The FLOW Toolkit

Reading version. Use the PDF above to record your answers.

Optional. Bring this with you if it helps. Type in the fields or print and write.

Bring if available: your current medication list, home readings, recent test reports, and the name of the clinician or person who referred you.

Why I’m Here Today

What changed? What prompted this visit?

Symptoms or Changes I’ve Noticed

New symptoms, worsening symptoms, or changes in tolerance:

• Chest pressure, pain, or discomfort

• Shortness of breath

• Fatigue or weakness

• Lightheadedness or dizziness

• Palpitations

• Leg swelling or pain

• Less able to walk or exercise than usual

Something else:

What I’m Most Concerned About

Naming the concern can help make the decision clearer.

Questions I Want Answered

The one question I most need answered:

• What might explain my symptoms, and which causes need to be ruled out?

• Which test, if any, would answer the question?

• What does this mean for my short-term and long-term risk?

• What should I do before the next review?

• What would not help right now?

Next Steps We Agreed On

Tests, if any:

Medication changes, if any:

Follow-up timing:

Bring this sheet to your appointment.

Reading version. Use the PDF above to record your answers.

Complete this using your medication list or with your pharmacist. Use one section per medicine. Record missed-dose, sick-day, or procedure instructions only when a clinician or pharmacist has given them to you. Include prescribed medicines, over-the-counter products, vitamins, and supplements. Photocopy these pages if you need more space.

Medicine 1

Medicine, dose, and time:

Why I take it:

Prescriber:

Expected duration or next review, if known:

Missed-dose, sick-day, or procedure instructions I was given:

Questions, side effects, cost, or refill concerns:

Medicine 2

Medicine, dose, and time:

Why I take it:

Prescriber:

Expected duration or next review, if known:

Missed-dose, sick-day, or procedure instructions I was given:

Questions, side effects, cost, or refill concerns:

Medicine 3

Medicine, dose, and time:

Why I take it:

Prescriber:

Expected duration or next review, if known:

Missed-dose, sick-day, or procedure instructions I was given:

Questions, side effects, cost, or refill concerns:

Medicine 4

Medicine, dose, and time:

Why I take it:

Prescriber:

Expected duration or next review, if known:

Missed-dose, sick-day, or procedure instructions I was given:

Questions, side effects, cost, or refill concerns:

Medicine 5

Medicine, dose, and time:

Why I take it:

Prescriber:

Expected duration or next review, if known:

Missed-dose, sick-day, or procedure instructions I was given:

Questions, side effects, cost, or refill concerns:

Medicine 6

Medicine, dose, and time:

Why I take it:

Prescriber:

Expected duration or next review, if known:

Missed-dose, sick-day, or procedure instructions I was given:

Questions, side effects, cost, or refill concerns:

Medication Safety

After a stent

Personalized stent-related medication safety advice:

Anticoagulant safety

Take exactly as directed and do not skip doses unless a clinician tells you to. Call for guidance before surgery, dental work, or if bleeding, bruising, or falls become a concern.

Warning signs:

Beta blocker or rhythm-medicine safety

Notes and safety tips:

Medication Safety

SGLT2 and other diabetes/heart-failure medicine instructions

Instructions and specific guidelines:

Potential side effects to monitor:

Supplement safety

Supplement-related safety considerations:

My Specific Hold / Restart Instructions

Use this area for your care team to enter patient-specific instructions about holding, stopping, or restarting medicines around procedures or illness.

Instructions from my care team:

Reading version. Use the PDF above to record your answers.

A heart attack is an injury. A stent treats one site. Recovery and prevention protect the whole cardiovascular system.

Safety

Call 911 for severe or uncontrolled bleeding, fainting, new chest pressure, severe breathlessness, or stroke symptoms. Follow your discharge instructions for procedure-site concerns.

Medicines

• Take antiplatelet medicine exactly as prescribed. Do not stop it without direct guidance from the prescribing cardiology team.

• Continue the prescribed statin or other lipid-lowering medicine even when the numbers improve. Ask what low-density lipoprotein cholesterol (LDL-C) goal applies to you.

• Know what to do after a missed dose. Do not double a dose unless instructed.

• Ask before using an anti-inflammatory pain reliever, decongestant, supplement, or herbal product.

