HEART AND SOUL STUDY CARDIOLOGY DATA COLLECTION FORM

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1 DATE / / STAFF ID YPPTID YDATE YSTAFID VISIT BASELINE CARDIOLOGY DATA COLLECTION FORM SSN: - - YCSSN YCDOB DOB: / / First Name: YCFNM YCWGHT Weight: YCWGHT lbs oz Last Name: YCLNM Height: YHGHT inches Fellow's Last Name: YCFEL BSA: YCBSA m RESTING MEASUREMENTS YREST YREST Cuff size: Small Medium Large Arm used: Right Left (Make sure the same arm and cuff size will be used during treadmill) Supine blood pressure (taken manually, after at least minutes supine): YREST / mmhg Pulse (after at least minutes supine): YREST beats/min YREST O Sat: % SUPINE -LEAD EKG (RESTING) YEKG Time of resting EKG: : Date fellow completed EKG form: / / YEKG Heart & Soul Baseline CHD Data Collection Form, Version 9/08/00, page Act

2 RESTING ECHO MEASUREMENTS Date: / / YRECH Time: : YRECH YRECH Nonstenotic aortic sclerosis: Yes 0 No YRECH Aortic valve area: cm Transaortic gradient, peak: YRECH mmhg YRECH6 Transaortic gradient, mean: mmhg Aortic regurgitation: YRECH7 0 None Trace Mild Moderate Severe Pulmonic stenosis: YRECH Yes 0 No YRECH Right atrial pressure: mmhg (Measured by IVC) YRECH RV/RA gradient: mmhg YRECH6 Avg end systolic left atrial volume: ml YRECH7 Posterior wall thickness (M-mode): mm Tricuspid regurgitation: YRECH8 0 None Trace Mild YRECH8 Septum thickness (M-mode): mm Moderate Severe YRECH9 LV mass (truncated ellipsoid): grams Mitral stenosis: YRECH9 Yes 0 No YRECH0 Avg LV end systolic volume: ml Mitral valve prolapse: YRECH0 Yes 0 No Mitral anular calcification (MAC) grade: 0 None YRECH Mitral regurgitation: YRECH 0 None Trace Mild Moderate Severe Avg LV end diastolic volume: YRECH ml Pulmonary venous flow: YRECH systolic dominant 0 diastolic dominant E wave: YRECH m/s A wave: YRECH m/s Heart & Soul Baseline CHD Data Collection Form, Version 9/08/00, page 0096 Act

3 RESTING ECHO WALL MOTION SCORE Normal Hypokinesis Akinesis Dyskinesis Aneurysm Not visualized Basal anteroseptum YRECH Basal anterior wall YRECH6 Basal anterolateral wall YRECH7 Basal posterolateral wall YRECH8 Postero-(or infero-) basal wall YRECH9 Inferobasal septum YRECH0 Midanteroseptum YRECH Midanterior wall YRECH Midanterolateral wall YRECH Midposterolateral wall YRECH Midinferior wall YRECH Midinferoseptum YRECH6 Apical septum Anteroapex Lateral apex Inferior apex YRECH7 YRECH8 YRECH9 YRECH0 Heart & Soul Baseline CHD Data Collection Form, Version 9/08/00, page Act

4 TREADMILL MEASUREMENTS (including *for Duke Treadmill score), Standard Bruce Protocol) YTRDM Date: / / Time: : YTRDM BP at peak exercise, taken manually: / YTRDM mmhg (Make sure the same arm and cuff size as resting BP are used) HR at peak exercise: YTRDM beats/min *Duration of exerciseytrdm YTRDM6 mins secs HR at exactly 60 seconds post exercise: YTRDM7 beats/min YTRDM8 *Angina: 0 No Angina Nonlimiting angina Angina was the reason patient stopped exercising Patient stopped exercise due to: Chest pain ST segment depression YTRDM9A YTRDM9F Shortness of breath Fatigue YTRDM9B YTRDM9G Leg pain Other YTRDM9H YTRDM9C Please specify: Arrhythmia YTRDM9D Knee pain YTRDM9E YTRDM0 Arrhythmia during exercise: YTRDM Arrhythmia during recovery: YTRDM 0 None Atrial Ventricular 0 None Atrial Ventricular Maximal number of PVCs per minute: Maximum number of METS achieved: YTRDM YTRDM Other electrocardiographic findings: YTRDM Heart & Soul Baseline CHD Data Collection Form, Version 9/08/00, page Act

