An independent provider of cardiovascular health care

In association with Phoenix Hospital Group

Conditions

High Cholesterol

High Cholesterol (hypercholesterolaemia) is a major cardiovascular risk factor. Cholesterol levels should be measured periodically in adults as part of a structured cardiovascular screening and risk reduction program.

Treatment of high cholesterol if required will involve a healthy lifestyle and may involve drug therapy, usually including a class of drugs called statins. There are many statins available to treat high cholesterol and an effective well tolerated drug can usually be found for a given individual. Occasionally when statins alone can’t control the cholesterol level other drug combinations or treatments may be necessary. High cholesterol levels can be hereditary and in these situations a careful family history, family screening and sometimes genetic studies might be appropriate.

National Heart Lung and Blood Institute

The treatment strategy for any individual cardiac risk factor should always take into account whether it is in the context of primary or secondary prevention, other risk factors, and overall patient risk. Appropriate management of cardiovascular risk factors should be seen as an investment in future health.

Many sets of guidelines exist on cardiovascular prevention and cholesterol levels however your doctor will be able to advise you on how these guidelines should be applied to the individual so that you may reach a mutually agreeable management plan.

High Blood Pressure

High blood pressure (hypertension) is a major cardiovascular risk factor. As a result, hypertension can cause heart attack and stroke. It is particularly important because it usually causes no symptoms. Blood pressure should be measured periodically in adults as part of a structured cardiovascular screening and risk reduction program.

Treatment of blood pressure will involve a healthy lifestyle and may involve drug therapy. There are many drugs available to treat blood pressure and an effective, well tolerated drug or combination can be identified for most patients. There are also a number of non-drug procedures which can reduce blood pressure using nerve block techniques including a procedure called renal denervation which works by interrupting the nerves accompanying the arteries to the kidneys and is currently under investigation for patients in whom drug therapy is not effective.

National Heart Lung and Blood Institute

When investigating hypertension in the clinic your cardiologist will need to take a history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray, ECG and echocardiogram as well as an ambulatory blood pressure monitor which usually gives a clearer picture than individual readings.

The treatment strategy for any individual cardiac risk factor should always take into account whether it is in the context of primary or secondary prevention, other risk factors, and overall patient risk. Appropriate management of cardiovascular risk factors should be seen as an investment in future health.

Many sets of guidelines exist on cardiovascular prevention however your doctor will be able to advise you on how these guidelines should be applied to the individual so that you may reach a mutually agreeable management plan.

Diabetes

High blood sugar (diabetes) is a major cardiovascular risk factor. Different types of diabetes manifest themselves in different ways however elevated blood sugars sometimes cause no symptoms. As such, blood sugar should be measured periodically in adults as part of a structured cardiovascular screening and risk reduction program.

Treatment of diabetes will involve a healthy lifestyle and appropriate diet. In addition drug therapy may be necessary with tablets and or insulin. Diabetic care will usually be offered by your family doctor or an enocrinologist. Diabetes and its management are also very important to your cardiologist because of the cardiovascular problems it can cause.

National Heart Lung and Blood Institute

The treatment strategy for any individual cardiac risk factor should always take into account whether it is in the context of primary or secondary prevention, other risk factors, and overall patient risk. Because diabetes is such an important cardiovascular risk factor, it is often suggested that an aggressive secondary prevention type approach should be taken even in the absence of any prior clinical event because of the high risk of cardiovascular problems. Appropriate management of cardiovascular risk factors should be seen as an investment in future health.

Many sets of guidelines exist on cardiovascular prevention however your doctor will be able to advise you on how these guidelines should be applied to the individual so that you may reach a mutually agreeable management plan.

Angina

Angina is a symptom that occurs when the blood supply through the coronary arteries to the heart is limited by narrowing or coronary atheroscleosis, such that the supply to the muscle of the heart is inadequate.

