Download CARDIAC CATHETERIZATION REFERRAL FORM SBH

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
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% oInpatient
o Outpatient 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
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
Valvular Disease: (include Echo/Cath report) o None
Hypertension
oYes
oNo
o Aortic stenosis
o Aortic regurgitation
Hyperlipidemia
oYes
oNo
o Mitral stenosis
o Mitral regurgitation
Previous CVA or TIA
oYes
oNo
Severity: o mild
o moderate o severe
Peripheral Vascular Disease oYes
oNo
Severe
COPD
(FEV1<1L)
o
Yes
oNo
2
Valve area (cm ):_______ Comments:______________________
History of cancer (< 5 yrs)
oYes
oNo
Other (specify): _________________________________________
History of bleeding (< 1 yr)
oYes
oNo
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
March 20, 2015
7102-1555-7
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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
Inability to carry out any physical activity without discomfort -- anginal syndrome may be present at rest.
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
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