Form 4: Coronary Evaluation

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Jodie Reed
6 years ago
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1 Patient Details Hidden Show Show/Hide Annotations Form : Coronary Evaluation Print this Form t Started Date of Coronary Evaluation Coronary Evaluation Indication for Coronary Evaluation Check only one. Angio NOT DONE: n invasive test performed Followup from PTCA / Revascularization (to check patency) n invasive test prior to this date indicated coronary disease Objective evidence of graft dysfunction/cad Research Protocol Routine, per established protocol (i.e. yearly evaluation) Symptoms (suggesting CHF or angina equivalent) Other, specify n invasive test prior to this date indicated coronary disease, specify test Check only one. Cardiac CT Dobutamine Stress Echo Exercise Test MRI Radionuclide Angiogram (MUGA) Resting Echo Stress Perfusion Other, specify Angio NOT DONE: ninvasive test performed Cardiac CT Dobutamine Stress Echo Exercise Stress Echo Exercise Test MRI Radionuclide Angiogram (MUGA) Resting Echo Stress Perfusion Other, specify Angiography

2 a b c Injection sites Check all that apply. Method of Interpretation (Pertains to the angiogram) Check only one. Pre angiogram nitroglycerin Aorta Left Ventricle Selective Left Coronary Selective Right Coronary Caliper Computer Assisted Visual Estimate Angiography Results a Angiography Results Abnormal rmal a If abnormal, indicate ISHLT CAV score (J Heart Lung Transplant July ;9(7):77 7) t Graded ISHLT CAV (t significant): detectable angiographic lesion ISHLT CAV (Mild): Angiographic left main (LM) <5%, or primary vessel with maximum lesion of <7%, or any branch stenosis <7% (including diffuse narrowing) without allograft dysfunction ISHLT CAV (Moderate): Angiographic LM <5%; a single primary vessel >7%, or isolated branch stenosis >7% in branches of systems, without allograft dysfunction ISHLT CAV (Severe): Angiographic LM >5%, or two or more primary vessels >7% stenosis, or isolated branch stenosis >7% in all systems; or ISHLT CAV or CAV with allograft dysfunction (defined as LVEF <5% usually in the presence of regional wall motion abnormalities) b L Main LAD LCx RCA PDA rmal t Visualized Absent (congenital) Mild Stenosis (% to 5%) Moderate Stenosis (5% to 7%) Severe Stenosis (7% to %) Ectasia L Main = Left Main Coronary Artery LAD = Left Anterior Descending LCx = Left Circumflex RCA = Right Coronary Artery PDA = Posterior Descending

3 Severe Distal Pruning Coronary Flow Functional assessment of coronary flow performed using catheter based methods Abnormal Fractional Flow Reserve (FFR) is defined as <.75 Abnormal Coronary Flow Reserve (CFR) is defined as <. Maximal Flow: Resting Flow Fractional Flow Reserve Performed Vessels Studied Check all that apply. LAD LCx Left Main RCA Left Main Coronary Artery (L Main) Left Anterior Descending (LAD) Left Circumflex (LCx) Right Coronary Artery (RCA) 5b Coronary Flow Reserve (CFR) Performed 5b If CFR Performed, CFR abnormal (Abnormal is defined as:. Maximal Flow: Resting Flow) Intravascular Ultrasound Intravascular Ultrasound Performed

4 Vessels Studied LAD LCx Left Main RCA If Left Main, Maximal Intimal If Left Main, If LAD, Maximal Intimal If LAD, If LCx, Maximal Intimal If LCx, If RCA, Maximal Intimal If RCA, <. mm >=.mm t Done <. mm >=.mm t Done <. mm >=.mm t Done <. mm >=.mm

5 t Done Left Ventricular Function Evaluation Left Ventricular Function Evaluation 7 Nearest to coronary angiogram 7a Date of study Missing Reason: t Done 7b Method of Interpretation Contrast ventriculogram Echocardiogram MRI Radionuclide angiogram (MUGA) 7c 7c Left Ventricular Ejection Fraction Echo Shortening Fraction Missing Missing Reason: t Done Reason: t Done Wall Motion Akinesis Dyskinesis Hypokinesis rmal t interpreted for wall motion abnormalities Hypokinesis Akinesis Dyskinesis

6 Dobutamine or Exercise Stress Echo Was Dobutamine or Exercise Stress Echo performed? Date Missing Reason: Maximum Dobutamine Dose mcg/kg/min Missing Reason: t Done Baseline Akinesis/dyskinesis Hypokinesis rmal Is there segmental hypokinesis and if so, how many segments? Is there segmental Akinesis/dyskinesis and if so, how many segments? less than Stress New Akinesis/dyskinesis New Hypokinesis rmal If Stress is New Hypokinesis If Stress is New Akinesis/dyskinesis Maximum Heart Rate Achieved Missing Reason: LV Dilatation with Stress

Form 4: Coronary Evaluation

Form 4: Coronary Evaluation Form : Coronary Evaluation Print this Form t Started Date of Coronary Evaluation Coronary Evaluation Indication for Coronary Evaluation Check only one. Angio NOT DONE: n invasive test performed Followup