© The State of Queensland (Queensland Health), 2011

Permission to reproduce should be sought from [email protected]

(Affix identification label here)

URN:

Family name:

Coronary Angiogram and/or Given name(s):

Angioplasty and Stenting Address:

Date of birth: Sex: M F I

Facility: ........................................................................................................................................

A. Interpreter / cultural needs There are risks and complications with this procedure.
They include but are not limited to the following.
An Interpreter Service is required? Yes No
Common risks and complications (more than 5%)
If Yes, is a qualified Interpreter present? Yes No include:
A Cultural Support Person is required? Yes No  Minor bruising at the puncture site.
If Yes, is a Cultural Support Person present? Yes No  The coronary artery can become narrowed or
blocked again. Many factors can influence this
B. Condition and treatment and your doctor will discuss these with you.
The doctor has explained that you have the following  Loss of pulse in the arm after a radial artery (arm)
condition: (Doctor to document in patient’s own words) procedure.
 Major bruising or swelling at the puncture site.
...........................................................................................................................................................................
Uncommon risks and complications (1- 5%)
........................................................................................................................................................................... include:
This condition requires the following procedure.  Abnormal heart rhythm that continues for a long
(Doctor to document - include site and/or side where time. This may need an electric shock to correct.
DO NOT WRITE IN THIS BINDING MARGIN

relevant to the procedure)  A heart attack.

...........................................................................................................................................................................  Surgical repair of the groin/arm puncture site or
blood vessel.
...........................................................................................................................................................................
Rare risks and complications (less than 1%)
The following will be performed: include:
After an injection of local anaesthetic, a fine tube  The stent may suddenly close within the first
(catheter) is put into the artery in the groin or arm. The month. This can cause angina or heart attack. It
tube is carefully passed into the coronary arteries. A may be treated with another angioplasty or with
series of pictures are taken using x-rays and x-ray surgery.

PROCEDURAL CONSENT FORM

dye. If any narrowing or blockages are found, then a
 Emergency heart surgery due to complications
tube with a tiny wire is passed down the affected
with the procedure.
artery so that a sausage shaped balloon can be
passed over it and into the part that is narrowed or  A reaction to the medications given to prevent
blocked. blood clotting.
To open up the artery, the balloon is blown up with  Minor reaction to the x-ray dye such as hives.
fluid, which then presses against the plaque, pushing  Loss of kidney function due to the side effects of
it out of the way. the x-ray dye.
Most of the time, one or more stents may be placed in  A stroke. This can cause long term disability.
the artery to help keep the artery open. A stent is a  An allergic reaction to the x-ray dye.
metal tube or spring coil which is passed into the
 A higher lifetime risk of cancer from x-ray
diseased part of the artery using a balloon. The
balloon is removed once the stent is in place. exposure.
 Rupture of a blood vessel requiring surgical repair
The stent stays in for life. After the procedure, you will
be given some drugs, which reduce your risk of blood and blood transfusion.
clotting and the stent blocking.  Skin injury from radiation, causing reddening of
At the end of the procedure the artery may be closed the skin.
with a special plug to stop the bleeding.  Death as a result of this procedure is rare.
v2.00 – 02/2011

C. Risks of coronary angiogram and/or If you are having angioplasty and stenting as
angioplasty and stenting treatment for a heart attack, the risk of poor outcomes
In recommending this procedure your doctor has may be higher than the risks above and depend on
balanced the benefits and risks of the procedure the severity of the heart attack.
against the benefits and risks of not proceeding. Your
doctor believes there is a net benefit to you going
ahead. This is a very complicated assessment. The
SW9018

risks are higher if you are having the procedure for a

heart attack.

Page 1 of 3 Continues over page ►►►

 (Affix identification label here)

URN:

Family name:

Coronary Angiogram and/or Given name(s):

Angioplasty and Stenting Address:

Date of birth: Sex: M F I

Facility: ........................................................................................................................................

D. Significant risks and procedure options

(Doctor to document in space provided. Continue in
Medical Record if necessary.)
- This consent document continues on page 3 -
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DO NOT WRITE IN THIS BINDING MARGIN

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E. Risks of not having this procedure

(Doctor to document in space provided. Continue in
Medical Record if necessary.)
............................................................................................................................................................................

............................................................................................................................................................................

............................................................................................................................................................................

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F. Anaesthetic
This procedure may require an anaesthetic. (Doctor to
document type of anaesthetic discussed)
............................................................................................................................................................................

............................................................................................................................................................................

