Cardiac Electrophysiology

Valve Disease

Structural heart disease is any type of abnormality of the heart’s muscle, valves, arteries or other supporting structures. The most common type of structural heart disease is aortic stenosis, which affects about 1.5 million Americans.

In the past, open heart surgery offered the only option for repairing structural heart conditions. But now, minimally invasive surgery offers you or your loved one a far less complex way to correct some structural heart and valve problems. Our heart providers have expertise in all types of heart valve surgeries, including minimally invasive aortic valve and mitral valve surgery. We offer valve repair as well as both aortic valve replacement (AVR) and transcatheter aortic valve replacement (TAVR)] a revolutionary, minimally invasive alternative to open heart surgery.

What is Structural Heart and Valve Disease?

Aortic stenosis is a condition that affects the aorta, which is the main artery through which blood flows from the heart to the rest of your body. The aortic valve must open fully to allow blood to flow and then close to prevent blood from flowing back into the heart. When your aortic valve doesn’t function properly, blood flow from the heart is decreased and the heart must work harder to pump blood, which can cause thickening of the heart as well as chest pain. Over time, blood can back up into your lungs.

Although aortic stenosis can develop before birth (congenital aortic stenosis), it is more likely to occur later in life, because of a buildup of calcium deposits on the aortic valve. Aortic stenosis afflicts about 2 percent of people over age 65. It’s important to diagnose and replace faulty heart valves, because if you have severe aortic stenosis and don’t have the valve replaced, the chance of dying in two to three years increases by roughly 50 percent.

Another common type of structural heart disease is mitral valve stenosis. The mitral valve is located between the left atrium and the left ventricle of the heart and controls blood to flow from the left atrium into the left ventricle. Problems with this valve can make it harder for your heart to pump blood properly.

Recognize Valve Disorder Symptoms

Valve disorders can cause the following symptoms:

Chest pain or discomfort that may worsen with activity
A feeling of pressure or squeezing in the chest that can extend into the arm, jaw or neck
Cough, sometimes bloody
Trouble breathing during activity
Fatigue
Heart palpitations
Fainting
Weakness, lightheadedness or dizziness, particularly with activity
Swelling of the feet or legs

How Do You Determine Structural Heart Disease?

To diagnose structural heart disease, your cardiologist starts by giving you a physical exam and talking with you about your symptoms and health history. You may also receive one or more of the following diagnostic tests:

Electrocardiogram (ECG): This test uses small sensors (electrodes) attached to your chest and arms to record electrical signals as they travel through your heart.
Echocardiogram: In this noninvasive test, sound waves are used to produce a video image of your heart in motion.
Chest X-ray: This test can show whether your heart is enlarged and whether you have enlarged blood vessels or calcium buildup in your heart.
Cardiac stress test (also known as a treadmill test or exercise EKG or ECG): This test measures how your heart performs in response to exercise or stress by monitoring blood flow and oxygen levels as your heart beats faster and works harder.
Cardiac computerized tomography (CT) scan. This test uses a series of X-rays to look at the size and condition of your heart and heart valves.
Catheterization and angiogram: During this test, a cardiologist guides a catheter (a thin plastic tube) through an artery in the arm or leg into coronary arteries. Dye is injected through the catheter, to make images that can be captured in an X-ray. This test allows your providers to look at your heart and heart valves.
Cardiac MRI: This test uses magnets and radio waves to create images of your heart as it beats. It can give your providers a better idea of whether your heart or valves are damaged.

Diagnosis: Cardiovascular Services

Cardiac Stress Test

A cardiac stress test measures how the heart performs in response to exercise or stress. The test monitors blood flow and oxygen levels as the heart beats faster and works harder. Stress tests are often performed to help determine the cause of chest pain or shortness-of-breath. A stress test can help diagnose coronary artery disease (CAD – narrowing of the heart’s blood vessels), which can cause chest pain and increases a patient’s risk for a heart attack. The test can also reveal irregular heart rhythms and determine if medical treatments have been effective.

Prior to the Treadmill Test, (also known as as an exercise stress test or an exercise ECG) patients are given an electrocardiograph (EKG or ECG) and an echocardiogram. The EKG measures heart rate, while the echocardiogram gives images of the heart’s structures. It assesses heart and valve health and blood flow. Both tests are painless and the patient’s heart rate, blood pressure and cardiac electrical system are monitored.

