Anticoagulation Clinics monitor and manage medication that prevents blood clots. Our medical staff, working in conjunction with your physician, will check your blood test and adjust your dose of warfarin as well as other medicines that may be needed (such as heparin shots or Vitamin K, the antidote to warfarin). The most common medication used to prevent blood clots is called warfarin (also known by the brand names Warfarin® or Jantoven®). “Anti” means against and “coagulant” means clotting. Anticoagulants are often called “blood thinners” because these medicines work on the clotting system in the body to help prevent the formation of blood clots. Anticoagulants are prescribed for a variety of conditions, and regular monitoring and adjustments are often necessary to make sure your condition is appropriately treated. A portion of the patients who are referred to Eranga Cardiology are taking warfarin. This medicine requires a blood test called International Normalized Ratio (INR). This blood test tells your provider how much or how little the medicine is working to prevent blood clots. The INR test usually requires a simple finger stick for blood, and the result is available within seconds. As soon as the results are available, our Anticoagulation Clinic staff will have a face-to-face visit with the patient where the results are discussed. A bleeding risk assessment is conducted, education is provided, and adjustment of medicine dosing, if necessary, is determined. Prior to leaving the office, the patient is provided with written instructions about what was discussed during the visit, and when to return for future testing. Our Anticoagulation Clinic will also:

• Instruct you on the medication dosage and how to take it safely.
• Help you understand how your diet and medicines will affect your medication’s effectiveness.
• Help you be aware of warning signs and other indicators while taking anticoagulants.
• Help you to know what to do if you are ill or injured.
• Allow you to ask questions are welcome at any time, either at appointments or by phone.
• Allow you to include family members and caregivers during appointments so that they may also understand your condition and treatment plan.

The test is performed by a registered cardiac sonographer. A transducer (a small microphone-like device), which emits ultrasound waves is placed in several different areas on the chest. The sound waves are reflected by the heart walls and heart valves back to the transducer to form a digital two-dimensional image of the heart. This test uses the same technology that is used on pregnant women to evaluate the baby and is considered perfectly safe. The test time varies from patient to patient, but an echo usually takes anywhere from 45 to 60 minutes. A large number of images will be taken, and a cardiologist will interpret those images.

Exercise Stress Echocardiogram Testing: The test is performed to:

• Determine how well your heart tolerates activity.
• Evaluate the function of your heart and valves.
• Determine your likelihood of having coronary artery disease.
• Evaluate the effectiveness of your cardiac treatment plan.

The exercise stress echo test involves exercising on a treadmill while you are closely monitored. DO NOT take the following heart medications on the day of your test unless your physician tells you otherwise or if it is needed to treat chest discomfort the day of the test: Beta-blockers (e.g., atenolol (Tenormin), carvedilol (Coreg), metoprolol (Lopressor, Toprol), Propranolol (Inderal)) Isosorbide dinitrate (e.g., Dilatrate®, Isordil®, Sorbitrate®) Isosorbide mononitrate (e.g., Ismo®, Imdur®, Monoket®) Nitroglycerin (e.g., Minitran®, Nitropatches®, Nitrostat®) Your physician may also ask you to stop taking other heart medications on the day of your test. If you have any questions about your medications, ask your physician. If you use an inhaler for your breathing, please bring it to the test. NOTE: Do not discontinue any medication without first talking with your physician. The test will take about an hour. You may eat a light meal as long as you do so more than three hours before your test. Wear comfortable clothes and walking shoes. No perfume, cologne, or moisturizers. No one-piece outfits, such as a dress or overalls. Please contact your physician before having this test if you are pregnant or if you have any other problems that would make it difficult to exercise on a treadmill. Please keep in mind we will need to elevate your heart rate considerably for this test, so be ready to work out.

The exercise stress test involves exercising on a treadmill while you are closely monitored.

The test is used to:

• Determine your likelihood of having coronary artery disease.
• Identify abnormal heart rhythms.
• Evaluate the effectiveness of your cardiac treatment plan.
• Help you develop a safe exercise program.

DO NOT eat or drink anything except water for four hours before the test. Avoid all products that contain caffeine for 24 hours before the test. In general, caffeine is found in coffee, tea, colas, and other soft drinks, most chocolate products, as caffeine will interfere with the results of the test. Also avoid decaffeinated or caffeine-free products for 24 hours before the test, as these products contain trace amounts of caffeine.