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02/2011 – v2.00

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Page 2 of 3 Continues over page ►►►

 © The State of Queensland (Queensland Health), 2011
Permission to reproduce should be sought from [email protected]
(Affix identification label here)

URN:

Family name:

Coronary Angiogram and/or Given name(s):

Angioplasty and Stenting Address:

Date of birth: Sex: M F I

Facility: ..............................................................................................................................................

G. Patient consent Patients who lack capacity to provide consent

I acknowledge that the doctor has explained; Consent must be obtained from a substitute decision
 my medical condition and the proposed procedure, maker/s in the order below.
including additional treatment if the doctor finds Does the patient have an Advance Health Directive
something unexpected. I understand the risks, (AHD)?
including the risks that are specific to me. Yes Location of the original or certified copy of the
 the anaesthetic required for this procedure. I AHD:
understand the risks, including the risks that are ....................................................................................................................................
specific to me.
 other relevant procedure options and their No Name of Substitute
Decision Maker/s: ..................................................................................
associated risks.
 my prognosis and the risks of not having the Signature: ........................................................................................................
procedure. Relationship to patient: ...................................................................
 that no guarantee has been made that the
procedure will improve my condition even though it Date: .......................................... PH No: ..................................................
DO NOT WRITE IN THIS BINDING MARGIN

has been carried out with due professional care. Source of decision making authority (tick
one):
 the procedure may include a blood transfusion.
Tribunal-appointed Guardian
 tissues and blood may be removed and could be
Attorney/s for health matters under
used for diagnosis or management of my condition, Enduring Power of Attorney or AHD
stored and disposed of sensitively by the hospital.
Statutory Health Attorney
 if immediate life-threatening events happen during
If none of these, the Adult Guardian has
the procedure, they will be treated based on my provided consent. Ph 1300 QLD OAG
discussions with the doctor or my Acute (753 624)
Resuscitation Plan.
 a doctor other than the Consultant may conduct
the procedure. I understand this could be a doctor H. Doctor/delegate statement
undergoing further training. I have explained to the patient all the above points
I have been given the following Patient under the Patient Consent section (G) and I am of
Information Sheet/s: the opinion that the patient/substitute decision-
Local Anaesthetic and Sedation for Your maker has understood the information.
Procedure Name of
Doctor/delegate: ..........................................................................................................................
Coronary Angiogram and/or Angioplasty
and Stenting Designation: ....................................................................................................................................

 I was able to ask questions and raise concerns Signature: ..........................................................................................................................................

with the doctor about my condition, the proposed
procedure and its risks, and my treatment options. Date: ......................................................................................................................................................
My questions and concerns have been discussed
and answered to my satisfaction. I. Interpreter’s statement
 I understand I have the right to change my mind at I have given a sight translation in
any time, including after I have signed this form
but, preferably following a discussion with my ....................................................................................................................................................................

doctor. (state the patient’s language here) of the consent

 I understand that image/s or video footage may be form and assisted in the provision of any verbal and
recorded as part of and during my procedure and written information given to the patient/parent or
that these image/s or video/s will assist the doctor guardian/substitute decision-maker by the doctor.
to provide appropriate treatment. Name of
Interpreter: ........................................................................................................................................
On the basis of the above statements,
I request to have the procedure Signature: ..........................................................................................................................................
02/2011 – v2.00

Name of Patient: ......................................................................................................................... Date: ......................................................................................................................................................

Signature: ..........................................................................................................................................

Date:......................................................................................................................................................

Page 3 of 3
 © The State of Queensland (Queensland Health), 2011
Permission to reproduce should be sought from [email protected]
Consent Information - Patient Copy
Coronary Angiogram and/or Angioplasty and Stenting

1. What is a coronary angiogram? The balloon

An Angiogram is used to show any narrowing or In some people,
blockage of your coronary arteries  the coronary artery may be split or damaged; OR
 the artery may become narrowed again as the
2. What is angioplasty and stenting? balloon goes down; OR
Angioplasty and stenting is often used instead of  the artery may become blocked again.
surgery to treat narrowed or blocked coronary arteries. Most of the time, one or more stents may be placed in
You may have one or both of the following the artery to help keep the artery open. A stent is a
procedures. metal tube or spring coil. This is passed into the
diseased part of your artery using a balloon. The
A needle with a tube connected to it will be put in your
balloon is removed once the stent is in place.
arm. This is called an intravenous line or IV.
The stent stays in for life. After the procedure, you will
After an injection of local anaesthetic, a fine tube
be given drugs which reduce your risk of blood clotting
(catheter) is put into the artery in your groin or arm.
and the stent blocking.
The tube is carefully passed into the coronary arteries.
A series of pictures are taken using x-rays and x-ray While the catheter is in the artery, a number of
dye. additional mechanical devices may be used to
complete the procedure. These include pressure
If any narrowing or blockages are found then a tube
wires and an Intravascular Ultrasound (IVUS).
with a tiny wire is passed down the affected artery so
that a sausage shaped balloon can be passed over it If the heart becomes unstable during the procedure,
and into the part that is narrowed or blocked. an additional balloon device to stabilise the heart may
be required. This is called an intracardiac balloon
To open up the artery, the balloon is blown up with
pump.
fluid, which then presses against the plaque, pushing
it out of the way. At the end of the procedure the artery may be closed
with a special plug to stop the bleeding. Your
Cardiologist will discuss this with you.
Medication such as Clopidogrel (Plavix or Iscover) is
used for up to four weeks and sometimes longer. A
small daily dose of Aspirin may need to be taken for
the rest of your life.

