Download WRHA Cardiac Sciences Wednesday 1600 Hours Weekly Complex Case Rounds Referral Form

WRHA Cardiac Sciences
Wednesday 1600 Hours Weekly
Complex Case Rounds Referral Form
Submission deadline is Monday at 1700 Hours
Call Cath Lab Booking Clerk at 204.235.3834
fax #: 204.235.3586 to submit case
Guidelines for referral are complex patients when the best treatment option is uncertain. May include left main
coronary disease; 3 vessel coronary disease; adult congenital disease, complex valve cases, redo cardiac surgery cases,
high surgical risk; adverse patient factors including frailty, cognitive impairment, significant comorbid disease and
therapeutic uncertainty
Question to be addressed:
I. CABG Vs. PCI Vs. Medical
II. Valve Surgery Vs. TAVI Vs. Medical
III. Transplantation
IV. VAD
V. Pericardectomy
VI. Adverse Event ______________________
VII.Other _____________________________
Therapeutic Problem:
a. Angina b. Congestive Heart Failure
c. Asymptomatic LV Dysfunction
d. Asymptomatic CAD
e. Other
Diagnostic Category: a. CAD
b. Valvular Disease c. Mixed CAD Valvular Disease
e.Pericardial
f.Cardiomyopathy g. Other
Indicate favored treatment option: a.CABG
b. Valve Surgery
f. Medical Therapy
g. Palliative Care/Pain Control
Referring MD Name
(print):
c. TAVI
d. PCI
e. Further Investigation
h. Further discussion with patient about options
___________________________ Presenting MD Name
Date of Cardiac Cath
D
D
M
M
M
Y
Y
Y
d. Congenital
(print):
___________________________
Date of CT
Y
D
D
M
M
M
Y
Y
Y
Y
D
D
M
M
M
Y
Y
Y
Y
Date of ECHODate of MRI
D
D
M
M
M
Y
Dementia (see back of form) q
None
Age _______
Gender _______
Y
Y
Y
q
Mild
qModerate
Weight _______
q
Severe
Serum Creatinine _______ umol/L
Extra Cardiac Arteriopathy...................................................................................................................... qYes
qNo
(claudication, carotid occlusion or >50% stenosis, amputation for peripheral vascular disease previous/planned intervention)
Clinical Fraility Score (see back of form)..............................................................................................______________
Previous Cardiac Surgery ...................................................................................................................... qYes qNo
Chronic Lung Disease ........................................................................................................................... qYes
qNo
Active Endocarditis ................................................................................................................................ qYes
qNo
Critical Preoperative State ..................................................................................................................... qYes
qNo
Euroscore II Parameters
(long term use bronchodilators or steroids)
(antibiotic or endocarditis at time of surgery)
(pre-op ventricular tachycardia or ventricular fibrillation or aborted sudden death, cardiac massage, inotropes or IABP,
anuria or oliguria <10ml/hr)
Diabetic requiring Insulin ........................................................................................................................ qYes qNo
NYHA Class (see back of form) .......................................................................................... qI qII qIII qIV
CCS Class (see back of form) ............................................................................................
qI
LV Function (see back of form) ............................................... qGood
qModerate
MI < 90 days ......................................................................................................................
qII
qIII qIV
qPoor qVery Poor
qYes q No
Pulmonary hypertension
qNo
qModerate (PA systolic 31-55 mmHg)
qSevere (PA systolic >55 mmHg)
Urgency: ............................................................................. qElective q
Urgent
qEmergency qSalvage
Elective, Urgent (stable, cannot be sent home), Emergency (Must be done today), Salvage (CPR/ECMO preop)
Weight of Intervention: .....
