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
C0006384 (UMLS CUI [1])
Item
If Yes specify type
integer
C0023211 (UMLS CUI [1])
C0085615 (UMLS CUI [2])
Code List
If Yes specify type
Item
6. Rhythm:
integer
C0232187 (UMLS CUI [1])
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
C1532338 (UMLS CUI [1])
Myocardial Infarction
Item
8. Was myocardial infarction confirmed by enzymes or biomarkers?
boolean
C0443763 (UMLS CUI [1])
C0027051 (UMLS CUI [2,1])
C0005516 (UMLS CUI [2,2])
Item
Value
text
C1522609 (UMLS CUI [1])
Item
Local Lab ranges Upper Limit Of Normal
text
C0523584 (UMLS CUI [1,1])
C1519815 (UMLS CUI [1,2])
C0920210 (UMLS CUI [2,1])
C1519815 (UMLS CUI [2,2])
C0523953 (UMLS CUI [3,1])
C1519815 (UMLS CUI [3,2])
C0201973 (UMLS CUI [4,1])
C1519815 (UMLS CUI [4,2])
C0202113 (UMLS CUI [5,1])
C1519815 (UMLS CUI [5,2])
C0201899 (UMLS CUI [6,1])
C1519815 (UMLS CUI [6,2])
Code List
Local Lab ranges Upper Limit Of Normal
Hospitalization
Item
Did the vent lead to hospitalization. If yes please complete the Hospitalization Report Form.
boolean
C0019993 (UMLS CUI [1])
Fatal Event
Item
Was the event fatal (death within 28days). If yes please complete Death Report Form
boolean
C1705232 (UMLS CUI [1])
Item
Please indicate which supporting documentation has been supplied:
integer
C0678257 (UMLS CUI [1])
Code List
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
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])