Date
Item
1. Date of MI event (dd mon yy)
date
C0011008 (UMLS CUI [1,1])
C0027051 (UMLS CUI [1,2])
Chest Pain
Item
2. Chest pain?
boolean
C0008031 (UMLS CUI [1])
Item
If `YES` please indicate whether typical or atypical chest pain
integer
C0027051 (UMLS CUI [1,1])
C1521902 (UMLS CUI [1,2])
Code List
If `YES` please indicate whether typical or atypical chest pain
Patient on study medication
Item
3. Was the patient on study medication within the 7 days prior to event?
boolean
C0013227 (UMLS CUI [1])
Item
If no indicate which medication the patient was not taking (Please indicate all that apply)
integer
C2348235 (UMLS CUI [1])
Code List
If no indicate which medication the patient was not taking (Please indicate all that apply)
CL Item
Blister Card C (3)
CL Item
Blister Card D (4)
ECG Changes
Item
4. is infarction documented by ECG changes.
boolean
C0855329 (UMLS CUI [1])
details of ECG
Item
If Yes, please provide details of ECG
text
C1522508 (UMLS CUI [1])
Item
Q Waves
integer
C1305738 (UMLS CUI [1])
CL Item
Anterolateral (4)
Item
ST elevation
integer
C0520886 (UMLS CUI [1])
CL Item
Anterolateral (4)
Item
ST depression >2mm
integer
C0520887 (UMLS CUI [1])
Code List
ST depression >2mm
CL Item
Anterolateral (4)
Item
T inversion >3mm
integer
C0520888 (UMLS CUI [1])
Code List
T inversion >3mm
CL Item
Anterolateral (4)
bundle branch block
Item
5. New bundle branch block (BBB)?
boolean
Item
If Yes specify type
integer
Code List
If Yes specify type
CL Item
Atrial fib/flutter (2)
CL Item
Other (specify) (3)
Coronary Intervention
Item
7. Was coronary intervention done within the 3 days prior to the event?
boolean
Myocardial Infarction
Item
8. Was myocardial infarction confirmed by enzymes or biomarkers?
boolean
Item
Value
text
C1522609 (UMLS CUI [1])
Item
Local Lab ranges Upper Limit Of Normal
text
Code List
Local Lab ranges Upper Limit Of Normal
Hospitalization
Item
1. Did the vent lead to hospitalization. If yes please complete the Hospitalization Report Form.
boolean
C0019993 (UMLS CUI [1])
Fatal Event
Item
2. Was the event fatal (death within 28days). If yes please complete Death Report Form
boolean
Item
3. Please indicate which supporting documentation has been supplied:
integer
Code List
3. Please indicate which supporting documentation has been supplied:
CL Item
Hospital discharge summaries (2)
CL Item
Clinical description of event (3)
Invenstigator´s Declaration
Item
3. Invenstigator´s Declaration By signing and dating this page, I declare that I have reviewed for accuracy all case report form pages for this patient; the information contained on these pages accurately reflects the medical record including the results of tests and evaluations performed in the dates specified.
text
Investigator´s signature
Item
Investigator´s signature
text
C2346576 (UMLS CUI [1])
Date of Signature
Item
Date of Signature
date
C0011008 (UMLS CUI [1,1])
C1519316 (UMLS CUI [1,2])