Microsoft word - ctaformfin.doc

DOB (or place label here)_________________________ Emergency Department
Acute Chest Pain Protocol
ED Physician Name:_______________________________________ Telephone Number________________________________________ ED MD Pager#____________________________________________ Referring/Follow-up Physician Name:_____________________________________________________________________________________ Office Number:____________________________________________ Pager#:__________________________________________________
Cardiac CTA:

Coronary and Aortic CTA for ruling CAD and/or Aortic Dissection (estimated radiation dose: less than 5 millisivert) Triple Rule out for ruling out CAD, acute PE, and Aortic Dissection (estimated radiation dose: 10-13 millisivert) Diagnosis/explanation for patient’s symptoms:

3. Acute Aortic Dissection (type A or B) 4. Others:_______________________________________ Inclusion Criteria
Exclusion Criteria
History of documented coronary artery disease, Possible acute coronary syndrome with or without e.g. previous MI, coronary stenting or coronary artery on-going chest pain (must have no dynamic ST bypass surgery, unless ordered in agreement with segment deviation on initial ECG in the ED and Heart rate remains greater than 70 bpm 1 hour after oral administration of 100 mg metoprolol or IV Test may be appropriate for patient with previous calcium channel blocker for those who can not take interpretable or equivocal stress test results (exercise, perfusion, or stress echo) unless patient is scheduled to have coronary angiography in the near future. Inability to cooperate with scan acquisition and/or Contraindication to nitroglycerin (use of Viagra, Cialis, or Levitra within the last 24 (Viagra) – 48 (Cialis and Levitra) hr. Date__________________________Time_____________________ Physician Order:
1. A 20 gauge angiograph and preferably on right antecubital vein. 2. Give 50 mg oral metoprolol if the heart rate is lower than 70 but greater than or equal to 50. No beta blocker if 3. Give 100 mg of oral metoprolol if the heart rate is greater than or equal to 70. 4. Use intravenous calcium channel blocker, e.g. cardizem or verapamil, if patient is a labile asthmatic.
Please complete the form below before ordering a cardiac CTA.

1. Family History of Coronary Artery Disease (MI age <55) 2. HTN (blood pressure > 140/90 or on BP Meds) 3. Dyslipidemia (LDL >100 mg/dL, HDL <40 mg/dL, or Triglyceride > 150 mg/dL) if yes, HDL level _______ and total cholesterol level ________ and on meds recent (quit >1 month but less than 1 year) 6. Known CAD (stenosis ≥ 50% or history of MI, Stent, or CABG) 8. Sedentary life style (sitting or remaining inactive most of the day and exercise less than 1.5 hours a week) 14. History of significant valve disease 18. Chronic kidney disease (Cr < 1.5 or eGFR >50) 19. Any diagnostic study with intravenous contrast (within 48 hours)?



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