2013 ACCF/AHA Key Data Elements and Definitions for Measuring the Clinical Management and Outcomes of Patients With Acute Coronary Syndromes and Coronary Artery Disease

Beskrivning

Patient ID is a unique number that permanently identifies each patient. Once assigned to a patient, this numbercan never be changed or reassigned to a different patient. Each time a patient returns to the site, the patient MUST receive the same unique patient identifier.

Datatyp

integer

Alias

UMLS CUI-1

C2348585

Beskrivning

Indicate the patient's sex at birth as either male or female.

Datatyp

text

Alias

UMLS CUI-1

C0079399

Beskrivning

Indicate the patients date of birth.

Datatyp

date

Alias

UMLS CUI-1

C0421451

Beskrivning

Indicate the patient’s race as determined by the patient or family.

Datatyp

text

Alias

UMLS CUI-1

C0034510

Beskrivning

Indicate if the patient is of Hispanic or Latino ethnicity as determined by the patient or family. Hispanic ethnicity includes patient reports of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Datatyp

boolean

Alias

UMLS CUI-1

C0015031

Beskrivning

Indicate the postal code for the patient’s residence. For US ZIP codes, the hyphen is implied. If the patient is determined to not have a permanent residence, then the patient is considered homeless.

Datatyp

text

Alias

UMLS CUI-1

C0421454

Beskrivning

Indicate the date the patient was admitted as an inpatient to the facility for the current episode of care. For outpatients, note the date (month/day/year) of the encounter (eg, physician visit, nurse visit, consultation, procedures).

Datatyp

date

Alias

UMLS CUI-1

C1302393

Beskrivning

Indicate the source of the patients admission as an inpatient to your facility.

Datatyp

text

Alias

UMLS CUI-1

C0553514

Beskrivning

Indicate the patient’s primary insurance payer for this admission.

Datatyp

text

Alias

UMLS CUI-1

C0021672

Beskrivning

Date and time the patient first presented to the hospital

Datatyp

datetime

Alias

UMLS CUI-1

C0439629

Beskrivning

Indicate if the patient was first evaluated in your facilitys ED. This includes traditional ED locations, as well as ED-based chest pain units, clinics, and short-stay CCUs housed in the ED.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0450429

UMLS CUI [1,2]

C0220825

UMLS CUI [1,3]

C3840745

Beskrivning

If the patient was first evaluated in your facilitys ED, enter the date and time the patient was moved out of the ED, either to another location within your facility or to another acute care center.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C3495034

UMLS CUI [1,2]

C0011008

Beskrivning

Elective or Urgent

Datatyp

text

Alias

UMLS CUI-1

C1550330

Beskrivning

The categories of location of a patient at the time of admission to the hospital or observation unit

Datatyp

text

Alias

UMLS CUI [1,1]

C0184666

UMLS CUI [1,2]

C0450429

Beskrivning

Indicate the means by which a nontransfer patient was transported to your facility

Datatyp

text

Alias

UMLS CUI-1

C3258270

Beskrivning

Indicate the date and time of prearrival first medical contact, when the patient was first evaluated by either. Note: Enter the date and time of first medical contact only for patients who were transported by ambulance (ground or air) or mobile ICU. EMS or another healthcare professional before arrival at your facility. This is not the date and time of arrival at your facility.

Datatyp

datetime

Alias

UMLS CUI [1]

C1320531

Beskrivning

Indicate if the patient was transferred directly to your facility from another ED or hospital unit and indicate which.

Datatyp

text

Alias

UMLS CUI-1

C1546432

Beskrivning

Indicate the means by which the transfer patient was transported to your facility.

Datatyp

text

Alias

UMLS CUI-1

C0449375

Beskrivning

Indicate the date and time the patient arrived at the outside hospital. If unknown, leave blank.

Datatyp

datetime

Alias

UMLS CUI-1

C1320532

Beskrivning

Indicate the date and time the patient left the outside facility

Datatyp

datetime

Alias

UMLS CUI [1,1]

C1546432

UMLS CUI [1,2]

C0011008

Beskrivning

Symptom-onset date/time

Datatyp

datetime

Alias

UMLS CUI-1

C1320528

Beskrivning

If ground or air ambulance, indicate EMS first medical contact date/time

Datatyp

datetime

Alias

UMLS CUI [1,1]

C3261085

UMLS CUI [1,2]

C1264639

Beskrivning

Non-EMS first medical contact date/time

Datatyp

datetime

Alias

UMLS CUI [1,1]

C1518384

UMLS CUI [1,2]

C1279901

UMLS CUI [1,3]

C1521801

UMLS CUI [1,4]

C0011008

Beskrivning

EMS leaving scene date/time

Datatyp

datetime

Alias

UMLS CUI [1,1]

C3261085

UMLS CUI [1,2]

C1264639

Beskrivning

Hospital arrival date/time

Datatyp

datetime

Alias

UMLS CUI-1

C1320532

Beskrivning

First ECG date/time

Datatyp

datetime

Alias

UMLS CUI-1

C2826846

Beskrivning

Catheterization lab activation date/time

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0018795

UMLS CUI [1,2]

C1879547

UMLS CUI [1,3]

C0011008

Beskrivning

History of angina before the current admission. “Angina� refers to evidence or knowledge of symptoms before this acute event described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia. Indicate if angina existed >2 wk before admission and/or within 2 wk before admission.

Datatyp

text

Alias

UMLS CUI [1]

C0455530

Beskrivning

Average number of distinct episodes of anginal pain that occurred in the last week before hospital admission or this visit

Datatyp

integer

Alias

UMLS CUI [1,1]

C0002962

UMLS CUI [1,2]

C4086638

UMLS CUI [1,3]

C0332185

Beskrivning

Total number of distinct episodes of anginal pain that occurred in the last 6 wk before hospital admission or visit should be recorded. Duration of each episode and requirement for sublingual nitroglycerin are also documented.

Datatyp

text

Alias

UMLS CUI [1,1]

C0002962

UMLS CUI [1,2]

C4086638

UMLS CUI [1,3]

C0332185

Beskrivning

History of claudication that typically presents as exertional fatigue, cramping, or aching in the muscles of the legs that is reproducible and resolves promptly with rest.

Datatyp

boolean

Alias

UMLS CUI-1

C0021775

Beskrivning

Indicate if the patient has had at least 1 documented previous myocardial infarction. Any occurrence between birth and arrival at first facility. The term acute MI 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: � Detection of the rise and/or fall of cardiac biomarkers (preferably cTn) with at least 1 value above the 99th percentile and with at least 1 of the following: — Symptoms of ischemia — New or presumed new significant ST-T changes or new LBBB — Development of pathological Q waves on the ECG — Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality — Identification of an intracoronary thrombus by angiography or autopsy � Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic electrocardiographic changes or new LBBB, but death occurred before cardiac biomarkers were obtained or before cardiac biomarker values would be increased. � PCI-related MI is arbitrarily defined by elevation of cTn values (>5 times the 99th percentile URL) in patients with normal baseline values (≤99th percentile URL) or a rise in cTn values ≥20% if baseline values are elevated and stable or falling; in addition, either symptoms suggestive of myocardial ischemia or new ischemic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality � Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least 1 value >99th percentile URL. � CABG-related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 times the 99th percentile URL) in patients with normal baseline cTn values (≤99th percentile URL) plus either new pathological Q waves or new LBBB, or angiographically documented new graft or new native coronary artery occlusion, or imaging evidence of new loss of viable myocardium. � The 99th percentile is observed after the procedure in conjunction with symptoms suggestive of myocardial ischemia or new ischemic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium or in patients with a preprocedure elevated biomarker that is stable or falling, a rise of biomarker values ≥20% in conjunction with the PCI-related criteria stated above. A prior MI can also be documented if the patient has any 1 of the following criteria that meets the diagnosis for prior MI: � Pathological Q waves with or without symptoms in the absence of nonischemic causes � Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract, in the absence of a nonischemic cause � Pathological findings of a prior MI

Datatyp

boolean

Alias

UMLS CUI-1

C1275835

Beskrivning

Indicate if there is a previous history of heart failure before this care encounter. A previous hospital admission with the principal diagnosis of heart failure is considered evidence of a history of heart failure. Heart failure is defined as physician documentation or report of any of the following clinical symptoms of heart failure described as unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention, or the description of rales, jugular venous distention, pulmonary edema on physical examination, or pulmonary edema on chest x-ray. A low ejection fraction without clinical evidence of heart failure does not qualify as heart failure.

Datatyp

boolean

Alias

UMLS CUI-1

C0455531

Beskrivning

If heart failure is present, indicate the NYHA functional class. Choose 1 of the following: â—� Class I: patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea. â—� Class II: patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, or dyspnea. â—� Class III: patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea. â—� Class IV: patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms are present even at rest or minimal exertion. If any physical activity is undertaken, discomfort is increased.

Datatyp

text

Alias

UMLS CUI-1

C1275491

Beskrivning

Indicate if the patient had a previous PCI (even if unsuccessful) of any type (balloon angioplasty, stent, or other), performed before the current admission.

Datatyp

text

Alias

UMLS CUI-1

C1320647

Beskrivning

If the patient had a previous PCI of any type (balloon angioplasty, stent, or other) performed before the current admission, indicate the date of the most recent PCI. If month or day is unknown, year is sufficient.

