Microsoft word - dse consent form - supine bike.doc

You have been booked to have a
Combined DOBUTAMINE and SUPINE BIKE EXERCISE STRESS
ECHO at Hearts West, Subiaco

Purpose of the test
Dobutamine stress echocardiography (DSE) is used to measure how your heart
responds to stress, under medically supervised conditions. The test gives us very
important information, and is usually performed for suspected coronary artery
disease.
The test itself
An echocardiogram is ultrasound of the heart. Images of the heart will be taken at
rest, along with an ECG recording. You will be fitted onto our state-of-the-art supine
bicycle for the duration of the test. You will be secured to the bicycle to allow for
movement of the bicycle later in the test. An intravenous cannula (IV) will be
inserted in your hand or forearm, and you will be connected to an infusion pump
(“drip”) containing Dobutamine. Dobutamine is a drug which stimulates the heart to
pump faster and harder, similar to the effects of exercise but with you resting on the
bed. Continuous ECG recordings will be made until the end of the test, and
dobutamine will be given at increasing doses every three minutes until you have
reached an appropriate level of stress, similar to exercise. At the end of each stage,
your blood pressure is taken, the ECG is printed, further ultrasound images are
taken. When the ultrasound images are taken, the bicycle is tilted on an angle to
allow for the best images possible to be obtained. The test will be stopped if you
develop chest pain or other symptoms, or if the ultrasound shows an abnormality of
your heart in response to stress. Towards the end of the test, the cardiologist will
request that you pedal gently to help increase your heart rate, and to produce a
more physiological result to the test.
Three staff will be present for each test – the cardiologist, sonographer and cardiac
technician.
Symptoms you may feel
Many patients initially describe a tingling in their scalp when we begin the infusion
of dobutamine. As the test progresses, you may feel your heart thumping as if you
had just stopped running. When we stop the infusion, the symptoms usually go
away within about 2 minutes. If you develop chest pain, palpitations, shortness of
breath, dizziness or other symptoms it is important you tell the doctor immediately.

Risks associated with the test
The risks of DSE are approximately the same as sudden unaccustomed exercise.
We carefully control the infusion of dobutamine, and take into account any medical
problems you may have. Despite this, there is the small risk you may develop heart
rhythm abnormalities, and an even smaller risk you may have a heart attack caused
by the dobutamine. We are equipped with all necessary resuscitation facilities, and
all staff involved are trained to deal with any complications that may arise.
Consent to the test
By signing below you are consenting to undergo dobutamine stress
echocardiography, and understand the purpose of the test, the test itself, symptoms
you may feel and any risks associated with the test.
Signature
If you have any questions regarding the test, or would like more information please call our office on 9391 1234. PRIVATE FEE PAYABLE ON THE DAY OF TESTING : $ 675.00
(Medicare
$339.20)

PENSION/HCC CARD HOLDERS INJECTION FEE : $30.00
PAYABLE ON DAY OF TESTING
BETA BLOCKERS ARE TO BE CEASED
PRIOR TO STRESS TESTING
AM APPOINTMENT – last dose 2 days prior
PM APPOINTMENT - last dose am day prior
ANSELOL (atenolol)
ATEHEXAL (atenolol)
BARBLOC (pindolol)
BETALOC (metoprolol)
BICOR (bisoprolol fumarate)
CARDOL (sotalol hydrochloride)
CORBETON (oxprenolol)
DERALIN (propanolol)
DILATREND (carvedilol)
GENRX ATENOLOL (atenolol)
GENRX METOPROLOL (metoprolol)
INDERAL (propanolol)
LOPRESOR (metoprolol)
METOHEXAL (metoprolol)
METOPROLOL-BC (metoprolol)
METROL (metoprolol)
MINAX (metoprolol)
NOTEN (atenolol)
SOTAHEXAL (hexal)
TENORMIN (atenolol)
TENSIG (atenolol)
TOPROL (metoprolol)
VISKEN (pindolol)

Source: http://www.heartswest.com.au/pdfs/DSE%20consent%20form%20-%20Supine%20bike.pdf