Patient history
Indicate if the patient has a current or previous diagnosis of hypertension as defined by any of the following: - History of hypertension diagnosed and treated with medication, diet, and/or exercise - On at least 2 occasions, documented blood pressure >140 mm Hg systolic and/or 90 mm Hg diastolic in patients without diabetes or chronic kidney disease; >130 mm Hg systolic or 80 mm Hg diastolic in patients with diabetes or chronic kidney disease - Currently on pharmacological therapy for treatment of hypertension More than 1 of the above may apply. The year of onset (first diagnosis) may be helpful.
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History of diabetes diagnosed and/or treated by a physician. The American Diabetes Association criteria include documentation of the following - Hemoglobin A1c >6.5%; or - Fasting plasma glucose >126 mg/dL (7.0 mmol/L); or - Two-hour plasma glucose >200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test; or - In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose >200 mg/dL (11.1 mmol/L). This does not include gestational diabetes. Indicate the following: 1. Type 1 or type 2 diabetes 2. Year of onset (if known)
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Current or previous diagnosis of dyslipidemia per the National Cholesterol Education Program criteria, defined as any 1 of the following: - Total cholesterol >200 mg/dL (5.18 mmol/L) - LDL >=130 mg/dL (3.37 mmol/L) - HDL <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.30 mmol/L) in women Treatment is also initiated if LDL is >100 mg/dL (2.59 mmol/L) in patients with known coronary artery disease or CHD equivalent, and this would qualify as hypercholesterolemia.
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History confirming cigarette smoking in the past.
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Specify the patient’s history of alcohol consumption. Choose from the following categories: - None - <=1 alcoholic drinks/wk - 2–7 alcoholic drinks/wk - 8–13 alcoholic drinks/wk - 14–20 alcoholic drinks/wk - >=21 alcoholic drinks/wk Specify alcohol-dependency history. Choose all that apply: Documented alcohol dependency Medical sequelae of alcohol consumption (alcoholic hepatitis, cirrhosis, alcohol neuropathy, Wernicke-Korsakoff syndrome) Treatment for alcohol dependency For patients with alcohol dependency, note treatment for dependency, cessation of use, or continued use.
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Indicate history of current, recent, or remote abuse of any illicit drug (eg, cocaine, methamphetamine, marijuana) or controlled substance.
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The term myocardial infarction should be used when there is evidence of myocardial necrosis in a clinical setting consistent with myocardial ischemia. Under these conditions, any 1 of the following criteria meets the diagnosis for MI: 1) Detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least 1 value above the 99th percentile of URL together with evidence of myocardial ischemia with at least 1 of the following: — Symptoms of ischemia — Electrocardiographic changes indicative of new ischemia (new ST-T changes or new LBBB) — Development of pathological Q waves in the ECG — Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality 2) Sudden unexpected cardiac death, involving cardiac arrest, often with symptoms suggestive of myocardial ischemia, and accompanied by presumably new ST elevation or new LBBB and/or evidence of fresh thrombus by coronary angiography a time before the appearance of cardiac biomarkers in the blood. 3) For PCI in patients with normal baseline indicative of periprocedural myocardial necrosis. By convention, increases of biomarkers >3x99th percentile URL have been designated as PCI-related MI. A subtype related to a documented stent thrombosis is recognized. 4) For CABG in patients with normal baseline troponin values, elevations of cardiac biomarkers above the 99th percentile URL are indicative of periprocedural myocardial necrosis. By convention, increases of biomarkers >5x99th percentile URL plus either new pathological Q waves or new or imaging evidence of new loss of viable myocardium have been designated as defining CABG-related MI. 5) Pathological findings of an acute MI.
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Indicate if the patient had an MI within 6 wk prior to the index procedure as evidenced by the following: 1.) Acute MI (<=7 d) manifested as a rise and fall of cardiac biomarkers (preferably troponin) with at least 1 value above the range of normal for your laboratory (above the 99th percentile of the URL) together with evidence of myocardial ischemia with at least 1 of the following: a. Ischemic symptoms b. Electrocardiographic changes indicative of new ischemia (new ST-T and/or T-wave changes or new LBBB) c. Development of pathological Q waves on the ECG d. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality 2.) Recent MI (>7 d) manifested by a. An MI meeting the criteria for an acute MI as documented in the medical record, or b. By any 1 of the following: 1. Development of new pathological Q waves with or without symptoms 2. Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract 3. In the absence of a nonischemic cause
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History of angina - Stable angina (CCS class, date of onset) - Unstable angina (date of onset) - Prior angina (currently asymptomatic)
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Indicate history of prior Coronary Artery Bypass Graft (CABG) surgery, including the date or year of surgery. The total number of CABG procedures and the year of the most recent procedure may be helpful.