Datatyp

date

Alias

UMLS CUI [1,1]

C1532338

UMLS CUI [1,2]

C1264639

Beskrivning

Indicate whether the patient had a previous CABG (Coronary Artery Bypass Grafting) surgery before the current admission.

Datatyp

boolean

Alias

UMLS CUI-1

C1275842

Beskrivning

If the patient had a previous CABG (Coronary Artery Bypass Grafting) before the current admission, indicate the date of the most recent CABG. If month or day is unknown, year is sufficient.

Datatyp

date

Alias

UMLS CUI-1

C2164190

Beskrivning

The patient has documented CAD at coronary angiography at any time before the current admission, with at least a 50% stenosis in the diameter of a major coronary artery. If the patient had a cardiac catheterization before the index event that demonstrated a stenosis of 90% that was successfully stented to a 0% residual, this should be coded as “yes,� because a stenosis ≥50% diameter was documented.

Datatyp

boolean

Alias

UMLS CUI [1]

C3494526

Beskrivning

Current or previous history of any of the following: � Ischemic stroke: an acute episode of focal, cerebral, spinal, or retinal dysfunction caused by infarction of the central nervous system tissue � TIA: transient episode of neurological dysfunction caused by focal or global brain, spinal cord, or retinal ischemia without acute infarction � Noninvasive or invasive arterial imaging test demonstrating ≥50% stenosis of any of the major extracranial or intracranial vessels to the brain � Previous cervical or cerebral artery revascularization surgery or percutaneous intervention This does not include chronic (nonvascular) neurological diseases or other acute neurological insults such as metabolic and anoxic ischemic encephalopathy.

Datatyp

boolean

Alias

UMLS CUI-1

C0585890

Beskrivning

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.

Datatyp

text

Alias

UMLS CUI-1

C0559159

Beskrivning

If the patient has a history of ischemic stroke, indicate the most likely etiology

Datatyp

text

Alias

UMLS CUI [1]

C3897486

Beskrivning

Current or previous history of PAD (includes lower extremity from iliac to tibials and upper extremity with subclavian and brachials. Excludes renal, coronary, cerebral, and mesenteric vessels and aneurysms). This can include: � Claudication on exertion that is relieved by rest � Amputation for severe arterial vascular insufficiency � Vascular reconstruction, bypass surgery, or percutaneous revascularization in the arteries of the lower and upper extremities � Positive noninvasive test (eg, ankle brachial index ≤0.9, ultrasound, MR imaging or CT scanning of >50% diameter stenosis in any peripheral artery [ie, subclavian, femoral, iliac]) or angiographic imaging

Datatyp

boolean

Alias

UMLS CUI [1]

C1881056

Beskrivning

Current or previous history of disease of the thoracic, thoracoabdominal, or abdominal aorta (typically aneurysm)

Datatyp

boolean

Alias

UMLS CUI-1

C0003493

Beskrivning

Current or previous history of disease of the main renal arteries or extrarenal branches

Datatyp

boolean

Alias

UMLS CUI-1

C3640053

Beskrivning

Specify alcohol consumption history. Choose from the following categories:

Datatyp

text

Alias

UMLS CUI-1

C0552479

Beskrivning

Indicate if the patient has a history of erectile dysfunction. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI-1

C0242350

Beskrivning

Current or previous diagnosis of depression or documentation of a depressed mood or affect

Datatyp

boolean

Alias

UMLS CUI-1

C0455503

Beskrivning

History of diabetes diagnosed and/or treated by a healthcare provider. The American Diabetes Association criteria include documentation of the following: 1. Hemoglobin A1c ≥6.5%; or 2. Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L); or 3. 2-h Plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test; or 4. 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.

Datatyp

boolean

Alias

UMLS CUI-1

C0011849

Beskrivning

Indicate the patients diabetes control method as presented on admission. Patients placed on a preprocedure diabetic pathway of insulin drip at admission but whose diabetes was controlled by diet or oral methods are not coded as being treated with insulin. Choose the most aggressive therapy from the order below:

Datatyp

text

Alias

UMLS CUI-1

C3274787

Beskrivning

Indicate if the patient has a current diagnosis of hypertension defined by any 1 of the following: � History of hypertension diagnosed and treated with medication, diet, and/or exercise � Prior documentation of blood pressure ≥140 mm Hg systolic and/or 90 mm Hg diastolic for patients without diabetes or chronic kidney disease, or prior documentation of blood pressure ≥130 mm Hg systolic or 80 mm Hg diastolic on at least 2 occasions for patients with diabetes or chronic kidney disease � Currently undergoing pharmacological therapy for treatment of hypertension

Datatyp

boolean

Alias

UMLS CUI [1]

C0455527

Beskrivning

Current or previous use of any tobacco product, including cigarettes, cigars, pipes, and chewing tobacco, captured as smoking status:

Datatyp

text

Alias

UMLS CUI-1

C0543414

Beskrivning

Documented history of current, recent, or remote abuse of any illicit drug (eg, cocaine, methamphetamine, marijuana) or controlled substance.

Datatyp

boolean

Alias

UMLS CUI-1

C2239127

Beskrivning

Indicate if the patient has a history of dyslipidemia that was diagnosed and/or treated by a physician. NCEP criteria include documentation of the following: � Total cholesterol >200 mg/dL (5.18 mmol/L); or � 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; � Currently receiving antilipidemic treatment

Datatyp

boolean

Alias

UMLS CUI-1

C0242339

Beskrivning

Indicate if the patient has any direct blood relatives (parents, siblings, children) who have had any of the following at age <55 y for male relatives or <65 y for female relatives: Angina Acute MI Sudden cardiac death without obvious cause CABG surgery PC

Datatyp

boolean

Alias

UMLS CUI-1

C0455404

Beskrivning

Indicate if the patient had a pacemaker or ICD implanted before the current encounter. Information about the type of device (pacemaker, biventricular/resynchronization/CRT, ICD, combination), cardiac chamber(s) involved, and year of implantation may be helpful.

Datatyp

text

Alias

UMLS CUI [1]

C0455666

Beskrivning

Indicate whether atrial fibrillation or flutter is present within 2 wk before admission.

Datatyp

boolean

Alias

UMLS CUI [1]

C0004238

UMLS CUI [2]

C0004239

Beskrivning

Indicate if the patient has a history of influenza immunization. The month and year of the most recent immunization should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C0586139

Beskrivning

Indicate if the patient has a history of pneumococcal immunization. The month and year of the most recent immunization should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C0588096

Beskrivning

Indicate if the patient currently requires dialysis treatment, including hemodialysis or peritoneal dialysis.

Datatyp

boolean

Alias

UMLS CUI-1

C0011946

Beskrivning

Indicate grade symptoms or signs in patients with suspected or presumed stable angina (or anginal equivalent) according to the CCS grading scale:

Datatyp

text

Alias

UMLS CUI-1

C1277207

Beskrivning

Record the number of sublingual nitroglycerin tablets or spray used each week for symptomatic episodes. Record prophylactic usage also. Average the total number of sublingual uses over the 6-wk interval and record the weekly range

Datatyp

integer

Alias

UMLS CUI [1]

C1827134

Beskrivning

Indicate the date and time the patient first noted ischemic symptoms lasting ≥10 min. If the patient had intermittent ischemic symptoms, record the date and time of the most recent ischemic symptoms before hospital presentation. Symptoms may include jaw pain, arm pain, shortness of breath, nausea, vomiting, fatigue/malaise, or other equivalent discomfort suggestive of an MI. In the event of stuttering symptoms, ACS symptom onset is the time at which symptoms became constant in quality or intensity.

Datatyp

datetime

Alias

UMLS CUI-1

C1320528

Beskrivning

Indicate if there is physician documentation or a report of heart failure on the first medical contact. Heart failure is defined as physician documentation or report of any of the following clinical symptoms of heart failure described as unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or the description of rales, jugular venous distention, pulmonary edema on physical examination, or pulmonary edema on chest x-ray. A low ejection fraction without clinical evidence of heart failure does not qualify as heart failure.

Datatyp

boolean

Alias

UMLS CUI [1]

C0018801

Beskrivning

Indicate the patient’s Killip class at the time of hospital admission

Datatyp

text

Alias

UMLS CUI-1

C1881332

Beskrivning

Indicate the first measurement or earliest record of heart rate (in beats per minute) for this episode of care. Measurement from the transferring facility is acceptable.

Datatyp

integer

Måttenheter

• bpm

Alias

UMLS CUI-1

C0018810

Beskrivning

Indicate the first measurement or earliest record of systolic blood pressure (in millimeters of mercury) for this episode of care. Measurement from the transferring facility is acceptable.