For the exercise test, electrodes are placed on the chest, arms and legs. A blood pressure cuff is worn on the arm and an oxygen monitor is placed on the finger. The patient exercises by walking on a treadmill or pedaling a bicycle until they develop symptoms or feels tired. The patient is given an EKG and echocardiogram afterward.

Metabolic stress testing – This test measures the performance of the heart and lungs while under physical stress. It is similar to an exercise stress test but includes an analysis of the patient’s respiratory system.

Pharmacological (medication-induced) stress echocardiogram – A stress echocardiogram integrates ultrasound imaging and exercise stress testing to measure how the heart functions while the patient walks on a treadmill or rides a stationary bicycle. Medication is be used to stimulate exercise for patients who are unable to exercise safely.

Nuclear stress test — Your provider may order a Nuclear Stress Test to assess the blood flow to your heart. This is done by taking two sets of pictures of your heart; one set of pictures shows the blood flow to your heart at rest, and the other set of pictures shows the blood flow to your heart at stress. Each set of pictures requires an intravenous injection of a radioactive material, which will not make you feel any different in any way. Your test may be scheduled with one set of pictures on different days, or it may be a one-day test. The stress test may be done on a treadmill, with medications, or a combination of both. For the pictures, you must lay very still on a table while a camera passes over your chest for about 15 minutes. While Nuclear Stress Testing is extremely safe, a provider will be at your side during stress testing.

Echocardiogram

A conventional or Transthoracic Echocardiogram (TTE) can be done in a resting state or during exercise (stress echo), the ultrasound source is outside the body, on top of the chest. A technician obtains views of the heart by moving a small instrument called a transducer to different locations on the chest or abdominal wall. A transducer, which resembles a microphone, sends sound waves into the chest and picks up echoes bouncing off the heart. A standard echo usually provides highly detailed images of the heart walls and chambers which can be analyzed by a cardiologist. There are no side effects from a TTE or recovery time needed.

Holter Monitor Applications and Interpretation

One tool that providers use to diagnose arrhythmia (an abnormal heart rhythm) is the Holter monitor. The Holter monitor, worn for one or two days, is a small appliance that can be attached to a belt or a shoulder strap. Several electrodes placed on the chest connect to the monitor. The monitor records heart rhythms. Patients may also be asked to keep a record of cardiac symptoms experienced while wearing the monitor. Symptoms include chest pain, heart flutters, faintness or dizziness. It is also helpful for the patient to record when he/she takes medications, exercises or experiences emotional events. The Holter monitor will not interfere with most activities, other than bathing or water-based activities, as it must remain dry.

Transesophageal Echocardiogram

Echocardiograms use sound waves bounced off the structures of the heart to generate images of the heart in motion. In some cases, most often when patients have serious lung disease, or are immobile or overweight, ultrasound images of the heart are not clear. In these cases, cardiologists may request a transesophageal echocardiography (TEE)

Unlike the standard echocardiogram, in which the transducer is placed over the chest wall, in TEE the transducer is passed into the esophagus (the swallowing tube) and sometimes into the stomach. The esophagus, in particular, provides an ideal viewing of the heart, aorta and other great vessels and produces high-quality images of these structures.

TEE examinations are useful in helping providers diagnose and evaluate patients with embolisms (clots), valvular heart disease, bacterial infections, lesions, aortic abnormalities and injuries, and congenital heart disease. TEE is also used to evaluate critically ill patients and potential heart surgery candidates. A TEE carries more risk than the standard echocardiogram procedure (which is essentially risk-free) but is still very safe and under the right circumstances can be extremely useful.

Contact Information

CMHVI Diagnostic Testing Center
60 High Street, Y1
Lewiston, Maine 04240
(207) 795-8200

Services:

Cardiac Catheterization Lab
Cardiac Diagnostic
Cardiac MRI
Cardiopulmonary Rehab
Electrophysiology (EP) Lab
Vascular Lab
Vein Center
Wound Center – 795-8260

_________________________________

Lipid Clinic
60 High Street, ground floor
Central Maine Heart Associates
(207) 753-3900

_________________________________

Single-Stay Unit (SSU)
60 High Street, Y3
Lewiston, Maine 04240
(207) 753-3907

Heart Attack

If you think you or a loved one is experiencing a heart attack, call 911 immediately. Do not attempt to drive to the hospital.

