Download Paper Questionnaire (For PCI Not Enable Hospital)

MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
MACE Registry Log Book
State:
City:
Hospital:
A. REGISTRATION
……………………………………………………………..
……………………………………………………………..
……………………………………………………………..
Patient Initials*:
Gender*:
Date of Birth Known*:
Registration Date* :
(at Registry Hospital)
Patient to be Registered in* :
( (Initials of First Name, Middle Name & Surname Only )
Male
Yes
No
……/……/………… (DD/MM/YY)
MACE Registry
Yes
No
Female
If Yes Mention Date ………../……../………
(DD/MM/YYYY)
Age : ……….Yrs
...... : …… (24 Hour Clock)
Informed consent
Yes
No
Please fill the reasons for non-inclusion
A1. REASONS FOR NON_INCLUSION
This questionairre needs to be completed in case the attending doctor suspects that the clinical diagnosis of Case is Acute
Coronary Syndromeand patient is not included in the registry. The MACE Registry intends to understand the reasons for
non-inclusion of such cases in the 'MACE' register.
Patient Admitted*
No
Yes
Plese tick the reasons for non-enrollment of this case in 'MACE' Registry.
Died before Consent could be
obtained*
Left hospital before Consent could be
obtained*
Patient / Relations refused consent*
Relations unavailable for consent*
Any Language barrier*
Miscellaneous*
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No
Yes
No
Yes
No
No
No
No
Yes
Yes
Yes
Yes
If Yes
……/……/………… (DD/MM/YY) ...... : ……(24 Hour Clock)
If Yes
Specify Here: ………………………………
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
REGISTERED IN MACE REGISTRY
Patient Initials*:
(Initials of First Name, Middle Name & Surname Only)
B. DEMOGRAPHIC DETAILS
Urban
Semi-Urban
Residence*:
Postal Code:
Current Employment Status*:
Rural
Professional,Big Business,Landlord,University Teacher
Trained,Clerical,Medium Bussiness Owner,Middle Level Farmer
Skilled Manual Labourer,Small Bussiness Owner,Small Farmer
Semi-Skilled Manual Labourer,Marginal LandOwner,Rickshaw Driver
Unskilled Manual Labourer,Landless Labourer
Housewife
Unemployed
Retired / Super Annuated
………….Years………Months
Rs. ………………………….
Monthly Income ( Past 1 Year )* :
C. INCLUSION/EXCLUSION CRITERIA
Inclusion Criteria* :
Acute Coronary Syndrome with definite ECG changes and/or enzyme elevation
Suspected of Unstable Angina but without definite ECG changes or elevation of cardiac enzymes.
Suspected case of ACS but no definite ECG changes and no ENZYME elevation. However the
patient has a definite history of any one or more of the following: Ischemic Heart Disease ,Prior MI, PTCA, CABG, Positive
TMT or Angiographic Evidence of Coronary Heart Disease.
Specify Here:
……………………………………………………………..
Exclusion Criteria :
1. Patients with serious unrelated disease [e.g. advanced malignancy, surgery or trauma] which may limit life expectancy to
less than the 30-day follow up period
2. Patient brought dead on arrival at hospital
Patient Participating in any other clinical trial?*
No
Yes
Specify Here : ………………………………
D. Medical History & Risk Factors
Not
Known
No
Yes
Stable Angina*
Prior MI*
PTCA*
CABG*
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If Yes
……………
(if > 1 Episode, Give Year of the most recent one)