In stable angina the blood flow to the heart is adequate at rest but on exertion the patient starts to experience symptoms such as chest pain. This is often a dull, heavy or squeezing discomfort, usually in the chest or upper abdomen and sometimes radiating to the arm or neck. Sometimes angina can manifest itself as breathlessness (sometimes called angina equivalent). Angina can however be quite variable and manifest itself in different ways. Angina usually resolves with rest or drug treatment for example a spray under the tongue (GTN). The key feature of stable angina is usually its relationship to exercise.

National Heart Lung and Blood Institute

Anyone who thinks they may be having a heart attack or who is having an angina attack which is not settling promptly with rest and or GTN spray should seek urgent medical attention from the emergency services (by dialling 999 in the UK).

When investigating possible angina in the clinic your cardiologist will need to take history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray, ECG, echocardiogram and sometimes an exercise ECG. If heart disease is suspected, a CT coronary angiogram, myocardial perfusion scan or stress echo. Following these and sometimes further tests a coronary angiogram may be necessary.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Heart Attack

A heart attack (also known as a ‘coronary’ or ‘myocardial infarction’) occurs when heart muscle cells die, nearly always from the sudden blockage of a coronary artery due to a blood clot (coronary thrombosis). This can range from a very small event after which a patient treated appropriately might be completely well and free from any restriction to a large event involving much of the muscle of the heart.

The key difference between stable angina and a heart attack is usually that the pain is persistent or comes on at rest. The pain is usually similar to angina pain in character (tight, heavy or squeezing chest or upper abdominal pain which may radiate to the neck and or arms) but usually worse, sometimes associated with nausea of vomiting and often doesn’t respond well to angina tablets or GTN spray

National Heart Lung and Blood Institute

Anyone who thinks they may be having a heart attack or who is having an angina attack which is not settling promptly with rest and or GTN spray should seek urgent medical attention from the emergency services (by dialling 999 in the UK).

The modern treatment of heart attack is complex and requires a dedicated pre-hospital , in hospital and post discharge team working closely together.

The emergency treatment of heart attack involves opening the blocked coronary artery using a technique called primary angioplasty. This requires an emergency coronary stent procedure both to open the blocked artery and to treat any underlying narrowing.

Following a heart attack it is essential that secondary prevention is undertaken to reduce as much as possible the risk of further events.

Your cardiologist will discuss the heart attack with you including its implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Cardiomyopathy

The term cardiomyoapthy is used to describe intrinsic disease of the heart muscle, in particular the left ventricle of the heart. The ventricles of the heart can be damaged by extrinsic causes such as heart attacks from blockages of the coronary arteries (known as ischaemic cardiomyopathy) however this section deals with intrinsic diseases of the muscle where no obvious extrinsic cause can be found.

Two of the two most important intrinsic cardiomyoapthies are dilated cardiomyopathy (DCM) and hypertophic cardiomyopathy (HCM or HOCM)

DCM results in weakening and enlargement of the left ventricle of the heart which can go on to produce symptoms of breathlessness and heart failure. Sometimes it will be necessary to recommend a myocardial biopsy to understand the cause. Drug therapy can be very effective in the treatment of DCM and in some cases an implantable defibrillator (ICD) may be recommended to protect the patient from dangerous heart rhythms.

HOCM describes asymmetrical hypertropy (thickening) of the left ventricular muscle of the heart in an area known as the septum. Drug therapy can sometimes be effective for the complications of HOCM and in some cases an implantable defibrillator (ICD) may be recommended to protect a patient from dangerous heart rhythms.

