ID
11910
Beschrijving
2012 ACCF / AHA Data Standard Peripheral Atherosclerotic Disease (PAD) General data elements see http://www.ncbi.nlm.nih.gov/pubmed/22144570
Link
http://www.ncbi.nlm.nih.gov/pubmed/22144570
Trefwoorden
Versies (4)
- 01-11-14 01-11-14 - Martin Dugas
- 06-06-15 06-06-15 - Martin Dugas
- 19-08-15 19-08-15 - Martin Dugas
- 20-09-21 20-09-21 -
Geüploaded op
19 augustus 2015
DOI
Voor een aanvraag inloggen.
Licentie
Creative Commons BY-NC 3.0 Legacy
Model Commentaren :
Hier kunt u commentaar leveren op het model. U kunt de tekstballonnen bij de itemgroepen en items gebruiken om er specifiek commentaar op te geven.
Itemgroep Commentaren voor :
Item Commentaren voor :
U moet ingelogd zijn om formulieren te downloaden. AUB inloggen of schrijf u gratis in.
Peripheral Atherosclerotic Vascular Disease EHR key data elements
Peripheral Atherosclerotic Disease (PAD) - General data elements
- StudyEvent: ODM-Test
Beschrijving
Patient history
Alias
- UMLS CUI-1
- C0679831
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C0455527
Beschrijving
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)
Datatype
text
Alias
- UMLS CUI-1
- C0455488
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C0242339
- UMLS CUI-2
- C0332119
Beschrijving
History confirming cigarette smoking in the past.
Datatype
integer
Alias
- UMLS CUI-1
- C1519384
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C0552479
Beschrijving
Indicate history of current, recent, or remote abuse of any illicit drug (eg, cocaine, methamphetamine, marijuana) or controlled substance.
Datatype
boolean
Alias
- UMLS CUI-1
- C2239127
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C1275835
Beschrijving
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
Datatype
boolean
Beschrijving
History of angina - Stable angina (CCS class, date of onset) - Unstable angina (date of onset) - Prior angina (currently asymptomatic)
Datatype
text
Alias
- UMLS CUI-1
- C0455530
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C1842251
Beschrijving
Prior PCI of any type (balloon angioplasty, atherectomy, stent, or other). Total number of PCI procedures and dates (years)
Datatype
text
Alias
- UMLS CUI-1
- C1320647
Beschrijving
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)
Datatype
boolean
Alias
- UMLS CUI-1
- C1881056
Beschrijving
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.
Datatype
boolean
Alias
- UMLS CUI-1
- C0459854
Beschrijving
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.
Datatype
boolean
Beschrijving
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
Datatype
text
Alias
- UMLS CUI-1
- C0455536
Beschrijving
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
Datatype
text
Alias
- UMLS CUI-1
- C0559159
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C0455531
Beschrijving
NYHA classification scale
Datatype
text
Alias
- UMLS CUI-1
- C1275491
Beschrijving
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.
Datatype
boolean
Alias
- UMLS CUI-1
- C0340398
- UMLS CUI-2
- C0332119
Beschrijving
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.
Datatype
text
Alias
- UMLS CUI-1
- C3532472
Beschrijving
Patient Assessment: Physical evaluation
Alias
- UMLS CUI-1
- C0031809
Beschrijving
Height
Datatype
float
Maateenheden
- cm
Alias
- UMLS CUI [1]
- C0005890
Beschrijving
Body weight
Datatype
float
Maateenheden
- kg
Alias
- UMLS CUI [1]
- C0005910
Beschrijving
Body Mass Index
Datatype
float
Maateenheden
- kg/m2
Alias
- UMLS CUI [1]
- C1305855
Beschrijving
Systolic
Datatype
integer
Maateenheden
- mmHg
Alias
- UMLS CUI [1]
- C0871470
Beschrijving
Diastolic
Datatype
integer
Maateenheden
- mmHg
Alias
- UMLS CUI [1]
- C0428883
Beschrijving
Heart rate
Datatype
integer
Maateenheden
- bpm
Alias
- UMLS CUI [1]
- C0018810
Beschrijving
Cardiac rhythm
Datatype
integer
Alias
- UMLS CUI-1
- C0232187
Beschrijving
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
Datatype
text
Alias
- UMLS CUI-1
- C2053830
Beschrijving
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
Datatype
text
Beschrijving
Limb edema. Note the presence/absence of lower extremity (less commonly, upper extremity) edema, including location, extent, and pitting versus nonpitting.
Datatype
text
Alias
- UMLS CUI-1
- C0085649
Beschrijving
Laboratory Testing
Alias
- UMLS CUI-1
- C0022885
Beschrijving
Include RBC, WBC, and platelet counts: 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
text
Alias
- UMLS CUI-1
- C0009555
Beschrijving
Hemoglobin
Datatype
float
Maateenheden
- g/dL
Alias
- UMLS CUI [1]
- C0019046
Beschrijving
Hematocrit
Datatype
float
Maateenheden
- %
Alias
- UMLS CUI [1]
- C0518014
Beschrijving
Glucose
Datatype
float
Maateenheden
- mg/dl
Alias
- UMLS CUI [1]
- C0202042
Beschrijving
BUN
Datatype
float
Maateenheden
- mg/dL
Alias
- UMLS CUI [1]
- C0005845
Beschrijving
Creatinine
Datatype
float
Maateenheden
- mg/dL
Alias
- UMLS CUI [1]
- C0201976
Beschrijving
Indicate estimated or actual GFR in milliliters per minute per 1.73 meters squared.
