IMPORTANT INFORMATION REGARDING YOUR NUCLEAR STRESS TEST

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Kory Price
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Name: Day One Appointment Day Two Appointment Test Results Appointment Time: Time: Time: IMPORTANT INFORMATION REGARDING YOUR NUCLEAR STRESS TEST A Stress test sometimes also called a treadmill test,

1 Name: Day One Appointment Day Two Appointment Test Results Appointment Time: Time: Time: IMPORTANT INFORMATION REGARDING YOUR NUCLEAR STRESS TEST A Stress test sometimes also called a treadmill test, helps your health care provider know how well your heart works during physical activity. As you exert yourself during the test your body requires more oxygen and energy. In order to meet that demand the heart must beat faster and harder. Your doctor has ordered a NUCLEAR STRESS TEST which combines the traditional treadmill test and monitoring with an imaging series that can look and measure the blood flow to the heart. The ultimate goal of the test is to see if your heart receives enough blood from its own arteries when the heart is required to work harder. Why are stress tests commonly ordered? 1. To determine whether the symptoms you are having are due to any heart condition such symptoms may be chest or arm pain, palpitations, shortness of breath, dizziness, excessive tiredness or swelling of the feet or ankles. 2. To visualize if a patient without symptoms has silent heart disease such as blockages or hardening of the arteries. 3. To determine the risk of future heart problems in patients with known heart disease. 4. To determine if the test can recreate an unusual feeling, sensation or heart rhythm. PREPARATION FOR THE TEST ( your test will take 3-4 hours) Do not take any BETA BLOCKERS OR NITRATES 12 hours prior to your appointment. (See the attached medication list). You may take your other medications with water. Do not eat or drink any foods containing CAFFEINE for 24 hours. (Such as coffee, tea, chocolate or certain migraine medications). This also includes all decaffeinated products. Do not EAT, DRINK or SMOKE at least 4 hours before your appointment. Water will be given to you upon your arrival. You may bring snacks and/or drinks with you to take after the test. Arrive in comfortable clothes with laced tennis shoes. Tank tops are highly recommended. Females should wear a good supportive bra. No girdles, body suits or dresses. If you have diabetes, please take your medications only if there will be time to eat prior to the test. You may bring a snack and drink that may be consumed following the test. If you have been prescribed an inhaler for any lung condition, please bring your inhaler to the test.

2 What will happen during the test? Please allow 3-4 hours for the entire nuclear stress test. The nuclear stress test allows your physician to view images of your heart while at rest and at stress. To create those image you will receive two injections of a small amount of radioactive material, Cardiolite. The level of radioactivity necessary is extremely low and safe. There are no side effects and the benefits far outweigh the risks. To minimize the number of needle sticks required for the test an intravenous line (IV) will be placed on your arm or hand prior to your first Cardiolite injection and will be used later for your second Cardiolite injection. Following the first injection you will be asked to drink water. You will then lie on a table and an initial or resting scan will be performed by the gamma camera. Pillows will be placed under your head and legs for comfort. You will be asked to place your arms over your head. The gamma camera will be placed over your heart and images will be recorded. This process takes approximately 30 minutes. This portion of the test is called the rest study. After your resting scan our trained staff will place EKG electrodes on your chest that will constantly monitor your heart during the stress study. Your heart will be stressed through exercising on a treadmill. During this portion of the test our staff will constantly monitor you. The actual physical stress portion of the test takes about minutes, however, the preparation takes longer (up to 60 minutes). Before the end of your stress test a second (Cardiolite) injection will be administered. This radiopharmaceutical is absorbed by the heart muscle and can be visualized by the gamma camera in the same manner as the rest study. The imaging portion of your stress test will take another 30 minutes. The exam is conducted in this manner: 1. Injection with imaging of resting scan, approximately 30 minutes. 2. Treadmill stress test with another injection. 3. Stress imaging after treadmill stress test, approximately 30 minutes. Sometimes the test is scheduled over 2 days with the stress portion of the test on day one and the resting portion of the test on day two. What to expect during the stress test: Normal responses during the treadmill stress test include feeling tired, shortness of breath and sweating. You should inform our staff or physician if you feel chest, arm or jaw discomfort, severe shortness of breath, extreme tiredness, dizziness, lightheadedness, leg cramps or soreness. The supervising practitioner and staff will stop the test early if it is unsafe for you to continue. What happens after the test: When the test is over you may eat, drink and return to your normal routine. You may resume all of your medications and you may have caffeinated products. The images will be reviewed by Dr. Tummala and Dr. Ahn. A report will be sent to your primary care physician. Dr. Ahn and Dr. Tummala or the Nurse Practitioner will discuss these results with you and explain how the results relate to your health at your follow up appointment. If you have any questions or comments please call the office at (909)