When investigating possible cardiomyopathy in the clinic your cardiologist will need to take history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray, ECG, and echocardiogram. Further tests to exclude significant coronary artery disease such as CT coronary angiogram, myocardial perfusion scan, stress echo or a coronary angiogram may be necessary. Sometimes a biopsy of the heart may be helpful. If a hereditary problem is suspected screening of relatives may be advised, and genetic testing may be reccomended.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Aortic Valve Disease

Position of Heart Valves

National Heart Lung and Blood Institute

The heart has valves to ensure that the blood flow is in the right direction. The aortic valve is situated between the main pumping chamber of the heart (the left ventricle) and the main artery (aorta) at the ‘outflow’ of the heart. Whilst the heart is pumping blood out or ejecting (known as systole) the valve is open. When the left ventricle is relaxing and filling with new blood (known as diastole) the aortic valve is shut. The two main problems with the aortic valve are narrowing (Aortic Stenosis, AS) and leaking (Aortic Regurgitation, AR. Both have different effects on the heart however ultimately they can both cause serious problems with breathlessness and heart failure. If treatment to a heart valve is proposed it is preferable to do this before the heart becomes significantly damaged so early diagnosis and careful surveillance are important.

When investigating possible aortic valve disease in the clinic your cardiologist will need to take history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray , ECG and echocardiogram. Further tests including a coronary angiogram and CT scan may also be necessary. Depending on the results your cardiologist may recommend continued follow up with medical therapy if appropriate and regular clinical surveillance including echocardiography. If intervention to the valve itself is needed this will usually require surgical aortic valve replacement (AVR) or transcatheter aortic valve replacement (TAVI).

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Image of Aortic Valve Stenosis

National Heart Lung and Blood Institute

Mitral Valve Disease

The heart has valves to ensure that the blood flow is in the right direction. The mitral valve is situated between the right atrium and the main pumping chamber of the heart (the left ventricle) at the inflow of the left ventricle allowing it to fill with blood (known as diastole) when the valve is open before ejecting blood into the circulation (known as systole) when the valve is closed. The two main problems in mitral valve disease are narrowing (Mitral Stenosis, MS) and leaking Mitral Regurgitation (MR). Both have different effects on the heart however ultimately they can both cause serious problems with breathlessness and heart failure. If treatment to a heart valve is proposed it is preferable to do this before the heart becomes significantly damaged so early diagnosis and careful surveillance are important.

When investigating possible mitral valve disease in the clinic your cardiologist will need to take history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray , ECG and echocardiogram. Further tests including a coronary angiogram , CT scan and MRI scan may also be necessary. Depending on the results your cardiologist may recommend continued follow up with medical therapy if appropriate and regular clinical surveillance including echocardiography.

Image of normal mitral valve and leaking mitral valve-in this case due to prolapse
National Heart Lung and Blood Institute

If intervention is needed this will usually require surgical treatment (mitral valve repair, a mitral ring or replacement). Transcatheter mitral valve repair and replacement is complex and at a relatively early stage of development however it is a rapidly evolving field.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Heart Failure

Heart failure is a complex condition, however from the patients perspective it is an illness that can result in breathlessness (on exertion or in more advanced cases at rest) and fluid retention (usually with swelling of the legs and or fluid in the lungs). The symptoms can range form very mild exertional breathlessness to a debilitating illness. Heart failure is also associated with a number of complex changes in the circulation and the body’s chemistry-which in turn provide the focus for a number of effective treatments.

The term heart failure doesn’t explain the precise cause however this is usually due to a problem with the heart muscle (typically due to a heart attack or an intrinsic problem with the muscle known as cardiomyopathy) or the heart valves.

The treatment of heart failure depends on the underlying cause and might involve correction of problems with the coronary arteries or heart valves.

A mainstay of treatment however and one of the great successes in modern cardiology is the drug treatment of heart failure. In addition to drug therapy which can be extremely effective, some patients have problems with the synchronisation or coordination of the pumping function of the heart and this can sometimes be improved with a special type of pacemaker known as a biventricular pacemaker. Known as cardiac resynchronisation therapy (CRT).

