rate and blood pressure normally rise during exercise. An abnormal heart rate (too fast, too slow) or a fall in blood pressure may indicate heart disease. What did the ECG show? Certain changes in the ECG tracing may indicate that the heart muscle is not getting enough oxygen-rich blood. Sometimes, the ECG during exercise shows arrhythmias (abnormal heart rhythms).

The exercise test is especially useful in diagnosing blockages in the coronary arteries. When the coronary arteries are blocked or narrowed, the heart muscle may not be getting enough oxygen during exercise. This often results in symptoms of angina (chest pain) and abnormal changes on the ECG. Preparing For A Test •

Do not eat or drink 3 hours prior to the test. This will prevent the possibility of nausea, which may accompany vigorous exercise after eating. If you are diabetic and take medications for diabetes, get special instructions from your doctor.

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If you are currently taking any heart medications, check with your doctor. You may be asked to stop certain medications a day or two before the test. This can help get more accurate test results. Wear loose, comfortable clothing that is suitable for exercise. Men usually don't wear a shirt during the test, and women generally wear a bra and a lightweight blouse or a hospital gown. You should also wear comfortable walking shoes or sneakers. Before the test, you will be given an explanation of the test and asked to sign a consent form. Feel free to ask any questions about the procedure. Several areas on your chest and shoulders will be cleansed with alcohol and an abrasive lotion, to prepare the skin for the electrodes. Men may need to have areas of their chest shaved, to ensure that the electrodes stay in place.

What Happens During the Test? The exercise ECG test can be performed in the doctor's office or at the hospital. A trained technician will place several electrodes (small sticky patches) on your chest and shoulders to allow recording of the ECG during exercise. Wires link the electrodes to an ECG machine. A cuff will be applied to your arm to monitor your blood pressure during the test. You will be shown how to step onto the treadmill and how to use the support railings to maintain your balance. The treadmill starts slowly, and then the speed and incline are increased gradually. Your blood pressure will be checked every few minutes, and the ECG will be carefully watched for abnormal changes. You will be instructed to report any symptoms, such as chest pain, shortness of breath, leg fatigue, or dizziness. The test may end when you become too tired to continue or when you experience significant symptoms. Other times, the test may be stopped when you reach your peak heart rate or when your ECG shows abnormal changes. After the exercise portion of the test is over, you'll be helped to a chair or a bed. Your blood pressure and ECG will be monitored while you recover. The technician will remove the electrodes and cleanse the electrode sites. The test typically takes between 45 minutes to one hour, which includes preparation for the test, the exercise portion, and the recovery period. The Results Typically, the doctor will review the images at a later time and prepare a report detailing his findings. We will forward a report to the patient's doctor as well as notify the patient of the results. It may take three to four days for the doctor to receive the report