Datatyp

integer

Måttenheter

• mmHg

Alias

UMLS CUI-1

C0871470

Beskrivning

Indicate the category of the patients type of angina if present. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1]

C0002962

Beskrivning

Indicate the number of distinct episodes of anginal pain that occurred in the past 24 h before hospital admission.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0002962

UMLS CUI [1,2]

C4086638

UMLS CUI [1,3]

C0332185

Beskrivning

Note whether angina was precipitated by a secondary factor such as fever, anemia, hypoxemia, tachycardia, thyrotoxicosis, or severe valvular disease as defined by Braunwald

Datatyp

boolean

Alias

UMLS CUI [1,1]

C1549996

UMLS CUI [1,2]

C0002962

Beskrivning

Indicate if the patient has had an episode of cardiac arrest evaluated by EMS or ED personnel and either 1) received external defibrillation attempts (by lay responders or emergency personnel) or chest compressions by organized EMS or ED personnel or 2) were pulseless but did not receive defibrillation attempts or CPR by EMS personnel. Choose 1 of the following: â—� Yes â—� No Note: [Sudden] cardiac arrest is the sudden cessation of cardiac activity. The victim becomes unresponsive with no normal breathing and no signs of circulation. If corrective measures are not taken rapidly, this condition progresses to sudden death. Cardiac arrest should be used to signify an event as described above that is reversed, usually by CPR and/or defibrillation or cardioversion or cardiac pacing. Sudden cardiac death should not be used to describe events that are not fatal.

Datatyp

boolean

Alias

UMLS CUI-1

C0018790

Beskrivning

Indicate the patient’s first recorded height in centimeters on admission/encounter to your facility

Datatyp

integer

Måttenheter

• cm

Alias

UMLS CUI-1

C0005890

Beskrivning

Indicate the patient’s weight in kilograms closest to the date of admission/encounter.

Datatyp

integer

Måttenheter

• kg

Alias

UMLS CUI-1

C0005910

Beskrivning

Indicate waist circumference based on the average of 2 measurements made while the patient is standing. Take 1 measurement after inspiration and another after expiration. Measurements should be taken at the midpoint between the lowest rib and the iliac crest. Indicate in centimeters.

Datatyp

integer

Måttenheter

• cm

Alias

UMLS CUI-1

C0455829

Beskrivning

The categories of rhythm are:

Datatyp

text

Alias

UMLS CUI-1

C0232187

Beskrivning

Indicate where the first ECG was obtained. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1,1]

C2825164

UMLS CUI [1,2]

C1623258

Beskrivning

Indicate the date and time of the first ECG.

Datatyp

datetime

Alias

UMLS CUI [1]

C2826640

Beskrivning

Indicate if there was either new or presumed new ST-segment elevation, new LBBB, or isolated inferobasal MI before any procedures and not more than 24 h after the initial presentation

Datatyp

boolean

Alias

UMLS CUI-1

C3538872

Beskrivning

Indicate if there was either new or presumed new ST-segment elevation, new LBBB, or isolated inferobasal (posterior) MI noted on the ECG before any procedures and not more than 24 h after the initial presentation. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1]

C3538872

Beskrivning

Indicate if a STEMI or STEMI equivalent was noted on either the first or a subsequent ECG. The subsequent ECG must be performed within 24 h of initial presentation, either to your facility or the transferring facility if a transfer patient.

Datatyp

text

Alias

UMLS CUI [1]

C3538872

Beskrivning

Indicate the date and time of the earliest subsequent ECG with ST-segment elevation, LBBB, or isolated inferobasal MI.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C3538872

UMLS CUI [1,2]

C0011008

Beskrivning

Other ischemic ECG findings

Datatyp

text

Alias

UMLS CUI-1

C1141959

Beskrivning

The location of each type of electrocardiographic change listed below can be divided into 4 categories: Consideration can be given to recording posterior ST changes, the maximal amount of ST (if applicable), and/ or the number of leads with ST.

Datatyp

text

Alias

UMLS CUI [1,1]

C0855329

UMLS CUI [1,2]

C0450429

Beskrivning

The presence of left or right BBB should be noted, as well as whether it is new, old, or of uncertain timing.

Datatyp

text

Alias

UMLS CUI-1

C0006384

Beskrivning

If a follow-up ECG is performed (at least 6 h after the initial ECG), the presence or absence of new Q waves that are ≥0.03 s in width, in at least 2 contiguous leads, and ≥1 mm (0.1 mV) in depth not seen on the initial ECG should be noted, as well as the location described above.

Datatyp

boolean

Alias

UMLS CUI [1]

C1305738

Beskrivning

Indicate the value of the LDL cholesterol. If the value is reported using a “>� symbol (eg, >300), record the number only (eg, 300). Lipids obtained within the first 24 h of this admission should take precedence. If >24 h after admission, then enter prior values.

Datatyp

float

Alias

UMLS CUI-1

C0428474

Beskrivning

Indicate the HDL-cholesterol value. If the value is reported using a “>� symbol (eg, >300), record the number only (eg, 300). Lipids obtained within the first 24 h of this admission should take precedence. If >24 h after admission, then enter prior values.

Datatyp

float

Alias

UMLS CUI-1

C0428472

Beskrivning

Indicate the value of triglycerides. If the value is reported using a “>� (eg, >300), record the number only (eg, 300). Lipids obtained within the first 24 h of this admission should take precedence. If >24 h of admission, then enter prior values.

Datatyp

float

Alias

UMLS CUI-1

C0202236

Beskrivning

Indicate the date the sample was collected (not the date and time results reported) OR check either Performed before hospitalization or Unknown. Lipids obtained within the first 24 h of this admission should take precedence. If >24 h after admission, then enter prior values.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0596192

UMLS CUI [1,2]

C0011008

Beskrivning

Indicate the date and time the sample was collected (not the date and time results reported) OR check either "Performed before hospitalization" or "Unknown". Lipids obtained within the first 24 h of this admission should take precedence. If >24 h after admission, then enter prior values

Datatyp

text

Alias

UMLS CUI [1,1]

C0596192

UMLS CUI [1,2]

C2348792

Beskrivning

Indicate the results from first BNP or first NT-proBNP performed during this admission. If done, enter the numerical value and specify which assay type was done.

Datatyp

float

Alias

UMLS CUI [1]

C1095989

UMLS CUI [2]

C1319570

Beskrivning

Indicate the value of the first serum hs-CRP level and units.

Datatyp

float

Alias

UMLS CUI-1

C0201657

Beskrivning

Indicate the first glucose value taken. Indicate if fasting or not.

Datatyp

float

Alias

UMLS CUI-1

C0202042

Beskrivning

Indicate the creatinine value taken at the time of admission and at the time of discharge

Datatyp

float

Alias

UMLS CUI-1

C0201975

Beskrivning

Indicate the value and units for the first hemoglobin collected during this admission. Date and time of collection should also be indicated.

Datatyp

float

Alias

UMLS CUI-1

C0518015

Beskrivning

Indicate the percentage value for the first hemoglobin A1c collected during this admission. Date and time of collection should also be indicated.

Datatyp

float

Alias

UMLS CUI-1

C0202054

Beskrivning

Indicate the numerical value of INR on admission. Date and time of collection should also be indicated.

Datatyp

integer

Alias

UMLS CUI-1

C0525032

Beskrivning

Indicate the results of the first CK sample obtained within the first 24 h of care, either from a transferring hospital or your hospital. If the patient was transferred into your hospital, data available from the transferring facility should take precedence.

Datatyp

float

Alias

UMLS CUI-1

C0201973

Beskrivning

Indicate the results of the peak CK sample obtained during this admission.

Datatyp

float

Alias

UMLS CUI [1,1]

C0201973

UMLS CUI [1,2]

C0444505

Beskrivning

Indicate the total CK ULN as defined by individual hospital laboratory standards. The units of CK and type of units (eg, IU, ng/dL, kCat/L) should be noted.

Datatyp

float

Alias

UMLS CUI [1,1]

C0201973

UMLS CUI [1,2]

C1519815

Beskrivning

Indicate the initial CK-MB value. The initial sample value refers to the first sample obtained within the first 24 h of care, either from a transferring hospital or your hospital. If the patient was transferred, data available from the transferring facility should take precedence.

Datatyp

float

Alias

UMLS CUI-1

C0523584

Beskrivning

Indicate the initial CK-MB sample ULN for the test. If a range is given, record the highest number in the range. Examples: 1. Reference range given as 05: Record ULN as 5 2. ULN given as <5: Record ULN as 5 The initial sample value refers to the first sample obtained within the first 24 h of care, either from a transferring hospital or your hospital. If the patient was transferred, data available from the transferring facility should take precedence.

Datatyp

float

Alias

UMLS CUI [1,1]

C0523584

UMLS CUI [1,2]

C1519815

Beskrivning

Indicate the results of the highest sample obtained during this admission. Note: Enter the value. If the value is reported using a < symbol (eg, <0.02), record the number only (eg, 0.02).

Datatyp

float

Alias

UMLS CUI [1,1]

C0523584

UMLS CUI [1,2]

C0444505

Beskrivning

Indicate the results of the first sample obtained within the first 24 h of care, either from a transferring hospital or your hospital. If the patient was transferred, data available from the transferring facility should take precedence. Note: Enter the value. If the value is reported using a “<� symbol (eg, “<0.02�), record the number only (eg, “0.02�).

Datatyp

float

Alias

UMLS CUI-1

C0523952

Beskrivning

Indicate which type:

Datatyp

text

Alias

UMLS CUI [1,1]

C0523952

UMLS CUI [1,2]

C0332307

Beskrivning

Indicate the results of the highest sample obtained during this admission. Note: Enter the value. If the value is reported using a < symbol (eg, <0.02), record the number only (eg, 0.02).