DO NOT SMOKE ON THE DAY OF THE TEST, as nicotine will interfere with the results of your test.

DO NOT take the following heart medications on the day of your test unless your physician tells you otherwise or if it is needed to treat chest discomfort the day of the test:

Isosorbide dinitrate (for example Dilatrate®, Isordil®) Isosorbide mononitrate (for example Imdur®, Ismo®, Monoket®) Nitroglycerin (for example Minitran®, Nitropatches®, Nitrostat®)

Your physician may also ask you to stop taking other heart medications on the day of your test. If you have any questions about your medications, ask your physician. If you use an inhaler for your breathing, please bring it to the test.

NOTE: Do not discontinue any medication without first talking with your physician.

If you take insulin to control your blood sugar, ask your physician what amount of your medication you should take on the day of the test. If you take pills to control your blood sugar, do not take your medication until after the test is complete.

Do not take your diabetes medication and skip a meal before the test.

If you own a glucose monitor, bring it with you to check your blood sugar levels before and after your test. If you think your blood sugar is low, tell the lab personnel immediately. Plan to eat and take your diabetes medication following your test.

Please wear comfortable clothes and shoes suitable for walking. Please do not bring valuables.

Your test will take place in the Stress Room. The testing area is supervised by a physician.

First, a stress lab technician will gently rub 10 small areas on your chest and place electrodes (small, flat, sticky patches) on these areas. The electrodes are attached to an electrocardiograph (EKG) monitor that charts your heart’s electrical activity during the test. Before you start exercising, the technician will perform a resting EKG, measure your resting heart rate and take your blood pressure. You will exercise on a treadmill. The lab personnel will ask you to start exercising and will gradually increase the intensity of exercise. You will be asked to continue exercising until you are exhausted. At regular intervals, the lab personnel will ask how you are feeling. Please tell them if you feel chest, arm, or jaw pain or discomfort; shortness of breath, dizziness, lightheaded, or if you have any other unusual symptoms. The lab personnel will watch for any changes on the EKG monitor that suggest the test should be stopped. After the test, you will walk slowly for a few minutes to cool down. Your heart rate, blood pressure, and EKG will continue to be monitored until the levels are returning to normal.

A pharmacological nuclear stress test is a diagnostic test used to evaluate blood flow to the heart. During the test, a small amount of radioactive tracer is injected into a vein. A special camera, called a gamma camera, detects the radiation released by the tracer to produce computer images of the heart. Combined with medication, the test can help determine if there is adequate blood flow to the heart during activity versus at rest. The medication does not increase your heart rate. The medication dilates blood vessels leading into the heart, increasing blood flow, therefore simulating exercise for patients unable to exercise on a treadmill. DO NOT eat or drink anything except water for four hours before the test.

Avoid all products that contain caffeine for 24 hours before the test. In general, caffeine is found in coffee, tea, colas, and other soft drinks, most chocolate products, as caffeine will interfere with the results of the test. Also avoid decaffeinated or caffeine-free products for 24 hours before the test, as these products contain trace amounts of caffeine.

DO NOT SMOKE ON THE DAY OF THE TEST, as nicotine will interfere with the results of your test. Please bring a copy of all of your medications, including over-the-counter medications and supplements that you routinely take, to the test appointment. Please follow these guidelines about taking your medications on the day of the test. Medications with caffeine: Do not take any over-the-counter medication that contains caffeine for 24 hours before the test. Ask your physician, pharmacist, or nurse if you have questions about other medications that may contain caffeine. If you have asthma, please plan to bring your asthma inhaler medication to the test. If you take insulin to control your blood sugar, ask your physician how much insulin you should take on the day of the test. If you take pills to control your blood sugar, do not take your medication until after the test is complete. Bring your diabetes medications with you so you can take it when the test is complete. Do not take your diabetes medication and skip a meal before the test. If you own a glucose monitor, bring it with you to check your blood sugar levels before and after your test. If you think your blood sugar is low, tell the lab personnel immediately. Plan to eat and take your blood sugar medication following your test. If you take heart medications: Do not take the following heart medications on the day of the test unless your physician tells you otherwise, or unless it is needed to treat chest discomfort the day of the test: Beta Blockers – Beta blockers block the effect of adrenaline on the cardiovascular system, slow the heart rate, and reduce stress on the heart and the arteries.

