Download AMIS Plus Questionnai Instructions MIS Plus Questionnaire Data

A
M
I
S
Acute
Myocardial
Infarction in
Switzerland
AMIS Plus Data Center
AMIS Plus Questionnaire Data Entry
Instructions
Version 01.2014
Inclusion criteria:
• Patients who had symptoms within the last 48 hours at hospital admission with a discharge
clinical diagnosis of acute myocardial infarction or
• Patients who suffered an acute myocardial infarction in hospital during a hospitalization for other
reasons
All patients with initial suspicion of acute myocardial infarction at hospital
hospital admission regardless of
admission mode (emergency room, cath.
cath lab.,, intensive care unit, another ward) should be
considered for inclusion in the AMIS Plus registry.
Acute myocardial infarction definition:
1. Characteristic ischemic symptoms
2. ECG changes indicating new ischemia (ST-T
(ST T changes or new left bundle branch block) or
developing pathological Q-waves
Q
3. A dynamic increase or decrease in biomarker or troponin (I or T) levels above the individual
hospital cut-off
off for MI. The internationally accepted guidelines
guidelines for troponin levels are set at least
one value above the 99th percentile of the upper reference limit (URL).
(URL)
Cut-off
off levels for either total creatine kinase (CK) or creatine kinase MB fraction (CK-MB)
(CK
at least
twice the upper limit of normal
Patients can also be categorized as having ST-segment
ST segment elevation MI (STEMI) or non-STEMI
non
(NSTEMI)
based on initial ECG findings:
• STEMI includes evidence of clinical and laboratory findings as described above and ST-segment
ST
elevation and/or new left bundle branch
b
block on the initial ECG
• NSTEMI includes patients with ischemic symptoms, ST-segment
ST segment depression or T-wave
T
abnormalities in the absence of ST-elevation
ST
on the initial ECG
Filling out the questionnaire:
Data can be either entered online at www.amis-plus.ch
www.amis
-> “Data Entry” ->”AMIS
>”AMIS Online
Questionnaire” (recommended) or the paper questionnaire can be filled out and posted to the AMIS
Plus Data Center.
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AMIS Plus Questionnaire Data Entry Instructions
Please pay attention to the following points:
• Completeness: If data are unobtainable write “unknown” in the corresponding comments box.
• Special cases, ambiguities when filling out the questionnaire: Please use the comments box for
online entry or write directly on the paper questionnaire.
• Transfer: If the patient was transferred for percutaneous coronary intervention (PCI) and then
transferred back to your hospital, this should be treated as 1 case for the entire hospitalization
duration.
• Follow-up: Please complete the patient follow-up section at the end of the questionnaire and keep
the patient’s signed consent form in the patient’s hospital file.
• Paper questionnaire: Please write clearly in capital letters.
If you have any questions please ring the AMIS Plus Data Center, Telephone 044 634 48 30 (MonThurs 09:00-12:00 / 13:30-17:00) or send an email to [email protected].
Contact:
University of Zurich
Institute of Social and Preventive Medicine
AMIS Plus Data Center
Hirschengraben 84
CH-8001 Zurich
Tel: +41 (0)44 634 48 30
Fax:+41 (0)44 634 49 86
e-mail: [email protected]
website: www.amis-plus.ch
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AMIS Plus Questionnaire Data Entry Instructions
AMIS DATA ENTRY IDENTIFICATION
Hospital
Each participating hospital receives its own official four-letter code. This code appears automatically
when entering data online.
Patient ID number
The ID number is a number assigned by the hospital, which enables the physician to clearly identify
the patient and find the specific hospital record again, in combination with the admission date.
hcri AG set number (nr) / code
The hcri set nr and code concerns hcri hospitals only. The hcri set nr is obligatory and must be filled
out without exception. hcri provides questionnaires with pre-printed hcri nrs. The hcri code is
optional as it serves internal hospital purposes only. Please contact hcri if you have any questions.
Physician ID
The person completing the questionnaire must not always be a physician. The Physician ID and
password are both provided by the Data Center to enable online data entry. Please contact the AMIS
Plus Data Center ([email protected]) for your personal user name and password
Date of data entry
The date the paper questionnaire was completed. This date is entered automatically by online entry.