Datatyp

float

Alias

UMLS CUI [1,1]

C0523952

UMLS CUI [1,2]

C0444505

Beskrivning

If a pacemaker was placed during this admission, indicate what type of device

Datatyp

text

Alias

UMLS CUI [1]

C0189842

Beskrivning

Temporary pacemaker placed during this admission An ICD may be placed for: • VF • Symptomatic VT • Asymptomatic VT • Other (specify) • Inducible VT/VF at electrophysiological study • Syncope • Primary prevention for patients in high-risk heart failure group The brand, model number, and serial number of the device may be recorded.

Datatyp

boolean

Alias

UMLS CUI [1]

C0162589

Beskrivning

Indicate if the patient underwent exercise or pharmacological stress testing with or without echocardiographic or radionuclide imaging.

Datatyp

boolean

Alias

UMLS CUI-1

C3272313

Beskrivning

Indicate the date of exercise or pharmacological stress testing with or without echocardiographic or radionuclide imaging

Datatyp

datetime

Alias

UMLS CUI [1,1]

C3272313

UMLS CUI [1,2]

C0011008

Beskrivning

Indicate if the patient underwent 1 of the following: MR angiogram Multislice CT scan

Datatyp

boolean

Alias

UMLS CUI [1]

C0085532

Beskrivning

Stenosis represents the percentage occlusion, from 0% to 100%, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the normal vessel proximal to the lesion. For the denominator, take the maximum internal lumen diameter proximal and distal to the lesion. In instances where multiple lesions are present, enter the highest percentage stenosis noted. The systems of interest are as follows and should include major branch vessels of >2 mm diameter: Greatest stenosis assessed in the LAD or any major branch vessel Greatest stenosis assessed in the LCx or any major branch vessel Greatest stenosis assessed in the RCA or any major branch vessel Greatest stenosis assessed in the LM Greatest stenosis assessed in bypass graft

Datatyp

text

Alias

UMLS CUI [1]

C0242231

Beskrivning

Maximal stress test (symptom limited) or submaximal test (eg, modified Bruce protocol ending with stage 1 or stage 2)

Datatyp

text

Alias

UMLS CUI [1]

C1384495

Beskrivning

Ischemia result (positive, negative, equivocal, nondiagnostic test)

Datatyp

text

Alias

UMLS CUI [1,1]

C1274040

UMLS CUI [1,2]

C1384495

Beskrivning

Indicate whether the patient had LVEF assessed via invasive (ie, LV gram) or noninvasive (ie, echo, MR, CT or nuclear) testing before or during the admission

Datatyp

boolean

Alias

UMLS CUI-1

C2114363

Beskrivning

Indicate the ejection fraction category. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1]

C0428772

Beskrivning

Indicate if the patient had diagnostic coronary angiography. This is defined as the passage of a catheter into the aortic root or other great vessels for angiography of the native coronary arteries or bypass grafts supplying native coronary arteries. This element would NOT include noninvasive CT angiography.

Datatyp

boolean

Alias

UMLS CUI-1

C0085532

Beskrivning

Indicate the date and time the patient had diagnostic coronary angiography, defined as the passage of a catheter into the aortic root or other great vessels.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0085532

UMLS CUI [1,2]

C0011008

Beskrivning

This is the vessel considered to be responsible for the ACS. The investigator should use his or her judgment in choosing the primary vessel. In cases in which this is difficult to determine (despite correlation of electrocardiographic changes and angiographic data), the vessel supplying the largest territory of myocardium should be selected:

Datatyp

text

Alias

UMLS CUI [1]

C1299364

Beskrivning

TIMI grade flow in the culprit artery is defined as follows:

Datatyp

text

Alias

UMLS CUI [1]

C3272266

Beskrivning

The best estimate of the most severe percent stenosis in the LM coronary artery. This does not include collaterals. Indicate the following: • Percent stenosis of the LM coronary artery. • If no stenosis, then enter 0%. • If data are not available, indicate “not available.� Stenosis: Stenosis represents the percent diameter reduction, from 0 to 100, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the “normal� reference vessel proximal to the lesion. In instances where multiple lesions are present, enter the single highest percent stenosis noted. Note: If the patient only has a PCI (without a diagnostic catheterization at the same sitting), it is acceptable to use prior and recent catheterization lab visit information, even if at another institution.

Datatyp

integer

Alias

UMLS CUI-1

C2825221

Beskrivning

Indicate the best estimate of the most severe percent stenosis in the proximal LAD and first diagonal coronary artery branches of ≥2.0 mm in diameter as determined by angiography. This does not include collateral circulation. Indicate the following: • Percent stenosis of the proximal LAD and first diagonal branches. • If no stenosis, then enter 0%. • If data are not available, indicate “not available.� Stenosis: Stenosis represents the percent diameter reduction, from 0 to 100, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the “normal� reference vessel proximal to the lesion. In instances where multiple lesions are present, enter the single highest percent stenosis noted. Note: If the patient only has a PCI (without a diagnostic catheterization at the same sitting), it is acceptable to use prior and recent catheterization lab visit information, even if at another institution.

Datatyp

integer

Alias

UMLS CUI-1

C2825222

Beskrivning

Indicate the best estimate of the most severe percent stenosis in the mid or distal LAD and diagonal coronary artery branches after the first diagonal of 2.0 mm in diameter as determined by angiography. This does not include collateral circulation. Indicate the following: Percent stenosis of the mid or distal LAD, D2, and D3. If no stenosis, then enter 0 percent. If data are not available, indicate not available. Stenosis: Stenosis represents the percent diameter reduction, from 0 to 100, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the normal reference vessel proximal to the lesion. In instances where multiple lesions are present, enter the single highest percent stenosis noted. If the patient only has a PCI (without a diagnostic catheterization at the same sitting), it is acceptable to use prior and recent catheterization lab visit information, even if at another institution.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0242231

UMLS CUI [1,2]

C0439165

Beskrivning

Indicate the best estimate of the most severe percent stenosis in the Circ, OMs, LPDA, and LPL coronary artery branches of 2.0 mm in diameter as determined by angiography. This does not include collaterals. Indicate the following: Percent stenosis of the Circ, OMs, LPDA, and LPL branches. If no stenosis, then enter 0 percent. If data are not available, indicate not available. Stenosis: Stenosis represents the percent diameter reduction, from 0 to 100, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the normal reference vessel proximal to the lesion. In instances where multiple lesions are present, enter the single highest percent stenosis noted. If the patient only has a PCI (without a diagnostic catheterization at the same sitting), it is acceptable to use prior and recent catheterization lab visit information, even if at another institution.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0242231

UMLS CUI [1,2]

C0439165

Beskrivning

Indicate the best estimate of the most severe percent stenosis in the RCA, PDA, RPL, and AM branches of ≥2.0 mm in diameter as determined by angiography. This does not include collaterals. Indicate the following: • Percent stenosis of the RCA, PDA, RPL, and AM branches. • If no stenosis, then enter 0%. • If data are not available, indicate “not available.� Stenosis: Stenosis represents the percent diameter reduction, from 0 to 100, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the “normal� reference vessel proximal to the lesion. In instances where multiple lesions are present, enter the single highest percent stenosis noted. If the patient only has a PCI (without a diagnostic catheterization at the same sitting), it is acceptable to use prior and recent catheterization lab visit information, even if at another institution.

Datatyp

integer

Alias

UMLS CUI [1,1]

C3267166

UMLS CUI [1,2]

C0439165

Beskrivning

Indicate the best estimate of the most severe percent stenosis in the ramus artery (if present) of 2.0 mm in diameter as determined by angiography. This does not include collaterals. Indicate the following: Percent stenosis of the ramus. If no stenosis, then enter 0%. If data are not available, indicate not available. Stenosis: Stenosis represents the percent diameter reduction, from 0 to 100, associated with the identified vessel systems. Percent stenosis at its maximal point is estimated to be the amount of reduction in the diameter of the normal reference vessel proximal to the lesion. In instances where multiple lesions are present, enter the single highest percent stenosis noted. If the patient only has a PCI (without a diagnostic catheterization at the same sitting), it is acceptable to use prior and recent catheterization lab visit information, even if at another institution.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0242231

UMLS CUI [1,2]

C0439165

Beskrivning

Indicate if catheterization was not performed. Contraindications may include patient refusal, advanced age, patient not a candidate for revascularization, DNR order, active bleeding, and clinical contraindications/severe comorbidities.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C1532338

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if the patient is a candidate for reperfusion therapy for treatment of STEMI. Reperfusion therapy includes thrombolysis and primary PCI

Datatyp

boolean

Alias

UMLS CUI-1

C0035124

Beskrivning

the patient received reperfusion therapy, indicate the type of reperfusion. Choose all that apply:

Datatyp

text

Alias

UMLS CUI [1]

C1320534

Beskrivning

Indicate if the patient underwent PCI, placement of an angioplasty guidewire, balloon, or other device (eg, stent, atherectomy, brachytherapy, or thrombectomy catheter) into a native coronary artery or CABG for the purpose of mechanical coronary revascularization.

Datatyp

boolean

Alias

UMLS CUI-1

C1532338

Beskrivning

Indicate the date and time the patient arrived at the catheterization lab where the PCI was being performed as documented in the medical record.

