CT Coronary Angiogram and IV Contrast Consent / Questionnaire

The following form is a consent for two parts of your CT Coronary angiogram scan.

1. Cardiac premedication - to help slow down faster heart rates and enlarge the blood vessels. These effects allow for a clearer image of your heart and it's arteries.

2. CT Contrast injection - to be able to see your blood vessels for diagnosis.

Please read each section carefully and provide your consent for each of these parts. Following the consent, there is an important screening questionnaire that also needs to be completed prior to your appointment.

There will be an opportunity to discuss this further with the clinical staff before commencing with your examination. Any further questions will be readily answered and you can change your consent preference before the scan.

Your doctor has requested us to perform a CT scan to investigate your heart and its blood vessels. To achieve clear and still images, the heart ideally should be beating at a slow and steady rate (<60bpm). A normal heart rate can vary between 55-100 bpm, so in order to achieve a reliable heart rate of <60 bpm, medication is normally given before the scan to lower the heart rate to the target range. The medications commonly given are known as beta blockers (Metoprolol) and HCN channel blockers (Ivabradine).

Metoprolol and/or Ivabradine:The medication is usually given in a tablet form, which normally takes 1 - 1.5 hrs to take effect. Occasionally, an injection form of the medication is also given. The medication will lower your heart rate as well as your blood pressure temporarily. The effects of the medication will last for a few hours, where it will slowly wear off and you should return to your normal heart rate and blood pressure.

It is common to experience some mild dizziness, light-headedness and tiredness after you are given the medication, especially if it is your first time using it. Therefore, it is important that you have organised a driver to take you home after the examination, as it may not be safe to drive or operate machinery for a few hours.

The amount of medication you will be given will depend on your initial heart rate, and your medical history factors. If you have a history of moderate to severe asthma or obstructive lung conditions, you will most likely be given Ivabradine only. Metoprolol can increase the chances and severity of an asthma attack.

Nitrolingual Spray: A medication called Nitrolingual Spray (GTN) will also be sprayed under your tongue just before the scan. This medication will open up the blood vessels of the heart for better diagnosis. The spray can give you a headache afterwards, but the effects of the spray only last for approx 20-30 mins before wearing off. Your blood pressure may decrease temporarily after having the spray.

You will be closely monitored during the exam. Adverse or allergic reactions are very rare, but can occur. These can include very low blood pressure, low heart rate, severe dizziness and fatigue, fainting and loss of consciousness, breathing difficulties, asthma, shock, and circulatory disturbance. Signs of an allergic reaction can be sneezing, itchy rash/hives, tingling of the lips, swelling of the face, lips, tongue or throat.

IV Contrast media injection:

• This examination also requires an intravenous injection of an iodine-based contrast medium (x-ray dye). This allows your heart's blood vessels to be seen, in a relatively safe manner.

• The injection is often associated with a warm feeling around throughout the face and body which lasts for 1 minute.

• In rare cases (1 in 1,000 injections), a mild allergic reaction such as rash or sneezing may occur.

• Even more rarely (1 in 180,000), a more severe reaction can occur. This can include asthma, shock, and circulatory disturbance. Severe life- threatening reactions up to and including death have occurred but are extremely rare.

Click NEXT: Proceed to IV Contrast and Premedication Questionnaire

• Please arrive 1 hour prior to your appointment time, as there will be other medical and consent forms that you will need to complete. 

• You may also be given some medication in preparation for your cardiac scan, which will need time to take effect.