Cardiology Audit and Registration Data Standards for Coronary Care Unit [CCU]/Acute Coronary Syndrome [ACS] admissions.

Beschrijving

Hospital identification number

Datatype

integer

Alias

UMLS CUI [1,1]

C0600091

UMLS CUI [1,2]

C0019994

Beschrijving

Patient identification number

Datatype

integer

Alias

UMLS CUI-1

C2348585

Beschrijving

The date the patient was born as recorded on their birth certificate.

Datatype

date

Alias

UMLS CUI-1

C0421451

Beschrijving

The sex of the patient.

Datatype

text

Alias

UMLS CUI-1

C0079399

Beschrijving

Height in cms.

Datatype

integer

Maateenheden

• cm

Alias

UMLS CUI-1

C0005890

Beschrijving

Weight in kgs.

Datatype

integer

Alias

UMLS CUI-1

C0005910

Beschrijving

Indicate if the patient was transferred from another hospital for this admission

Datatype

text

Alias

UMLS CUI-1

C1546432

Beschrijving

Indicate if the patient had at least one previous myocardial infarction before this admission.

Datatype

text

Alias

UMLS CUI-1

C1275835

Beschrijving

Indicate if the patient has a history of angina and / or has been treated previously for angina by a physician.

Datatype

text

Alias

UMLS CUI-1

C0455530

Beschrijving

Indicate if the patient has a history of congestive heart failure and/or has previously been treated for congestive heart failure by a physician.

Datatype

text

Alias

UMLS CUI-1

C0455531

Beschrijving

Indicate if the patient has a history of cerebrovascular accident (CVA) / stroke, as evidenced by a persistent neurological deficit due to ischaemia.

Datatype

text

Alias

UMLS CUI-1

C0559159

Beschrijving

History or evidence of aneurysm or occlusive peripheral Code vascular disease or carotid disease, including aortic aneurysm, previous aorto-iliac or peripheral vascular surgery, or reduced or absent peripheral pulses and / or angiographic stenosis of more than 50%.

Datatype

text

Alias

UMLS CUI-1

C1881056

Beschrijving

Indicate if the patient has a history of chronic renal failure documented by any one of the following: (a) Serum creatinine greater than 2.0 mg/dl or 200 umol/l in the past (b) On dialysis (c) Has had a renal transplantation

Datatype

text

Alias

UMLS CUI-1

C1533077

Beschrijving

Indicate if the patient has a history of chronic lung disease and/or has previously been treated for chronic lung disease by a physician.

Datatype

text

Alias

UMLS CUI-1

C1533075

Beschrijving

Indicate if the patient has had a previous PCI of any type before the current admission (e.g. balloon angioplasty, implantation of intra coronary stent or other catheter devices for treating coronary atheroma, atherectomy, laser angioplasty or other).

Datatype

text

Alias

UMLS CUI-1

C1320647

Beschrijving

Indicate if the patient had coronary artery bypass graft (CABG) done prior to this admission

Datatype

text

Alias

UMLS CUI-1

C1275842

Beschrijving

Indicate if the patient has a history confirming any form of tobacco use in the past. This includes cigarettes/cigar/pipe.

Datatype

text

Alias

UMLS CUI-1

C0543414

Beschrijving

Indicate if the patient has a history of diabetes mellitus diagnosed prior to the current admission.

Datatype

text

Alias

UMLS CUI-1

C0011849

Beschrijving

Indicate if the patient has a history of hypertension diagnosed and/or treated by a physician.

Datatype

text

Alias

UMLS CUI-1

C0455527

Beschrijving

Indicate if the patient has a documented history of hypercholesterolemia diagnosed and/or treated by a physician.

Datatype

text

Alias

UMLS CUI-1

C1533076

Beschrijving

Indicate if the patient was taking aspirin regularly prior to this admission to hospital.

Datatype

text

Alias

UMLS CUI-1

C0004057

Beschrijving

Indicate if the patient was taking antiplatelet medication (other than aspirin) regularly prior to this admission to hospital.

Datatype

text

Beschrijving

Indicate if the patient was taking anticoagulant medication before this hospital admission.

Datatype

text

Alias

UMLS CUI-1

C0003280

Beschrijving

Indicate if the patient was taking Beta-blockers regularly prior to this admission to hospital

Datatype

text

Alias

UMLS CUI-1

C0304516

Beschrijving

Indicate if the patient was taking ACE inhibitors regularly prior to this admission to hospital.