5 *Largest net ST segment deviation during or after exercise (millimeters): YTRDM6 mm What lead?(check one only) I II III avr avl 6 avf 7V 8V 9 V 0V V V6 YTRDM7 Largest net ST segment elevation during or after exercise (millimeters): YTRDM8 mm What lead?(check one only) I II III avr avl 6 avf 7V 8V 9 V 0V V V6 YTRDM9 Number of leads showing ST segment depression or elevation of mm or more: YTRDM0 Time to onset of ST segment deviation: YTRDM YTRDM mins secs ECHO MEASUREMENTS POST-EXERCISE Time of post-exercise echo: : YEXEC YEXEC Avg LV end systolic volume: ml YEXEC Avg LV end diastolic volume: ml Exercise-induced wall motion abnormality: 0 No Yes YEXEC territory YEXEC territories territories Heart & Soul Baseline CHD Data Collection Form, Version 9/08/00, page Act

6 POST-EXERCISE ECHO WALL MOTION SCORE Normal Hypokinesis Akinesis Dyskinesis Aneurysm Not visualized Basal anteroseptum YEXEC6 Basal anterior wall YEXEC7 Basal anterolateral wall YEXEC8 YEXEC Basal posterolateral wall YEXEC9 Postero-(or infero-) basal wall YEXEC0 Inferobasal septum YEXEC Midanteroseptum Midanterior wall YEXEC YEXEC Midanterolateral wall YEXEC Midposterolateral wall YEXEC Midinferior wall Midinferoseptum Apical septum YEXEC6 YEXEC7 YEXEC8 Anteroapex YEXEC9 Lateral apex YEXEC0 Inferior apex YEXEC Heart & Soul Baseline CHD Data Collection Form, Version 9/08/00, page Act

7 DATE / / STAFF ID VISIT BASELINE EXTRA ECHOCARDIOGRAPHIC DATA COLLECTION FORM Parasternal long Septum thickness (cm) D: Post wall thickness (cm) D: Asc Aorta diameter (cm) D: LA diameter (cm) D: LVOT diameter (cm) D: YECHO6 TR velocity (m/s): Apical four YPPTID YDATE YSTAFID YECHO9 0 None Moderate Trace Color (Aortic valve): Mild Severe YECHO0 0 None Moderate Trace Color (Mitral valve): Mild Severe YECHO MV VTI: YECHO MR velocity (m/s): YECHO YECHO YECHO YECHO YECHO gradient Mitral inflow (valve tips): YECHO YECHO YECHO6 E: A: E/A: YECHO7 YECHO gradient Parasternal short PA VTI: YECHO9 PI velocity diastolic (m/s): YECHO TR velocity (m/s): Septum thickness M-mode (cm): Post wall thickness M-mode (cm): YECHO8 gradient YECHO MV annular diameter (cm): YECHO MV annulus level VTI: YECHO MV color Mmode inflow: (Delta t, duration msec, slope) YECHO Pulmonary vein VTI (systolic): YECHO Pulmonary vein VTI (diastolic): YECHO6 Pulmonary vein a wave duration (msec): YECHO7 YECHO8 TR velocity (m/s): YECHO0 YECHO gradient YECHO YECHO gradient Mitral DT: MV a wave duration (msec): Mitral P / Time: Mitral IVRT (msec): YECHO7 YECHO8 YECHO9 YECHO0 YECHO9 LAES vol ML (vent systole) at rest: YECHO0 LAED vol ML (vent diastole) at rest: YECHO RAES vol ML (vent systole): YECHO RAED vol ML (vent diastole): Heart & Soul Baseline Extra Echo Data Collection Form, Version //0, page Act-6-0