When investigating possible heart failure in the clinic your cardiologist will need to take history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray , ECG and echocardiogram. Further tests to exclude significant coronary artery disease may be necessary such as a CT scan, myocardial perfusion scan, stress echo or coronary angiogram . An MRI scan may also be necessary.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Atrial Fibrillation

Atrial fibrillation (AF) is caused by rapid disorganised electrical activity of the atria of the heart. The hallmark of AF is an irregular pulse. AF is a very important rhythm abnormality because it is common and can cause two principal problems. Firstly AF makes the pumping function of the heart less efficient, especially if the heart rate is too fast or slow which can cause breathlessness or reduced exercise tolerance and sometimes damage to the heart muscle. Secondly, because the atria of the heart don’t pump properly in AF, blood can become stagnant, particularly in a small outpouching called the left atrial appendage (LAA) which can result in blood clots which can travel to the brain causing stroke. AF can be permanent or can come and go ‘paroxysmal AF, PAF’

Treatment of AF falls into two areas.

First whether to ‘accept’ the AF and manage the related issues or to try to restore or maintain normal sinus rhythm using drugs or a controlled electric impulse ‘cardioversion’. Maintaining sinus rhythm can be difficult, however it has significant benefits for the heart and depending on the individual patient may be achievable with drug therapy or AF catheter ablation.

The second consideration is thromboprophylaxis (with warfarin, an alternative anticoagulant drug or a LAA occlusion device) and this will depend on the individual patient stroke risk. There are a number of scoring systems to aid this decision.

When investigating AF in the clinic your cardiologist will need to take history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray, ECG and echocardiogram. A holter monitor will usually be performed especially if PAF is suspected. Further tests to exclude significant coronary artery disease such as a CT scan, myocardial perfusion scan, stress echo or coronary angiogram may be recommended.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Other Rhythm Disturbances

Although atrial fibrillation is the commonest important heart rhythm abnormality a number of other rhythm problems can cause concern. There are complicated classifications and names for these problems which can be difficult to understand however it can be helpful to differentiate between single extra (ectopic) beats and continuous abnormal beats-which may be very shortlived, more sutained, come and go (paroxysmal) or be permanent.

Ectopic beats can come from the atria (atrial ectoics) or the ventricles (ventricular ectopics, VEs). These ectopic beats are common and often asymptomatic however they can sometimes causes an awareness of the heart beat, particularly VEs. Depending on their characteristics, frequency, and the underlying condition of the heart these ectopic beats can be harmless or can cause a significant cardiac problem. Treatment of ectopic beats can include conservative management and avoidance of precipitating factors (eg caffeine), drug therapy and sometimes catheter ablation.

Sustained rhythm abnormalities can be helpfully divided into those arising in the atria of the heart and those arising in the ventricles of the heart.

In addition to atrial fibrillation (AF) other atrial arrhythmias include atrial flutter, atrial tachycardia and re-entrant tachycardias sometimes called ‘supraventricular tachycardias’ or SVT. These problems can often be managed conservatively with no specific treatments but sometimes drug treatment or catheter ablation will be recommended.

Ventricular tachycardia or VT is a potentially serious rhythm abnormality and always requires careful evaluation often including scans of the heart and a coronary angiogram. VT often requires drug therapy and sometimes an implantable defibrillator (ICD) will be recommended to protect the patient from a dangerous rhythm. Sometimes catheter ablation may be recommended.

When investigating rhythm disturbances in the clinic your cardiologist will need to take a history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray, ECG and echocardiogram as well as a holter monitor. The length of monitoring will usually depend on how frequently the abnormal rhythm is occurring. Sometimes a patient activated monitor or implantable monitor may be necessary Sometimes a catheter electrophysiological study (EPS) will be necessary.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Slow Heart Beat

A slow heart beat can be normal and commonly occurs at night, in athletes, in many normal people and in patients on cardiac, medication. Sometimes however the heart beat can become inappropriately slow such that the pumping function of the heart is impaired resulting in symptoms such as dizziness, fainting or breathlessness.

