CASE REPORT FORM



העמותה הישראלית למחקרי לב וכלי דם (ע"ר)

THE ISRAELI ASSOCIATION FOR CARDIOVASCULAR TRIALS (R.A)

|מטה המחקר | |Coordinating Center |

|המכון לחקר הלב ע"ש נויפלד | |Neufeld Cardiac Research institute |

|המרכז הרפואי ע"ש שיבא | |Sheba Medical Center |

|תל-השומר 52621 | |Tel-Hashomer, 52621 |

| טל . |03-5344703 | Tel. |

| פקס. |03-5342392 | Fax. |

| דואר אלקטרוני |ispha@sheba..il | e-mail |

Multivessel CAD Database

CASE REPORT FORM

Version 1

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|2.ACE Inhibitors |θ Yes θ No θ Unknown |

|3.ARB |θ Yes θ No θ Unknown |

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|4.Statin |θ Yes θ No θ Unknown |

|5.Nitrates |θ Yes θ No θ Unknown |

|6.Coumadin |θ Yes θ No θ Unknown |

|7.Pradaxa |θ Yes θ No θ Unknown |

| | |

|8.Xarelto |θ Yes θ No θ Unknown |

| | |

|9.fusid |θ Yes θ No θ Unknown |

|10.Aldactone/ Inspra |θ Yes θ No θ Unknown |

|11.Oral anti-hyperglycemic |θ Yes θ No θ Unknown |

| | |

|12.Insulin |θ Yes θ No θ Unknown |

|13.Aspirin |θ Yes θ No θ Unknown |

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|14.Clopidogrel |θ Yes θ No θ Unknown |

| | |

|15.Prasugrel |θ Yes θ No θ Unknown |

| | |

|16.Ca Antagonists |θ Yes θ No θ Unknown |

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|17.Ezetimibe |θ Yes θ No θ Unknown |

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|18.Amiodarone |θ Yes θ No θ Unknown |

| | |

|19.Other anti-arrhythmic |θ Yes θ No θ Unknown |

| | |

|20.Ticagrelor |θ Yes θ No θ Unknown |

| | |

|21.Viagra |θ Yes θ No θ Unknown |

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|22.Cialis |θ Yes θ No θ Unknown |

| | |

|23.Lavitra |θ Yes θ No θ Unknown |

24. Smoking cessation θ Yes θ No θ Unknown

Therapy

INDICATION FOR CARDIAC CATHETERIZATION

θStable angina θACS θCHF θother

CCS Class: (0-4)θ θUnstable angina θAngina

θ Non STEMI θ Non anginotic

θLate angiography after STEMI

Positive imaging test

θ C.T angio

θ MPI

θ Stress Echo

θ Stress test

θ MPI for Viability

Heart rate bpm

Systolic blood pressure (at time of presentation) mmHg

Diastolic blood pressure (at time of presentation) mmHg

Cardiogenic shock θ Yes θ No θ Unknown

Killip Class: θ1 θ2 θ3 θ4 (complete only for ACS)

Baseline ECG (at arrival)

Rhythm: θNSR θA.Fib/flutter θPacemaker

QRS: θNormal θLBBB θRBBB θOther______ θUnknown

ECG ST-T Pattern: (only one)

θNormal θST-elevation θST-depression θT inversion only θNo new ST-T changes θUndetermined ECG findings (LBBB, Pacing, Severe LVH)

| |Baseline |

|Hematology |Value |

|Hemoglobin (5-20) |__ __ . __ |θND |

|Serum creatinine 0.4-20 |__ __ . __ |θND |

|Urea 10-400 |__ __ __ |θND |

|Cardiac Enzymes | | |

|Troponin (For ACS only) |θPositive θNegative |θPositive θNegative |

| |Value |

|Lipid Profile | |

|Total Cholesterol 50-500 |__ __ __ |θND |

| LDL 10-400 |__ __ __ |θND |

|HDL 10-100 |__ __ __ |θND |

|Triglycerides 20-5000|_ _ _ _ |θND |

|Diabetic Profile |if available |

|Fasting Glucose 20-400 |__ __ __ |θND |

|HBA1C(%) 3-25 |__ __ |θND |

Angiographic (PCI+ CABG patients)

PROCEDURE INFORMATION

Procedure priority θElective θUrgent θ Emergent

Access site θ Femoral θ Rt Radial θ Lt Radial θ Other

Diseased artery:

|LM |LAD |LCx |RCA |

θostial |___% |θostial |___% |θostial |___% |θostial |___% | |θproximal |___% |θproximal |___% |θproximal |___% |θproximal |___% | |θmid |___% |θmid |___% |θmid |___% |θmid |___% | |θdistal |___% |θdistal |___% |θdistal |___% |θdistal |___% | |

LVEF function: θNormal θMild θModerate θSevere θUnknown or LVEF _____ %

IABP Support θYes θNo

Treatment decision

PCI θYes

CABG θYes

PCI + planned CABG* θYes

Conservative treatment θYes

Syntax Score θ (to be completed by core Lab)

*if Patient undergone PCI and CABG both form should be completed

Any complication during Angiographic procedure θYes θNo If Yes, specify_________________

Patient referred to other hospital θYes θNo

If yes (

Specify the name of institute_________(list of centers)

Name of Coordinator/ Physician:__________ Date: dd/mm/yyyy

(END of Baseline CRF)

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Demographics

History: Medical History and Risk Factors

Clinical Presentation

Peri-Procedural Hematology / Biochemistry (LABS)

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