8 Apical five YECHO7 LVOT VTI: YECHO8 LVOT PW velocity (m/s): YECHO9 LVOT gradient peak: YECHO0 LVOT gradient mean: YECHO Ao VTI: YECHO Ao velocity CW (m/s): YECHO Ao gradient peak: YECHO Ao gradient mean: YECHO AVA: Subcostal YECHO6 IVC collapse-rap (mmhg): 0 0 YECHO7 Hepatic vein flow S vs D: Diastolic Systolic Codominant YECHO8 Abd aorta plaque score at rest: Suprasternal (Rest) YECHO9 Aortic arch diameter (cm) diastolic: Aortic arch diameter (cm) systolic: YECHO6 RPA diameter (cm) diastolic: RPAdiameter (cm) systolic: YECHO6 YECHO6 YECHO67 Decending aorta flow PW: YECHO69 YECHO70 SVC doppler flow: Diastolic Systolic Codominant LA: Calculations Rest Stress YECHO7 LVEDV biplaner: YECHO76 LVESV biplaner: YECHO80 SI: YECHO8 EF (Bi-planar) %: YECHO8 LV Mass Index (g/m): YECHO8 LV Mass (g): YECHO86 PA systolic pressure (mmhg): YECHO7 YECHO77 YECHO8 YECHO8 Heart & Soul Baseline Extra Echo Data Collection Form, Version //0, page Act-6-0

9 YPPTID Last Name: YECGLNM DATE / / YDATE STAFF ID YSTAFID First Initial: YECGFI VISIT BASELINE Last : YECGSSN EKG DATA COLLECTION FORM SECTION ONE Date of EKG Reading: / / Rate: YRATE beats/min YECGDAT Reader #: Reader #: Ndrio YREAD Aggarwal Arain Ndrio YREAD Aggarwal Arain RHYTHM (choose one): AV CONDUCTION (choose one): Sinus YECG Normal YECG Atrial Fibrillation First Degree AV Block P-R interval >= 0 seconds in any of the limb leads Atrial Flutter Wndr Atrial Pacemaker Mobitz I block (AV Wenckebach) P-R interval becomes progressively longer until an atrial depolarization no longer initiates a ventricular response The cycle is then resumed Supravent Arrhythmia Mobitz II block Not every P wave is followed by a QRS complex The dropped beat occurs periodically with no change in the other P-R intervals Vent Arrhythmia A paced V or A-V paced 6 Third degree block P waves are not associated with QRS complexes Other The atrioventricular conduction defect cannot be determined Heart & Soul EKG Data Collection Form, Version /0/00, page Act-0-00

10 VENTRICULAR HYPERTROPHY (choose one): ATRIAL ENLARGEMENT (choose one): None YECG None YECG LVH (Left Ventricular Hypertrophy) R amplitude > 6 mm in either V or V6 or R amplitude > 0 mm in any leads I, II, III, or AVF or R amplitude > mm in Lead AVL measured only on second to last complete normal beat or R amplitude > mm but <= 0 mm in lead I or R amplitude in V or V6, plus S amplitude in V > mm LAE (Left Atrial Enlargement) Notched P wave in any standard lead with interpeak duration > 00 seconds or total P wave duration in any standard lead > 0 seconds or biphasic P wave with terminal negative deflection (P > 00 sec and >= mm amplitude) in V LVH with strain Criteria of LVH plus: J point depression changes in any of the following leads: I, II, AVL, AVF, V-V6 RAE (Right Atrial Enlargement) Tall P wave > mm in a majority of beats in any of leads II, III, AVF RVH (Right Ventricular Hypertrophy) R amplitude >= mm and R amplitude >= S amplitude in the majority of beats in V, plus S amplitude > R amplitude in V, V, V, V or V6 BAE (Bilateral Atrial Enlargement) Criteria present for both LAE and RAE Undeterminable by EKG BVH (Bilateral Ventricular Hypertrophy) Criteria for both LVH and RVH are present Heart & Soul EKG Data Collection Form, Version /0/00, page Act-0-00

