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Pacific Cardiology

Stress Test/Stress Echo Consent Form

PROCEDURE

Your doctor has referred you for a stress test. It will help diagnose narrowed or blocked arteries in the heart and it is also done to see how your heart beat (or pacemaker) responds to exercise.

Testing consists of walking on a treadmill and the speed and gradient of the treadmill will be increased every three minutes. The test is eventually stopped if and when you develop symptoms such as fatigue, breathlessness, tired legs, chest pain or other symptoms.

RISKS OF THIS PROCEDURE

Serious potential complications include the possibility of a major disturbance of heart rhythm requiring resuscitation, the development of heart failure or prolonged angina (heart pain), or the development of a heart attack. The risk of one of these occurring is approximately 2 or 3 in 10,000 tests. Unfortunately, there is also a very small risk of death occurring as a result of an exercise test. The chance of this in the average patient is approximately 1 in 10,000 although the risks both of complications and of death may be higher in patients who are already known to have severe coronary disease. There is a small risk of muscle or joint injury.

Throughout the test a Cardiologist/Doctor is present & the patient’s pulse, blood pressure & electrocardiogram are monitored. Emergency equipment and trained personnel are available with any complications that may arise.

CONSENT

The out of pocket fee is a stress echocardiogram is $100.00

Before proceeding with the test, your doctor needs your signed consent. Please feel free to ask any questions you have about the test and about the risks.

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 at the Pacific Cardiology Centre.