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