Datatyp

datetime

Alias

UMLS CUI-1

C3838354

Beskrivning

Indicate the date and time the first device was activated regardless of the type of device used. Use the earliest time from the following: • Time of first balloon inflation • Time of first stent deployment • Time of first treatment of lesion (thrombectomy/aspiration device, laser, rotational atherectomy) • If the lesion cannot be crossed with a guidewire or device (and thus none of the above apply), use the time of guidewire introduction. Please note that this is a process measure about the timeliness of treatment. It is NOT a clinical outcomes measure based on TIMI flow or clinical reperfusion. It does not matter whether the baseline angiogram showed TIMI 3 flow or if the final post-PCI angiogram showed TIMI 0 flow. What is being measured is the time of the first mechanical treatment of the culprit lesion, not the time when TIMI 3 flow was (or was not) restored.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0025080

UMLS CUI [1,2]

C1879547

UMLS CUI [1,3]

C0011008

Beskrivning

Indicate the primary reason PCI was performed or attempted. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1,1]

C1532338

UMLS CUI [1,2]

C0392360

Beskrivning

Indicate if there is documentation of a reason for a delay in doing the first PCI after hospital arrival by a physician/advanced practice nurse/physician assistant. System reasons for delay are NOT acceptable.

Datatyp

text

Alias

UMLS CUI [1]

C3640267

Beskrivning

Indicate if a stent was placed in the affected coronary artery.

Datatyp

boolean

Alias

UMLS CUI-1

C3272316

Beskrivning

Indicate the type of stent if a stent was placed in the affected coronary artery. Choose all that apply:

Datatyp

text

Alias

UMLS CUI [1,1]

C0687568

UMLS CUI [1,2]

C0332307

Beskrivning

Number of stents placed. The exact type of stent should be collected

Datatyp

integer

Alias

UMLS CUI-1

C2024081

Beskrivning

If the patient received reperfusion therapy with thrombolytics, indicate the type of thrombolytics used. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1]

C0040044

Beskrivning

If the patient received reperfusion therapy with thrombolytics, indicate the strength of dose of the thrombolytics. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1,1]

C0178602

UMLS CUI [1,2]

C0040044

Beskrivning

If the patient received reperfusion therapy with thrombolytics, indicate the time of either the first bolus or the beginning of the infusion. Note: If the facility receives a transfer patient with ongoing infusion, record the time that the infusion was started at the transferring facility

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0040044

UMLS CUI [1,2]

C1301880

Beskrivning

Indicate if there is documentation of a nonsystem reason for delay in initiating thrombolytic therapy >30 min from the time of first facility arrival (including an ambulance capable of administering thrombolytic therapy). Note: A patient being transferred into a facility is not considered a nonsystem reason for delay.

Datatyp

boolean

Alias

UMLS CUI [1]

C3640267

Beskrivning

Indicate why PCI was not performed as reperfusion therapy. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1,1]

C0522473

UMLS CUI [1,2]

C1532338

Beskrivning

Indicate why thrombolytics were not administered as reperfusion therapy. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI-1

C3260558

Beskrivning

Indicate if the patient underwent CABG surgery during this admission

Datatyp

boolean

Alias

UMLS CUI-1

C0010055

Beskrivning

Indicate the date and time the patient entered the operating room suite or the first time surgery was documented on the operating room report.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0010055

UMLS CUI [1,2]

C0011008

Beskrivning

Indicate if IABP was used during this admission

Datatyp

boolean

Alias

UMLS CUI-1

C0021860

Beskrivning

Indicate if circulatory support was provided during this admission and which type:

Datatyp

text

Alias

UMLS CUI [1]

C0457617

Beskrivning

Indicate if a pulmonary artery (Swan Ganz) catheter was used during this admission

Datatyp

boolean

Alias

UMLS CUI [1]

C0190658

Beskrivning

Indicate the need for intubation and respiratory support on a ventilator. Include the date and time the patient was put on and taken off the ventilator.

Datatyp

text

Alias

UMLS CUI [1]

C0087153

Beskrivning

Indicate if a GP IIb/IIIa inhibitor was administered during the hospital stay. If yes, indicate which of the following:

Datatyp

text

Alias

UMLS CUI [1]

C3640054

Beskrivning

Indicate the GP IIb/IIIa blocker dose given.

Datatyp

integer

Alias

UMLS CUI [1,1]

C3640054

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate the date and time a GP IIb/IIIa inhibitor infusion was initiated during the hospital stay.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C1301880

UMLS CUI [1,2]

C3640054

Beskrivning

Indicate the date and time the GP IIb/IIIa inhibitor infusion was permanently discontinued during the hospital stay.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C1522314

UMLS CUI [1,2]

C3640054

Beskrivning

Indicate if a GP IIb/IIIa inhibitor was contraindicated during the hospital stay.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C3640054

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if an anticoagulant was administered during the hospital stay. If yes, indicate which of the following:

Datatyp

text

Alias

UMLS CUI [1]

C0354565

Beskrivning

Indicate the anticoagulant dose given.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0354565

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate the date and time an anticoagulant infusion was initiated during the hospital stay.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0354565

UMLS CUI [1,2]

C1301880

Beskrivning

Indicate the date and time an anticoagulant infusion was permanently discontinued during the hospital stay.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0354565

UMLS CUI [1,2]

C1522314

Beskrivning

Indicate if an anticoagulant agent was contraindicated during the hospital stay.

Datatyp

boolean

Alias

UMLS CUI-1

C1531588

Beskrivning

Nitroglycerin was administered intravenously.

Datatyp

boolean

Alias

UMLS CUI-1

C0017887

Beskrivning

Oral or topical nitroglycerin was administered. Commonly prescribed agents include isosorbide dinitrate, isosorbide mononitrate, transdermal infusion system, or nitroglycerin paste. Sublingual nitroglycerin or nitroglycerin spray used on an as-needed basis only should not be noted in this category.

Datatyp

boolean

Alias

UMLS CUI-1

C3214208

Beskrivning

Indicate if IV beta blockers were administered. Some forms of IV beta blockers include atenolol, metoprolol, propranolol, timolol, esmolol, and labetalol.

Datatyp

boolean

Alias

UMLS CUI-1

C0304516

Beskrivning

Indicate if the patient has been taking a beta blocker routinely at home before this hospitalization. If yes, indicate which type.

Datatyp

text

Alias

UMLS CUI [1]

C0304516

Beskrivning

Indicate if the beta blocker was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). If yes, indicate which type. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

text

Alias

UMLS CUI [1]

C0304516

Beskrivning

Indicate if a beta blocker was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C1278474

Beskrivning

Indicate if a beta blocker was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

text

Alias

UMLS CUI [1]

C0304516

Beskrivning

Indicate if a beta blocker was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

text

Alias

UMLS CUI [1]

C1278474

Beskrivning

Indicate if calcium channel blockers were administered. If yes, indicate which type. Some generic forms of calcium channel blockers are verapamil, nifedipine, diltiazem, nicardipine, nimodipine, nisoldipine, felodipine, and amlodipine.

Datatyp

text

Alias

UMLS CUI-1

C0006684

Beskrivning

Indicate if the patient has been taking ranolazine routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C0073633

Beskrivning

Indicate if ranolazine was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C0073633

Beskrivning

Indicate if ranolazine was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

boolean

Alias

UMLS CUI [1]

C0073633

Beskrivning

Indicate if the patient has been taking aspirin routinely at home before this hospitalization:

Datatyp

text

Alias

UMLS CUI [1]

C0004057

Beskrivning

Indicate if aspirin was administered in the first 24 h before or after hospital arrival, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C1964151

Beskrivning

Indicate dose of aspirin given for the first 24 h.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0004057

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate if aspirin was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C0729798

Beskrivning

Indicate if aspirin was continued or prescribed at hospital discharge.

Datatyp

boolean

Alias

UMLS CUI [1]

C3871333

Beskrivning

Indicate the daily dose prescribed.

Datatyp

text

Alias

UMLS CUI [1,1]

C0004057

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate if aspirin was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C0729798

Beskrivning

Indicate if the patient has been taking other oral anticoagulants (oral direct antithrombin inhibitor, eg, dabigatran or oral direct factor Xa inhibitor, eg, rivaroxaban, apixaban) routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI [1]

C0354604

Beskrivning

Indicate if other oral anticoagulant was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). If yes, indicate which type. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C0354604

Beskrivning

Indicate if other oral anticoagulant was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

boolean

Alias

UMLS CUI [1]

C0354604

Beskrivning

Indicate if the patient has been taking warfarin routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0043031

UMLS CUI [1,2]

C1302393

UMLS CUI [1,3]

C0332152

Beskrivning

Indicate if warfarin was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). If yes, indicate which type. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

text

Alias

UMLS CUI-1

C0043031

Beskrivning

Indicate if warfarin was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

text

Alias

UMLS CUI [1,1]

C0043031

UMLS CUI [1,2]

C0030685

Beskrivning

Indicate if warfarin was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0043031

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if the patient has been taking clopidogrel routinely at home before this hospitalization

Datatyp

boolean

Alias

UMLS CUI [1]

C0070166

Beskrivning

Indicate if clopidogrel was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C0070166

Beskrivning

Indicate the amount of the initial dose:

Datatyp

text

Alias

UMLS CUI [1,1]

C0070166

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate the date and time the initial dose was given.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0070166

UMLS CUI [1,2]

C1301880

Beskrivning

Indicate if clopidogrel was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C1319916

Beskrivning

Indicate if clopidogrel was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

text

Alias

UMLS CUI [1]

C1301880

Beskrivning

Indicate if clopidogrel was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C1319916

Beskrivning

Indicate if the patient has been taking prasugrel routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C1620287

Beskrivning

Indicate if prasugrel was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C1620287

Beskrivning

Indicate the date and time the initial dose was given.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C1620287

UMLS CUI [1,2]

C1301880

Beskrivning

Indicate if prasugrel was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C1620287

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if prasugrel was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C1620287

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if the patient has been taking ticagrelor routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C1999375

Beskrivning

Indicate if ticagrelor was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C1999375

Beskrivning

Indicate the date and time the initial dose was given.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C1999375

UMLS CUI [1,2]

C1301880

Beskrivning

Indicate if ticagrelor was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.

