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CARDIAC CATHETERIZATION REFERRAL FORM Name: ________________________________________________________ Address: ______________________________________________________ SBH City: ___________ Request Date: ___/___/___ Phone: Home: ( Province: ________ )____________ DOB: ___/___/___ dd mmm yy Allergy: Other: o Cell/Work: ( Age: _____ years MHSC#: _______________ Postal Code: ______________ Sex: )_________________ M F PHIN#: _______________________________ X-ray Contrast o ASA o No Known Allergy Phone(204) 235-3834 dd mmm yy Fax : (204) 235-3586 www.cardiacsciences.mb.ca Referring Physician:(print)_________________________________ MD Contact # ___________________________________________ Hospital Name:__________________________________________ Unit/Ward: __________________ Ward Phone #_______________ Isolation: o Yes o No ACP Status________________________ Translator Needed? o Yes o No Language: MANDATORY REPORTS MUST BE SUBMITTED OR PROCEDURE WILL BE DELAYED: All PCI Reports, most recent Angiogram, MIBI, ECHO, Stress Tests and CABG OR Reports TO BE COMPLETED BY PHYSICIAN Procedure requested: o Coronary Angiography oLeft Heart Cath o Planned PTCA/Stent oRight Heart Cath oMyocardial biopsy oShunt Run oConsult oNitric Oxide Reversibility oOther:___________________o Supravalvular aortogram EXERCISE ECG (see Codes and Definitions on reverse) o Done o Not done Risk: o Low o High o Uninterpretable REFERRAL PHYSICIAN’S ESTIMATE OF URGENCY Area at risk: oAnterior oApical oInferior oLateral oSeptal LVEF: o Echo o Other o Not done o > 60% o 40-59% o 20-39% o < 20% o Inpatient Urgent (while still in hospital) o Outpatient Elective o Outpatient Urgent (within 2 weeks) Reason for Cardiac Cath: (check all reasons) see codes & definitions on reverse o MI this admission o STEMI o NSTEMI o Thrombolytics (this admit): Date: ___/___/___ Time: ________ dd mmm yy o TNK o RPA Ischemia o Stable Angina o Acute Coronary Syndrome CCS Angina class: o I o II o III o IV- A o IV-B o IV-C o IV-D o Atypical Heart Failure o CHF NYHA class: o1 o 2 o3 o4 FUNCTIONAL IMAGING (see Codes and Definitions on reverse) o Done o Not done If done, please specify: o Low Risk o High Risk COMORBIDITY ASSESSMENT: Most Recent Lab Data: (48 - 72 Hemoglobin (g/l): _______ Potassium: _______ hours for Inpatients) Platelets: _______ INR: _______ Creatinine (umol/L): _______ Hemoglobin A1C _______ Dialysis oYes oNo Days ____________ Diabetes oYes oNo If yes oType I oType II o Insulin o Oral Smoker - Current oYes oNo Hypertension oYes oNo Valvular Disease: (include Echo/Cath report) o None Hyperlipidemia oYes oNo o Aortic stenosis o Aortic regurgitation Previous CVA or TIA o Yes oNo o Mitral stenosis o Mitral regurgitation Peripheral Vascular Disease oYes oNo Severity: o mild o moderate o severe Severe COPD (FEV1<1L) oYes oNo Valve area (cm2):_______ Comments:______________________ History of cancer (< 5 yrs) oYes oNo History of bleeding (< 1 yr) oYes oNo Other (specify): _________________________________________ Weight _____________ On oral anticoagulation (eg. warfarin or alternative antithrombotic) o Yes o No Cardiac History: o No Previous Cardiac History On ASA oYes oNo Previous MI o < 1 week - 3 months o > 3 months On Antiplatelet Agent o Yes oNo o Prosthetic valve o CHF Ticagrelor o Clopidogrel (Plavix) Previous Bypass Surgery o Yes o No Yr _____ Location ____ o Previous Angiogram o Yes o No Yr _____ Location ______ On Heparin/LMWH/Fondaparinux oYes oNo Previous PTCA o Yes o No Yr _____ Location ______ PLEASE SEND Emergency Record / Admission Note / Consultation letter Complete for Inpatients only: Acute Coronary Syndrome: Peak CPK: ________ Peak Troponin:________ o Pacemaker o LBBB o LVH Circle all that apply: STEMI NSTEMI Please send 12 Lead ECG (Most Acute ECG) COMMENTS/PERTINENT PHYSICAL FINDINGS: Signature January 16, 2013 