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Medical History Form - Chart FORM CODE: MHC VERSION:A 05/13/10 ID NUMBER: Contact Occasion 0 1 SEQ # Administrative Information / 0a. Completion Date: Month / Day 0b. Staff ID: Year Instructions: This form is completed by chart abstraction. Conditions in the chart up to and including discharge from the index event should be considered. Any condition that is in the chart after the day of discharge of the index event to the assessment date (2-6 months later) is not to be coded. Affix the participant ID label above. Part A. Charlson Comorbidity Questions Does the medical chart indicate the presence or history of any of the following medical comorbidities at the time of the index ACS event? Condition ICD-9 Code(s) 1 Myocardial infarction 410, 411 2 Congestive heart failure * 398, 402, 428 3 Peripheral vascular disease * 440-447 4 Dementia 290, 291, 294 5 Cerebrovascular disease 430-433, 435 6 Chronic pulmonary disease 491-493 7 Connective tissue disease 710, 714, 725 8 Ulcer disease 531-534 9 Mild liver disease 571, 573 10 Hemiplegia 342, 434, 436, 437 11 Moderate or severe renal disease 403, 404, 580-586 12 Diabetes 250 13 Any tumor 140-195 14 Leukemia 204-208 15 Lymphoma 200, 202, 203 16 Moderate or severe liver disease 070, 570, 572 17 Metastatic solid tumor 196-199 No Yes *Also part of GRACE Medical History Form – Chart (MHC) Page 1 of 6 ID #: Part B. GRACE Comorbidity Questions Medical History and Presentation characteristics Does the medical chart indicate the presence or history of any of the following medical comorbidities at the time of the index ACS event? 1. Hypertension No Yes 2. PCI No Yes 3. Pulse 4. bpm Blood pressure (SBP/DBP) at initial (index) presentation: a. b. Systolic (mmHg) 5. Killip class at initial (index) presentation: I . 6. Initial serum creatinine II III Diastolic (mmHg) IV mg/dL Initial elevated cardiac markers or enzymes 7. Troponin I or T performed? No Yes If YES to 7, answer 7a-7c. 7a. Instrument: cTnI (cardiac troponin I) cTnT (cardiac troponin T) Other, specify: ________________ 7b. Assay: Abbott AxSYM ADV Abbott Architect Abbott i-STAT Beckman Access Accu Beckman Access hs-cTnI bioMerieux Vidas Ultra Innotrac Aio! Inverness Bisite Triage 7c. Mitsubishi PATHFAST Nanosphere hs-cTnI Ortho Vitros ECi ES Radiometer AQT90 Response RAMP Roche E170 Roche Elecsys 2010 Siemens Centaur Ultra Siemens Dimension RxL Siemens Immulite 2500 Siemens Stratus CS Siemens VISTA Singulex hs-cTnI Tosoh AIA II Other, specify: _________________________ . Troponin at initial hospital presentation: ng/dL 8. CK-MB > upper limit of hospital’s normal range, or if no CK-MB available, then total CPK > 2x upper limit of the hospital’s normal range? No Yes 9. Initial total cholesterol: mg/dL 10. Initial triglycerides: mg/dL 11. Initial LDL: mg/dL 12. Initial HDL: mg/dL . 13. Initial hemoglobin A1c: % 14. Cardiac arrest at initial (index) presentation? Medical History Form – Chart (MHC) No Yes Page 2 of 6 ID #: Part C. Medical Comorbidity Questions Does the medical chart indicate the presence or history of any of the following medical comorbidities at the time of the index ACS event? NOTE: For questions 2-5, Unknown = No documentation of Positive or Negative History OR Unclear documentation. 1. How many previous PCIs prior to the index cardiac event? 0 1 2 3 or more 2. Coronary Artery Bypass Surgery (CABG) / 2a. If Yes, most recent date: No Yes Unknown / Month 3. Dyslipidemia No Day Yes Year Unknown (As documented by (1) intake/discharge note, or (2) current use of hypolipidemic medication) 4. AIDS No 5. Thyroid disease Yes Unknown (Note: not including those with asymptomatic HIV+) No 5a. If Yes, type: Yes Unknown Hyperthyroidism Hypothyroidism Part D. Index Acute Coronary Syndrome (ACS) Event 1. Hospital Name: ________________________________________ 2. Hospital admission date: / / Month Day Year 3. Transferred from another hospital? No Yes If Yes: 3a. Hospital Name: ________________________________________ / 3b. Transfer date: / Month 4. Day / Date of ACS diagnosis: / Month 5. Year Day Year / Hospital discharge date: Month / Day Year 6. Heart rate at discharge from index hospitalization: 7. Blood pressure (SBP/DBP) at discharge from index hospitalization: a. bpm b. Systolic (mmHg) Medical History Form – Chart (MHC) Diastolic (mmHg) Page 3 of 6 ID #: Part E. ECG Findings for Index ACS Event 1. Admitting ECG available? No / 1a. Date of ECG: / Month Day Hour Pre-discharge ECG available? AM / PM Minute (circle one) No Yes / 2a. Date of ECG: Month / Day : 2b. Time of ECG: Hour 3. ECG changes? Year : 1b. Time of ECG: 2. Yes No Year AM / PM Minute (circle one) Yes If Yes, retain a copy of ECG on which diagnosis was made and a copy of subsequent ECG after “evolution” of the changes. If Yes to #3 ECG changes, answer #4 and #5. If No, go to #6. 