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
Not
Known
No
D. Medical History & Risk Factors (Contd.)
Yes
Positive TMT*
CAG Evidence of CAD*
Other Cardiovascular
Events*
If Yes
TIA/Stroke
Peripheral Artery Disease
Renovascular Disease
Any Other Vascular Disease
CHF
Family History
of CHD / Stroke*
Dyslipidemia*
Hypertension*
If Yes
Diabetes*
Smoking Status*
If Yes
Never
Yes
Current Smoker
Past Status
Smokeless Tobacco
Status [Paan with
tobacco,Gutka Etc.]*
Never
Yes
Current Status
Past Status
Symptom Onset *:
First Contact With Medical Professional*:
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Less than 1 Yr
1 or more Yrs
Duration (Yrs) : ………………
Less than 1 Yr
1 or more Yrs
Duration (Yrs) : ………………
Smoking Since : ………….Yrs ………….Months;
Number : ………….Per Day
Smoked For : …………. Yrs …………. Months ;
Left Since : ………….Yrs ………….Months
Taking Since : ………….Yrs ………….Months ;
Number : ………….Per Day
Took For: ………….Yrs ………….Months;
Left Since : ………….Yrs ………….Months
E. Presentation
……/……/………… (DD/MM/YY) …... : …… (24 Hour Clock)
……/……/………… (DD/MM/YY) …... : …… (24 Hour Clock)
First Medical Contact
Registry Hospital
Other (e.g. General Physician, Nursing Home etc)
If Other please specify: ………………………………………….
Time lapsed after symptom onset to first medical contact: ……………………….
If time lapse is more than 6 Hrs, Reasons for delay: ………………………..
Patient did not recognize symptoms
Confused with gastritis/acidity
Long travel time
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
Lack of transportation
Event occured at odd hours
Went to alternate systems of medicine
Financial reasons
Others Specify Here: ……………………
Whether patient admitted at first medical contact health facility:
No
Yes
If Yes:
Dischaged
Referred
Treatment given at first
Aspirin
Clopidogrel
medical contact facility:
Thrombolytic Therapy
Statin
None
Mode of Transport to First Medical
ContactFacility *:
(Select One)
Mode of Transport to Registry Hospital*:
(Select One)
Transfer From Other Hospital*
Ambulance
Private Transport e.g. Car
Public Transport e.g. Bus
Other
Specify : …………………………………
Ambulance
Private Transport e.g. Car
Public Transport e.g. Bus
Other
Specify : …………………………………
No
Yes
Presentation to Emergency
Room/Casuality*:
If Yes
Name of The Hospital : …………………………………..
Date/Time
……/……/…………
…... : ……
(DD/MM/YY)
(24 Hour Clock)
Documentation
No
Yes
Available?
……/……/………… (DD/MM/YY)
F.
PROVISIONAL DIAGNOSIS ON ADMISSION*:
(Select Any One)
…... : …… (24 Hour Clock)
Provisional Diagnosis
Unstable Angina
ST Elevation
MI
Non ST Elevation MI
Rule Out MI/ACE
Other Cardiac
Other
G. Physical Examination at Time of Presentation
Heart Rate(per minute) *: ………………..
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Blood Pressure (Systolic): ………………….
Blood Pressure (Diastolic): ………………….
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
Kilip Class*:
I (No CHF)
III (Pulmonary Edema)
H. ECG Findings
……/……/………… (DD/MM/YY)
1a. Index ECG in Registry Hospital
1b. ECG System of the heart
STEMI
NTEMI / USA
Left Bundle Branch Block*
Right Bundle Branch Block*
II(Rales)
IV (Cardiogenic Shock)
No
Yes
No
Yes
…... : …… (24 Hour Clock)
ST elevation
Anterior leads
Lateral leads
Inferior leads
Septal leads
ST depression
T waves
None
If Yes
New
Old
Unknown
If Yes
New
Old
Unknown
1c. Other abnormalities ? (Fill in all that apply) *
No
Yes
If Yes
Atrial Fib/Flutter
Vtach
Posterior Infarction
RBBB
Nonspecific ST/T Change
Paced Rhythm
Left Ventricular Hypertrophy
AV Block
First Degree
(mobitz,3) →
Type I 2nd Degree
Type II 2nd Degree
3rd Degree
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MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
FORM 2
I.