Datatype

text

Alias

UMLS CUI-1

C0003015

Beschrijving

Indicate if the patient was taking angiotensin II receptorblockers regularly prior to this admission to hospital.

Datatype

text

Alias

UMLS CUI-1

C0521942

Beschrijving

Indicate the main method of diabetic treatment the patient has been receiving.

Datatype

text

Alias

UMLS CUI-1

C3274787

Beschrijving

Indicate if the patient was taking statins regularly prior to this admission to hospital.

Datatype

text

Alias

UMLS CUI-1

C0360714

Beschrijving

Indicate if the patient was taking non-statin lipid lowering agents regularly prior to this admission to hospital.

Datatype

text

Alias

UMLS CUI-1

C0086440

Beschrijving

Indicate the predominant symptom /reason why patient presented for medical attention.

Datatype

text

Alias

UMLS CUI-1

C3177142

Beschrijving

Indicate the date and time of onset of symptom / reason that prompted the patient's presentation for medical attention.

Datatype

datetime

Alias

UMLS CUI-1

C1320528

Beschrijving

Indicate the patient's heart rate (beats per minute) reading. This should be the first heart rate recorded by a health care provider (GP/ ambulance staff/A&E staff) AND when the patient is in a stable cardiac rhythm.

Datatype

integer

Maateenheden

• bpm

Alias

UMLS CUI-1

C0018810

Beschrijving

Indicate the patient's systolic blood pressure reading (mm Hg). This should be the first blood pressure recorded by a health care provider (GP/ ambulance staff/A&E staff) AND when the patient is in a stable cardiac rhythm.

Datatype

integer

Maateenheden

• mmHg

Alias

UMLS CUI-1

C0871470

Beschrijving

Indicate the date and time the patient first presented to the hospital for this admission.

Datatype

datetime

Alias

UMLS CUI-1

C1320532

Beschrijving

Indicate the Killip class of the patient at the time of hospital admission.

Datatype

text

Alias

UMLS CUI-1

C1881332

Beschrijving

Indicate the rhythm on the first admission ECG.

Datatype

text

Alias

UMLS CUI-1

C0232187

Beschrijving

Indicate if first admission ECG has any QRS abnormalities.

Datatype

text

Alias

UMLS CUI-1

C2983649

Beschrijving

Indicate if the first admission ECG has any STT changes. Note: if more than one of these options are applicable to a patient then the most severe should be coded. For example if the patient has 2,3,and 4 then 2 should be coded. Options 2, 3, 4 and 88 are ranked in order.

Datatype

text

Alias

UMLS CUI-1

C0232326

Beschrijving

Indicate if biochemical markers were raised above the levels recognised in guidelines for diagnosis of acute myocardial infarction (NB these levels may vary between laboratories).

Datatype

text

Alias

UMLS CUI [1,1]

C1271630

UMLS CUI [1,2]

C07022401

Beschrijving

Indicate which biochemical marker was tested to indicate the presence/absence of an acute MI Note: these options are ranked in order so if all three biochemical markers were tested code option one, if option 2 and 3 were raised code option 2 etc.

Datatype

text

Alias

UMLS CUI-1

C1271630

Beschrijving

Indicate the first total serum cholesterol level in mmol/l [ideally taken within 24 hours of this admission].

Datatype

float

Maateenheden

• mmol/l

Alias

UMLS CUI-1

C1445957

Beschrijving

Indicate the level of the serum creatinine (first) during this admission in mg/dl or umol/l.

Datatype

float

Alias

UMLS CUI-1

C0201975

Beschrijving

After initial assessment of the patient, indicate the diagnosis on which further management of the patient is based.

Datatype

text

Alias

UMLS CUI-1

C0332135

Beschrijving

Indicate the type of thrombolysis therapy administered. NB if in field ACS 6.04 option 'facilitated' is ticked the type of thrombolysis used should also be indicated in this field (6.01).

Datatype

text

Alias

UMLS CUI-1

C0040044

Beschrijving

Indicate the date and time thrombolysis was commenced. This is defined as the time the infusion was commenced and/or time of bolus injection.

Datatype

datetime

Alias

UMLS CUI [1,1]

C0040044

UMLS CUI [1,2]

C1301880

Beschrijving

Reason why thrombolysis not administered

Datatype

text

Alias

UMLS CUI-1

C3260558

Beschrijving

If the patient underwent a percutaneous coronary intervention indicate the type.

Datatype

text

Alias

UMLS CUI-1

C0027054

Beschrijving

Indicate the date and time of percutaneous coronary intervention [PCI].