PATIENT AT ADMISSION
Date of birth
Mandatory field.
Gender
Mandatory field.
Weight
Rounded up to the nearest kilogram.
Height
In centimeters.
Insurance coverage
Does the patient have basic or (semi-)private insurance?
Symptoms at admission
Mandatory field. Please tick whether the symptoms that led to this hospital admission were typical
or atypical for acute myocardial infarction.
• Pain
Mandatory field. Please tick if the patient was in pain. If the patient received painkillers before
admission and was therefore not in pain at admission, please tick that the patient was in pain. If
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the patient was unable to answer this question, e.g., patient was intubated, please tick not
applicable.
• Dyspnea
Please tick whether the patient had dyspnea (shortness of breath).
Symptom onset date and time
Date and time of symptom onset refer to the time the symptoms of this acute myocardial infarction
event occurred leading to this hospitalization with pain lasting longer than 30 minutes. Time of
occurrence is normally before admission. (If patient had an AMI in hospital whilst being hospitalized
for a different complaint please note this in the comments box). Time can be approximate. If
unknown, please note this in the comments box. Early symptoms appearing days before the actual
event should be noted in the comments box.
Time of first medical contact leading to hospitalization
Prior to hospital admission this first medical contact could be with a family or emergency doctor, or
another hospital if the patient was transferred. If such a medical contact took place, please note the
date and time otherwise the admission time will be defined as time of first medical contact.
Direct transportation with telemetric ECG transmission to PCI center
Please indicate whether the ECG was telemetrically transmitted directly to the PCI center by the
emergency doctor or emergency services to trigger cath lab activation for patient arrival by
ambulance. This also applies to pre-hospital activation without ECG transmission.
Admission date and time to this hospital
Date (mandatory field) and time of patient arrival to your hospital.
Transfer
Please tick whether the patient was transferred to your hospital. If yes, please indicate from which
hospital (mandatory field) the patient was transferred.
Condition
Killip classification
Killip classification measures the severity of heart failure after myocardial infarction (Killip and
Kimball; Am J Card 1967; 20:457-64). Patients are ranked by Killip class:
• I: no clinical signs of heart failure
• II: crackles, S3 gallop and elevated jugular venous pressure
• III: frank pulmonary edema
• IV: cardiogenic shock – hypotension (systolic<90mmHg) and evidence of peripheral
vasoconstriction (oliguria, cyanosis, sweating).
ECG on admission
Mandatory field. Please tick all changes on the initial ECG. Other ECG deviations should be noted in
the comments field. If there are no new changes or ECG is normal please tick the corresponding
option.
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Location of ischemic region
Please tick the ischemic regions. If none found, tick undetermined.
Heart rhythm
Mandatory field. Only one answer possible. If patient has a pacemaker,tick paced rhythm. If not
listed, please specify.
Vital signs
Blood pressure levels and heart rate from the first medical contact can be given if these are more
informative.
Systolic blood pressure
Systolic blood pressure measured at admission.
Diastolic blood pressure
Diastolic blood pressure measured at admission.
Heart rate:
Heart rate measured at admission.
Admission diagnosis
Please choose one of the following:
STEMI: acute myocardial infarction with ST-elevation
NSTEMI: acute myocardial infarction without ST-elevation
LBBB-MI: acute myocardial infarction with new left branch bundle block
Others: please specify.
REPORTED HISTORY
Resuscitation prior to arrival at hospital?
Mandatory field. If resuscitation was performed (also in previous hospital if transferred), please tick
which kind: cardiopulmonary (mechanical) reanimation and/or cardioversion/defibrillation
Regular medication
Tick each drug the patient has been taking daily or regularly at the time of admission. If the specific
drug is unknown, e.g., anti-hypertensive drug, please note this in the comments field.
Comorbidities (Charlson Index)
Mandatory field. The comorbidities are documented in accordance with the Charlson Index
(Charlson ME et al. J Chronic Dis 1987;40:373-83). Please tick whether or not comorbidities exist.