Initial Creatinine*
Random Glucose*
Fasting Glucose*
No
Yes
µmol/liter …………………………………
mg/dl
…………………………………
No
Yes
µmol/liter …………………………………
mg/dl
…………………………………
No
Yes
µmol/liter …………………………………
mg/dl
…………………………………
Cardiac Marker - Maximum Values in 1st 24 hrs
CPK*
Not Done
Done
CK-MB*
Troponin*
Not Done
Done
Not Done
Done
Pre-Hospital Management*
Laboratory
+ve
-ve
+ve
-ve
Trop I
Trop T
+ve
-ve
J. Hospital Treatment & Counselling (Fill in all that apply)
Aspirin
Statins
Others  Select From List
Clopidogrel / Prasugrel / Ticagretor
None
Unfractionated Heparin
LMWH & Fondaparinux
Oral Anticoagulants
Glycoprotein II B/ III A Inhibitors
Nitrates
Trimetazidine
Ranolazine
Beta-Blockers
Calcium Channel Blockers
a) Non-Dihydropyridine
b) Dihydropyridine
ACE Inhibitors
ARBs
Fibrates
Insulin
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MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
Other Antidiabetics
None
During Admission*
Aspirin
Prescribed at Discharge*
Calcium Channel Blockers:
Clopidogrel / Prasugrel / Ticagretor
a)
Unfractionated Heparin
b) Dihydropyridine
LMWH & Fondaparinux
ARBs
Glycoprotein II B/III A Inhibitors
Statins
Nitrates
Fibrates
Beta-Blockers
Insulin
ACE Inhibitors
Other Antidiabetics
Aspirin
Clopidogrel / Prasugrel / Ticagretor
Oral Anticoagulants
Nitrates
Trimetazidine
Ranolazine
Beta-Blockers
ACE Inhibitors
Non-Dihydropyridine
Calcium Channel Blockers:
a) Non-Dihydropyridine
b) Dihydropyridine
ARBs
Statins
Fibrates
Insulin
Other Antidiabetics
None
K. Revascularization Therapy
Did the Patient undergo following Treatment / Procedure during Hospitalization ?
Thrombolysis*
No
If No
Out of window period
Patient could not afford
Eligible but no consent
Done before patient reached Reg
Hospital
Underwent PTCA
ECHO*
Was the patient
referred to PCI
enabled
hospital?*
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Yes
If Yes
……/……/………… (DD/MM/YY) …... : …… (24 Hour Clock)
Thrombolytic Agents
Streptokinase
Urokinase
Tenecteplase
RTPA
No
Yes
If Yes
LVEF Ejection Fraction %
RWMA
Value : ………………...
Yes
No
No
Yes
Registry Hospital
Other Hospital
Name ………………………………………….
Name ………………………………………….
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
L.
Reinfarction*
Stroke*
Events and Outcome in The Hospital
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
Hemorrhagic[CT/MRI Confirmed]
Ischemic[CT/MRI confirmed]
Unclassified [Only Clinical Diagnosis or Uncertain]
LV Failure/CHF*
Recurrent Ischemia/Angina*
Cardiac Arrest*
Cardiogenic Shock*
Pulmonary Embolism*
Bleeding Requiring
Transfusion*
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
Ventricular Fibrillation
Pulseless VT
Asystole
Un-witnessed Arrest
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
Yes
If Yes :
……/……/………… (DD/MM/YY)
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
Cause:
Cardiovascular
No
Final Outcome*
Death
Discharge
Diagnosis at discharge*
Unstable
Angina
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No
Yes
No
Yes
If Yes :
……/……/………… (DD/MM/YY)
Non-Cardiovascular
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
MI
No
Yes
If Yes :
STEMI
Location of MI:
NSTEMI
AWMI
IWMI + RVMI
IWMI
Lateral Wall MI
Physical measurements at discharge
Height(cm) :
…………………………………………………….
Weight(kg) :
…………………………………………………….
BMI(kg/m2) :
Automaticlly Calculated [Please do not fill]
Payment Methods Adopted by ACS Patient? *
Completely by Patient
Partially by Patient and Partially by Insurance
Partially by Patient and Partially by Govt.
Partially by Patient and Partially by Employer
Completely by Insurance
Completely by Govt.