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Prior PCI of any type (balloon angioplasty, atherectomy, stent, or other). Total number of PCI procedures and dates (years)
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Indicate if the patient has a history of lower extremity PAD (from iliac to tibials). Excludes renal, coronary, cerebral, and mesenteric vessels and aneurysm. Major symptoms can include - Asymptomatic (confirmed by noninvasive diagnostic test) - Claudication relieved by rest - Ischemic rest pain - Tissue loss (including ischemic ulcer and/or gangrene) - Amputation for critical limb ischemia - Vascular reconstruction, bypass surgery, or percutaneous revascularization in the arteries of the lower extremities - Positive noninvasive test (eg, ABI <=0.90, ultrasound, MR or CT imaging demonstrating >50% diameter stenosis in any peripheral artery, ie, aorta, iliac, femoral, popliteal, tibial, peroneal)
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Indicate if the patient has a history of aortic aneurysm. This can include - Thoracic aneurysm - Thoracoabdominal aneurysm - AAA Confirmed by ultrasound, CT, and/or MR imaging.
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Indicate if the patient has a history of renal or mesenteric artery disease. This can include an abnormal imaging study such as duplex ultrasonography, MRA, CTA, or catheter-based contrast angiography demonstrating >50% diameter stenosis in the renal artery, celiac trunk, SMA, or IMA.
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Indicate if the patient has a documented history of TIA consisting of a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction. Note the following: - Right retinal - Right hemispheric - Left retinal - Left hemispheric - Vertebrobasilar - Unknown distribution
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Indicate whether the patient has a history of stroke, which is defined as an acute episode of neurological dysfunction caused by focal or global brain, spinal cord, or retinal vascular injury as a result of hemorrhage or infarction. If present, record the type of stroke: - Ischemic - Intracerebral hemorrhage - Subarachnoid hemorrhage - Unknown If ischemic, list the most likely etiologies: - Large-artery atherosclerosis of the extracranial vessels (eg, carotid) - Large-artery atherosclerosis of the intracranial vessels (eg, middle cerebral artery stenosis) - Cardioembolism - Small-vessel occlusion (lacunar) - Ischemic stroke of other determined etiology (eg, arterial dissection) - Ischemic stroke of undetermined etiology
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Indicate if the patient has a previous history of Congestive Heart Failure (CHF). This includes a previous hospital admission with a principal diagnosis of CHF. CHF is defined as documentation or report of any 2 of the following Framingham major criteria of heart failure: orthopnea/paroxysmal nocturnal dyspnea; or the description of rales, jugular venous distention, hepatojugular reflux, S3 gallop, or pulmonary edema on chest x-ray; or 1 of the major criteria plus 2 Framingham minor criteria, including dyspnea on exertion, nocturnal cough, ankle edema, pleural effusion, or tachycardia. A low ejection fraction without clinical evidence of heart failure does not qualify as heart failure. Include the year of onset if known.
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NYHA classification scale
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Indicate if the patient has a history of pulmonary insufficiency. Pulmonary insufficiency is defined as PaO2 of <60 mm Hg while breathing air or PaCO2 of >50 mm Hg.
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Current or previous history of chronic kidney disease. Chronic kidney disease is defined as either kidney damage or GFR <60 mL/min/1.73 m2 for >=3 mo. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Indicate the patient’s stage of disease: - Stage 0: No known kidney disease - Stage 1: Kidney damage with normal or high GFR >=90 mL/min/1.73 m2 - Stage 2: Kidney damage with mildly decreased GFR—60–89 mL/min/1.73 m2 - Stage 3: Moderately decreased GFR—30–59 mL/min/1.73 m2 - Stage 4: Severely decreased GFR—15–29 mL/min/1.73 m2 - Stage 5: Kidney failure—GFR <15 mL/min/1.73 m2 or on dialysis Year of onset (first diagnosis) may be helpful.
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Patient Assessment: Physical evaluation
Patient’s height in centimeters. To be converted from conventional units if needed Note: May be measured or reported by the patient.