Take all listed comorbidities (as defined below) into account. Please note any further relevant
comorbidites in the comments field.
• Myocardial infarction: All patients with at least one definite or probable MI, these patients were
hospitalized and had ECG and/or enzyme changes.
• Cardiac insufficiency: Patients with stress or paroxysmal nocturnal dyspnea who take digitalis,
diuretics or afterload reducing drugs. This does not include patients on medication if there is no
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change in symptoms or improvement in clinical findings.
NYHA III and IV correspond to dyspnea during walking on the flat or at rest.
Peripheral vascular disease: Patients with intermittent claudication, post-bypass status due to
arterial circulatory disorder, gangrene or acute arterial occlusive disease, untreated thoracic or
abdominal aortic aneurysm of at least 6cm in diameter.
Cerebrovascular disease: Patients with a history of a cerebrovascular insult with few or no
residuals as well as patients with transient ischemic attacks.
Hemiplegia: Monolateral paresis/plegia, independent of its origin.
Dementia: Patients with chronic cognitive deficits.
Chronic lung disease: Patients with at least one hospitalization due to decompensated COPD in
the past. This also includes patients with dyspnea at rest in spite of treatment, those with
permanent oxygen therapy, CO2 retention as well as those with PO2 at rest below 50mmHg.
Connective tissue disorder: Patients with systemic lupus erythematosus, polymyositis, mixed
connective tissue disease, polymyalgia rheumatica and moderate to severe rheumatic arthritis.
Peptic ulcer disease: Patients who have been treated for peptic ulcer disease including those who
had bleeding ulcers.
Diabetes: Patient was treated with insulin or oral anti-diabetics but not diet alone.
Diabetes with target organ damage: Diabetics with neuropathy, angiopathy, kidney disease and
other manifested target organ damage.
Mild liver disease: Patients with increased transaminase levels less than twice the upper normal
limit.
Moderate liver disease: Patients with increased transaminase levels above twice the upper normal
limit.
Severe liver disease: Patients with coagulopathy and/or ascites.
Moderate to severe renal disease: Patients with a serum creatinine of at least 260 micromol/l
(3mg%).
Malignant neoplasm: Patients with solid malignant tumors without metastases but with initial
treatment during the last five years (e.g., breast, colon, bronchial).
Leukemia: Patients with acute and/or chronic myeloid leukemia, acute and/or chronic lymphatic
leukemia and polycythemia vera.
Lymphoma: Patients with e.g., Hodgkin’s disease, lymphosarcoma, Waldenström’s
macroglobulinemia and myeloma (plasmacytoma).
Metastatic solid tumor: Patients with metastatic solid tumors (e.g., breast, colon, bronchial).
AIDS (stage C): Patients with definite or probable AIDS, ie., AIDS-related complex.
Care
Please indicate if the patient lives in a retirement or nursing home.
Please indicate whether the patient receives homecare, e.g. through a nursing service, family
members etc.
Past history
Ischemic heart diseases
Mandatory field. Please tick if patient previously had angina pectoris, a myocardial infarction (AMI),
coronary artery bypass grafting (CABG) and/or percutaneous coronary intervention (PCI).
Please state the date(s) of all previous PCI(s).
These data help to identify re-hospitalizations.
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Risk factors
Tick each documented or treated risk factor.
• Family history
Is there a family history of ischemic heart disease in a first-degree relative younger than 60 years?
• Arterial hypertension
Does this patient have a diagnosed history of hypertension and has this been treated or not?
Please check that your answer corresponds with your answers for regular medication.
• Hyperlipidemia
Does this patient have a history of dyslipidemia and has this been treated or not? Please check that
your answer corresponds with your answers for regular medication.
• Diabetes mellitus
Does this patient have a history of diabetes mellitus and has this been treated? If yes, please tick
whether the patient was treated with oral antidiabetics and/or insulin. If diabetes was newly
diagnosed in hospital please tick “yes” and “untreated”.