Datatype

datetime

Alias

UMLS CUI-1

C1532338

UMLS CUI-2

C1264639

UMLS CUI-3

P

Beschrijving

If the patient underwent a stress test during hospital stay indicate the type of stress test.

Datatype

text

Alias

UMLS CUI-1

C1384495

Beschrijving

Indicate if signs of ischaemia were present on the stress test used (as determined by the clinician).

Datatype

text

Alias

UMLS CUI-1

C1274040

UMLS CUI-2

C1384495

UMLS CUI-3

P

Beschrijving

Indicate the patients estimated or calculated left ventricular [LV] function This categorises the percentage of the blood emptied from the left ventricle at the end of the contraction. Data may have been derived from angiography, echocardiography, nuclear imaging, magnetic resonance imaging etc.

Datatype

text

Alias

UMLS CUI-1

C0428772

Beschrijving

Indicate if the patient underwent diagnostic coronary angiography during this admission episode.

Datatype

text

Alias

UMLS CUI-1

C0085532

Beschrijving

Indicate from the coronary angiogram performed the number of vessels with significant reduction in luminal diameter due to coronary atheroma (I.e. with stenosis greater than 50%) Significant disease is indicated if the luminal diameter of the coronary artery is reduced by > 50% due to coronary arteromatous disease.

Datatype

text

Alias

UMLS CUI-1

C3275120

Beschrijving

Indicate if the patient underwent a PCI during this admission episode. This is for patients who had PCI during this admission that was not for primary reperfusion. Patients who had PCI for primary reperfusion and who had no subsequent PCI during this admission are coded as 'no'.

Datatype

text

Alias

UMLS CUI-1

C1532338

Beschrijving

Indicate the date the PCI was performed if performed during this admission episode.

Datatype

datetime

Alias

UMLS CUI [1,1]

C1532338

UMLS CUI [1,2]

C1264639

Beschrijving

Indicate if the patient underwent CABG during this admission episode.

Datatype

text

Alias

UMLS CUI-1

C0010055

Beschrijving

Indicate the date the CABG was performed if performed during this admission episode.

Datatype

datetime

Alias

UMLS CUI [1,1]

C0010055

UMLS CUI [1,2]

C0011008

Beschrijving

Indicate if the patient had any of the following electrical devices implanted during this admission episode.

Datatype

text

Alias

UMLS CUI-1

C0018831

Beschrijving

Indicate if aspirin was administered in the treatment of ACS.

Datatype

text

Alias

UMLS CUI-1

C0004057

Beschrijving

Indicate if heparin/low molecular weight heparin [LMWH] was administered in the treatment of ACS .

Datatype

text

Beschrijving

Indicate the use of IV Glycoprotein IIb/IIIa inhibitors and type in the treatment of ACS.

Datatype

text

Alias

UMLS CUI-1

C3640054

Beschrijving

Indicate if ACE inhibitors were administered in the treatment of ACS.

Datatype

text

Alias

UMLS CUI-1

C0003015

Beschrijving

Indicate if Beta-blockers were administered in the treatment of ACS.

Datatype

text

Alias

UMLS CUI-1

C0304516

Beschrijving

Indicate if diuretics were administered in the treatment of ACS.

Datatype

text

Alias

UMLS CUI-1

C0012798

Beschrijving

Indicate if inotropes were administered in the treatment of ACS.

Datatype

text

Alias

UMLS CUI-1

C0304509

Beschrijving

Indicate if the patient had a myocardial reinfarction during this hospital stay. To meet the criteria as a post admission event, an MI must be distinct from the index event at the time of admission. See ESC/ACC definition of MI (appendix 1)

Datatype

text

Alias

UMLS CUI-1

C2882123

Beschrijving

Indicate if there was an episode of bleeding during the hospital stay that required close monitoring and/ or specific treatment, e.g. transfusion (blood or blood products).

Datatype

text

Alias

UMLS CUI-1

C0019080

Beschrijving

Indicate if the patient was diagnosed as having a stroke during hospital stay, as evidenced by persistent loss of neurological function caused by an ischaemic event.

Datatype

text

Alias

UMLS CUI-1

C0038454

Beschrijving

Indicate if the patient had a cardiac arrest during hospital admission and was successfully resuscitated.

Datatype

text

Alias

UMLS CUI-1

C0018790

UMLS CUI-2

C1882942

Beschrijving

Indicate the date and time of cardiac arrest

Datatype

datetime

Alias

UMLS CUI-1

C2825160

Beschrijving

Indicate if the patient developed any of the following mechanical complications during this admission. If more than one occurred indicate the most life threatening complications - i.e. 2>3>4.

