ONLINE FORMS

Informed Consent for Adenosine Nuclear Stress Testing
After completing this form, please print, sign and bring it with you to your appointment.  

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Your physician has ordered a stress test with nuclear imaging. An infusion of Adenosine will be used to dilate your blood vessels in addition to or instead of walking on a treadmill. By evaluating the function of your heart during administration of this medication, the presence of coronary artery disease can be assessed.

An intravenous line will be inserted into your arm. An initial scan will be performed. You will be attached to a cardiac monitor and an ECG will be taken. Adenosine will be administered and your ECG and blood pressure will be measured and recorded. You will be encouraged to report any symptoms which develop during testing, including chest pain, lightheadedness, shortness of breath and wheezing. A repeat scan will then be performed.

The testing will include performing a radioactive isotope scan in conjunction with the stress test.  A small amount of the isotope will be injected into an arm vein at the appropriate time.  The heart will then be scanned using a special camera.  The amount of radioactive isotope injected is small and according to current scientific knowledge, free of hazard, except during pregnancy.  You understand that if you are or may be pregnant or are breast feeding, you should not undergo this test procedure because of possible adverse effects to the fetus or baby.

Adenosine infusion has been associated with the following transient side effects: nausea, headache, lightheadedness/fainting, weakness, chest pain, shortness of breath, wheezing and irregular heartbeats (too slow or too rapid). For this reason, you will be continuously monitored throughout the infusion, and the infusion will be stopped if there is any evidence that a serious adverse reaction or rhythm abnormality has occurred. Like any stress test, there is also a small risk of heart attack, cardiac arrest or death; the laboratory personnel are trained to administer any emergency care necessary. Effects of Adenosine can be reversed with medication.

Participant’s Statement

I have read this consent form, discussed the procedure and I have been given the opportunity to ask questions, which have been answered to my satisfaction.

I have been fully informed of the above described procedure with its risks and benefits, and I hereby consent to the procedure set forth.

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