• Smoking
History confirming cigarette smoking: current smoker: has smoked at least 100 cigarettes (5 packs)
in his life and is currently smoking, former smoker: stopped smoking cigarettes more than 1 year
before this admission, never smoker: never smoked more than 100 cigarettes (5 packs) or more.
• Alcohol or drug consumption
• Regular alcohol intake?
Regular alcohol intake: at least 1-2 drinks/day on at least 4 days/week. Please tick whether or
not the patient drank more than 2 drinks per day.
• Cocaine consumption?
Please tick whether or not the patient consumed cocaine in any form during the previous
month or months.
• Anabolics or other lifestyle drugs?
Please tick whether or not the patient ever consumed anabolic steroids or other lifestyle drugs
(psychoactive substances such as cannabis, ecstasy, GHB, speed, LSD). Please specify in the
comments field following.
IMMEDIATE THERAPY
Initial therapeutic strategy
Mandatory field. Please note the first therapeutic strategy intended. This does not have to
correspond with the therapy actually performed.
• Primary PCI, emergent: Was PCI the first planned choice of therapy? This is usually within 24
hours of symptom onset.
• Invasive strategy (within 48h): Was PCI the planned therapeutic strategy within 48 hours?
• PCI facilitated (before catheter laboratory): Treatment with lysis and/or GPIIb/IIIa antagonist
before PCI.
• Thrombolysis with immediate transfer for angiography: Was thrombolysis the first planned choice
of therapy with immediate transfer for angiography?
• Thrombolysis without immediate transfer for angiography: Was thrombolysis the first planned
choice of therapy without immediate transfer for angiography?
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• Primary conservative treatment, angiography planned: Was conservative therapy the first planned
choice of therapy along with a planned angiography?
• Conservative treatment, elective angiography if problems: Was conservative therapy the first
planned choice of therapy with angiography as an option in case of additional problems?
• Primary palliative/symptomatic therapy: Was palliative and/or symptomatic therapy the first
planned strategy? This only includes patients who were NOT connected to a monitor after transfer
from ICU.
IF YES, please write why the patient was treated with palliative therapy.
Reperfusion: Thombolysis / PCI
Mandatory field. Please tick whether or not the patient received reperfusion (restoration of blood
flow to a blocked vessel) by thrombolysis or PCI. If not, please tick the most important reason.
Thrombolysis
Mandatory field. Please tick whether or not thrombolysis was performed.
If thrombolysis was performed in your hospital, please note the date (mandatory field) and starting
time of thrombolysis. If performed in another hospital please state which hospital (mandatory field).
Coronary angiography
Mandatory field. Please tick whether or not coronary angiography was performed.
If only a coronary angiography and no PCI was performed, please complete the questions concerning
location of procedure, date and starting time of procedure, angiographic findings, left ventricular
ejection fraction and then proceed to immediate drug therapy.
Percutaneous Coronary Intervention (PCI)
Mandatory field. Please tick whether PCI was performed.
PCI is a more general term than the formerly used PTCA (percutaneous transluminal coronary
angioplasty) and also includes interventions such as stenting.
Reason for performing PCI
Please tick whether PCI was the first strategy (emergent), an invasive strategy (within 48h), primary
PCI for stent thrombosis, rescue PCI after unsuccessful thrombolysis, rescue PCI after primary
conservative therapy or elective (optional) PCI. If PCI was the first strategy, it is normally performed
within 24 hours of symptom onset. Please state reasons for any time deviations in the comments field.
Location of procedure (Coronary angiography/PCI)
Please tick where coronary angiography/PCI was performed and state where if in another hospital.
Date and starting time of procedure (Coronary angiography/PCI)
Date (mandatory field) and starting time of coronary angiography/PCI, defined as the time of the
patient’s first automatic arterial blood pressure measurement in the heart catheter laboratory. This is
normally after hospital admission. Starting time is obligatory if performed in your hospital. Please
note if a transferred patient received a coronary angiography/PCI before admission to your hospital.
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Vascular access route
Please tick if the initial vascular access route was femoral or radial and then tick if the final vascular
access route for PCI was femoral or radial.
Angiographic findings
Using the current results please tick whether one, two or three vessels and/or the left main stem were
affected. If there were no pathological angiographic abnormalities please tick no angiographic
abnormalities.
