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Percutaneous Coronary
Intervention Report
NEW YORK STATE DEPARTMENT OF HEALTH
State Cardiac Advisory Committee
Facility Name
PFI Number
Sequence Number
I. Patient Information
Patient Name
last
first
Medical Record Number
Social Security Number
Age in Years
Date of Birth
m
Sex
1
2
Male
Female
d
y
Ethnicity
Race
Residence (see instructions)
Hospital Admission
1
2
1
2
White
Black
Code
Date
8
Other
Hispanic
Non-Hispanic
State or Country
m
d
y
d
y
II. Procedural Information
Hospital that performed diagnostic cath
Hospital Name
PFI
Primary Physician Performing PCI
Name
License Number
Date of PCI
m
Diagnostic Cath during same lab visit?
1
Yes
2
No
Other PCI this admission?
1
Yes
2
No
Date of PCI
PCI Prior to this admission at this hospital?
1
Yes
2
No
Date of PCI
m
m
Cardiac Enzymes
d
y
d
y
Troponin
CK
MB
CK-MB
Tn-I
Tn-T
Pre-Proc:
≤ 24 hrs:
U/L
ng/ml
%
ng/ml
ng/ml
Post-Proc:
6-8 hrs:
U/L
ng/ml
%
ng/ml
ng/ml
12-24 hrs:
U/L
ng/ml
%
ng/ml
ng/ml
Procedure Related Medicines
Thrombolytics:
Heparin?
IV Nitro within 24 hours pre-proc?
1
<3 hrs Pre-Proc
IV GPIIbIIIa Platelet Inhibitors (i.e., Reo Pro) during or within
3 hours post-proc?
2
3-6 hrs Pre-Proc
3
>6 hrs - within 7 days Pre-proc
Contraindicated
Oral GPIIbIIIa Platelet Inhibitors pre or post proc?
III. Major Events Following PCI (check all that apply)
0
None
10
Renal Failure, dialysis
1
Stroke (new neurological deficit) 24 hrs or less
14
Emergency Bypass Surgery, hemodynamically unstable
Stroke (new neurological deficit) over 24 hrs
15
Emergency Bypass Surgery, hemodynamically stable
7
Acute Occlusion at Site of Intervention
17
Stent Thrombosis
8
A/V Injury at Cath Entry Site, requiring surgery
1A
IV. Discharge Information
Discharged to:
11
Home
Died in:
2
Operating Room
12
Hospice
3
Recovery Room
13
Acute Care Fac (including rehab)
4
Critical Care Unit
14
Skilled Nursing Home
5
Medical/Surgical Floor
19
Other (specify)
6
Cath Lab
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Hospital Discharge Date
7
In Transit to Other
Facility
8
Elsewhere in Hospital
(specify)
m
d
y
V. Peri-Procedural MI Information
Timing
Timing
Pre-Proc Post-Proc
No MI
1
2
New Abnormal Wall Motion
1
2
New Q Waves
1
2
ST Elevation Only
1
2
Time from onset of chest pain to hospital admission
Both
3
3
3
3
.
hours
Pre-Proc
New ST � or T �
1
New LBBB
1
TIMI ≤ II
1
Ischemic type chest pain
1
Ongoing Ischemia at time of proc
Post-Proc
2
2
2
2
Both
3
3
3
3
VI. Pre-intervention Risk Factors (answer all that apply)
Priority
Ejection Fraction
Height
1
Elective
2
Urgent
3
Emergency
cm
Measure
%
Weight
LV Angiogram
CCS Functional Class
2
Echocardiogram
1
Class I
Radionuclide Studies
2
Class II
1
Calculated
3
2
Estimated
4
TEE including Intra-Op
3
Class III
Unknown
8
Other
4
Class IV
9
Unknown
9
kg
Angina Type:
Angina:
1
1
Stable
2
Unstable
Vessels Diseased (check all that apply)
LMT
Prox LAD or Major Diag
1
50 - 69%
2
70 - 89%
3
90 - 100%
Mid/Dist LAD or Major Diag RCA or PDA
LCX or Large Marg
4
50 - 69%
6
50 - 69%
8
50 - 69%
10
50 - 69%
5
70 - 100%
7
70 - 100%
9
70 - 100%
11
70 - 100%
Lesion-Specific Information
Complete one line for each lesion for which PCI was attempted, and one line for each non-attempted lesion with stenosis of at least
50% — even if lesion has been bypassed. See instructions for diagram and codes for the following fields:
Bypassed
(A or V)
Location
0
Lesion
Type
% Pre-op
Stenosis
Previous
PCI
Primary
Device
Secondary
Device
Stent
Radiation
% Post-op
Stenosis
None of the pre-intervention risk factors listed below were present
Previous PCIs
1
One
4
<6 hours
8
Stroke
Hemodynamic Instability at
time of procedure
2
Two
5
≥6-<12 hours
9
Carotid/Cerebrovascular
12
Unstable
3
Three or more
6
≥12-<24 hours
10
Aortoiliac
13
Shock
11
Femoral/Popliteal
33
CPR
Previous MI (most recent)
7
days (use 21 for 21 or more)
Peripheral Vascular Disease
14
More than one previous MI
23
Renal Failure, creatinine > 2.5 mg/dl
15
Hypertension history
24
Renal Failure, dialysis
17
ECG Evidence of Left Ventricular Hypertrophy
26
IABP required at start of procedure
18
Congestive Heart Failure, this admission
28
Previous Open Heart Surgery
19
Congestive Heart Failure, before this admission
30
Smoking history, in past 2 weeks
20
Malignant Ventricular Arrhythmia
31
Smoking history, in past year
21
Chronic Obstructive Pulmonary Disease
32
Emergency PCI due to Dx cath complication
22
Diabetes requiring medication
34
Stent Thrombosis
VII. Person Completing Report
Name
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