Virginia Radiology Associates 8401 Dorsey Circle Suite 101 Manassas, VA 20110_____________ Ph: (703) 396-7669 Fax: (703) 361-2687 PRIOR TO YOUR EXAM ----------------------
IF YOU HAVE EVER HAD HISTORY OF CARDIAC BYPASS OR STENT INSERTION ANY OF THE FOLLOWING WITHIN THE PAST YEAR: STRESS TEST CHOLESTEROL BLOOD WORK CARDIAC CATHETERIZATION BRING OR FAX ANY OF THE ABOVE TO OUR OFFICE Before the Study -------------------------------------------- Please follow these instructions in preparation for your exam:
x Do not consume any form of caffeine 12 hours prior to the study.
x Do not eat any solid food 4 hours prior to the study. x Drink two 8 ounce glasses of water 1 hour before the study
x Take 100mg of Metoprolol (Lopressor) orally 1 hour prior to the study.
During the Study ----------------------------------------------
x You will have contrast (x-ray dye) for this study. A needle will be placed in your arm,
x You will have a 3-lead EKG attached to monitor your heart rate.
x You will have oxygen, via nasal canula (oxygen tube under your nose), to help your
x You will receive one squirt of nitroglycerine during your exam (under your tongue).
After the Study -----------------------------------------------------
x The radiologist will evaluate your study and issue a report to your doctor. You may
request to go over your study with the radiologist at a future time.
x Be sure to eat and drink plenty of fluids after the study.
Lopressor Pronounced: low-PRESS-or Generic name: Metoprolol tartrate *Warning: Please keep this medication out of the reach of children. Store Lopressor at room temperature in a tightly closed container, away from light. Protect from moisture. Lopressor, a type of medication known as a beta blocker. Beta blockers decrease the force and rate of heart contractions. It is essential for your Coronary CTA exam to have a heart rate of 60 or preferably slightly lower. More common side effects of Lopressor may include, but not limited to: Itching, rash, dizziness, tiredness, diarrhea, slow heart rate and shortness of breath. ***If you have any of these symptoms prior to your appointment please contact your doctor or seek immediate medical treatment. Who should NOT take this medication? If you have a slow heartbeat, certain heart irregularities, low blood pressure, inadequate output from your heart or heart failure, you should NOT take this medication. If you suffer from asthma, seasonal allergies or other bronchial conditions, or live disease, this medication should be used with caution. If you are currently taking a beta blocker or high blood pressure medication, PLEASE check with your doctor prior to taking Lopressor. Any other questions about the Coronary CTA exam please contact our office at (703) 396-7669
Virginia Radiology Associates Coronary CTA Database
If you have chest pain:
If you go up a hill on 10 separate occasions, on how many of these do you
If you have the pain 10 times in a row, how many happen when you are
resting or sitting quietly?. ________(0-10)
How long does the pain usually last in minutes? ««««««««««
Risk Factors Have you ever had blockages or
partial blockages of the arteries in the
heart? Have you had other heart disease?
If no longer smoking, time since quit _______years _______months
in arteries other than the heart? If female:
What age did they stop ________ Hormone replacement ___________
VRA Coronary CT Arteriography Database
Do you exercise enough to cause a fast heart beat for at
least 20 minutes, at least twice a week?
Weight ________lbs Height _____ft ____in
Medications
or similar medicine to lower ________ yrs
cholesterol or triglycerides ? ________ months
Recent Tests Location
Stress Test in past 12 months or scheduled?
Cardiac Catheterization in past 12 months or scheduled?
Cholesterol test in past 12 months or scheduled?
History of allergies:
Previous Surgery:
Other Conditions:
Signed consent ____________________________________________________________
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Virginia Radiology Associates 
Virginia Radiology Associates Coronary CTA Database