3. My anaesthetic
This procedure will require an anaesthetic.
See Local Anaesthetic and Sedation for Your
Procedure information sheet for information about
the anaesthetic and the risks involved. If you have any
concerns, discuss these with your doctor.
If you have not been given an information sheet,
please ask for one.
4. What are the risks of this specific
procedure?
There are risks and complications with this procedure.
They include but are not limited to the following.
Common risks and complications (more than 5%)
include:
 Minor bruising at the puncture site.
 The coronary artery can become narrowed or
blocked again. Many factors can influence this
and your doctor will discuss these with you.
 Loss of pulse in the arm after a radial artery (arm)
procedure.
 Major bruising or swelling at the puncture site.
Fig 1. National Heart, Lung and Blood Institute
02/2011 – v2.00

Page 1 of 2 Continues over page ►►►

 Consent Information - Patient Copy
Coronary Angiogram and/or Angioplasty and Stenting

Uncommon risks and complications (1- 5%) Notes to talk to my doctor about:
include:
............................................................................................................................................................................
 Abnormal heart rhythm that continues for a long
time. This may need an electric shock to correct. ............................................................................................................................................................................

 A heart attack.
............................................................................................................................................................................
 Surgical repair of the groin/arm puncture site or
blood vessel. ............................................................................................................................................................................

Rare risks and complications (less than 1%) ............................................................................................................................................................................

include:
............................................................................................................................................................................
 The stent may suddenly close within the first
month. This can cause angina or heart attack. It ............................................................................................................................................................................
may be treated with another angioplasty or with
............................................................................................................................................................................
surgery.
 Emergency heart surgery due to complications ............................................................................................................................................................................

with the procedure. ............................................................................................................................................................................

 A reaction to the medications given to prevent

blood clotting. ............................................................................................................................................................................

 Minor reaction to the x-ray dye such as hives. ............................................................................................................................................................................

 Loss of kidney function due to the side effects of ............................................................................................................................................................................

the x-ray dye.
 A stroke. This can cause long term disability. ............................................................................................................................................................................

 An allergic reaction to the x-ray dye. ............................................................................................................................................................................

 A higher lifetime risk of cancer from x-ray

............................................................................................................................................................................
exposure.
............................................................................................................................................................................
 Rupture of a blood vessel requiring surgical repair
and blood transfusion. ............................................................................................................................................................................

 Skin injury from radiation, causing reddening of ............................................................................................................................................................................

the skin.
 Death as a result of this procedure is rare. ............................................................................................................................................................................

............................................................................................................................................................................

A coronary angioplasty and possible stenting may ............................................................................................................................................................................

be offered as a treatment option for patients
presenting with heart attacks at some centres. An ............................................................................................................................................................................

alternative treatment is for patients to be given a clot ............................................................................................................................................................................

busting medication.
............................................................................................................................................................................

Outcomes after angioplasty and stenting depend ............................................................................................................................................................................

upon the following:

............................................................................................................................................................................
 age of the patient
 number of arteries supplying blood to the heart ............................................................................................................................................................................

that are diseased ............................................................................................................................................................................

 location of the heart attack

............................................................................................................................................................................
 time taken to present to the hospital following the
heart attack ............................................................................................................................................................................

 degree of blood flow in the blocked artery ............................................................................................................................................................................

 clinical status of the patient. ............................................................................................................................................................................

............................................................................................................................................................................
The less of these risk factors you have the better the
clinical outcomes. If more than one artery is diseased ............................................................................................................................................................................

you may need further procedures after some time.

............................................................................................................................................................................
If you are having angioplasty and stenting as
02/2011 – v2.00

treatment for a heart attack, the risk of a poor outcome ............................................................................................................................................................................

may be higher than the risks above and depend on the

............................................................................................................................................................................
severity of the heart attack.

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