Each year, about 800,000 Americans have a heart attack, which happens when the blood supply to your heart is cut off. Having a heart attack is a frightening experience, but the good news is about 85 percent of people survive if treated quickly.

The best cure is prevention: as part of our commitment to cardiac and vascular health, we sponsor wellness and prevention programs throughout the region.

Around 85 percent of heart damage occurs within the first two hours of a heart attack, so be sure to call 911 right away if you or someone you’re with shows symptoms of a heart attack.

Certified for Rapid Response: CMMC’s Chest Pain Center

We are proud of the fact that our CMMC Chest Pain Center, which is part of our Emergency Department in Lewiston, is certified for its rapid-response care. If you come in with chest pain, the emergency professionals in our Chest Pain Center provide the immediate care you need. We treat all patients with chest pain as potential cardiac patients until we determine a definite diagnosis.

If you arrive at our Emergency Department with chest pain or other heart attack symptoms, you will be immediately connected to a cardiac monitor, receive oxygen and started on intravenous lines so that life-saving drugs can be administered quickly if needed. Our experienced emergency professionals conduct diagnostic testing to determine what’s causing your symptoms and once your condition is stable, we connect you with one or more cardiologists for possible follow-up care.

Know the Warning Signs of Heart Attack

It’s important to be aware of the signs of heart attack so that if you or someone you’re with is having a heart attack, you can get emergency care as rapidly as possible. Warning signs include:

Chest pain or discomfort that occurs in the center or left side of the chest; it may last for a few minutes or more or it may come and go
Pressure or a feeling of squeezing or fullness in the chest
Pain or discomfort in one or both arms or your back, neck, stomach or jaw
Shortness of breath
Cold sweat
Nausea (with or without vomiting)
Light-headedness or fainting

The signs of heart attack may look different in men than in women. Although men and women may both feel chest pain or pressure, women often don’t have chest pain with a heart attack. Instead, they may have other symptoms, such as shortness of breath or dizziness, that are less commonly associated with heart attack.

Keep in mind that your chance of having a heart attack goes up if you have risk factors such as high blood pressure, high cholesterol or diabetes or if you smoke or have had a previous heart attack or stroke.

Learn How We Provide Diagnosis

To determine whether you’re having a heart attack, our chest pain specialists may conduct one or more of the following tests:

Blood tests: These tests measure certain enzymes in your blood. For example, high levels of an enzyme known as troponin in the blood can indicate a heart attack has taken place.
Electrocardiogram (ECG or EKG): A test that measures heart rate, monitors the heart’s electrical system and provides images of the heart’s structures, assessing heart and valve health and blood flow.
Chest X-ray: X-rays may show whether the heart muscle has been damaged.
Echocardiogram: An ultrasound test that uses sound waves and the echoes they produce to obtain highly detailed images of the walls and chambers of the heart.
Cardiac stress test (also known as a treadmill test or exercise EKG or ECG): A test that measures how your heart performs in response to exercise or stress. This test monitors blood flow and oxygen levels as your heart beats faster and works harder.
Nuclear stress test: A test that assesses the blood flow to your heart by taking two sets of pictures of your heart: one set while you’re at rest and the second while your heart is being stressed by exercise, medication or a combination of both. Radioactive material is injected into your vein to highlight healthy and damaged tissue in the pictures.

Get Access to a Range of Treatments

Heart attack treatment varies based on several factors, including the type and severity of the attack and other health considerations. After we determine that you’re having a heart attack, we may provide one or more of the following treatments:

Medications: Depending on the type and extent of your heart attack, as well as any other health conditions you have, your provider may prescribe drugs such as anticoagulants, ACE inhibitors, beta blockers, calcium channel blockers, cholesterol-lowering medications, diuretics or vasodilators.
Thrombolysis: A procedure in which a clot-dissolving agent is injected to restore blood flow in a coronary artery.
Catheterization and balloon angioplasty: A test in which an inflatable balloon-type tool is used to compress plaque against artery walls, allowing increased blood flow. Balloon angioplasty is performed during a catheterization.
Percutaneous Coronary Intervention (PCI): Also known as angioplasty and stent treatment, PCI implants a tiny mesh tube in an artery to prevent plaque from blocking the blood vessel. After clearing blockage in an artery, your provider uses a catheter to place the stent in the newly opened artery. The stent helps hold the artery open and reduces the chance that plaque will block the artery again.
Coronary artery bypass grafts (CABG): Also known as heart bypass surgery, this procedure is open-heart surgery requiring general anesthesia. During bypass surgery the surgeon removes a piece of a healthy blood vessel from your leg, arm or chest wall to use as a graft to create a new path for blood flow around a blocked artery. One end of the healthy graft is sewn to the blood vessel just below the blocked artery. The other end of the graft is sewn above the blocked artery. Blood can then flow around the blocked area. After bypass surgery, blood moves more freely through the coronary arteries, lowering the risk of heart attack.