11 VENTRICULAR CONDUCTION (choose one): YECG Normal QRS duration < 00 seconds and axis between -0 and 0 degrees 7 LAD Left axis deviation of -0 degrees or more negative Incomplete RBBB (Right Bundle Branch Block) QRS duration >= 00 sec and < 0 sec in each of leads I, II, III, AVL, AVF, plus R' > R in either of leads V or V 8 LPFB (Left Posterior Fascicular Block) QRS axis > 0 degrees plus QRS duration is normal plus initial Q wave in leads II, III, AVF plus initial R wave in leads I, AVL RBBB QRS duration >= 0 sec in majority of beats in any of leads I, II, III, AVL, AVF, plus R' > R in leads V or V or QRS majority are upright, plus R peak duration >= 006 sec in V or V or S duration > R duration in all beats in leads I or II 9 RBBB & LAFB RBBB with QRS axis of - degrees or more negative RBBB & LPFB RBBB with QRS axis +0 degrees or greater Incomplete LBBB (Left Bundle Branch Block) QRS duration >= 00 sec and < 0 sec in majority of beats of each of leads I, AVL, V, or V6 IVCD (Intraventricular Conduction Defect) QRS duration >= 0 sec in a majority of beats in leads I, II, III, AVL, or AVF LBBB QRS duration >= 0 sec in a majority of beats in any of leads I, II, III, AVL, AVF, plus R peak duration >= 006 sec in a majority of beats in any of leads I, II, AVL, V, V6 **Do not code in presence of third degree block or paced rhythm** 6 LAFB (Left Anterior Fascicular Block) QRS duration < 0 sec in the majority of beats in leads I, II, III, AVL, AVF, plus initial Q wave amplitude >= 0 mm and < 00 sec duration in lead I, plus left axis deviation of - degrees or more negative Heart & Soul EKG Data Collection Form, Version /0/00, page Act-0-00

12 SECTION TWO MINNESOTA CODE Lateral site (leads I, avl, V6) (PLEASE CHOOSE ONE): YECG6 -- Q/R amplitiude ratio >= /, plus Q duration >= 00 sec in lead I or V6 -- Q duration >= 00 sec in lead I or V6 -- Q duration >= 00 sec, plus R amplitude >= mm in lead avl -- Q/R amplitiude ratio >= /, plus Q duration >= 00 sec and < 00 sec in lead I or V6 -- Q duration >= 00 sec and < 00 sec in lead I or V QS pattern in lead I Do not code in the presence of complete LBBB Initial R amplitude decreasing to mm or less in every beat between V and V6 (All beats in lead V must have an initial R > mm) DO NOT CODE IN PRESENCE OF: complete LBBB, incomplete or complete RBBB, or RVH Q/R amplitiude ratio >= / and < /, plus Q duration >= 00 sec and < 00 sec in lead I or V Q duration >= 00 sec and < 00 sec, plus R amplitude >= mm in lead avl None of the above Heart & Soul EKG Data Collection Form, Version /0/00, page 6779 Act-0-00

13 Posterior (inferior) site (leads II, III, avf) (PLEASE CHOOSE ONE): YECG7 -- Q/R amplitiude ratio >= /, plus Q duration >= 00 sec in lead II -- Q duration >= 00 sec in lead II -- Q duration >= 00 sec in lead III, plus a Q wave amplitude >= 0 mm in the majority of beats in lead avf -- Q duration >= 00 sec in lead avf -- Q/R amplitiude ratio >= /, plus Q duration >= 00 sec and < 00 sec in lead II -- 6 Q duration >= 00 sec and < 00 sec in lead II -- 7 QS pattern in lead II Do not code in presence of complete LBBB -- 8 Q duration >= 00 sec and < 00 sec in lead III, plus a Q wave >= 0 mm amplitude in the majority of beats in lead avf -- 9 Q duration >= 00 sec and < 00 sec in lead avf --6 Q amplitude >= 0 mm in leads III or avf -- Q/R amplitiude ratio >= / and < /, plus Q duration >= 00 sec and < 00 sec in lead II -- Q duration >= 00 sec and < 00 sec in lead III, plus a Q-wave >= 0 mm amplitude in the majority of beats in lead avf -- Q duration >= 00 sec and < 00 sec in lead avf --6 QS pattern in each of leads III and avf (Do not code in presence of complete LBBB) None of the above Heart & Soul EKG Data Collection Form, Version /0/00, page Act-0-00

