nuclear stress instructions and consent form - Heart & Vein Center

EXERCISE STRESS TEST:
Patient:
• Takes 3 hours (assuming there are no unforeseen delays)
• Temporary IV is started, enabling the 1 st dose of Cardiolite® to be injected
• Once injected, you will wait for the Cardiolite® to reach your heart (30 minutes)
• Next, images of your heart (at rest) will be taken by the nuclear camera (15 minutes)
• After the 1 st nuclear scan, you will exercise on a treadmill while monitored by an EKG
• When you’ve reached your target heart rate, a 2 nd dose of Cardiolite® is injected
• Once the 2 nd dose of Cardiolite® has been injected, you will exercise for 1 additional
minute and then wait for the Cardiolite® to reach your heart (25 minutes)
• Lastly, a 2 nd scan of your heart (after stress) will be done by the nuclear camera (15 minutes)
PHARMACOLOGICAL STRESS TEST:
• Takes 3 hours (assuming there are no unforeseen delays)
• Temporary IV is started, enabling the 1 st dose of Cardiolite® to be injected
• Once injected, you will wait for the Cardiolite® to reach your heart (30 minutes)
• Next, images of your heart (at rest) will be taken by the nuclear camera (15 minutes)
• After the 1 st scan, you will undergo a Lexiscan® infusion while monitored by an EKG
• Immediately after the infusion, a 2 nd dose of Cardiolite® is injected
• After 2 nd dose of Cardiolite® is injected, it will be given time to circulate in your system (25 minutes)
• Lastly, a 2 nd scan of your heart (after stress) will be done by the nuclear camera (15 minutes)
PATIENT CONSENT
(Please read and sign)
There exists the possibility of certain events occurring during any form of stress testing. These events
include abnormal blood pressure, fainting, abnormal heart rate (too fast, too slow, or ineffective) and rare
instances of heart attack. A preliminary examination and close observations during the test allow us to
minimize these risks as much as possible. Emergency equipment and trained personnel are present at all
times during your test, to deal with these situations, should they arise.
The information that is obtained from your stress test results is privileged and confidential and will not be
released or revealed to any person (except your treating physicians) without your written consent. The
information obtained may be used, however, without your actual identification being revealed, for a statistical
or scientific purpose.
Date of Appointment: Time:
I have read and understand the previous explanations of the test preparations, risks, and
confidentiality pertaining to my scheduled stress test.
-AND-
I am aware that there is a $250.00 charge if I fail to cancel or reschedule my appointment at least 48
hours prior to my scheduled appointment.
Patient Signature Date