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Patient’s measured actual weight in kilograms. To be converted from conventional units if needed Note: Must be measured during encounter. It is advisable to standardize clothing worn (ie, whether shoes are worn).
float
BMI is calculated according to the following formula: the patient’s weight in kilograms, divided by height in meters squared. Obesity is defined as a BMI >=30 kg/m2
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Systolic blood pressure (mm Hg) in both the right and left arms recorded closest to the time of presentation at the healthcare facility. The patient’s position (supine, sitting, other) may be noted.
integer
Diastolic blood pressure (mm Hg) in both the right and left arms recorded closest to the time of presentation at the healthcare facility. The patient’s position (supine, sitting, other) may be noted.
integer
Number of heart beats over 1 min. Note: Recorded closest to the time of presentation at the healthcare facility and/or on discharge (for inpatient). Specify whether the heart rate is regular or irregular. Heart rate may be ascertained from the ECG or record of physical examination.
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Cardiac rhythm
integer
Complete vascular examination: Carotid, upper, lower extremity pulses, auscultation of the neck for carotid bruits, auscultation of the abdomen and femoral arteries for bruits, palpation of the abdomen and popliteal fossa for aneurysms
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Complete cardiac examination: Palpation and auscultation of the heart, assessing rate, rhythm, presence of murmur, presence of gallop (eg, S3 suggesting left ventricular dysfunction; S4 suggesting noncompliant left ventricle), notation of location of point of maximal intensity
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Limb edema. Note the presence/absence of lower extremity (less commonly, upper extremity) edema, including location, extent, and pitting versus nonpitting.
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Laboratory Testing
Include RBC, WBC, and platelet counts: 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Hemoglobin 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
Hematocrit 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
Glucose 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
BUN 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
Creatinine 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
Indicate estimated or actual GFR in milliliters per minute per 1.73 meters squared.
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Sodium 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
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Potassium 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
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Hemoglobin A1C 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Prothrombin time Measured in seconds. Report INR as ratio.
float
Partial thromboplastin time Indicate whether activators used (aPTT) or not (PTT). Measured in seconds.
float
Total cholesterol 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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LDL 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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HDL 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
Triglycerides 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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hs-CRP 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
ESR 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Calcium 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
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Phosphorus 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
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Magnesium 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
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TSH 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
BNP or N-terminal BNP 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
float
AST 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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ALT 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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The upper limit of normal of total CK as defined by individual hospital laboratory standards. Units of CK and type of units should be noted (eg, IU, ng/dL, kCat/L). All CK values during hospitalization should be noted; include units, date, and time.
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Indicate the upper limit of normal (usually the 99th percentile of a normal population) and units (eg, ng/dL). All troponin T values during hospitalization should be noted; include units, date, and time.
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Indicate the upper limit of normal (usually the 99th percentile of a normal population) and units (eg, ng/dL). All troponin I values during hospitalization should be noted; include units, date, and time.
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Homocysteine 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Vitamin B12 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Folate 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Prothrombin 20210 gene mutation 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Protein C activity 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Protein S activity 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Antithrombin III 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Anticardiolipin antibody 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Lupus anticoagulant 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
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Current Pharmacologic Therapy to Manage Cardiovascular Disease
Aspirin. Note specific dose.
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Clopidogrel. Note specific dose.
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Prasugrel. Note specific dose.
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Other P2Y12 antagonists (Purinergic P2Y12 Receptor Antagonists). Note specific drug and dose.
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Dipyridamole. Note specific dose.
integer
Other antiplatelet drugs. Note specific drug and dose.
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Unfractionated heparin. Note specific dose.
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Low–molecular-weight heparin. Note specific drug and dose.
integer
Fondaparinux. Note specific dose.
integer
Other factor Xa inhibitor. Note specific drug and dose.
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Direct thrombin inhibitor. Note specific drug and dose.
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Warfarin. Indicate whether this drug has been prescribed; note INR.
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Other anticoagulant drug. Note specific drug and dose.
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Antihypertensive drugs. Note specific drug and dose.
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Statins and lipid-control agents. Note specific drug and dose.
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Drugs for diabetes. Note specific drug and dose.
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Drugs to aid in smoking cessation. Note specific drug and dose.
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Antiarrhythmic drugs. Note specific drug and dose.
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Heart failure medications. Note specific drug and dose.
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Drugs for symptoms of PAD. Note specific drug and dose.
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Noncardiovascular medications. Note the specific drug and dose.
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Medication allergy. Specify the medication and type of reaction
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Medication side effect. Describe the side effect and whether the medication was stopped.
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