Datatyp

boolean

Alias

UMLS CUI [1]

C1999375

Beskrivning

Indicate if ticagrelor was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C1999375

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if the patient has been taking other oral antiplatelet medications routinely at home before this hospitalization. These may include ticlopidine, dipyridamole, or cilostazol.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0085826

UMLS CUI [1,2]

C0175795

UMLS CUI [1,3]

C0332152

UMLS CUI [1,4]

C1302393

Beskrivning

Indicate if other oral antiplatelets were administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Indicate which type and the dose administered. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

text

Alias

UMLS CUI [1,1]

C0085826

UMLS CUI [1,2]

C0175795

Beskrivning

Indicate if other oral antiplatelet medications were continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.

Datatyp

text

Alias

UMLS CUI [1,1]

C0085826

UMLS CUI [1,2]

C0175795

UMLS CUI [1,3]

C2361123

Beskrivning

Indicate if other oral antiplatelet medications were discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0085826

UMLS CUI [1,2]

C0175795

UMLS CUI [1,3]

C0522473

UMLS CUI [1,4]

C2361123

Beskrivning

Indicate if the patient has been taking an ACE inhibitor routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C0003015

Beskrivning

Indicate if an ACE inhibitor was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C0003015

Beskrivning

Indicate if an ACE inhibitor was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0003015

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if an ACE inhibitor was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.

Datatyp

text

Alias

UMLS CUI [1]

C0003015

Beskrivning

Indicate if an ACE inhibitor was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.

Datatyp

text

Alias

UMLS CUI [1,1]

C0003015

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if the patient has been taking an ARB routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C0521942

Beskrivning

Indicate if an ARB was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C0521942

Beskrivning

Indicate if an ARB was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0521942

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if an ARB was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

boolean

Alias

UMLS CUI [1]

C0521942

Beskrivning

Indicate if an ARB was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0521942

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if a diuretic was continued or prescribed at hospital discharge. Aldosterone inhibitor is listed separately.

Datatyp

boolean

Alias

UMLS CUI-1

C0012798

Beskrivning

Indicate if the patient has been taking an aldosterone blocking agent routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C0002007

Beskrivning

Indicate if an aldosterone blocking agent was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Indicate which type and the dose administered. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C0002007

Beskrivning

Indicate the aldosterone blocking agent dose given.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0002007

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate if an aldosterone blocking agent was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0002007

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if an aldosterone blocking agent was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.

Datatyp

boolean

Alias

UMLS CUI [1]

C0002007

Beskrivning

Indicate if an aldosterone blocking agent was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0002007

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if the patient has been taking a statin routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C2585159

Beskrivning

Indicate if a statin was administered in the first 24 h of care provided, regardless of location of care (eg, transferring facility or EMS). Indicate which type of statin was administered. Medications taken at home before hospital arrival and therefore not readministered until the next day of the hospitalization should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C0360714

Beskrivning

Indicate the following: • Specific statin agent • Statin dose given

Datatyp

text

Alias

UMLS CUI [1,1]

C0360714

UMLS CUI [1,2]

C0178602

Beskrivning

Indicate if statin was not administered during the first 24 h of care because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI-1

C1277178

Beskrivning

Indicate if a statin was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed. DO NOT record discharge medication if the patient was transferred to another acute care facility from your hospital.

Datatyp

text

Alias

UMLS CUI [1]

C0360714

Beskrivning

Indicate if statin medication was discontinued or not prescribed because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1]

C1277178

Beskrivning

Indicate if the patient has been taking another lipid-lowering agent routinely at home before this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C0086440

Beskrivning

Indicate if another lipid-lowering agent was continued or prescribed at hospital discharge. Indicate which type and the dose prescribed.

Datatyp

text

Alias

UMLS CUI-1

C2729227

Beskrivning

Indicate if another lipid-lowering agent was discontinued or not prescribed at discharge because of a contraindication. A contraindication that is not documented explicitly by the healthcare provider but is evidenced clearly within the medical record should be noted.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0086440

UMLS CUI [1,2]

C0522473

Beskrivning

Indicate if a preparation of omega-3 fatty acid supplement/medication was taken at discharge.

Datatyp

boolean

Alias

UMLS CUI-1

C0561929

Beskrivning

Indicate if an antiarrhythmic was administered.

Datatyp

boolean

Alias

UMLS CUI-1

C0003195

Beskrivning

Indicate if the patient has been prescribed an antidepressant.

Datatyp

boolean

Alias

UMLS CUI-1

C0003289

Beskrivning

Indicate if female hormone replacement therapy was administered.3

Datatyp

boolean

Alias

UMLS CUI-1

C0282402

Beskrivning

Indicate if nicotine replacement and/or suppression agents were administered (eg, bupropion, varenicline).

Datatyp

boolean

Alias

UMLS CUI-1

C1278444

Beskrivning

Indicate if the patient has been prescribed an NSAID. Indicate the type:

Datatyp

text

Alias

UMLS CUI-1

C0003211

Beskrivning

Indicate if the patient has been prescribed insulin.

Datatyp

boolean

Alias

UMLS CUI-1

C0021641

Beskrivning

Indicate if the patient has been prescribed an oral hypoglycemic agent for treatment of diabetes. Specify the agent:

Datatyp

text

Alias

UMLS CUI-1

C0359086

Beskrivning

Indicate if the patient has been prescribed a subcutaneous hypoglycemic agent for treatment of diabetes.

Datatyp

boolean

Alias

UMLS CUI-1

C3532679

Beskrivning

Indicate if the patient has received immunization for influenza or received one in the past 12 mo.

Datatyp

boolean

Alias

UMLS CUI-1

C0042200

Beskrivning

Indicate if the patient has been immunized for pneumococcal pneumonia or received one in the past 12 mo.

Datatyp

boolean

Alias

UMLS CUI-1

C2082604

Beskrivning

The patient died during this hospitalization.

Datatyp

boolean

Alias

UMLS CUI-1

C1306577

Beskrivning

Indicate the patient’s date and time of death.

Datatyp

datetime

Alias

UMLS CUI-1

C1301931

Beskrivning

The term acute MI 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: • Detection of the rise and/or fall of cardiac biomarkers (preferably cTn) with at least 1 value above the 99th percentile and with at least 1 of the following: – Symptoms of ischemia – New or presumed new significant ST-T changes or new LBBB – Development of pathological Q waves on the ECG – Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality – Identification of an intracoronary thrombus by angiography or autopsy • Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic electrocardiographic changes or new LBBB, but death occurred before cardiac biomarkers were obtained or before cardiac biomarker values would be increased. • PCI-related MI is arbitrarily defined by elevation of cTn values (>5 times the 99th percentile URL) in patients with normal baseline values (≤99th percentile URL) or a rise in cTn values ≥20% if baseline values are elevated and stable or falling; in addition, either symptoms suggestive of myocardial ischemia or new ischemic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality • Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least 1 value >99th percentile URL. • CABG-related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 times the 99th percentile URL) in patients with normal baseline cTn values (≤99th percentile URL) plus either new pathological Q waves or new LBBB, or angiographically documented new graft or new native coronary artery occlusion, or imaging evidence of new loss of viable myocardium. • The 99th percentile is observed after the procedure in conjunction with symptoms suggestive of myocardial ischemia or new ischemic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium or in patients with a preprocedure elevated biomarker that is stable or falling, a rise of biomarker values ≥20% in conjunction with the PCI-related criteria stated above.