Datatype

text

Beschrijving

Indicate the patients discharge ECG rhythm.

Datatype

text

Alias

UMLS CUI-1

C0232187

Beschrijving

Indicate the discharge diagnosis.

Datatype

text

Alias

UMLS CUI-1

C0332144

Beschrijving

Indicate vital status at discharge.

Datatype

text

Alias

UMLS CUI-1

C0586514

Beschrijving

Indicate the date the patient was discharged from hospital or if patient died record the date of death.

Datatype

datetime

Alias

UMLS CUI-1

C2361123

UMLS CUI-2

C1148348

Beschrijving

Indicate if the patient was prescribed aspirin on discharge from hospital.

Datatype

text

Beschrijving

Indicate if the patient was prescribed antiplatelet medication (other than aspirin) on discharge from hospital.

Datatype

text

Beschrijving

Indicate if the patient was prescribed anticoagulant medication on discharge from hospital.

Datatype

text

Beschrijving

Indicate if the patient was prescribed Beta-Blockers on discharge from hospital.

Datatype

text

Beschrijving

Indicate if the patient was prescribed ACE inhibitors on discharge from hospital.

Datatype

text

Beschrijving

Indicate if the patient was prescribed angiotensin II receptor blockers on discharge from hospital.

Datatype

text

Beschrijving

Indicate the main method of diabetic treatment the patient was prescribed on discharge from hospital.

Datatype

text

Beschrijving

Indicate if the patient was prescribed statins on discharge.

Datatype

text

Beschrijving

Indicate if the patient was prescribed non-statin lipid lowering agents on discharge.

Datatype

text

Beschrijving

Indicate the date of last follow up alive. This may be the date of follow up or the date the patient is last seen alive by verifiable sources.

Datatype

date

Alias

UMLS CUI-1

C3694716

Beschrijving

Indicate vital status at follow up.

Datatype

text

Beschrijving

If the patient died indicate the date of death.

Datatype

date

Alias

UMLS CUI-1

C1148348

Beschrijving

Indicate the primary cause of death.

Datatype

text

Alias

UMLS CUI-1

C0007465

Beschrijving

Indicate the patients anginal status at the time of followup using the Canadian Cardiovascular Society (CCS) grading system NB: there are eight blocks to a mile.

Datatype

text

Alias

UMLS CUI-1

C1277207

Beschrijving

Grade breathing status using the New York Heart Association (NYHA) functional classification.

Datatype

text

Alias

UMLS CUI-1

C1275491

Beschrijving

If the patient was readmitted to hospital indicate the date.

Datatype

date

Alias

UMLS CUI [1,1]

C0030700

UMLS CUI [1,2]

C0011008

Beschrijving

Indicate if the patient was diagnosed as having an myocardial infarction since the date of discharge. See Appendix 1 for ESC/ACC definition of MI.

Datatype

text

Alias

UMLS CUI-1

C0027051

Beschrijving

Indicate the date of the myocardial infarction.

Datatype

date

Alias

UMLS CUI-1

C2924287

Beschrijving

Indicate if the patient was diagnosed as having a stroke since discharge from hospital, as evidenced by persistent loss of neurological function caused by an ischaemic event.

Datatype

text

Beschrijving

Indicate the date of the stroke. Date

Datatype

date

Beschrijving

Indicate if the patient had a percutaneous coronary intervention since the date of discharge.

Datatype

text

Beschrijving

Indicate the date of percutaneous coronary intervention [PCI].

Datatype

date

Beschrijving

Indicate if the patient had coronary artery bypass graft [CABG] since the date of discharge.

Datatype

text

Beschrijving

Indicate the date of coronary artery bypass graft [CABG].

Datatype

date

Beschrijving

Indicate if the patient attended or is attending a cardiac rehabilitation programme since discharge.

Datatype

text

Alias

UMLS CUI-1

C0700431

Beschrijving

On follow up indicate if the patient is taking aspirin regularly.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking antiplatelet medication (other than aspirin) regularly.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking anticoagulant medication regularly.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking Beta-Blockers regularly.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking ACE inhibitors regularly.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking angiotensin II receptor blockers regularly.

Datatype

text

Beschrijving

On follow-up indicate the main method of diabetic control the patient is regularly receiving.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking statins regularly.

Datatype

text

Beschrijving

On follow-up indicate if the patient is taking non-statin lipid lowering agents regularly.

Datatype

text