Follow-Up

My cardiology follow-up date:

My primary-care follow-up date:

Cardiac rehabilitation referral placed: Yes / No / Not sure

Whom to call during office hours:

Whom to call after hours:

Tests, laboratory work, or referrals still pending:

Procedure Site or Incision

Follow your discharge instructions. Call 911 if a catheter puncture site swells rapidly or bleeding does not slow with firm pressure. Call your care team for numbness or tingling, a cold or blue limb, increasing bruising or swelling, drainage, fever, increasing pain, or another wound concern. Record any instructions specific to you:

Instructions specific to me:

Activity and Recovery

Activity or lifting restrictions:

Driving or work restrictions:

Cardiac-rehabilitation start date:

Mood, sleep, pain, or support concern to discuss:

Rescue Plan

Was nitroglycerin or another rescue medicine prescribed? Yes / No

Instructions I was given:

Never combine nitroglycerin or another nitrate with sildenafil, tadalafil, vardenafil, avanafil, or riociguat. The combination can cause a dangerous drop in blood pressure. If chest discomfort occurs after taking one of these medicines, call 911. Do not drive. Tell responders what you took and when, and do not take nitroglycerin unless emergency personnel specifically direct you.

Reading version. Use the PDF above to record your answers.

A normal result is good news. These questions help you understand what the test settled and how far its reassurance extends.

• What exactly did this test rule out?

• Does it tell us whether I have plaque?

• Can this test predict which plaque will break open or when? (No.)

• If my symptoms continue, what possible cause have we not yet evaluated?

• Should my prevention change based on my overall risk?

• What noncardiac causes should we consider if the heart evaluation does not explain the symptoms?

Remember: A normal stress test means the test did not find evidence that part of the heart was receiving too little blood under the conditions tested. It does not show all plaque that is present without a major blockage or rule out every problem involving the heart’s smallest vessels. New or worsening symptoms still require reassessment.

Reading version. Use the PDF above to record your answers.

Symptoms can come from a major coronary blockage, problems in the heart’s smallest vessels, coronary spasm, rhythm problems, structural heart disease, or causes outside the heart. Use this page to describe the pattern and identify history that may change risk assessment. It does not diagnose the cause. Pregnancy and ovarian history can be clinically relevant regardless of gender identity.

Describe the Pattern

• Chest pressure, tightness, heaviness, burning, or discomfort

• Breathlessness out of proportion to the activity

• Jaw, neck, back, shoulder, arm, or upper-abdominal discomfort

• New or unusual fatigue, nausea, sweating, or reduced exercise capacity

• Symptoms with exertion, emotional stress, cold exposure, or meals

• Symptoms at rest, overnight, or in the early morning

• Palpitations, faintness, or near-fainting

• A new, worsening, or more frequent pattern

Do not assume a new symptom or palpitation is caused by menopause, anxiety, reflux, or a muscle problem without appropriate evaluation.

History That May Change the Conversation

• Preeclampsia, gestational hypertension, gestational diabetes, preterm delivery, or another serious pregnancy complication

• Menopause before age 40 or removal of both ovaries at a young age

• Polycystic ovary syndrome (PCOS), especially with diabetes, high blood pressure, abnormal cholesterol, or excess weight

• Autoimmune or chronic inflammatory disease

• Breast or chest radiation, anthracycline treatment, HER2-directed therapy (used for some breast cancers), or another cancer treatment that can affect the heart or blood vessels

• Prior spontaneous coronary artery dissection (SCAD, a tear within a coronary artery wall), myocardial infarction with nonobstructive coronary arteries (MINOCA, a heart attack without a major artery blockage), Takotsubo or stress cardiomyopathy, or heart failure related to pregnancy (peripartum cardiomyopathy)

• Migraine with aura, meaning temporary visual, sensory, or speech symptoms before or during a migraine, especially when discussing stroke risk or estrogen-containing contraception

• A strong family history or known high lipoprotein(a), or Lp(a)

Questions to Ask

• Could a major coronary blockage still explain this pattern?

• Could reduced heart-muscle blood flow without a major artery blockage, called ischemia with no obstructive coronary arteries (INOCA), explain this? Possibilities include problems in the smallest coronary vessels, coronary spasm, or more than one mechanism.

• Does my pregnancy, menopause, autoimmune, or cancer-treatment history change prevention or testing?

• If the first test was reassuring but symptoms continue, what question remains unanswered?

Emergency Reminder

For emergency warning signs and timing, use Flow Tool 6.