An inappropriately slow heart beat or ‘pauses’ during which the heart stops for a short period are usually a result of problems with the electrical conduction of the heart. These abnormalities affect the conduction at different levels, but the commonest important bradycardia is caused by ‘heart block’ due to problems with conduction between the atria and the ventricles of the heart. Sometimes drugs can cause or exacerbate problems with a slow heart rate and stopping or changing them can improve the situation.

Limited degrees of heart block can be well tolerated and may simply need careful follow up with periodic ECGs or holter monitors. However more significant levels of heart block such as ‘complete heart block’ particularly when they result in very slow heart rates or long pauses, dizziness or fainting may need to be treated with a pacemaker.

When investigating rhythm disturbances in the clinic your cardiologist will need to take a history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests, a chest x-ray, ECG and echocardiogram as well as a holter monitor. The length of monitoring will usually depend on how frequently the abnormal rhythm is occurring. Sometimes a patient activated monitor or implantable monitor may be necessary.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Sudden Cardiac Death

Sudden cardiac death (SCD) is obviously devastating. It can be caused by more common conditions such as heart attacks however when used in cardiovascular medicine it is usually applied to a particular group of conditions which can affect young patients and can strike ‘out of the blue’. Some causes of SCD are hereditary and therefore family history is especially important in this group of conditions. Because the first presentation of these conditions can be with a fatal event, appropriate screening and investigation of any suspicious episodes such as collapse or fainting are central to the management. These conditions are especially important in the modern era since effective preventive strategies exist including drug therapy and implantable cardiac defibrillator (ICD)

Causes of SCD can be broadly categorised into structural causes-that can often be identified on scans and electrical causes relating to the electrical conduction of the heart. Genetic tests are playing an increasing role in assessing risk from SCD.

Structural causes include hypertrophic (obstructive) cardiomyopathy (HOCM) and arrhythmgenic right ventricular dysplasia (ARVD). Electrical conduction causes include pre-excitation syndromes (such as Wolff Parkinson White-WPW), Brugada syndrome, Long QT syndrome, Short QT syndrome and catecholamine induced tachyarrhtymia.

When investigating the risk of SCD in the clinic your cardiologist will need to take a history including a very detailed family history and perform a physical examination. In addition they will want to perform some tests which will often include blood tests often including genetic tests, a chest x-ray, ECG and echocardiogram. Further tests may be required including a CT or MRI scan, period of holter monitoring and an exercise test. In some situations tests may include a ‘provocative’ study under close medical supervision and monitoring to look for evidence of a problem.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Stroke and TIA

National Heart Lung and Blood Institute

Stroke is an important condition because it can cause disabling problems and furthermore can sometimes be prevented with appropriate treatment. It is often manifest as weakness, particularly when this affects one side of the body or difficulty speaking. A stroke that resolves completely within 24 hours is known as a transient ischaemic attack (TIA)

Strokes are caused by damage to the brain, usually due to starvation of blood supply (iscahemia). Less commonly strokes are caused by bleeding affecting the brain(haemorrhage).

Ischaemic strokes are often caused by a blood clot travelling to the brain (embolic). This may be due to atherosclerosis of the aorta (main artery in the chest) or carotid arterties (arteries in the neck), but one of the most common and important causes of embolic stroke is atrial fibrillation (AF). Stroke risk in AF can be significantly reduced by drug treatment to thin the blood (anticoagulation) and sometimes by a procedure called left atrial appendage occlusion. Less frequently, strokes may be caused by a ‘paradoxical embolus’ passing through a small hole in the heart between the atria ‘PFO’. In such cases it may be appropriate to suggest closing the PFO, usually through a minimally invasive catheter technique.

Narrowing of the carotid arteries supplying blood to the brain may need treatment with drugs, an operation called carotid endarterectomy or carotid senting.

Haemorrhagic (bleeding) strokes are often managed with drug therapy however occasionally an operation will be needed to relieve pressure form the blood onteh brain, sometimes as an emergency.

