Consent

PROCEDURE:
Your doctor has referred you for an exercise stress test/exercise stress echocardiogram. The stress test will evaluate your heart and vascular system’s response to exercise. It will help diagnose blocked arteries in the heart (coronary artery disease), assess abnormal heart beats, evaluate exercise capacity, evaluate heart rate and blood pressure response to exercise. You will be connected to an electrocardiogram (ECG), which records your heart beat, and a blood pressure monitor. Your heart will be exercised or ‘stressed’ by walking on a treadmill. The speed and slope of the treadmill will increase every three minutes. Exercise intensity may be high. The test will be stopped if you have significant chest pain, become very tired or very short of breath.

Your heart rate, electrocardiogram and blood pressure will be monitored during and after the test. An echocardiogram may be administered as well to provide additional diagnostic information. If you feel unwell or experience any symptoms you should tell the doctor or technician immediately.

RISKS OF THIS PROCEDURE
The risks of this test are small. They include chest pain, inducing an irregular heartbeat and fainting/feeling faint. The risk of a heart attack or death is very small (roughly 1 in 2,500 patients and 1 in 10,000 patients respectively). There is a small risk of muscle or joint injury. Emergency equipment and trained personnel will be available to deal with any complications arising from the test.

Ultrasound contrast may also be used for image enhancement.

The contrast is administered by a technologist or nurse using an intravenous (IV) line.

The use of contrast provides a valuable option for improving image quality and aiding with certain diagnoses. The contrast agent is generally very safe. It does not affect the kidneys and does not involve radiation. There are very small risks of an allergic reaction, around 1 in 10,000 patients


Please advise staff if you have any of the following conditions.
• Very recent heart attack (within 2 days).
• Unstable chest pain (angina) not yet settled by medical treatment.
• Heart valve problems causing symptoms.
• Fluid in the lungs that is not controlled by medication and is causing symptoms.
• Recent blood clots in the lungs.
• Current swelling of the heart muscle or the sac containing the heart.
• Recent tearing of the wall of the large artery (aorta).

I have read and fully understood the above information regarding the test procedure and associated risks. I hereby consent to undergoing the procedure of an exercise stress test to be performed.
I also consent to such further treatment measures as may be deemed necessary during the course of the procedure.



Access to Medical records Consent *
I allow my physician @ Noble to access my medical records @ the referring Hospital/facility and/or on Connecting Ontario Clinical Viewer if applicable