• Acebutolol – Sectral
• Atenolol – Tenormin
• Betaxolol – Kerlone
• Bisoprolol – Zebeta, also sold as Ziac
• Carteolol – Cartrol
• Carvedilol – Coreg
• Labetalol – Normodyne, also sold as Trandate
• Metoprolol – Lopressor, also sold as Toprol
• Nadolol – Corgard
• Penbutolol – Levatol
• Propranolol – Inderal, Inderal LA
• Timolol – Blocadre

• Calcium Channel Blockers – Calcium channel blockers can reduce blood pressure by dilating the arteries and, in some cases, reducing the force of the heart’s contractions
• Amlopdipine – Norvasc, also sold as Caduet and Lotrel
• Diltiazem – Cardizem, also sold as Dilacor Tiazac
• Felopdipine – Plendil
• Isradipine – DynaCirc
• Nicardipine – Cardene
• Nifedipine – Procardia XL, also sold as Adalat
• Nisoldipine – Sular
• Verapamil hydrochloride – Isoptin, also sold as Calan. Verelan and Covera

Your physician may also ask you to stop taking other heart medications on the day of your test. If you have any questions about your medications, ask your physician. Do not discontinue any medication without first talking with your physician. What to expect during the test A nuclear medicine technologist will place an IV into a vein in your arm or hand and inject a small amount of radioactive tracer. The tracer is not a dye or contrast. After the tracer is injected, you will wait about 30 minutes before the first set of “resting” images are taken. Then you will be asked to lie very still under the gamma camera with both arms above your head for about 15 to 20 minutes. The camera will record images that show blood flow through your heart at rest. Next, a technician will place electrodes on your chest to monitor your EKG. Before the medication is infused into the IV, the technician will discuss the possible side effects so you will know what to expect. If you are able, you will slowly walk on a treadmill during the administration of the medication. Otherwise, you will lie on the exam table for the duration of the test. Your heart rate, EKG, and blood pressure will be monitored throughout the test. After waiting about 30 minutes, you will be asked to again lie very still under the camera with both arms over your head for about 15-20 minutes. The camera will record images that show blood flow through your heart during cardiac stress/activity. These images will be compared to the first set.

Imaging using ultrasound and listening with Doppler to evaluate the flow of blood in the arteries of the neck which feed the brain. This checks for narrowing or closures. * NO PREPARATION REQUIRED. TAKES ABOUT 45 MINUTES. * Best not to wear turtleneck-type clothing.

A multigated acquisition scan (also called equilibrium radionuclide angiogram or blood pool scan) is a noninvasive diagnostic test used to evaluate the pumping function of the ventricles (lower chambers of the heart). During the test, a small amount of radioactive tracer is injected into a vein. A special camera, called a gamma camera, detects the radiation released by the tracer to produce computer-generated movie images of the beating heart. The MUGA scan is a highly accurate test used to determine the heart’s pumping function. There is no special preparation required for this test; there are no medication or food restrictions. Wear comfortable clothes that can be easily removed, as you may be asked to wear a hospital gown during the test.

Taking blood pressures at each ankle and arm, (may or may not include just a little walking on a treadmill) listening with Doppler, and taking images of the arteries in the legs with ultrasound. This evaluates the flow of blood in the arteries of the legs for narrowings or closures. * NO PREPARATION REQUIRED. TAKES ABOUT 45 MINUTES. * Best to wear clothes easy to put on and take off with comfortable shoes.

Imaging with ultrasound of the veins in the legs to check for blood clots. * NO PREPARATION REQUIRED. TAKES ABOUT 30 MINUTES. * Wear easily removable pants/skirts and comfortable shoes.

Imaging with ultrasound of the veins in the legs to check for blood clots. * NO PREPARATION REQUIRED. TAKES ABOUT 30 MINUTES. * Wear easily removable pants/skirts and comfortable shoes.

Using blood pressure cuffs on both arms, listening with Doppler, and imaging with ultrasound the arteries in the arms are evaluated for narrowing or closures. * NO PREPARATION REQUIRED. TAKES ABOUT 30 MINUTES. * Wear a shirt that is easy to get on and off.

Imaging using ultrasound to evaluate the veins in the neck and arms to check for blood clots. * NO PREPARATION REQUIRED. TAKES ABOUT 30 MINUTES. *