Datatyp

boolean

Alias

UMLS CUI-1

C0155626

Beskrivning

Reinfarction occurs when there are clinical signs and symptoms of ischemia that are distinct from the presenting ischemic event and meeting at least 1 of the following criteria: 1. Spontaneous (before or without revascularization, >48 h after PCI, and/or after CABG) A. New, significant Q waves in at least 2 contiguous leads of an ECG that were not present with the presenting ischemic event B. Patients whose most recent cardiac markers drawn before reinfarction, which were normal, require an increase in CK-MB or troponin above the 99th percentile ULN, which is at least ≥20% above the most recent value. 2. Within 48 h after PCI: A. Patients with normal biomarker values (preprocedure) who then develop an increase in biomarker values >5 times the 99th percentile URL or if the baseline values are elevated and are stable or falling, a rise of cTn values ≥20%. In addition, symptoms suggestive of myocardial ischemia or new ischemic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium are required. Note: Some patients presenting with ACS will not have biomarker elevations before the PCI. Elevated biomarkers after PCI in these cases do not necessarily mean a reinfarction occurred. B. Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least 1 value above the 99th percentile URL C. For patients with elevated baseline (preprocedure) cardiac biomarkers, there are 2 possible scenarios. In these scenarios, electrocardiographic changes or symptoms are not required to qualify. i. Patients with cardiac markers above the ULN (preprocedure) assumed to be in the midst of an acute MI i i. Patients with elevated biomarkers with a characteristic rise and fall in biomarker levels preprocedure most likely have completed their presenting infarct. Further rises in cardiac markers must be ≥20% above the most recent value to be coded as reinfarction. D. Patients with new, significant Q waves in at least 2 contiguous leads of an ECG that were not present with the presenting ischemic event 3. Within 48 h after CABG: A CABG-related MI is defined by elevation of cardiac biomarker values >10 times the 99th percentile URL in patients with normal baseline cTn values (≤99th percentile URL) plus either new pathological Q waves or new LBBB or angiographically documented new graft or new native coronary artery occlusion or imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. Note: Patients with cardiac biomarkers above the ULN before CABG require the increase in biomarkers to be ≥20% above the most recent value associated with symptoms/signs of myocardial ischemia.

Datatyp

boolean

Alias

UMLS CUI-1

C2882123

Beskrivning

Indicate the date when the clinical signs and symptoms of the reinfarction first occurred.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C0948369

UMLS CUI [1,2]

C0011008

Beskrivning

Recurrent ischemic pain occurring at rest (and believed to be cardiac in origin) with associated electrocardiographic changes.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0002965

UMLS CUI [1,2]

C0277556

UMLS CUI [1,3]

C0855329

Beskrivning

Recurrent ischemic pain occurring at rest (and believed to be cardiac in origin) without associated electrocardiographic changes

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0002965

UMLS CUI [1,2]

C0277556

UMLS CUI [1,3]

C0855329

UMLS CUI [1,4]

C0332288

Beskrivning

Unstable angina requiring hospitalization is defined as: 1. Ischemic discomfort (angina or symptoms thought to be equivalent) 10 min in duration occurring at rest, or in an accelerating pattern with frequent episodes associated with progressively decreased exercise capacity 2. Prompting an unscheduled hospitalization within 24 h of the most recent symptoms. Hospitalization is defined as an admission to an inpatient unit or a visit to an emergency department that results in at least a 24 h stay (or a change in calendar date if the hospital admission or discharge times are not available) 3. At least one of the following: a. New or worsening ST or T wave changes on resting ECG (in the absence of confounders, such as LBBB or LVH) Transient ST elevation (duration <20 min) New ST elevation at the J point in 2 contiguous leads with the cut-points: 0.1 mV in all leads other than leads V2 through V3 where the following cutpoints apply: 0.2 mV in men 40 y (0.25 mV in men <40 y) or 0.14 mV in women ST depression and T-wave changes New horizontal or downsloping ST depression 0.05 mV in two contiguous leads and/or new T inversion 0.3 mV in 2 contiguous leads with prominent R wave or R/S ratio >1. b. Definite evidence of inducible myocardial ischemia as demonstrated by: an early positive exercise stress test, defined as ST elevation or 2 mm ST depression prior to 5 METS, or stress echocardiography (reversible wall motion abnormality), or myocardial scintigraphy (reversible perfusion defect), or MRI (myocardial perfusion deficit under pharmacologic stress) and believed to be responsible for the myocardial ischemic symptoms/signs. c. Angiographic evidence of new or worse 70% lesion and/or thrombus in an epicardial coronary artery that is believed to be responsible for the myocardial ischemic symptoms/signs. d. Need for coronary revascularization procedure (PCI or CABG) for the presumed culprit lesion(s). This criterion would be fulfilled if revascularization was undertaken during the unscheduled hospitalization, or subsequent transfer to another institution without interceding home discharge. 4. Negative cardiac biomarkers.

Datatyp

boolean

Alias

UMLS CUI [1]

C0002965

Beskrivning

Indicate if there is physician documentation or report of either new-onset or acute reoccurrence of heart failure. Heart failure is defined as physician documentation or report of any of the following clinical symptoms of heart failure described as unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or the description of rales, jugular venous distention, or pulmonary edema on physical examination. A low ejection fraction without clinical presentation does not qualify as heart failure. *Note: Killip class 2 is defined as rales over ≤50% of the lung fields or the presence of an S3. Killip class 3 is defined as rales over >50% of the lung fields. Either class would qualify as a “yes.�

Datatyp

boolean

Alias

UMLS CUI-1

C0018801

Beskrivning

Indicate the date of the acute reoccurrence of heart failure.

Datatyp

datetime

Alias

UMLS CUI-1

C2984177

Beskrivning

(>30 min) episode of systolic blood pressure <90 mm Hg and/or cardiac index <2.2 L/min per square meter determined to be secondary to cardiac dysfunction and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (eg, IABP, extracorporeal circulation, VADs) to maintain blood pressure and cardiac index above those specified levels. Note: Transient episodes of hypotension reversed with IV fluid or atropine do not constitute cardiogenic shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30 min.3

Datatyp

boolean

Alias

UMLS CUI-1

C0036980

Beskrivning

Indicate the date when a diagnosis for cardiogenic shock was made.

Datatyp

date

Alias

UMLS CUI [1,1]

C0036980

UMLS CUI [1,2]

C0011008

Beskrivning

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 stroke type: • Ischemic stroke • Intracerebral hemorrhage • Subarachnoid hemorrhage • Unknown type 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

Datatyp

boolean

Alias

UMLS CUI-1

C0038454

Beskrivning

Indicate the date of onset of stroke symptoms.

Datatyp

date

Alias

UMLS CUI [1,1]

C0038454

UMLS CUI [1,2]

C0011008

Beskrivning

Indicate if the patient experienced a hemorrhagic or ischemic stroke with documentation on imaging (eg, CT scan or MRI of hemorrhage in the cerebral parenchyma or a subdural or subarachnoid hemorrhage). Evidence of hemorrhagic stroke obtained from lumbar puncture, neurosurgery, or autopsy can also confirm the diagnosis. Note: If stroke occurs during sleep, last awake time may be used.

Datatyp

text

Alias

UMLS CUI [1]

C3897486

Beskrivning

An episode of bleeding is defined by the TIMI criteria as • Major: overt clinical bleeding (or documented intracranial or retroperitoneal hemorrhage) associated with a drop in hemoglobin of ≥5 g/dL (0.5 g/L) or in hematocrit of ≥15% (absolute) Note: A patient who experiences an intracranial hemorrhage should be considered to have a major hemorrhage. • Minor: overt clinical bleeding associated with a fall in hemoglobin of 3 to <5 g/dL or in hematocrit of 9% to ≤15% (absolute) • None: no bleeding event that meets the major or minor definition Note: In calculating the fall in hemoglobin or hematocrit, a transfusion of whole blood or packed RBCs is counted as 1 g/dL hemoglobin or 3% absolute in hematocrit. This would be in addition to the actual fall in hemoglobin or hematocrit.

Datatyp

boolean

Alias

UMLS CUI-1

C0019080

Beskrivning

Indicate the GUSTO bleeding classification:

Datatyp

text

Alias

UMLS CUI [1,1]

C0019080

UMLS CUI [1,2]

C0008902

Beskrivning

Indicate if there was a bleeding event observed and documented in the medical record that was associated with a hematocrit drop of 10% and/or a hemoglobin drop of 3 g/dL or that required transfusion or surgical intervention.

Datatyp

boolean

Alias

UMLS CUI-1

C0019080

Beskrivning

Indicate the location thought to be responsible for the bleeding event. Choose all that apply:

Datatyp

text

Alias

UMLS CUI [1,1]

C0019080

UMLS CUI [1,2]

C0450429

Beskrivning

Indicate the date of the suspected bleeding event.

Datatyp

date

Alias

UMLS CUI [1,1]

C0019080

UMLS CUI [1,2]

C0011008

Beskrivning

Indicate if the suspected bleeding event required a surgical or procedural intervention. Interventions may include surgery, protamine (heparin reversal agent), fibrin injection, transfusion of blood products, angioplasty,or stenting. Prolonged pressure does not qualify as an intervention, but ultrasonic guided compression after making a diagnosis of pseudoaneurysm does qualify.

Datatyp

boolean

Alias

UMLS CUI [1]

C0543467

Beskrivning

Indicate if there was a nonautologous transfusion(s) of either whole blood or packed RBCs.

Datatyp

boolean

Alias

UMLS CUI-1

C1879316

Beskrivning

Indicate the units of blood given.

Datatyp

integer

Alias

UMLS CUI-1

C0439184

Beskrivning

Indicate the date of the first RBC transfusion.

Datatyp

date

Alias

UMLS CUI-1

C0808300

Beskrivning

Indicate if any RBC/whole blood transfusion was related to CABG. If any units were given for reasons not related to CABG, check No. Check Yes only if all transfusions given were related to CABG.

