Your physician has ordered a stress test with nuclear imaging. An infusion of dobutamine will be used to simulate the cardiac response to exercise. 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. Dobutamine will be administered in gradually increasing doses until your heart rate has achieved a sufficient level, you complain of chest discomfort that feels like angina, or the maximum dose has been administered. Repeat ECG’s will be performed during and after infusion. 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.

Dobutamine infusion has been associated with the following side effects: nausea, anxiety, headache, tremor, and palpitations. Dobutamine can also cause abnormal heart rhythms, general brief and minor, but a serious heart rhythm abnormality including cardiac arrest can rarely occur. 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 rhythm abnormality has occurred or is about to occur. 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 dobutamine 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.