Download HEA 110.F3F - Think Ottawa Medicine

ICD AND CRT REFERRAL FORM
Implantable Cardioverter Defibrillator
Cardiac Resynchronization Therapy
WAIT LIST MANAGEMENT OFFICE
Fax: 613-761-4922 Phone: 613-761-4436
Referral Data (To be completed by Referring Physician/Center. Please
send completed form along with copies of echo/cardiac cath/MUGA/ECGs
and/or rhythm strips of arrhythmia if applicable).
CLINICAL HISTORY
Unique Number ___________________________
DOB _______ / ____ / ____ Age
Sex
year
month day
Surname
First Name
_______________________________________________________________________________
Ontario Health # ____________________________________
or
 Other Province
 Other Country
 Not available
Street no.
Street name
apt.
_______________________________________________________________________________
City
Province
Postal Code
_______________________________________________________________________________
Phone no. (home)
(work)
Referring Physician or Center:
Referring contact phone no.:
1 Documented Ventricular Arrhythmias (Check one answer):
 Documented VT, VF or cardiac arrest
 Non-sustained VT >110 bpm,  3 beats and < 30 sec)
 NO documented VT, VF or ns VT
2
Symptoms suggesting high risk for SCD (syncope,
presyncope or rapid palpitations):
 Yes
 NO
YES NO
 
 
3 Basis of Heart Disease? (Check all that apply):
4a Any previous myocardial infarction?
4b STEMI or NSTEMI within last 40 days?
 Ischemic Heart Disease
 Nonischemic Dilated (CM)
 Valvular Heart Disease
 Hypertrophic CM
 Arrhythmogenic RV CM (ARVD)
 Infiltrative CM (sarcoidosis, hemochromatosis, etc.)
4c Previous PCI or CABG?
4d PCI or CABG within last 3 months?




4e History of Congestive Heart Failure?
4f CHF Hospitalization ( 12 months)




 Congenital Heart Disease
5a NYHA Heart Failure Class:  I  II
5b CCS Angina Class:
0 1
 No Structural Heart Disease
6
a
b
c
d
e
f
g
h
i
Co-morbidities:
Diabetes mellitus
Hyperlipidemia
Hypertension
Hx of TIA/CVA
Hx of Atrial Fibrillation
Chronic Lung Disease
Cigarette smoking  Current  Ex  Never
Peripheral Vascular Disease
Chronic Renal Failure (Cr > 300 mmol/L)
If yes, is patient on dialysis?
YES










NO










j Drug/EtOH abuse, psychiatric illness
k Past or present Malignancies (don’t include remote
malignancies considered cured for > 5 yrs)




l Pre-existing pacemaker system


a Beta blockers
b ACEI


c ARB


d Spironolactone


e Loop Diuretics


f Oral anticoagulation


g Digoxin


h Aspirin


i Amiodarone


j Other Class 3 AAD


k Statins


 native QRS
 paced
2 LVEF:   20
 36-40
  51
 31-35
 41-50
If on oral anticoagulant please state indication:  AF
Signature of Referring Physician
HEA 110 (05/2010)
YES NO
 
7 Current medications:
8 Investigations:
1 ECG: QRS duration ____ msec
 21-30
 III  IV
2 3 4
Method:
 Echo RNAc
 LV angio
 CVA/TIA  Other (state):
Referral date (yyyy/mm/dd):
1-2
Patient:
Chart no.:
B ICD Assessment (to be completed by ICD center)
1 ICD Registry number:
2
EPS:  VT/VF induced
 No VT/VF induced  Not performed
3a Was patient assessed in face to face meeting?
 Yes
Initial assessment date (yyyy/mm/dd):
 No, patient accepted directly for ICD implant
 No, patient died while waiting
 No, patient not contacted
 No, referral withdrawn
4a Final decision and/or ICD wait-listed date:
(yyyy/mm/dd):
4b Was patient an ICD candidate?
 Yes and patient agreed to ICD
 Yes, but patient refused ICD or deferred decision
 No, patient has prohibitive risks
 No, patient does not meet criteria as follows:
(mark as many as applies)
 EF improved with medical therapy
 EF improved with revascularization
 Other reason (please state):
5 ICD type to be implanted:
 VVI-ICD
 CRT-ICD (RA, RV & LV leads)
Physicians at ICD ROUNDS (circle):
Birnie
Davis
Gollob
Green
Keren
Lemery Nery
Redpath
 DDD-ICD
 CRT-ICD (RV & LV)
Coumadin instructions:  Stop 5 days before - no substitution
 Stop 5 days before and substitute with: __________________
Responsible Electrophysiologist‘s signature:
Date (yyyy/mm/dd):
C Triage Use/Patient Contact (to be completed by ICD center)
 Procedure date (yyyy/mm/dd): ____________________
 Notified
 Coumadin instructions given
Comments:
 OP
D Waiting Period (to be completed by ICD center)
5 Any reasons for undue delay in time to assessment/implant?
 None, usual wait time for our center
 Cardiac investigation/treatment required first
 Other medical problems required resolution
 Geographical distance from ICD center
 Patient/referring physician requested delay/time to decide
 More information required from referring center
 Difficulty contacting patient/missed appointment
 Research study/protocol issues
 ICD centre resource (space/schedule/etc) issues
 Other (specify):
 Admission
 Telephone
 Letter
6a Did patient have adverse CV event while waiting?
 No
 Yes, patient died
 Yes, VF, sustained VT or cardiac arrest
 Yes, other CV event (MI, CVA etc)
6b Date of adverse event:
6c If death occurred while wait-listed, was it?:
 Cardiac
 Non-cardiac  Unknown
If cardiac death, was it?:
 Sudden
 Non-sudden
E ICD Implantation (to be completed by ICD center)
1 Date of ICD implant:(yyyy/mm/dd): ____________________
2 Patient location while awaiting implant:
 Out of hospital
 In-patient at ICD center
 In-patient at referral center
HEA 110
3 ICD type implanted:
 VVI-ICD
 CRT-ICD (RA, RV & LV leads)
 DDD-ICD
 CRT-ICD (RV & LV)
2-2