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 |
| | |
|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 |
| | |
|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 |
| | |
|17.Ezetimibe |θ Yes θ No θ Unknown |
| | |
|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 |
| | |
|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)
-----------------------
Demographics
History: Medical History and Risk Factors
Clinical Presentation
Peri-Procedural Hematology / Biochemistry (LABS)
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