Reading version. Use the PDF above to record your answers.

Practical triage, not a substitute for medical advice.

This page helps you sort urgency. It does not replace clinical judgment, and the examples are not exhaustive. If you are unsure whether symptoms could be an emergency, call 911. If the question is nonurgent, call your clinician.

Call 911 Now

Do not drive yourself. Do not wait to see whether it passes. Do not assume it is anxiety, reflux, or muscle pain.

• Chest pressure, heaviness, squeezing, or tightness that is new and happening now; is severe or worsening; lasts more than a few minutes; or repeatedly returns

• Sudden severe chest or upper-back pain, especially with faintness, sweating, weakness, or a sense that something is seriously wrong

• New chest discomfort or breathlessness happening now at rest or with minimal exertion, especially with sweating, nausea, fainting, or marked weakness

• New pain or pressure spreading to the arm, jaw, neck, back, or shoulder, especially with chest discomfort or breathlessness

• Sudden severe shortness of breath; fainting or near-fainting; or a very fast or irregular heartbeat with dizziness or fainting

• Possible stroke: sudden face droop or numbness or weakness on one side; sudden confusion or trouble speaking or understanding; sudden trouble seeing; sudden trouble walking, dizziness, or loss of balance or coordination; or a sudden severe headache with no known cause. Call 911 immediately.

Call Your Clinician the Same Day

Use this tier only if the symptom has completely stopped and no emergency feature above is present. Call your clinician now for same-day guidance. If you cannot reach a clinician promptly, or if the symptom returns, worsens, occurs at rest or with minimal activity, lasts more than a few minutes, or develops any emergency feature, call 911.

Examples: a new exertional pattern of chest pressure or breathlessness that has completely stopped; worsening exercise tolerance; recurrent palpitations without fainting; new or increasing swelling or rapid weight gain; or a concerning medication side effect without emergency signs. Trouble breathing or facial swelling is an emergency.

Blood pressure: Follow your clinician’s personal report range. If a home reading is above 180 systolic and/or 120 diastolic, wait at least one minute and repeat it. If it remains this high with chest pain, shortness of breath, back pain, numbness, weakness, vision change, trouble speaking, or another new severe symptom, call 911. Without those symptoms, contact your health care professional promptly. Do not take an extra dose unless instructed. During pregnancy or postpartum, follow the obstetric plan instead: 160 systolic or 110 diastolic is severe and requires immediate contact with the obstetric team or urgent evaluation.

Track Until Your Next Visit

Use this tier only when the finding has already been evaluated and you have a plan. Record the pattern and follow your clinician’s instructions about when to call or seek urgent care.

• A familiar, unchanged symptom your clinician has already evaluated

• A borderline laboratory result with a planned review

• Stable imaging findings with an agreed follow-up plan

• Difficulty following activity, nutrition, or monitoring plans when the issue is stable and a follow-up plan is already in place

Reminder: If you are running out of a critical medicine or expect missed doses, especially after a recent stent or while taking an anticoagulant, contact the prescribing team promptly rather than waiting for the next visit.

Reading version. Use the PDF above to record your answers.

Record early heart attacks, strokes, rhythm problems, heart-muscle or aortic disease, and sudden death.

For each relative, record the condition, age at onset, and notes.

You, Siblings, and Children

Self; sibling(s); child(ren).

Parent Generation

Father; mother; uncle or aunt; other relative.

Grandparent Generation

Father’s father; father’s mother; mother’s father; mother’s mother.

Tip: Flag a heart attack or stroke before age 55 in a male first-degree relative or before age 65 in a female first-degree relative. Write “unknown” if needed. Use another copy if you need more rows.

Look for patterns, not perfection.

Reading version. Use the PDF above to record your answers.

Track only what you and your clinician decide is useful.

Choose a few measures that can guide a decision. Your plan may change as recovery and treatment change.

Measures to Track

For each metric, record the starting point, your agreed goal or plan, and review.

Symptoms / function; blood pressure; lipid or other lab; movement / rehab; sleep / apnea plan; medication routine; follow-up; another measure.

Track only what matters. Bring this dashboard to your review and ask what should stay, change, or stop.

Complete only what applies. Use clinician-set goals and review patterns, not isolated readings.

Review Notes

Review date; what continues; what changes; what needs attention now; next review and what should happen before it.

Questions for the 90-Day Review

Medicine is not being taken consistently: Is the problem cost, side effects, confusion, schedule, access, or something else that can be solved?