Left ventricular ejection fraction
Tick the corresponding left ventricular ejection fraction. Only one choice is possible.
If only coronary angiography but no PCI was performed please now proceed to the question on
immediate drug therapy.
Culprit vessel
Please tick the vessel responsible for the infarct-related lesion. If other, please specify.
• Collaterals to culprit vessel persist
Please tick if the collaterals to culprit vessel persist. (if available)
• TIMI flow of culprit vessel at the start of PCI
Please tick the TIMI flow before the start of PCI. (if available)
0 = no antegrade flow beyond a coronary occlusion
I = minimal flow beyond the occlusion, filling of the distal coronary bed is incomplete
II = delayed or sluggish antegrade flow with complete filling of the distal territory
III = normal flow which fills the distal coronary bed completely
• TIMI flow at the end of PCI
Please tick the TIMI flow at the end of PCI. (see above)
Vessel treated
Tick which vessel was treated. Multiple answers are possible. In case more than one PCI was
performed during hospitalization, use the data from the first one. Please note details on further PCIs
in comments field.
PCI with stent
Mandatory field. If a stent was implanted, please note the type of stent.
• Bare-metal (e.g., Abbott Multi-Link, B. Braun Coroflex Blue, Biotronik Pro-Kinetik, etc.)
• Drug-eluting (e.g., Abbott Xience, Boston Scientific Promus, Medtronic Resolute, etc.)
• Biodegradable polymer-based drug-eluting (e.g., Biosensors Biomatrix, Biotronik Orsiro, Boston
Scientific Synergy, Terumo Nobori, etc.)
• Polymeric bioresorbable scaffolds (e.g., Abbott Absorb™)
• Metallic bioresorbable scaffolds (e.g., Biotronik DREAMS)
Multiple answers are possible. Please state in the comments field if stent type is unknown. Specify
number of stents.
Drug-eluting balloon
Please tick if a drug-eluting balloon was used.
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PCI complications
Please tick if any of these complications arose whilst performing PCI.
If myocardial infarction occurred after PCI, e.g., Stent thrombosis or occlusion of one of the branches,
then re-infarction must be ticked in the section “hospitalization”
Adjunctive techniques
Please tick whether or not a distal protection device and/or thrombus aspiration were also used
during PCI.
Mechanical circulatory support
Please tick whether an intra-aortic balloon pump (IABP), percutaneous left ventricular assist device
(LVAD), Impella® and/or extracorporeal membrane oxygenation (ECMO) was necessary during PCI.
Immediate drug therapy
Please tick whether each medication was administered or not within 24 hours after admission. This
also includes emergency medication administered before admission, as well as medication
administered by the transferring hospital if the patient was transferred. If the patient was transferred
to a PCI center and subsequently transferred back, then the medication administered in the PCI center
should also be listed if administered within 24 hours. Please state if medication was not given
according to guidelines due to contraindication.
If a coronary artery bypass grafting (CABG) was planned or performed, only take into account the
medication given prior to the operation.
LABORATORY PARAMETERS
Please check all the laboratory results available and measured in your hospital and in the case of
transferred patients in the transferred hospital. Please take care with the parameter units. If different
from the ones given in the questionnaire, please specify. If a CABG was performed only take into
account the laboratory results prior to the operation.
• Elevated cardiac markers at admission
Please tick whether the cardiac markers CK, CK-MB and/or troponin were elevated or not.
• Glycemia
Please note the glycemia level at admission in mmol/l.
• Creatinine
Please note the creatinine level at admission in µmol/l.
• Hemoglobin
Please note the hemoglobin level at admission in g/dl.
• White blood cell count
Please note the white blood cell count per volume unit at admission.
• Copeptin
Please note the copeptin level if available.
• Maximum CK
Please note the highest CK level available in IU/I.
• Maximum CK-MB
Please note the highest CK-MB level available in IU/l or µg/l.
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• Was the troponin level above your hospital cut-off for MI?
Mandatory question. Please tick yes or no.
• Troponin T
Please note the highest troponin T level available in µg/l.