3 LIST OF COMMONLY ORDERED MEDICATIONS Stop taking all Nitrates 12 hours prior to your test. Isosorbide dinitrate (BiDil, Isordil, Sorbitrate, Dilatrate-SR) Isosorbide mononitrate (ISMO, Monoket, Imdur) Nitroglycerin ointment / paste (Nitrol, Nitro-Bid) Nitroglycerin spray (Nitrolingual) Nitroglycerin sublingual (Nitrostat, NitroQuick) Nitroglycerin sustained release (Nitrong, Nitroglyn) Nitroglycerin transdermal (Deponit, Minitran, Nitrodisc, Nitro-Dur, Transderm-Nitro) Nitroglycerin transmucosal (Nitroguard) Stop taking all Beta-Blockers 12 hours prior to your test. Acebutolol ( Sectral ) Metoprolol ( Toprol, Lopressor, LopressorHCT ) Atenolol ( Tenormin, Tenoretic ) Nadolol ( Corgard, Corzide ) Betaxolol ( Kerlone ) Nebivolol ( Bystolic ) Bisoprolol ( Zebeta, Ziac ) Penbutolol ( Levatol ) Carteolol ( Cartrol ) Pindolol ( Visken ) Carvedilol ( Coreg ) Propranolol ( Inderal, Inderide LA ) Esmolol ( Breviloc ) Sotalol ( Betapace ) Labetalol ( Trandate, Normodyne ) Timolol ( Blocadren, Timolide )

4 Nuclear Cardiology Patient Questionnaire NAME TEST DATE Have you ever had a heart attack? Have you ever had an angioplasty? Have you had open heart surgery? No Yes, date and year No Yes, date and year No Yes, date and year Do you have: Hypertension No Yes Diabetes No Yes High Cholesterol No Yes Family history of heart disease Before age 55 No Yes Active smoking No Yes Have ever had a nuclear stress test? No Yes Date / / Do you have chest or other pain/pressure? No Yes (jaw, neck, throat, arm back) Do your symptoms occur at rest? No Yes Do your symptoms occur with exertion? No Yes Are your symptoms relieved with nitroglycerin? No Yes Are your symptoms relieved with rest? No Yes What medications do you currently take? Medication Dose Last taken Do you have asthma? No Yes Have you had caffeine within the past 24 hours? No Yes If yes please indicate what and when

5 Inland Cardiology Pregnancy and/or Breast-Feeding Verification Must be completed by all female patients Patient Name: Birth Date: 1. Are you (check appropriate box): Post-menopausal Pre-menopausal, surgically sterile (e.g. hysterectomy, tubal ligation, etc.) Pre-menopausal, not surgically sterile. If so, are you or do you think you may be pregnant? Yes No Date of your last menstrual period: 2. Have you ever had a mastectomy?. Yes. No Right Left Implant Prosthesis 3. Are you currently breast-feeding: Yes No Patient Signature: Date: If you are of child bearing age then you (the patient) are responsible for verifying with your ordering physician and informing us of your pregnancy status. Your Nuclear Cardiology test will be postponed as needed. If you are pregnant and the test is considered essential by your physicians, you will be referred to a Nuclear Lab better equipped to protect your baby during the test.

6 Inland Cardiology Instructions for Breast-Feeding Patients Patient Name: Date: Your physician has referred you to Inland Cardiology Nuclear Cardiology Laboratory for the following procedure: During this procedure, you will be given a small amount of radioactive material: You have also indicated that you are currently breast-feeding an infant/child. Please follow the instruction indicated below relating to breast-feeding after the administration of the radioactive material. Interrupt breast-feeding for a period of: 24 Hours. Recommended Breast Feeding Interruption Times Radiopharmaceutical Procedure Dose Recommended Breast Feeding Interruption Times 99m Tc Tetrofosmin/MIBI Myocardial Perfusion Studies 35 mci 24 hours after dose is given 99m Tc Myocardial 10 mci 24 hours after dose Tetrofosmin/MIBI Perfusion Studies 201 TI Myocardial Perfusion Studies is given 3-4 mci 2 weeks after dose is given Small quantities of the radioactive material you will be given will be present in your breast milk following the examination. Although failure to interrupt your breast-feeding will not produce any noticeable adverse effects in you infant/child, it is prudent to avoid the unnecessary radiation exposure to your infant/child during the interruption time recommended above. You may continue breast-feeding your infant/child after the interruption recommended above. At that time; your child will not receive any significant radiation exposure as a result of continuing breast-feeding. No interruption of breast-feeding is necessary. Although you are being administered a radioactive material, the radiation exposure to your infant/child will not be significant, even if breast-feeding is continued. Patient Signature: Date: Witness Signature: Date:

7 Name: Day One Appointment Day Two Appointment The scheduled time is reserved for you. The radiopharmaceutical used for the test is calibrated to a certain day and time. If it is not used it will expire in a few hours. For this reason 24 hour notice is required for cancellation so we can adjust the amount of medication we order. If you do not call to cancel and you do not come to your appointment $88.60 for each dose, two doses is customary, will be billed to you for the cost of the medication. Please call us at (909) if you have any questions or need to reschedule. Patient Signature: Date:

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