Taken consistently, but the result remains off target: Does the dose, medicine, diagnosis, or goal need to change?

Side effects develop or a blood-test result becomes concerning: Does treatment need prompt adjustment, further testing, or a different option?

Symptoms persist despite an improved number: Have we treated a risk marker without explaining the symptom?

Function is declining: Does the diagnosis, rehabilitation plan, rhythm, heart function, anemia, lung disease, sleep, or mood need review?

Set goals, safe ranges, and timing with your clinician. Follow any heart-failure daily-weight plan. Do not change medicines or activity limits based on this page alone. New, worsening, or severe symptoms should not wait for the review date.

Reading version. Use the PDF above to record your answers.

These questions clarify what decision the test or procedure could change, its likely benefits and risks, and the alternatives.

Most cardiac tests and elective procedures are planned decisions. The right choice depends on what the test or procedure is expected to change. In a true emergency, follow emergency instructions first. For a nonemergency decision, bring these questions to the conversation before you agree to a planned test, stent, or procedure.

• What decision will this test or procedure help us make?

• Which question matters most here: what the heart or arteries look like, whether blood flow is limited, or what my overall risk is?

• What benefit should I realistically expect: relief of symptoms, prevention of an event, longer life, or better information?

• What risks matter most for me, given my kidney function, bleeding risk, allergies, frailty, medicines, and other conditions?

• What are the reasonable alternatives, including medical treatment, a different test, watchful waiting, or no immediate procedure?

• What is likely to happen if I wait or decide not to proceed?

• Is this urgent, or is there time to discuss it further or obtain a second opinion?

For a visible narrowing, ask whether it explains symptoms or limits blood flow, and which outcome the proposed treatment is expected to improve.

Reading version. Use the PDF above to record your answers.

What I Can Change and What Changes the Goal

Fill in only the measures that apply to you, and leave the rest blank. Then set priorities with your clinician. This page is not a score or a diagnosis.

1. Blood Pressure

Recent readings:

My clinician-set goal:

Next step:

2. LDL-C and Apolipoprotein B (ApoB)

Low-density lipoprotein cholesterol (LDL-C) and ApoB: treatable plaque-forming risk.

LDL-C or ApoB, if measured:

My clinician-set LDL-C goal and ApoB goal, if used:

Next step:

3. Blood Sugar and Diabetes Risk

Hemoglobin A1c (average blood sugar over about three months) or fasting glucose:

My clinician-set goal:

Next step:

4. Smoking, Tobacco, and Vaping

Where I stand:

My quit or stay-quit plan:

5. Movement and Functional Fitness

Current activity, mobility, or function:

My next safe, repeatable step:

Sleep, Stress, and Support

Typical sleep (hours):

Sleep-apnea assessment or treatment, if applicable:

One practical support:

Context That Can Change the Goal

This tool tracks factors that can be modified, but it is not a complete risk calculator. Also review the medical and family-history context that may change treatment targets:

Established coronary artery disease, ischemic stroke or transient ischemic attack, aortic atherosclerosis, or peripheral artery disease

Coronary plaque or calcium on imaging

Chronic kidney disease

Strong family history or familial hypercholesterolemia

Lipoprotein(a), or Lp(a), if measured (include nmol/L or mg/dL):

How this result changes my LDL-C or prevention plan:

Lp(a) is mostly inherited and usually does not fall meaningfully with lifestyle change. Its main role is to help determine how intensively LDL-C, ApoB, and other treatable risks should be managed.

Context That Can Change the Goal (continued)

Pregnancy complications or menopause before age 40

Autoimmune or chronic inflammatory disease

Prior chest radiation or cancer treatment that can affect the heart or blood vessels

Use Flow Tool 7, Family Flow Map, for family history and Flow Tool 5, Women’s and Pregnancy-Related Cardiovascular History Guide, for sex-specific history.

Work with your clinician to begin with the modifiable risk factor most likely to matter now. Then choose one change you can repeat.

Reading version. Use the PDF above to record your answers.

Use one entry per symptom episode; use another sheet if several episodes occur in one day. Record the details when they occur rather than trying to reconstruct them later.

Safety

Stop completing the tracker if symptoms are happening now or their pattern has changed. If any emergency feature is present, call 911; do not delay to finish the form. A low score from 0 to 10, or improvement with rest or nitroglycerin, does not prove that a symptom is safe.

