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

Descrição

Hospital identification number

Tipo de dados

integer

Alias

UMLS CUI [1,1]

C0600091

UMLS CUI [1,2]

C0019994

Descrição

Patient identification number

Tipo de dados

integer

Alias

UMLS CUI-1

C2348585

Descrição

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

Tipo de dados

date

Alias

UMLS CUI-1

C0421451

Descrição

The sex of the patient.

Tipo de dados

text

Alias

UMLS CUI-1

C0079399

Descrição

Height in cms.

Tipo de dados

integer

Unidades de medida

• cm

Alias

UMLS CUI-1

C0005890

Descrição

Weight in kgs.

Tipo de dados

integer

Alias

UMLS CUI-1

C0005910

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1546432

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1275835

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0455530

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0455531

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0559159

Descrição

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%.

Tipo de dados

text

Alias

UMLS CUI-1

C1881056

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1533077

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1533075

Descrição

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).

Tipo de dados

text

Alias

UMLS CUI-1

C1320647

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1275842

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0543414

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0011849

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0455527

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1533076

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0004057

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0003280

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0304516

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0003015

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0521942

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C3274787

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0360714

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0086440

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C3177142

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI-1

C1320528

Descrição

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.

Tipo de dados

integer

Unidades de medida

• bpm

Alias

UMLS CUI-1

C0018810

Descrição

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.

Tipo de dados

integer

Unidades de medida

• mmHg

Alias

UMLS CUI-1

C0871470

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI-1

C1320532

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1881332

Descrição

Indicate the rhythm on the first admission ECG.

Tipo de dados

text

Alias

UMLS CUI-1

C0232187

Descrição

Indicate if first admission ECG has any QRS abnormalities.

Tipo de dados

text

Alias

UMLS CUI-1

C2983649

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C0232326

Descrição

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).

Tipo de dados

text

Alias

UMLS CUI [1,1]

C1271630

UMLS CUI [1,2]

C07022401

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C1271630

Descrição

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

Tipo de dados

float

Unidades de medida

• mmol/l

Alias

UMLS CUI-1

C1445957

Descrição

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

Tipo de dados

float

Alias

UMLS CUI-1

C0201975

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0332135

Descrição

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).

Tipo de dados

text

Alias

UMLS CUI-1

C0040044

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI [1,1]

C0040044

UMLS CUI [1,2]

C1301880

Descrição

Reason why thrombolysis not administered

Tipo de dados

text

Alias

UMLS CUI-1

C3260558

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0027054

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI-1

C1532338

UMLS CUI-2

C1264639

UMLS CUI-3

P

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1384495

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1274040

UMLS CUI-2

C1384495

UMLS CUI-3

P

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C0428772

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0085532

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C3275120

Descrição

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'.

Tipo de dados

text

Alias

UMLS CUI-1

C1532338

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI [1,1]

C1532338

UMLS CUI [1,2]

C1264639

Descrição

Indicate if the patient underwent CABG during this admission episode.

Tipo de dados

text

Alias

UMLS CUI-1

C0010055

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI [1,1]

C0010055

UMLS CUI [1,2]

C0011008

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0018831

Descrição

Indicate if aspirin was administered in the treatment of ACS.

Tipo de dados

text

Alias

UMLS CUI-1

C0004057

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C3640054

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0003015

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0304516

Descrição

Indicate if diuretics were administered in the treatment of ACS.

Tipo de dados

text

Alias

UMLS CUI-1

C0012798

Descrição

Indicate if inotropes were administered in the treatment of ACS.

Tipo de dados

text

Alias

UMLS CUI-1

C0304509

Descrição

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)

Tipo de dados

text

Alias

UMLS CUI-1

C2882123

Descrição

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).

Tipo de dados

text

Alias

UMLS CUI-1

C0019080

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C0038454

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0018790

UMLS CUI-2

C1882942

Descrição

Indicate the date and time of cardiac arrest

Tipo de dados

datetime

Alias

UMLS CUI-1

C2825160

Descrição

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.

Tipo de dados

text

Descrição

Indicate the patients discharge ECG rhythm.

Tipo de dados

text

Alias

UMLS CUI-1

C0232187

Descrição

Indicate the discharge diagnosis.

Tipo de dados

text

Alias

UMLS CUI-1

C0332144

Descrição

Indicate vital status at discharge.

Tipo de dados

text

Alias

UMLS CUI-1

C0586514

Descrição

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

Tipo de dados

datetime

Alias

UMLS CUI-1

C2361123

UMLS CUI-2

C1148348

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

Indicate if the patient was prescribed statins on discharge.

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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.

Tipo de dados

date

Alias

UMLS CUI-1

C3694716

Descrição

Indicate vital status at follow up.

Tipo de dados

text

Descrição

If the patient died indicate the date of death.

Tipo de dados

date

Alias

UMLS CUI-1

C1148348

Descrição

Indicate the primary cause of death.

Tipo de dados

text

Alias

UMLS CUI-1

C0007465

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C1277207

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C1275491

Descrição

If the patient was readmitted to hospital indicate the date.

Tipo de dados

date

Alias

UMLS CUI [1,1]

C0030700

UMLS CUI [1,2]

C0011008

Descrição

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.

Tipo de dados

text

Alias

UMLS CUI-1

C0027051

Descrição

Indicate the date of the myocardial infarction.

Tipo de dados

date

Alias

UMLS CUI-1

C2924287

Descrição

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.

Tipo de dados

text

Descrição

Indicate the date of the stroke. Date

Tipo de dados

date

Descrição

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

Tipo de dados

text

Descrição

Indicate the date of percutaneous coronary intervention [PCI].

Tipo de dados

date

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

date

Descrição

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

Tipo de dados

text

Alias

UMLS CUI-1

C0700431

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text

Descrição

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

Tipo de dados

text