Datatype
float
Maateenheden
- ml/(min*1,73m2)
Alias
- UMLS CUI-1
- C0017654
Beschrijving
Sodium
Datatype
float
Maateenheden
- mmol/L
Alias
- UMLS CUI [1]
- C0337443
Beschrijving
Potassium
Datatype
float
Maateenheden
- mmol/l
Alias
- UMLS CUI [1]
- C0202194
Beschrijving
Hemogloblin A1C
Datatype
float
Maateenheden
- %
Alias
- UMLS CUI [1]
- C0019018
Beschrijving
Prothrombin time Measured in seconds. Report INR as ratio.
Datatype
float
Maateenheden
- s
Alias
- UMLS CUI-1
- C0033707
Beschrijving
Partial thromboplastin time Indicate whether activators used (aPTT) or not (PTT). Measured in seconds.
Datatype
float
Maateenheden
- s
Alias
- UMLS CUI-1
- C0030605
Beschrijving
Total cholesterol 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Maateenheden
- mg/dL
Alias
- UMLS CUI [1]
- C1445957
Beschrijving
LDL
Datatype
float
Maateenheden
- mg/dL
Alias
- UMLS CUI [1]
- C0428474
Beschrijving
HDL
Datatype
float
Maateenheden
- mg/dL
Alias
- UMLS CUI [1]
- C0428472
Beschrijving
Triglycerides
Datatype
float
Maateenheden
- mg/dL
Alias
- UMLS CUI [1]
- C0202236
Beschrijving
hs-CRP 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0201657
Beschrijving
ESR 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0086250
Beschrijving
Calcium
Datatype
float
Maateenheden
- mmol/l
Alias
- UMLS CUI [1]
- C0201925
Beschrijving
Phosphorus 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0523826
Beschrijving
Magnesium 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper and lower limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0373675
Beschrijving
TSH 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0202230
Beschrijving
BNP or N-terminal BNP 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C1095989
Beschrijving
AST (SGOT)
Datatype
float
Maateenheden
- U/L
Alias
- UMLS CUI [1]
- C0201899
Beschrijving
ALT (SGPT)
Datatype
float
Maateenheden
- U/L
Alias
- UMLS CUI [1]
- C0201836
Beschrijving
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.
Datatype
float
Alias
- UMLS CUI-1
- C0201973
Beschrijving
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.
Datatype
float
Alias
- UMLS CUI-1
- C1141947
Beschrijving
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.
Datatype
float
Alias
- UMLS CUI-1
- C0920210
Beschrijving
Homocysteine 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C2242817
Beschrijving
Vitamin B12 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0202252
Beschrijving
Folate 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0523631
Beschrijving
Prothrombin 20210 gene mutation 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C1273306
Beschrijving
Protein C activity 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C1255234
Beschrijving
Protein S activity 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0919678
Beschrijving
Antithrombin III 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C2825854
Beschrijving
Anticardiolipin antibody 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C0201535
Beschrijving
Lupus anticoagulant 1) value, 2) unit of measurement, 3) date, and 4) normal range (upper limit of normal when appropriate)
Datatype
float
Alias
- UMLS CUI-1
- C1142517
Beschrijving
Current Pharmacologic Therapy to Manage Cardiovascular Disease
Beschrijving
Aspirin. Note specific dose.
Datatype
integer
Alias
- UMLS CUI-1
- C0004057
Beschrijving
Clopidogrel. Note specific dose.
Datatype
integer
Alias
- UMLS CUI-1
- C0070166
Beschrijving
Prasugrel. Note specific dose.
Datatype
integer
Alias
- UMLS CUI-1
- C1620287
Beschrijving
Other P2Y12 antagonists (Purinergic P2Y12 Receptor Antagonists). Note specific drug and dose.
Datatype
integer
Alias
- UMLS CUI-1
- C2936585
Beschrijving
Dipyridamole. Note specific dose.
Datatype
integer
Alias
- UMLS CUI-1
- C0012582
Beschrijving
Other antiplatelet drugs. Note specific drug and dose.
Datatype
text
Beschrijving
Unfractionated heparin. Note specific dose.
Datatype
integer
Alias
- UMLS CUI-1
- C2825026
Beschrijving
Low–molecular-weight heparin. Note specific drug and dose.
Datatype
integer
Alias
- UMLS CUI-1
- C0019139
Beschrijving
Fondaparinux. Note specific dose.
Datatype
integer
Alias
- UMLS CUI-1
- C1098510
Beschrijving
Other factor Xa inhibitor. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C2825027
Beschrijving
Direct thrombin inhibitor. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C3536847
Beschrijving
Warfarin. Indicate whether this drug has been prescribed; note INR.
Datatype
text
Alias
- UMLS CUI-1
- C0043031
Beschrijving
Other anticoagulant drug. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C0003280
Beschrijving
Antihypertensive drugs. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C0003364
Beschrijving
Statins and lipid-control agents. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C0360714
Beschrijving
Drugs for diabetes. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C3653344
Beschrijving
Drugs to aid in smoking cessation. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C1095963
Beschrijving
Antiarrhythmic drugs. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C0003195
Beschrijving
Heart failure medications. Note specific drug and dose.
Datatype
text
Alias
- UMLS CUI-1
- C0018801
- UMLS CUI-2
- C0013227
Beschrijving
Drugs for symptoms of PAD. Note specific drug and dose.
Datatype
text
Beschrijving
Noncardiovascular medications. Note the specific drug and dose.
Datatype
text
Beschrijving
Medication allergy. Specify the medication and type of reaction
Datatype
text
Alias
- UMLS CUI-1
- C0013182
Beschrijving
Medication side effect. Describe the side effect and whether the medication was stopped.
Datatype
text
Alias
- UMLS CUI-1
- C0041755
Similar models
Peripheral Atherosclerotic Disease (PAD) - General data elements
- StudyEvent: ODM-Test
C0332119 (UMLS CUI-2)
C0332119 (UMLS CUI-2)
C0013227 (UMLS CUI-2)