4. For the diagnostic ECG, indicate type(s) of ECG changes (check all that apply in 4a – 4d): a. ST-segment elevation 0.1 mV elevation in 2 or more contiguous leads (check all that apply): Inferior leads (II, III, AVF) Anterior leads (V1 to V4) Lateral leads (I, aVL, V5 to V6) True posterior (V1, V2) with tall R waves in these leads b. Q waves greater 0.04 seconds in width and 0.1 mV in depth in at least 2 contiguous leads (check all that apply): Inferior leads (II, III, AVF) Anterior leads (V1 to V4) Lateral leads (I, aVL, V5 to V6) True posterior (tall R waves in V1 V2) c. ST-segment depression > 0.05 mV in 2 more contiguous leads (includes reciprocal changes) d. T-wave inversion of at least 0.1 mV 5. For the ECG after evolution of the changes, indicate the pattern: .... 6. Paced rhythm? ................................ No Yes 7. Atrial fibrillation or flutter? ................ No Yes 8. Bundle branch block? ...................... No Yes 8a. Type ...................................... RBBB LBBB 8b. Timing .................................... New Old Medical History Form – Chart (MHC) Q wave non-Q wave Unknown Page 4 of 6 ID #: Part F. Procedures during hospitalization for Index ACS Event 1. Stress test? No Yes If Yes, then answer the following: / 1a. Date of test: / Month Day 1b. Stress test type Year Exercise Pharmacological If Exercise, to target heart rate? No 1c. Imaging type: EKG only 1d. Ischemia Result Positive Nuclear PET Negative 1e. Fixed defect indicating an old MI: 1f. Yes Present Echocardiogram Equivocal Absent Other findings (e.g, hypotension, delayed hysteresis): __________________________ 2. LV function assessed during hospitalization? No Yes If Yes, then answer the following: . 2a. Initial LVEF: % or check one: 2b. Normal/Low normal Mildly reduced Mild-moderately reduced 3. Moderately reduced Moderate-severely reduced Severely reduced Diagnostic cardiac catheterization? No Yes If Yes, then answer the following: / 3a. Date: / Month Day Year 3b. Maximum stenosis (%): LAD 4. PCI performed? LCx No RCx LM Yes If Yes, then answer the following: / 4a. Date: / Month Day Year 4b. Number of stents placed: 4c. Stent type: Bare metal Drug-eluting 4d. Complications of PCI? No Yes If Yes, type: (check all that apply) Bleeding Vascular complication Cardiac tamponade 5. Arrhythmia Stroke Contrast reaction Coronary Artery Bypass Surgery performed? No Acute renal failure Yes If Yes, then answer the following: / 5a. Date: Month / Day Medical History Form – Chart (MHC) Year Page 5 of 6 ID #: Part G. Medications at Discharge from Index ACS Event NOTE: Record the medications prescribed to the patient at the time of discharge from the index ACS event hospitalization. When entering the daily dose, use one of the boxes for the decimal point if necessary. No 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. ACE inhibitors ............................... Angiotensin II receptor blockers . Aspirin ............................................ Clopidogrel .................................... Other antiplatelet agents ............. Anticoagulants (e.g., Warfarin) ....... Beta-blockers ................................ Calcium channel blockers ........... Digitalis/Digoxin ............................ Other inotropic agent (not digitalis) Diuretics ......................................... Statin lipid-lowering agents ......... Non-statin lipid-lowering agents . Nitrates ........................................... Vasodilators (not ACE inhibitors) ..... PO hypoglycemic antidiabetic .... Insulin ........................................... Antiarrhythmics ............................. Female hormone replacement therapy ...................................... Thyroid replacement therapy ...... Antipsychotics ............................... Other drug class ........................... Other drug class ........................... Other drug class ........................... Other drug class ........................... Medical History Form – Chart (MHC) Yes Unknown Name Daily Dose Units ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ ______________ _____ Page 6 of 6