The Treadmill Cardiolite Stress Test is a non-invasive test used to evaluate your heart muscle and blood flow
from the coronary arteries. Abnormalities in cardiac rhythm (EKG) and cardiac perfusion can be detected. The
test is done in three parts, and takes 3-4 hours.
Appointment Date:______________________
Arrival Time:________________
Appointment Time:___________


1. Arrive and do paperwork-------------------------------- 2. I.V. and 1st injection------------------------------------- 3. Wait for injection to circulate-------------------------- 4. Resting imaging------------------------------------------ 5. Preparation for Chemical Stress----------------------- 6. Treadmill and recovery---------------------------------- 8. Break------------------------------------------------------ 9. Last imaging---------------------------------------------
The imaging requires that you lay down on your back while a camera scans around your chest area.
The amount of time you exercise on the treadmill depends on your overall conditioning and your age.

• Do not take any beta-blockers 24 hours prior to test (a list of beta-blockers is attached)
• Avoid caffeine at least 24 hours before test (coffee, decaf coffee, chocolate, tea or sodas- caffeine
• Wear comfortable clothing and walking shoes (2 piece clothing, no metal buttons or zippers on shirt • Bring a snack with high fat content (peanut butter crackers, cheese, etc.)
If you have diabetes, please take all your diabetic medications and eat lightly at your usual time.
If you have any questions regarding this test please call.
18370 Burbank Boulevard ● Suite 707 ● Tarzana, CA 91356
(818) 345-5580 ● (818) 774-0458
If you are taking any of the following medications, either in generic or brand-name form, please DO NOT take them for the 24 hours leading up to your procedure, unless specifically requested by your physician. You may resume your regular dosage upon completing the study.
Generic name
Brand name
Generic name
Brand name
Patient Name: Last _______________________ First ___________________ Primary Physician __________________________ Please answer the following questions: 1. Have you ever had a coronary angioplasty (PTCA) or a stent? If yes, was it bypass surgery? ___________ Have you experienced chest pain recently? Was the pain related to physical activity? If yes, for how long? __________________ Do you have family members with heart disease? Do you take medicines for high blood pressure? If yes, what medicines? _______________________________________________ Have you been told that you have high cholesterol? If yes, what medicines do you take? _____________________________________ Have you been told that you have asthma, emphysema or COPD? If yes, what medicines do you take? _____________________________________ If yes, what medicines? _______________________________________________ Have you had any other imaging procedures in the past 3 days? If yes, what procedures? ______________________________________________ What other medicines do you take? _____________________________________________ Signature__________________________________________ Date_____________________ 18370 Burbank Boulevard ● Suite 707 ● Tarzana, CA 91356
(818) 345-5580 ● (818) 774-0458
CCMG - Cardiology Consultants Medical Group of the Valley, Inc.
Information for Exercise Cardiac Imaging

Patient Name: Last __________________ First __________________ Date: _________________
In order to determine the state of blood supply of my heart muscle and as requested by my Doctor, I will
have a heart imaging procedure using maximal exercise on a treadmill as a stimulus for increasing blood
flow to the heart muscle.
The test which I shall undergo will be performed on a treadmill with the amount of effort increasing
gradually. This increase in effort will continue until symptoms such as fatigue, shortness of breath or
chest discomfort appear which would indicate to me to stop. My procedure will involve intravenous
injection of approved radioactivity before stopping exercise, and subsequently a perfusion scan will be
During the performance of the test, a Nurse Practitioner or a Registered Nurse will keep under
surveillance my pulse, blood pressure and electrocardiogram, and will be available to provide immediate
treatment of any complications.
There exists the possibility of certain changes occurring during the test. They include abnormal blood
pressure, fainting, disorders of heartbeat (too rapid, too slow, or ineffective) and in very rare instances
(less than one in 1,000), heart attack. Every effort will be made to minimize the potential risk by careful
observation during testing. Emergency equipment and trained personnel are available to deal with any
unusual situations which may arise.
The study has been explained to me. I have had the opportunity to discuss my questions with the
nuclear medicine staff and I believe that I have obtained a complete explanation regarding the procedure
to be performed, the medications to be administered and any and all potential hazards which are thought
to exist.
Patient Signature: _____________________________ Date: ______________________
18370 Burbank Boulevard ● Suite 707 ● Tarzana, CA 91356
(818) 345-5580 ● (818) 774-0458


An-5013 gtlp in btl applications

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