7102-1555-7 Page 1 of 2 Cardiac Catheterization Referral Form: Codes & Definitions (rev. 2000-02-21) CCS ANGINA CLASS Class Criteria CCS 0 Asymptomatic CCS I Ordinary physical activity such as walking or climbing stairs does not cause angina. Angina with strenuous, rapid or prolonged exertion at work or recreation. CCS II Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, or in the cold, or in wind, or under emotional stress, or during the few hours after awakening. Walking more than 2 blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions. CCS III Marked limitation of ordinary physical activity. Walking one or two blocks on the level or climbing one flight of stairs in normal conditions and at a normal pace. CCS IV-A Inability to carry out any physical activity without discomfort -- anginal syndrome may be present at rest. Patient admitted to hospital and becomes relatively asymptomatic with aggressive medical therapy and may be managed on an outpatient basis. CCS IV-B Inability to carry out any physical activity without discomfort -- anginal syndrome may be present at rest. Patient admitted to hospital continues to experience angina on maximal medical therapy and cannot be safely discharged home, but does not require IV nitroglycerin. CCS IV-C Inability to carry out any physical activity without discomfort -- anginal syndrome may be present at rest. Patient admitted to hospital and maximal medical therapy, including IV nitroglycerin, fails to control symptoms or there is hemodynamic instability. CCS IV-D Shock. HEART FAILURE CLASS (NYHA definitions) Class Criteria 1 2 3 4 No symptoms with ordinary physical activity. Symptoms with ordinary activity. Slight limitations of activity. Symptoms with less than ordinary activity. Marked limitation of activity. Symptoms with any physical activity or even at rest. EXERCISE ECG (criteria for classification of risk) Risk Criteria Low Associated with minor or no convincing findings for ischemia on exercise, ECG, Holter monitor, or radionuclide scanning. High Considered High Risk if any of the following are true: At least 2.5 mm of ST segment depression ST segment elevation greater than 1mm in leads without Q-waves Low workloads (heart rate below 120/beats/min) Early onset ST segment changes in first stage (3 min.) ST segment depression lasting longer than 8 minutes into the recovery phase: or Maximum heart rate of less than 120 beats/minute on no cardio-inhibitory medication; or A drop of systolic blood pressure of at least 10 mmHg at any time during the test; or Three or more beats of ventricular tachycardia at any time during the test. HIGH HOLTER MONITOR: For ambulatory ECG monitoring, shows prolonged and unequivocal ischemia. Uninterpretable Significant resting ST segment depression, or Left Bundle Branch Block (LBBB), or LVH, or digoxin therapy, or paced rhythm or WPW. FUNCTIONAL IMAGING (criteria for classification of risk; includes stress nuclear or stress echo) Risk Criteria Low Normal, or evidence of single-vessel disease not involving the anterior wall. High Clear evidence of multi-vessel disease or single-vessel disease involving a large segment of anterior wall. Legend: ACP - Advance Care Plan CCS - Canadian Cardiovascular Society CHF - Congestive Heart Failure COPD - Chronic Obstructive Pulmonary Disease CK - Creatine Phosphokinase CVA - Cerebral Vascular Accident ECG - Electrocardiogram ECHO - Echocardiogram 7102-1555-7 INR - International Normalized Ratio LBBB - Left Bundle Branch Block LMWH - Low Molecular Weight Heparin LVEF - Left Ventricle Ejection Fraction LVH - Left Ventricular Hypertrophy MI - Myocardial Infarction NSTEMI - Non ST Elevation Myocardial Infarction NYHA - New York Heart Association PTCA - Angiogram and Percutaneous Transluminal Coronary Angioplasty STEMI - ST Elevation Myocardial Infarction TIA - Transient Ischemic Attack TNK - Tenecteplase Page 2 of 2