Entry 1

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Entry 2

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Entry 3

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Entry 4

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Entry 5

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Entry 6

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Entry 7

Date and time:

Symptom and severity, 0 to 10:

Trigger, duration, and what relieved it:

Blood pressure or heart rate, only if instructed:

Action taken:

Prescribed rescue medicine taken and response, if applicable:

Bring this page to your appointment. Include how long each symptom lasted and whether it stopped with rest or prescribed medicine.

Reading version. Use the PDF above to record your answers.

Use this page at the interval you and your clinician choose. Long-term follow-up depends on diagnoses, medicines, recent events, and symptoms.

Symptoms and Function

• New or changing chest discomfort, breathlessness, palpitations, faintness, swelling, fatigue, or exercise limitation reviewed

• Daily function, work, driving, intimacy, and activity concerns discussed when relevant

• Emergency and same-day call instructions still understood

Medicines

• Medication list reconciled with what I actually take

• Purpose and intended duration of each medicine reviewed

• Side effects, cost, refills, missed doses, and access problems discussed

• Sick-day and procedure instructions recorded when needed

• Over-the-counter medicines and supplements reviewed for interactions

Measurements and Monitoring

• Home blood-pressure average reviewed if monitoring was assigned

• Lipid testing completed when due

• Kidney function and blood salts such as sodium and potassium checked for medicines or conditions that require them

• If applicable, A1c or another blood sugar measure reviewed along with related heart, kidney, or metabolic conditions

• Heart-failure weight or fluid plan reviewed if applicable

Recovery and Prevention

• Support and treatment for stopping tobacco or nicotine use reviewed if applicable

• Cardiac rehabilitation, activity, strength, balance, or fall concerns reviewed

• Sleep-apnea evaluation or treatment reviewed if applicable

• Mood, anxiety, trauma symptoms, and social support discussed

• Nutrition goals fit my diagnoses, culture, preferences, and access to food

Closing the Loop

• I know who will review each pending referral, test, or result

• I understand why repeat imaging is planned and how the result could change care

• Next review date is written down

• I know which change should prompt an earlier call

Record: what continues; what changes; next review date.

If symptoms are new or worsening, do not wait for the next scheduled review. If an emergency feature is present, call 911; otherwise contact your clinician promptly.

Reading version. Use the PDF above to record your answers.

How to support someone protecting their heart without taking over.

If someone you love is working to protect their heart, ask what kind of help they want. Some people welcome reminders or company; others do not. Agree on your role instead of assuming it.

• Ask how you can help instead of assigning tasks.

• Offer to walk, prepare meals, or adjust routines together.

• Learn the emergency warning signs together, and never discourage someone from calling for help.

• If side effects occur, help them contact the prescribing team rather than stopping a medicine.

• Review your own cardiovascular risk factors, especially when conditions run in the family.

Caregiving can affect your sleep, mood, health, and ability to function. Ask the clinical team or your own clinician for support when caregiving is affecting your well-being or becoming difficult to manage safely.

Reading version. Use the PDF above to record your answers.

If your watch flags possible atrial fibrillation (AFib), save what it recorded and check how you feel before deciding what to do next.

First: Check for Emergency Symptoms

Call 911 for stroke signs, severe chest pressure, fainting, severe breathlessness, or a fast or irregular heartbeat with dizziness or near-fainting. Do not drive yourself.

If You Feel Well

• Save the tracing or screenshot if your device recorded one.

• Write down the time, how long the alert lasted, any symptoms, what you were doing, and anything unusual such as illness, dehydration, poor sleep, or alcohol.

• Contact your clinician so the rhythm can be reviewed and, when appropriate, confirmed with an electrocardiogram (ECG) or medical monitor.

• Keep taking prescribed medicines unless the prescribing team tells you otherwise.

Wearable Alert Rule

An isolated alert without emergency symptoms is not, by itself, proof of AFib. Arrange prompt clinical review and do not self-treat. Repeated alerts, a sustained fast or irregular rhythm, new symptoms, or a worsening pattern warrant same-day contact with your clinician; use the emergency instructions above if severe symptoms develop.

A wearable alert is not a confirmed diagnosis, and the absence of an alert does not rule out AFib. Save the tracing when possible. Do not start aspirin or an anticoagulant, take extra heart-rate medicine, or change another prescription based on a watch alert alone.