Recover with Cardiac Rehabilitation

If you have a heart attack or any other heart conditions, we offer cardiac rehabilitation as part of our Cardiopulmonary Rehabilitation Program. Our cardiac rehabilitation is a medically supervised program that helps you recover with an individualized plan that provides evaluation and instruction on physical activity, nutrition, stress management and other health-related areas as needed. Cardiac rehabilitation can make a significant difference in your quality of life after a heart attack.

Coronary artery disease
Angina
Coronary artery angioplasty or stents
Open heart surgery such as coronary bypass or valve surgery
Heart failure
Heart transplantation

As a heart attack survivor, you will also be invited to join Mended Hearts™, a patient-run support group affiliated with the American Heart Association that offers support and encouragement through its visiting program, monthly meetings and educational forums. To learn more, call: (207) 795-8230.

Coronary Artery Disease

In a healthy heart, blood flows smoothly and easily through clear arteries and the heart gets all the oxygen it needs. But if you are diagnosed with coronary artery disease (CAD), the arteries that bring blood to your heart become hardened and narrowed by plaque buildup, reducing the amount of oxygenated blood delivered to your heart.

As the leading cause of heart attacks and death in the United States, it’s important to take a CAD diagnosis seriously. Our board-certified cardiovascular providers can help ease your concerns and improve your outlook by providing a full range of state-of-the-art cardiac care. In our Cardiac Catheterization Laboratory, known as our Cath Lab, we perform a range of diagnostic and interventional cardiac procedures, including heart catheterization to assess and diagnose CAD, and treat with angioplasty and stent placement.

CAD: The Most Common Type of Heart Disease

If you have CAD, you’re not alone. It’s the most common type of heart disease in the United States. CAD occurs when cholesterol and other materials build up on the insides of your arteries. This buildup, known as atherosclerosis, starves your heart muscle of oxygen and may create pain, which is known as angina. If plaque breaks up, a blood clot can form and cut off blood supply to your heart, causing a heart attack. CAD can also lead to other heart conditions, such as arrhythmia or heart failure.

Although you may never experience symptoms from CAD, especially in the early stages, if you have any of these symptoms, talk to one of our specialists to determine if you have the disease.

Chest pain or discomfort, especially with activity or emotion
Heaviness or pressure on your chest, under your breast bone or in your neck, upper back, stomach or arms
Shortness of breath
Fatigue
A general feeling of weakness

Determining Your Diagnosis

We offer a full range of tests to diagnose CAD and other cardiac conditions. Our diagnostic tests, many of which are non-invasive, offer safe, painless ways to check your cardiac function and determine the extent to which plaque may be blocking your arteries. Our specialists use the latest tests and tools to diagnose CAD, including:

