Cardio-Diagnostic Test - Home - TotalCardiology...2018/09/09 · Cardio-Diagnostic Test Requisition...
Transcript of Cardio-Diagnostic Test - Home - TotalCardiology...2018/09/09 · Cardio-Diagnostic Test Requisition...
Patient Demographics (please provide Height and Weight)
Height: cm / ft-in Weight: kg / lbs
Referring Information Name:
Specialty:
PRACID:
Cardio-Diagnostics #110, 2891 Sunridge Way NE, Calgary, AB T1Y 7K7 TotalCardiology® and the related logos are registered trademarks of TotalCardiology Inc. and are used under license.
Valvular heart abnormalities
Adult congenital heart diseaseCardiac structure and function
Syncope/Presyncope
TIA/Stroke
Endarterectomy/Carotid stenting
Evaluation of carotid bruits
Copy reports to:
1-Day 2-Day Palpitations Suspected dysrhythmia
Syncope /Presyncope
Pericardial abnormalities
Cardiac source of embolus
Known Atrial fibrillation / or Atrial flutter
ECHO Appt Date & Time:
CAROTID Appt Date & Time:
HOLTER Appt Date & Time:
Provisional Diagnosis /Additional History
Referral Date:
ECHO
CAROTID DOPPLER
HOLTER
You can choose TotalCardiology as your ECG interpreter on your CLS or lab requisition form.
MD signature/ Clinic Name/STAMP
Scan QR code to see
detailed Appropriate Criteria for
Tests
EXERCISE STRESS TESTMYOCARDIAL PERFUSION IMAGING (MPI) STRESS TEST
Assess Myocardial Ischemia/Infarction/Viability/Left Ventricular systolic function
Yes NoHave you asked your patient to hold anti-ischemic medications?
MPI or STRESS TEST Appt Date & Time:
For MPI or Exercise Stress Test please complete the following: (Please refer to the guidelines on the back of this requisition)
Yes NoAsthma?Yes No
Assess for exercise-induced dysrhythmia
Assess exercise capacity/fitness level/ HR & BP response
Abnormal Exercise Stress Test
(No imaging)
Does your patient have:
Exercise Pharmacologic Rest viability only
DyspneaChest pain Other:Is your patient? Asymptomatic Symptomatic
Very Low Low Intermediate High Known CADPretest likelihood of CAD? (based on age, gender, +/-symptoms)
Vascular disease or Risk factors
Global Cardiac Risk stratification OR Pre-op risk assessment for non-cardiac surgery
Family MD Name:
Fax:
Phone:
Last Name:
Phone:
Gender:DOB: mm/dd/yyyy
First Name:
PHN:
To Book an Appointment:
Online: totalcardiology.ca Fax: (403) 571-8658 Phone: (403) 571-8640 Cardio-Diagnostic Test
Requisition
Along with the requested test(s), I would like to book a consultation with the next available cardiologist.
Aug 19, 2015
Pacemaker?
ICD?
Yes No
NoYes Yes NoCABG? Yes NoAngioplasty/Stent?Diabetes?
Age
(years) Gender
Typical
Definite Angina
Atypical
Probable Angina
Non-anginal Chest pain Asymptomatic
30-39 Men Intermediate Intermediate Low Very lowWomen Intermediate Very low Very low Very low
40-49 Men High Intermediate Intermediate LowWomen Intermediate Low Very low Very low
50-59 Men High Intermediate Intermediate LowWomen Intermediate Intermediate Low Very low
60-69 Men High Intermediate Intermediate LowWomen High Intermediate Intermediate Low
(based on age, gender, +/- symptoms: typical angina, atypical angina, nonanginal chest pain, asymptomatic)Guide for assessing pretest likelihood of Coronary Artery Disease
- For men older than 70, with atypical or typical symptoms, assume an estimate of >90%. - For women older than 70, assume an estimate of 61-90% EXCEPT women at high risk AND with typical symptoms then a risk of >90% should be assumed. - If there are resting ECG ST-T changes or Q waves, the likelihood of CAD is higher in each cell of the table.
How do I choose the Right Stress Test for my patient?Choose Wisely* by asking the following: Question 1: Is my patient Asymptomatic OR Symptomatic? Question 2: What is my patient's Pretest Likelihood of Coronary Artery Disease (CAD)?
Question 3: Is my patient able to exercise or not? Question 4: Is the baseline rest ECG Normal or Abnormal? Question 5: Do I want to make a "Diagnosis" of Ischemic Heart Disease (IHD) or determine "Prognosis"?
Consider Exercise Stress Test (NO perfusion imaging): To detect IHD in patients with Symptoms + LOW pretest likelihood of CAD + ABLE to exercise + NORMAL rest ECG To determine prognosis in Asymptomatic or Symptomatic patients who can exercise: Assess adequacy of therapy in known stable CAD Assess exercise capacity Assess HR and BP response to exercise Assess for exercise induced dysrhythmia
Consider MPI Stress Test (stress test with perfusion imaging): To detect IHD in patients with Symptoms + INTERMEDIATE to HIGH pretest likelihood of CAD +ABLE or UNABLE to exercise + NORMAL or ABNORMAL rest ECG To determine prognosis in Asymptomatic or Symptomatic patients who can or cannot exercise: Assess volume/burden of Myocardial Ischemia Assess size of Myocardial Infarction/Viability/Left Ventricular systolic function/Size Assess adequacy of therapy in known stable CAD Assess Global Risk of Cardiac events Pre-operative Risk Stratification
Scan to go to www.tctests.ca
*Scan to go to www.choosingwiselycanada.org
From N
Eng J M
ed, Diam
ond G.A
. and Forrester J.S.,
Analysis of P
robability as an Aid in the C
linical Diagnosis
of Coronary-A
rtery Disease, 300: 1350-1358,
Copyright ©
1979 Massachusetts M
edical Society.
Reprinted w
ith permission from
Massachusetts M
edical Society.
Aug 19, 2015