• Troponin I
Please note the highest troponin I level available in µg/l
• Total Cholesterol
Please note the total cholesterol level within 24 hours of chest pain onset in mmol/l.
• HDL Cholesterol
Please note the HDL cholesterol level within 24 hours of chest pain onset in mmol/l.
• CRP
Please note the CRP level at admission in mg/l.
• BNP
Please note the BNP level in pg/ml.
• NT-ProBNP
Please note the NT-ProBNP level in pg/ml.
HOSPITALIZATION
If a CABG was performed during this hospitalization, this section concerns the time prior to the
operation.
Complications
Mandatory fields. Please tick each complication that occurred during this hospitalization in your
hospital or in another hospital in the case of transferred patients.
• Cardiogenic shock: should only be ticked if it occurred during hospitalization and not at
admission where it is then entered under the Killip classification.
• Re-infarction: includes stent thrombosis.
• Cerebrovascular event: includes transient ischemic attacks (TIA).
• SIRS = systemic inflammatory response syndrome.
• Bleeding: Please tick localization. Please define the bleeding by using the BARC score (BARC –
The Bleeding Academic Research Consortium)* :
BARC Type 0: no evidence of bleeding
BARC Typ 1: bleeding that is not actionable (pertaining to out-patients and not applicable to AMIS)
BARC Type 2: any overt, actionable sign of hemorrhage (e.g., more bleeding than would be
expected for a clinical circumstance)
BARC Type 3a: Overt bleeding plus hemoglobin drop of 3 to <5g/dL. Any transfusion with overt
bleeding
BARC Type 3b: Overt bleeding plus hemoglobin drop ≥ 5g/dL. Cardiac tamponade. Bleeding
requiring surgical intervention. Bleeding requiring intravenous vasoactive agents.
BARC Score 3c: Intracranial hemorrhage. Intraocular bleed compromising vision.
BARC Type 4: CABG-related bleeding (not applicable to AMIS).
BARC Type 5: fatal bleeding.
*Standardized Bleeding Definitions for Cardiovascular Clinical Trials: A Consensus Report From the
Bleeding Academic Research Consortium. Mehran et al. Circulation. 2011;123:2736-2747
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Therapeutic interventions:
Please tick each intervention performed during this hospitalization.
Performed diagnostic / therapeutic procedures
Please tick whether or not each procedure was performed during the hospitalization or planned for a
later date.
• Coronary angiography
Please tick whether coronary angiography (or PCI) was performed or planned in your hospital or
another hospital. Please note the number of coronary angiographies performed during the entire
hospitalization (also externally).
• Echocardiography
Please tick whether or not echocardiography was performed or planned for a later date. If
performed, please note the date of the first echocardiography during this hospitalization and note
the left ventricular ejection fraction level.
• Stress test
Please tick whether a stress test was performed or planned for a later date. This includes stress test,
stress echo or stress test with isotopes. If performed please tick if ischemia was found.
• MRI stress test
Please tick whether a MRI stress test was performed or planned for a later date. If performed
please tick whether there was myocardial viability.
• Electrophysiology study (EPS)
Please tick whether an invasive EPS was performed or planned.
• Computer tomography (CT)
Please tick whether a coronary CT was performed or planned.
• Coronary artery bypass grafting (CABG)
Please tick whether CABG was performed or planned.
Intensive care unit
• Number of days spent in the intensive care unit
If patient was in ICU, please note the number of days the patient spent in ICU. If the patient was
less than 24 hours in ICU please note the number of hours spent there.
• SAPS II score (if available)
Please note the SAPS II Score (Simplified Acute Physiology Score) usually calculated in every ICU
(Le Gall et al. JAMA 1993, 270:2957-63).
Intermediate care unit
• Number of days spent in the intermediate care unit
If patient was in an intermediate care unit please note the number of days the patient spent there.
24 hours or less count as 1 day but only whole hours are taken into account, i.e., 24.5 hours=1 day
but 25 hours=2 days. This also includes the days the patient was monitored using telemetry once
back on the ward.