qCABG
qNon-CABG
q2 Procedures
q> two 2 Procedures
Surgery on Thoracic Aorta .................................................................................................................... qYes
September 3, 2015
7102-4174-4
qNo
Page 1 of 3
WRHA Cardiac Sciences
Wednesday 1600 Hours Weekly
Complex Case Rounds Referral Form
Submission deadline is Monday at 1700 Hours
Call Cath Lab Booking Clerk at 204.235.3834
fax #: 204.235.3586 to submit case
Child-Pugh score
For patients with liver disease:
Measure
1 point
2 points
3 points
Total bilirubin μmol/l
<34
34-50
>50
Plasma albumin, g/l
>35
28-35
<28
PT INR
<1.7
1.71-2.30
> 2.30
Ascites (see back of form)
None
Mild
Moderate to Severe
Encephalopathy (see back of form) None
Grade I-II
Grade III-IV
(or suppressed with Rx) (or refractory)
Other significant comorbity or concerns not listed above ____________________________________________________________
Clinical Frailty Scale:
1 Very Fit
2 Well
3 Managing Well
4 Vulnerable
5 Mildly Frail
6 Moderately Frail
7 Severely Frail
8 Very Severely Frail
9 Terminally ill
Robust, active, energetic, motivated, exercise regularly
No active disease, less fit than category 1, exercise occasionally, e.g. seasonally
Medical problems well controlled, not regularly active beyond routine walking
Not dependent for daily help, symptoms limit activities
Evident slowing, transportation, heavy housework, medications, shopping, walking, meal preparation
Help with all outside activities, keeping house, stairs, bathing, minimal assistance dressing
Completely dependent for personal care (physical or cognitive; stable not high risk of dying < 6 mon
Completely dependent, approaching end of life, could not recover even from a minor illness
Life expectancy <6 months
CMAJ 2005; 173(5):489-95
Dementia Scoring:
Mild
Moderate
Severe
forgetting details of recent event though remembers event, repeating same question/story,
social withdrawal
recent memory very impaired, can remember past life events well, personal care with prompting
cannot do personal care without help
LV Function:
Good (LVEF > 50%)
NYHA Class: I (no dyspnea in ordinary activity) II (slight limitation during ordinary activity) III (marked limitation
during ordinary activity) IV (symptoms at rest)
CCS Class: 0 (no angina) I (angina during strenuous activity) II (angina during moderate physical activity)
III (angina with everyday living activities) IV (angina at rest)
Moderate (LVEF 31-50%)
Poor (LVEF 21-30%)
Very Poor (< 21%)
Ascites grades:
1: mild, only visible on ultrasound and CT
2: moderate symmetrical distension of abdomen detectable with flank bulging and shifting dullness
3: directly visible, large or gross ascites with marked abdominal distension
Hepatic encephalopathy:
1: Trivial lack awareness; euphoria or anxiety; shortened attention span; impaired simple math
2: Lethargy/apathy; minimal disorientation time/place; min personality change; inappropriate behavior
3: Somnolence-semi stupor but responsive to verbal stimuli; confusion; gross disorientation
CABG
Child-Pugh Points
Life Expectancy years
Perioperative Mortality
A = 5-6
15-20
10%
B = 7-9
4-14
30%
C = 10-15
4-14
80%
Journal of Hepatology 2005; 42: S100–S107; Lancet 2008; 371: 838–51
Coronary Artery Bypass Surgery
CCS
Canadian Cardiovascular Society
ECHOEchocardiogram
eGRF
estimated glomerular filtration rate
IABP
Intra Aortic Balloon pump
LV
Left ventricle
MI
Myocardial Infarction
NYHA
New York Heart Association
PA
Pulmonary Artery
PCI
Percutaneous Coronary Intervention
RV
Right ventricle
TAVI
Transtheter Aortic Valve Implantation
VAD
Ventricular Assisted Device
Page 2 of 3
WRHA Cardiac Sciences
Wednesday 1600 Hours Weekly
Complex Case Rounds Response
Date of Rounds
D
D
M
M
M
Y
Y
Y
Y
Completed by the Chairperson
Referring MD: ____________________________
Syntax Score ______________
EuroSCORE II
______________
1. Outcome of Discussion
a. CABG recommended
b. Valve surgery recommended
c. TAVI recommended
d. PCI recommended
e. Further investigation recommended
i. Cardiac MR
ii. Cardiac CT
iii.Dobutamine Stress Echo (DSE)
iv.Myocardial Perfusion Scan (MIBI)
v. Graded Exercise Test (GXT)
vi.Other: _________________________
f. Medical therapy recommended
g. Palliative care / Pain Control recommended
h. Other: ___________________________________________________________________________________
_________________________________________________________________________________________
2.
Discussion Vote
a. Unanimous decision
b. Majority vote
c. No conclusion could be reached
d. Further discussion with patient/family
Page 3 of 3