14 Anterior site (leads V, V, V, V, V) (PLEASE CHOOSE ONE): YECG8 -- Q/R amplitiude ratio >= /, plus Q duration >= 00 sec in any of leads V, V, V, V -- Q duration >= 00 sec in any of leads V, V, V, V, V --6 QS pattern when initial R-wave is present in adjacent lead to the right on the chest, in any of leads V, V, V, V, V6 --7 QS pattern in all leads V-V or V-V Q/R amplitiude ratio >= /, plus Q duration >= 00 sec and < 00 sec, in any of leads V, V, V, V Q duration >= 00 sec and < 00 sec in any of leads V, V, V, V QS pattern in all of leads V, V, and V (Do not code in presence of complete LBBB) Initial R amplitude decreasing to mm or less in every beat between V and V, V and V, or V and V (All beats in the lead immediately to the right on the chest must have an initial R > mm) DON NOT CODE IN PRESENCE OF: complete LBBB, incomplete or complete RBBB, or RVH Q/R amplitiude ratio >= / and < /, plus Q duration >= 00 sec and < 00 sec in any of leads V, V, V, V QS pattern in lead V and V (Do not code in presence of high amplitude R waves (> 6 mm in either V or V6; > 0 mm in any of leads I, II, III, avf; or > mm in lead avl) or complete LBBB) None of the above Heart & Soul EKG Data Collection Form, Version /0/00, page Act-0-00

15 SECTION THREE Q Wave (choose one for each set of leads) 0 LEADS I, avl, V6 II, III, avf V-V YECG9 YECG0 YECG No Q Wave Possible (Q dur 0-0 msec) Probable (Q Dur > 0 msec) 0 CLINICAL IMPRESSIONS 0No Q Wave Possible (Q dur 0-0 msec) Probable (Q Dur > 0 msec) No Q Wave Possible (Q dur 0-0 msec) Probable (Q Dur > 0 msec) YECG YECG YECG No ST Depression 0 No ST Depression 0 No ST Depression 0 Ischemic Ischemic Ischemic ST Depression Nonspecific LVH with strain Nonspecific LVH with strain Nonspecific LVH with strain 0 YECG YECG6 YECG7 No ST Elevation 0 No ST Elevation 0 No ST Elevation Ischemic Ischemic Ischemic ST Elevation Nonspecific Early repolarization Nonspecific Early repolarization Nonspecific Early repolarization 0 Normal YECG8 0 Normal YECG9 0 Normal YECG0 Inverted Inverted Inverted T Wave Flat Biphasic Flat Biphasic Flat Biphasic Peaked Peaked Peaked Comments: YECG Heart & Soul EKG Data Collection Form, Version /0/00, page Act-0-00

16 YPPTID Last Name: DATE / / YDATE STAFF ID YSTAFID First Initial: HOLTER DATA COLLECTION FORM Last : VISIT BASELINE YHLNM YHFI YHSSN YHOLDAT Date of Holter Reading: / / PLEASE ALSO SAVE HARD COPY OF REPORT Heart Rates: YMEANNN mean NN: YSDNN SDNN: ms ms YHRMIN MIN: YHRAVG AVG: beats/min beats/min YSDANN N SDANN: ms YHRMAX MAX: beats/min YSD ASDNN/SD: ms YLRR Longest RR: seconds YRMSSD rmssd: ms YHFREQ YHFREQ YHFREQ YHFREQ YHFREQ In/ms for very low frequencies** In/ms for low frequencies* In/ms for high frequencies* In/ms for wideband frequencies* low/high ratio *based on average of -minute segments in which >= 80% of the beats are normal pnn0: YPNN0 % YPNN0A pnn0a: % YPNN0B pnn0b: % BB0: YBB0 BB0a: YBB0A **based on en bloc analysis of the entire -hour recording BB0b: YBB0B Heart & Soul Holter Data Collection Form, Version /6/0, page 606 Act-6-0

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