Electrocardiogram (ECG or EKG): A test that measures heart rate, monitors the heart’s electrical system and provides images of the heart’s structures, assessing heart and valve health and blood flow.
Cardiac stress test (also known as a treadmill test or exercise EKG or ECG): A test that measures how your heart performs in response to exercise or stress. This test monitors blood flow and oxygen levels as your heart beats faster and works harder.
Pharmacological (medication-induced) stress echocardiogram: A stress test that uses medication to stimulate exercise for patients who are unable to exercise safely.
Metabolic stress testing: A test that measures the performance of the heart and lungs while under physical stress. Like an exercise stress test, it includes an analysis of your respiratory system.
Nuclear stress test: A test that assesses the blood flow to your heart by taking two sets of pictures of your heart: one set while you’re at rest and the second while your heart is being stressed by exercise, medication or a combination of both. Radioactive material is injected into your vein to highlight healthy and damaged tissue in the pictures.
Coronary arteriogram (or angiogram): With this procedure, X-rays are taken to locate the narrowing, occlusions and other abnormalities of specific arteries.
Echocardiogram (Echo): An ultrasound test that uses sound waves and the echoes they produce to obtain highly detailed images of the walls and chambers of the heart.
Transesophageal echocardiogram (TEE): This test is like an echocardiogram but is for patients who have conditions such as serious lung disease, immobility or excess weight that may interfere with the creation of high-quality images with a standard echocardiogram. Instead of using an external ultrasound transducer, this test passes the transducer into the esophagus or stomach through a thin swallowing tube.
Catheterization (Cath) and angiogram: This test, which is used both for CAD diagnosis and treatment, creates images that can be captured in an X-ray of artery blockages that may require repair. During the catheterization, a thin flexible tube called a catheter is inserted through a blood vessel in your groin (or sometimes in your arm) and guided toward the blocked vessel. Dye injected through the catheter allows images of your blood vessels to appear on a monitor for analysis.
Diagnostic peripheral arterial catheterization: This test is used to diagnose artery disease and blockage that occurs outside the heart, such as in the legs.

Treatment Options Available to You

Once we have a full understanding of your condition, as well as your health history and your risk factors, we work with you to develop a treatment plan that best meets your needs. We provide a wide range of CAD treatments, including:

Catheterization and balloon angioplasty: A test in which an inflatable balloon-type tool is used to compress plaque against artery walls, allowing increased blood flow. Balloon angioplasty is performed during a catheterization.
Angioplasty and coronary stent replacement: A stent is a tiny mesh tube that our providers implant in an artery to prevent plaque from blocking the blood vessel. Stents may be implanted in arteries in your heart (coronary arteries), neck (carotid arteries) or liver. After clearing blockage in an artery, your provider uses a catheter to place the stent in the newly opened artery. The stent helps hold the artery open and reduces the chance that plaque will block the artery again.
Coronary artery bypass grafts (CABG): Also known as heart bypass surgery, this procedure isopen-heart surgery requiring general anesthesia. During bypass surgery the surgeon removes a piece of a healthy blood vessel from your leg, arm or chest wall to use as a graft to create a new path for blood flow around a blocked artery. One end of the healthy graft is sewn to the blood vessel just below the blocked artery. The other end of the graft is sewn above the blocked artery. Blood can then flow around the blocked area. After bypass surgery, blood moves more freely through the coronary arteries, lowering the risk of heart attack.

Cardiac Rehab for a Smooth Recovery

We help our CAD patients get back on track with a comprehensive cardiac rehabilitation program. Our Cardiopulmonary Rehabilitation Program ensures exceptional care for all our patients. Our team guides you and your loved ones to achieve a good quality of life after surgery or other cardiac treatment. The program is held on the first floor of the Young wing in the Cardiopulmonary Rehabilitation Department.

Cardiac rehabilitation is a medically supervised program to help you recover by following an individualized plan that provides evaluation and instruction on physical activity, nutrition, stress management and other health-related areas as needed. Cardiac rehabilitation will help you achieve greater quality of life when recovering from CAD and other heart conditions such as:

Heart attack
Angina
Coronary artery angioplasty or stents
Open heart surgery such as coronary bypass or valve surgery
Heart failure
Heart transplantation

You will need to obtain a referral from your provider to enter our cardiopulmonary program; however, we encourage you to call us for more information (207) 795-8225 for assistance in accessing our services or to answer any questions you may have about our program.

A to Z Search for Services

Central Maine Healthcare covers all of your physical and mental health needs.
Click on a service below to learn more about what we offer and where to find care near you.