DISCHARGE
Survival
Mandatory field. Please tick whether the patient survived or not and proceed accordingly.
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IF SURVIVAL “YES”
»Discharge
• Date of discharge
Mandatory field. Please note the date of discharge from your hospital.
• Destination
Mandatory field. Please tick destination at discharge. Choose only one answer. If rehabilitation as
out-patient and home apply, please only tick rehabilitation as out-patient. If the patient is
transferred to another hospital please note to which hospital. Please specify if the patient went to a
different destination.
• Clinical diagnosis
Mandatory field. Please tick the appropriate clinical diagnosis.
Please be sure that:
(a) the diagnosis corresponds to the inclusion criteria (see page 1),
(b) biomarker levels are above your hospital cut-off level for MI.
If in doubt please comment in the space provided.
• Type of myocardial infarction according to the universal definitions
Please tick the type of myocardial infarction in accordance with Thygesen K et al. Eur Heart J 2007;
28(20): 2525-38.
Type 1: Spontaneous MI (plaque rupture and/or erosion)
Type 2: Secondary MI (spasm, anemia, arrhythmia, hyper/hypotension)
Type 3: Sudden cardiac death
Type 4a: Periprocedural PCI (>3x99th percentile of troponin or CK)
Type 4b: Stent thrombosis (>3x99th percentile of troponin or CK)
Type 5: Periprocedural CABG (>5x99th percentile of troponin or CK)
Drugs at discharge
• Total number of different drugs at discharge
Please count each and every drug at discharge in your hospital.
• Cardiovascular medication at discharge
Please tick each cardiovascular medication the patient did or didn’t receive at discharge with the
corresponding yes or no answer. Please state if medication was not given according to guidelines
due to contraindication.
• Other medication at discharge
Please tick each medication the patient did or didn’t receive at discharge with the corresponding
yes or no answer.
IF SURVIVAL “NO”
Death
• Date of death
• Cause of death
Mandatory fields. If the patient died during this hospitalization please fill out date of death and
cause of death.
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AMIS Plus Questionnaire Data Entry Instructions
• Clinical Diagnosis
Mandatory field. Please tick the appropriate clinical diagnosis.
Please be sure that:
(a) the diagnosis corresponds to the inclusion criteria (see page 1),
(b) biomarker levels are above your hospital cut-off level for MI.
If in doubt please comment in the space provided.
• Type of myocardial infarction according to the new universal definitions
Please tick the type of myocardial infarction in accordance with Thygesen K et al. Eur Heart J 2007;
28(20): 2525-38.
Type 1: Spontaneous MI (plaque rupture and/or erosion)
Type 2: Secondary MI (spasm, anemia, arrhythmia, hyper/hypotension)
Type 3: Sudden cardiac death
Type 4a: Periprocedural PCI (>3x99th percentile of troponin or CK)
Type 4b: Stent thrombosis (>3x99th percentile of troponin or CK)
Type 5: Periprocedural CABG (>5x99th percentile of troponin or CK)
PATIENT FOLLOW-UP
Was the patient asked to participate in the follow-up?
Mandatory field. Please tick if the patient was asked to take part in the follow-up interview?
IF YES:
Did the patient give his/her formal consent to a follow-up interview?
Please tick whether the patient signed the patient consent form. Patient consent forms can be
downloaded in PDF at the AMIS Plus Website.
The signed consent form remains with the medical records of the patient. (Please do not send these
to the AMIS Plus Data Center)
IF NO:
Why wasn’t the patient asked?
If the patient wasn’t asked to participate in the follow-up please tick the reason why.
First Name and Surname of Patient:
Once the consent form has been signed please note the first name and surname of patient.
Tel. Nr of Patient and/or Relative:
Please note the landline and mobile numbers of patient. Relatives can also be contacted.
Important Tips Concerning Follow-up:
The 3- and 12-Month follow-up interviews are normally carried out by the AMIS Plus Data Center
Team. This also includes patients from European countries. If desired, hospitals will be granted access
to perform their own follow-ups. The follow-up data are merged with the data from the AMIS Plus
Questionnaire in the AMIS Plus Data Center.
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