Completely by Employer
Charitable Hospital & Patient will get Free Care
M. Counselling
Adviced to Quit Smoking*
No
Yes
Not Known
Dietary Modification Counseling*
No
Yes
Not Known
Exercise Counseling*
No
Yes
Not Known
Cardiac Rehab Referral*
No
Yes
Not Available
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MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
FOLLOW UP ………… (To be filled AFTER ……………. of Acute Event by Treating Physician)
DATE OF FOLLOW-UP : ……/……/………… (DD/MM/YY)
Lost to Follow-up
No
Yes
Follow-up
Hospital Visit
Home Visit
Outcome
Alive
Death
If Dead:
Specify Reasons
Telephone
…………………………………………..
Postal
……/……/………… (DD/MM/YY) …... : …… (24 Hour Clock)
Cause:
Cardiovascular
Non-Cardiovascular
DRUGS PRESCRIBED AND TAKEN
Define Regularity
(Adherence Rate)↓
Anti Platlet Agents
Oral antithrombotics
Beta Blockers
ACE inhibitors
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No
Yes
If Yes
Aspirin
Cilostazol
Clopidogrel
Prasugrel
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
No
Yes
If Yes
Acitrom
Warfarin
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
No
Yes
If Yes
Atenolol
Carvedilol
Metoprolol
Nebivolol
Propranolol
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
No
Yes
If Yes
Enalapril
Lisinopril
Ramipril
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
FOLLOW UP ………………. (Contd.)
Calcium Channel Blockers
Angiotensin Receptor Antagonists
Lipid Lowering Drugs
Other Cardiovascular Drugs
Insulin
No
Yes
If Yes
Amlodipine
Diltiazem
Verapamil
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
No
Yes
If Yes
Losartan
Olmesartan
Telmisartan
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
No
Yes
If Yes
Atorvastatin
Fenofibrate
Rosuvastatin
Simvastatin
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
No
Yes
If Yes
No
Yes
If Yes
A. NITRATES
-- Nitrotryglcerine
--Isosorbide
Mononitrate
B. NICORANDIL
C. TRIMETAZIDINE
D. RANOLAZINE
E. DIURETICS
--Chlorthalidone
--Furosemide
-Hydrochlorothiazide
--Spironolactone
--Torsemide
F. OTHER
Regular Insulin
Other
< 50%
50 - 70%
71 - 90 %
> 90 %
< 50%
50 - 70%
71 - 90 %
> 90 %
EVENTS AND PROCEDURES AFTER DISCHARGE UPTO ______ FROM ADMISSION
Rehospitalization
No
Yes
If Yes
……/……/………… (DD/MM/YY)
Reason
Worsening Angina
Heart Failure
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MANAGEMENT OF ACUTE CORONARY EVENTS(MACE) Registry
DATA COLLECTION FORM
Unique ID (As Generated Automatically Online.):…………………………………………
FOLLOW UP ………………… (Contd.)
Reinfarction / Unstable Angina
Stroke
Cardiac Arrest
Coronary Angiography
PTCA
CABG Surgery
No
Yes
If Yes
……/……/………… (DD/MM/YY)
No
Yes
If Yes
……/……/………… (DD/MM/YY)
Cause
Hemorrhagic[CT/MRI
Confirmed]
Ischemic[CT/MRI
confirmed]
Unclassified [Only Clinical
Diagnosis or Uncertain]
No
Yes
If Yes
……/……/………… (DD/MM/YY)
Cause
Ventricular Fibrillation
Pulseless VT
Asystole
No
Yes
If Yes
……/……/………… (DD/MM/YY)
No
Yes
If Yes
……/……/………… (DD/MM/YY)
Reason
Recurrence of ACS
Worsening Angina
Inducible Ischemia on
Stress
Any Other
Specify: ………………….
No
Yes
If Yes
……/……/………… (DD/MM/YY)
Reason
Recurrence of ACS
Worsening Angina
Inducible Ischemia on
Stress
Any Other
Specify: ………………….
Mandatory Field -> *; Radio Button (Select One)) -> Red; Drop down Menu (Select One) -> Blue; Check Box
(Multiple Selection) -> Purple
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