Anyone who thinks they or anybody else may be having a stroke should seek urgent medical attention from the emergency services (by dialling 999 in the UK).

Strokes are usually managed by neurologists with tests including blood tests, a CT and or MRI brain scan, ECG, holter monitor to look for evidence of atria fibrillation, echocardiogram possibly with a bubble study to look for a PFO and carotid artery ultrasound, followed by appropriate treatment recommendations. For acute ischaemic stroke treatment may include emergency administration of ‘clot busting’ (thrombolytic) drugs to help restore brain function. Such treatment is very time dependant and requires early recognition of stroke.

From a cardiovascular perspective, the risk of having a stroke can be reduced with appropriate screening and subsequent management.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

PFO and ASD

National Heart Lung and Blood Institute

Patent Foramen Ovale (PFO) and atrial septal defect (ASD) are communications between the right and left atria of the heart. Such a communication is necessary before birth, but in most people it closes shortly after birth.

A PFO is a slit like hole between the atria and is present in perhaps 20% or so of the population and often causes no problems and needs no treatment. A PFO however can allow some blood to go from the right to the left side of the heart under some circumstances without passing through the lungs. In some cases of TIA, stroke and heart attack it is believed that blood clots from the veins of the body pass through a PFO and cause these complications. If that is likely to be the case then closing the hole, often with a transcatheter device (PFO closure) may be recommended.

An atrial septal defect (ASD) is usually a larger hole between the atria. It can cause the same problems as some PFOs however because it can allow significant flow of blood across the septum (a shunt) it can cause problems for the heart and lungs. Although small ASDs often cause few problems, under some circumstances closure of the ASD either with transcatheter closure or a surgical operation may be recommended.

When assessing PFO or ASD in the clinic your cardiologist will need to take a history and perform a physical examination. In addition they will want to perform some tests which, will often include blood tests, a chest x-ray, ECG, echocardiogram (often with a bubble echo), and transoesophageal ultrasound (TOE).

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Aortic Aneurysm

Atherosclerosis usually causes narrowing (stenosis) of arteries however it can also cause bulging or dilatation of arteries (aneurysms). Abdominal aortic aneurysm (AAA)-bulging of the main artery in the abdomen is a particularly important type of aneurysm because if it ruptures it needs emergency treatment and can be fatal, however AAA develops over many years and if found through screening it can be monitored and often treated electively either with a surgical repair or using a covered stent passed through a catheter when appropriate.

Screening for AAA has been shown to be of benefit in certain patient groups and as such forms an important part of an overall cardiovascular screening program. The abdominal aorta can be scanned in detail using ‘body scans’ such as CT and MRI which give a very accurate assessment however AAA can also be screened for using simple abdominal ultrasound.

National Heart Lung and Blood Institute

If there is evidence of AAA on screening then if the aneurysm is small, regular scans will usually be recommended. If the aneurysm is large then it may be appropriate to consider repairing it. This treatment may often be lead by a vascular surgeon but might also involve an interventional radiologist or cardiologist if a stent is being considered. Preventive therapies will also be important to reduce as much as possible the risk of future cardiovascular events.

Your cardiologist will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.

Claudication

Claudication, or intermittent claudication refers to leg pain which occurs on exercise and is usually due to narrowing or blockage of the arteries supplying blood to the legs due to atherosclerosis.

Patients with intermittent claudication usually have widespread atherosclerosis which can effect other organs and as such it is important that an aggressive ‘secondary prevention’ approach Is taken with lifestyle manoevres and drug therapy.

Regarding treatment of claudication this will often be managed by a vascular surgeon, or interventional radiologist. The management of this problem will depend on the level of symptoms and the precise cause based on a scan or angiogram. It may involve tablets alone, an arterial bypass operation or angioplasty and stenting.

National Heart Lung and Blood Institute

Your doctor will discuss these tests their implications and any subsequent tests, treatment or follow up with you so that you may reach a mutually agreeable management plan.