Electrocardiogram



*Date and time of ECG (yyyy-mm-dd): FORMCHECKBOX am FORMCHECKBOX pm FORMCHECKBOX 24-hour clockAtrial rate: beats/min FORMCHECKBOX N/A*Ventricular rate /Heart rate: beats/minPR interval: msecQRS duration: msec*QT interval: msec*QTc interval: msecECG results* (choose only one): FORMCHECKBOX Normal FORMCHECKBOX πAbnormal, not clinically significant FORMCHECKBOX πAbnormal, clinically significant FORMCHECKBOX πBorderline FORMCHECKBOX πUnable to evaluateπ For any ECG result that is not Normal, provide comments:*Heart rhythm: FORMCHECKBOX Normal sinus rhythm FORMCHECKBOX Sinus tachycardia FORMCHECKBOX Sinus bradycardia FORMCHECKBOX Atrial arrhythmia, specify type: FORMCHECKBOX Premature atrial contractions FORMCHECKBOX Atrial fibrillation FORMCHECKBOX Atrial flutter FORMCHECKBOX Other FORMCHECKBOX Ventricular arrhythmia, specify type: FORMCHECKBOX Premature ventricular contractions FORMCHECKBOX Ventricular fibrillation FORMCHECKBOX Ventricular tachycardia FORMCHECKBOX OtherIf ventricular arrhythmia, specify morphology: FORMCHECKBOX Uniform FORMCHECKBOX Multiform FORMCHECKBOX Paced rhythm, specify type: FORMCHECKBOX Atrial FORMCHECKBOX Ventricular FORMCHECKBOX Supraventricular tachycardia FORMCHECKBOX Other, specify:Axis direction: FORMCHECKBOX Normal FORMCHECKBOX Left axis deviation FORMCHECKBOX Right axis deviationRight atrial enlargement: FORMCHECKBOX Absent FORMCHECKBOX PresentLeft atrial enlargement: FORMCHECKBOX Absent FORMCHECKBOX PresentVentricular pre-excitation/ Wolff-Parkinson-White Syndrome: FORMCHECKBOX Absent FORMCHECKBOX Present*ST segment abnormality: FORMCHECKBOX Absent FORMCHECKBOX Present*T wave abnormality: FORMCHECKBOX Absent FORMCHECKBOX Present FORMCHECKBOX Peaked*Right ventricular hypertrophy: FORMCHECKBOX Absent FORMCHECKBOX Present*Left ventricular hypertrophy: FORMCHECKBOX Absent FORMCHECKBOX Present*Patterns of previous myocardial infarction: FORMCHECKBOX Absent FORMCHECKBOX PresentConduction block: FORMCHECKBOX Absent FORMCHECKBOX PresentIf conduction block present,First degree AV block: FORMCHECKBOX Absent FORMCHECKBOX PresentSecond degree AV block: FORMCHECKBOX Absent FORMCHECKBOX PresentThird degree (complete AV block): FORMCHECKBOX Absent FORMCHECKBOX PresentComplete bundle branch block: FORMCHECKBOX Absent FORMCHECKBOX PresentIncomplete bundle branch block: FORMCHECKBOX Absent FORMCHECKBOX PresentIf complete or incomplete buddle branch block present, type: FORMCHECKBOX Left FORMCHECKBOX Right FORMCHECKBOX Non-specific intraventricular conduction delayLeft anterior hemiblock: FORMCHECKBOX Absent FORMCHECKBOX PresentGeneral InstructionsAn electrocardiogram (ECG) is often used during the screening visit of a study to evaluate a participant’s/subject’s cardiac health and determine whether the participant/subject is eligible for the study. Follow up ECGs may be performed to continue to monitor the participant’s/subject’s heart rhythms over the course of the study.Specific InstructionsPlease see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Data and time ECG performed – Record the date/time according to the ISO 8601, the International Standard for the representation of dates and times (International Organization for Standardization ). The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.).Atrial rate – Record the atrial rate in beats per minute.Ventricular Rate/Heart Rate – Record the ventricular rate/heart rate in beats per minute.PR interval – Measure and record the PR interval in milliseconds (msec).QRS duration – Measure and record the QRS duration in milliseconds (msec).QT interval – Measure and record the QT interval in milliseconds (msec).QTc interval – Measure and record the QTc interval in milliseconds (msec).ECG Results – Choose all that apply. If 'Normal sinus rhythm' is chosen no other values can be chosen.Paced rhythm – Choose all that apply.Atrial arrhythmia – Choose all that apply.Ventricular arrhythmia – Choose all that apply.Axis direction – Choose one.Conduction block – Choose one.First degree AV block – Only answered if Present is answered for Conduction block. Choose one.Second degree AV block – Only answered if Present is answered for Conduction block. Choose one.Third degree AV block – Only answered if Present is answered for Conduction block. Choose plete bundle branch block - Only answered if Present is answered for Conduction block. Choose one.Incomplete bundle branch block - Only answered if Present is answered for Conduction block. Choose one.Left anterior hemiblock - Only answered if Present is answered for Conduction block. Choose one. ................
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