Datatyp

boolean

Alias

UMLS CUI [1,1]

C0086252

UMLS CUI [1,2]

C0010055

Beskrivning

Platelet count dropped to either <50 000/mm3 or between 50 000 and <100 000/mm3; the level should be noted. This platelet count should be confirmed as not being pseudothrombocytopenia (ie, platelet clumping in citrated blood).

Datatyp

boolean

Alias

UMLS CUI-1

C0040034

Beskrivning

Rupture of the ventricular myocardium as documented by cardiac echocardiography, ventriculography, pericardiocentesis, cardiac surgery, and/or autopsy. Rupture could be of the free wall or the ventricular septum. Included in this category is frank papillary muscle rupture.

Datatyp

boolean

Alias

UMLS CUI [1]

C0018813

UMLS CUI [2]

C0018818

Beskrivning

A new episode or acute recurrence of atrial fibrillation/flutter.

Datatyp

boolean

Alias

UMLS CUI-1

C0085611

Beskrivning

A new episode or acute recurrence of supraventricular tachycardia requiring treatment (supraventricular tachycardia that requires cardioversion or drug therapy, or is sustained for >1 min).

Datatyp

boolean

Alias

UMLS CUI-1

C0039240

Beskrivning

VT or VF requiring cardioversion and/or IV antiarrhythmics.

Datatyp

boolean

Alias

UMLS CUI [1]

C0085612

Beskrivning

High-level AV block defined as third-degree AV block or second-degree AV block with bradycardia requiring pacing.

Datatyp

boolean

Alias

UMLS CUI [1]

C0004245

Beskrivning

Indicate the month, day, and year the patient was discharged from acute care, left against medical advice, or died during this stay.

Datatyp

date

Alias

UMLS CUI-1

C2361123

Beskrivning

Indicate the patients destination after discharge. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI [1]

C1550391

Beskrivning

Discharge status: the place or setting to which the patient was discharged:

Datatyp

text

Alias

UMLS CUI [1]

C0586514

Beskrivning

Indicate whether the patient was alive or dead at discharge from hospitalization during which the procedure occurred.

Datatyp

text

Alias

UMLS CUI [1]

C0586514

Beskrivning

Indicate the primary cause of death:

Datatyp

text

Alias

UMLS CUI-1

C0007465

Beskrivning

Indicate if the patient was transferred to another acute care center (hospital) for further management.

Datatyp

boolean

Alias

UMLS CUI-1

C3846725

Beskrivning

Indicate the date and time the patient was transferred to another acute care center (hospital) for further management.

Datatyp

datetime

Alias

UMLS CUI [1,1]

C3846725

UMLS CUI [1,2]

C0011008

Beskrivning

Total number of days the patient spent in an intensive care bed at the index hospital only, either consecutively or intermittently. To count days: • Find the ICU/CCU admit date/time and the date/time patient was transferred to another unit (telemetry or unmonitored bed) • For every 24-h period, count 1 d • For any partial day remaining, round up if ≥12 h and round down if <12 h In the case of an in-hospital infarct in which the patient is already in an ICU bed, record the number of days spent in ICU/CCU after the diagnosis of MI was made.

Datatyp

integer

Alias

UMLS CUI [1,1]

C0023303

UMLS CUI [1,2]

C0021708

Beskrivning

• STEMI is defined as an ACS in which there is cardiac marker evidence of myocardial necrosis (eg, positive cTn or CK-MB) and new (or presumably new if no prior ECG is available) ST-segment elevation or LBBB on the admission ECG. (For a complete definition, please see “MI� in the “Outcomes� section.) • NSTEMI is defined as an ACS in which there is cardiac marker evidence of myocardial necrosis (eg, positive cTn or CK-MB) without new ST-segment elevation. (For a complete definition, please see “MI� in the “Outcomes� section.) • BBB/uncertain type: For a complete definition, please see “MI� in the “Outcomes� section. • UA is defined as angina pectoris (or equivalent type of ischemic discomfort) with any 1 of the 3 following features: 1. Angina occurring at rest and prolonged, usually ≥10 min 2. New-onset angina of at least CCS classification III severity 3. Recent acceleration of angina reflected by an increase in severity of at least 1 CCS class to at least CCS class III The patient must also not have any biochemical evidence of necrosis. Definite/probable UA: Patients with clinical history consistent with the diagnosis of UA as described above, in whom ischemia has been confirmed by the presence of ST changes on the initial ECG or in association with recurrent rest pain, by a positive stress test, negative cardiac biomarkers, and no evidence of acute MI. Possible UA is present when an acute ischemic process has not been excluded as a possible cause of the presenting symptoms or the clinical history is consistent with UA, but no diagnostic test (noted above) was performed to confirm the diagnosis. • Stable CAD: The patient has a clinical diagnosis or prior history of CAD, but after evaluation in the hospital, the episode of discomfort was not thought to have represented UA. • Noncardiac chest pain: Pain in the chest, neck, arms, or abdomen (or other clinical manifestation) not clearly exertional or not otherwise consistent with pain or discomfort of myocardial ischemic origin. Examples: 1. If a patient was admitted with rest pain but had negative cardiac markers and then on day 3 developed recurrent pain, and if it was determined that an MI had occurred, the event prompting admission should be coded as “unstable angina� here. The MI on day 3 should be recorded in the “Outcomes� section as a postadmission MI. 2. If a patient was admitted with rest pain and the initial cardiac markers were negative but the enzymes drawn over the subsequent 24 h became positive, this is most consistent with an NSTEMI as the admission event.

Datatyp

text

Alias

UMLS CUI-1

C0332144

Beskrivning

Indicate if there was physician/nurse practitioner/physician assistant documentation that the patient was receiving comfort measures only. • Comfort measures only are commonly referred to as “palliative care� in the medical community and “comfort care� by the general public. Palliative care includes attention to the psychological and spiritual needs of the patient and support for the dying patient and the patient’s family. Usual interventions are not received because a medical decision was made to limit care to comfort measures only. • Comfort measures only are not equivalent to a DNR order, living will, no code, or no heroic measure.

Datatyp

boolean

Alias

UMLS CUI-1

C0150521

Beskrivning

Indicate the specialty of the attending physician who primarily cared for the patient according to the most frequent and consistent notations in the medical record. Choose 1 of the following:

Datatyp

text

Alias

UMLS CUI-1

C1508823

Beskrivning

Indicate if the patient signed an informed consent to participate in a clinical trial during his or her hospitalization, even if the investigational medication, device, or procedure was never initiated.

Datatyp

boolean

Alias

UMLS CUI-1

C0422726

Beskrivning

Indicate if there was documentation in the medical record that smoking cessation advice or counseling was given during this hospital stay.

Datatyp

boolean

Alias

UMLS CUI-1

C1273715

Beskrivning

Advice is given or counseling conducted by a physician or nurse for patients who are >120% of ideal weight for height. Particular emphasis on weight loss may be given for patients with hypertension, elevated triglycerides, or elevated glucose levels.

Datatyp

boolean

Alias

UMLS CUI-1

C1444340

Beskrivning

Advice is given or a discussion conducted by a physician, nurse, or registered dietitian encouraging diet counseling. This can include consumption of low-cholesterol foods; moderate restriction of sodium intake; emphasis on consumption of fruits, vegetables, and low-fat dairy products; and increased consumption of omega-3 fatty acids.

Datatyp

boolean

Alias

UMLS CUI-1

C1828150

Beskrivning

Indicate if advice was given or discussion conducted by a physician, nurse, or exercise specialist or nurse encouraging patients to engage in a minimum of 30 to 60 min of physical activity daily or at least 3 to 4 times weekly.

Datatyp

boolean

Alias

UMLS CUI-1

C1629016

Beskrivning

Indicate if advice was given or discussion conducted with the patient (by physician, nurse, or other personnel) about the importance of joining a cardiac rehabilitation program or an appointment made.

Datatyp

boolean

Alias

UMLS CUI-1

C0700431

Beskrivning

Readmission to a hospital

Datatyp

boolean

Alias

UMLS CUI [1]

C0600290

Beskrivning

Date the patient was readmitted

Datatyp

date

Alias

UMLS CUI [1,1]

C0600290

UMLS CUI [1,2]

C0011008

Beskrivning

Reasons for admission (include all that apply):

Datatyp

text

Alias

UMLS CUI [1,1]

C0600290

UMLS CUI [1,2]

C0392360

Beskrivning

Indicate the results of BNP or first NT-proBNP. If done, enter the numerical value and specify which assay type was done.

Datatyp

integer

Alias

UMLS CUI [1]

C1095989

UMLS CUI [2]

C1319570

Beskrivning

Indicate the value of LDL cholesterol. If the value is reported using a “>� symbol (eg, “>300�), record the number only (eg, “300�).

Datatyp

float

Alias

UMLS CUI-1

C0428474

Beskrivning

Indicate the value of HDL cholesterol. If the value is reported using a “>� symbol (eg, “>300�), record the number only (eg, “300�).

Datatyp

float

Alias

UMLS CUI-1

C0428472

Beskrivning

Indicate value and date performed.

Datatyp

text

Alias

UMLS CUI-1

C0202054

Beskrivning

Documented evidence of an MI. For a complete definition, please see “MI� in the “Outcomes� section.

Datatyp

boolean