Addiction Services
We are committed to understanding and serving people who are living with addiction. We provide compassionate trauma-informed care based on best practi… Learn More >
Bariatric Surgery
Central Maine Bariatric Surgery understands how important weight loss is for patients. We have been established since 2007 and have a team ready to su… Learn More >
Breast Health
When it comes to caring for your breast health, Central Maine Healthcare offers a spectrum of services to help screen, diagnose, and treat. From the m… Learn More >
Cancer care
The Cancer Care Center at Central Maine Medical Center is an integrated, multi-disciplinary program that combines a full spectrum of services and med… Learn More >
Cardiovascular services
Central Maine Heart and Vascular Institute (CMHVI) brings skilled medical specialists and innovative treatments to the people of central Maine and bey… Learn More >
Diabetes and Endocrinology
Diabetes and other endocrine-system conditions are complex, and when you’ve been diagnosed with one, it’s hard to know what to do next. Learn More >
Ear, Nose and Throat
At Central Maine Healthcare, our board-certified ear, nose and throat (ENT) specialists understand how this connected system works and can identify th… Learn More >
Emergency Care
If you’re experiencing a life-threatening emergency, dial 9-1-1 immediately or go to your nearest ER. Emergencies happen when you least expect them,… Learn More >
Gastroenterology
Your digestive system involves so many parts of the body – your throat, stomach, intestines, colon, rectum, pancreas, gallbladder and liver. So, whe… Learn More >
Imaging Services
Welcome to Central Maine Medical Center Imaging Services. We take pride in providing our community with technologically advanced, up-to-date imaging s… Learn More >
Integrative Medicine
At Central Maine Healthcare, we’re focused on the whole you — mind, body and spirit. That’s why we specialize in integrative medicine, with a va… Learn More >
Laboratory Services
Central Maine Healthcare offers lab services at convenient locations for tests as part of your routine appointment or for screening of specific condit… Learn More >
Long-Term Care
At Central Maine Healthcare, our long-term care feels exactly like home. We believe in taking complete care of you or your loved one’s physical, med… Learn More >
Neurology
Central Maine Healthcare's neurologists and other doctors are specialists in epilepsy, movement disorders and other neurological disorders. Learn More >
Nutrition Services
Clinical Nutrition A Registered Dietitian (RD) is a “food and nutrition expert” who has completed a Bachelor’s or Master’s degree ... <a class… Learn More >
Orthopedic care
The Orthopedic Institute of Central Maine (OICM) serves the people of Central, Western and Midcoast Maine. OICM works collaboratively with our outpati… Learn More >
Palliative Care
Central Maine Healthcare's palliative care is specialized medical care for people with serious illness. This type of care is focused on providing reli… Learn More >
Pediatrics
CMH’s kid-friendly team members and ambience — as well as our kid-sized examination tables and tools — instantly put children at ease. And we fi… Learn More >
Pharmacy
The CMMC Pharmacy is open to the public and accepts all major insurance plans. As part of your healthcare team, let our pharmacy assist you with manag… Learn More >
Plastic and Reconstructive Surgery
Plastic and reconstructive surgery is a personal choice, and a personal journey. At Central Maine Healthcare, our double-board certified physician a… Learn More >
Primary Care
At Central Maine Healthcare, we make primary care easy and accessible to community members like you. We believe in providing compassionate, quality ca… Learn More >
Pulmonary
At Central Maine Healthcare we provide diagnosis and treatment to our patients as well as education to both the patient and family. Learn More >
Rehabilitation and Therapy
Whether you have suffered an injury at work or on the field, are recovering from surgery or just want to better manage pain, the Orthopedic Institute… Learn More >
Rheumatology
Rheumatology is the study and treatment of rheumatic disorders, a wide range of conditions affecting the joints and connective tissue and typically ca… Learn More >
Sleep Medicine
At Central Maine Healthcare, we know what a peaceful night’s sleep means for your health and life. Our board-certified sleep medicine specialist and… Learn More >
Surgical services
Central Maine Heart and Vascular Institute (CMHVI) brings skilled medical specialists and innovative treatments to the people of central Maine and bey… Learn More >
Telehealth Services
Central Maine Healthcare now offers telehealth services, bringing you the care you need when you’re unable to leave home. Online and telephone visit… Learn More >
Trauma Center
We offer three ERs right in the communities we serve – each staffed 24/7 with board-certified emergency providers and specialty trained team members… Learn More >
Urology
Using the latest and most advanced screening technology allows our medical team to scan with amazing detail. This allows us to more accurately detect… Learn More >
Women’s and children’s health
Women of all ages have unique health and medical needs, which is why Central Maine Healthcare has spent decades building services, treatment, educatio… Learn More >
Wound Care
Central Maine Medical Center’s Comprehensive Wound Center is a centralized location for all aspects of wound care. Our team of specialists provides… Learn More >

Providers & Locations

Services

Patients & Visitors

Find Care