CARDIAC SERVICES PATIENT ASSESSMENT GUIDE 1 of 5

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1 down PATIENT ASSESSMENT GUIDE 1 of 5 RISK FACTORS Age: 9 between 75 and 80 Weight: (kg) Height: (cm) Body Mass Index (BMI): SOCIAL HISTORY Support at Home on Discharge 9 Family 9 Friends 9 Other (name): Level of Support: 9 Minimal 9 Adequate 9 Good Health Care Proxy: 9 copy on chart Tobacco Use 9 Smoker within the last year 9 Smoker within a week from surgery 9 Other tobacco use (pipes, cigars, chewing tobacco) Alcohol Consumption (drinks) Per week: 9 1 or less greater than 8 Per day: 9 4 or more Illicit Drug Use (heroin, marijuana, cocaine, methamphetamines): 9 Prior 9 Continuous FAMILY HISTORY Premature Coronary Artery Disease (CAD) 1 male less than 55 years old; female less than 65 years old 9 Parent 9 Sibling 9 Children Gender: 9 male 9 female Age: (must be documented) Diabetes 1 Type: 9 I 9 II Diabetes Control: 9 None 9 Diet 9 Oral 9 Insulin 9 Other Glycosylated Hemoglobin (Hgb A1c ) level: 9 uncontrolled (greater than 7) Diabetic: 9 Retinopathy 9 Nephropathy 9 Neuropathy Dyslipidemia 1 Renal Disease: 9 On Dialysis Last Creatinine: Hypertension 1 CHRONIC DISEASE/COMORBIDITIES Chronic Anemia: cause, if known: Chronic Lung Disease/Chronic Obstructive Pulmonary Disease (COPD) 1 Type: 9 Emphysema 9 Asthma 9 Chronic Bronchitis 9 Other Level: 9 Mild (Forced Expiratory Volume in 1 second [FEV1] 60-75% predicted and/or on chronic bronchodilator therapy) 9 Moderate (FEV % predicted and/or on chronic steroid therapy for lung disease oral or inhaled) 9 Severe (FEV1 less than 50% predicted and/or on room air partial pressure oxygen [po 2 ] less than 60% or partial pressure carbon dioxide [po 2 ] greater than 50%) RESPIRATORY Pulmonary Function Tests (PFTs): Predicted FEV1 (%): Predicted diffusion capacity of carbon dioxide in lungs [DLCO 2 ] (%): Home Oxygen: 9 Continuous 9 As Needed Sleep Apnea Use: 9 Continuous Positive Airway Pressure (CPAP) 9 Bilevel Positive Airway Pressure (BiPAP) Inhaled Medication or Oral Bronchodilator Therapy History of Pneumonia: 9 within 1 month of procedure 9 remote greater than 1 month to procedure 9 recurrent Immunocompromise present 1 Underlying Cause, if known: IMMUNE Systemic steroids Anti-rejection medications/chemotherapy Mediastinal radiation Cancer within 5 years Type: 9 Active Treatment GI Liver Disease: 9 Hepatitis B 9 Hepatitis C 9 Cirrhosis 9 Portal Hypertension 9 Esophageal Varices 9 Chronic Alcohol Abuse (4 or more drinks per day) 9 Congestive Hepatopathy Prior Gastrointestinal (GI) Bleed 9 Peptic Ulcer Disease 9 Hemorrhoids 9 Esophageal Varices 9 Colon polyps

2 down PATIENT ASSESSMENT GUIDE 2 of 5 CHRONIC DISEASE/COMORBIDITIES PERIPHERAL ARTERY DISEASE 2 NEUROLOGIC/ CEREBROVASCULAR Claudication Amputation for Arterial Disease Vascular reconstruction, bypass surgery, percutaneous intervention Aortic Aneurysm (below the diaphragm) Diagnostic Testing Syncope within past 1 year Unresponsive neurological state 9 ankle brachial index 0.9 or less 9 doppler/magnetic resonance imaging (MRI)/computerized tomography (CT) imaging with greater than 50% stenosis in any peripheral artery Prior Cerebrovascular Accident (CVA) Residual Deficits: 9 Recent within 2 weeks 9 Remote 2 weeks or more 9 Transient ischemic attack (TIA) 9 Carotid stenosis: 9 none 9 right 9 left 9 both 9 Prior carotid artery stenosis surgery or intervention Type: Date: History of dementia Prior Coronary Artery Bypass Graft (CABG) PREVIOUS CARDIAC INTERVENTIONS Prior Valve Surgery Date of procedure: Type of procedure: 9 Repair 9 Replacement Valve: Approach: 9 Sternal 9 Thoracotomy 9 Percutaneous Prior Percutaneous Cardiac Intervention (PCI) 9 PCI within this episode of care Date: 9 PCI stent of procedure: stent type: 9 bare metal 9 drug-eluding 9 unknown Prior implantable cardioverter/defibrillator (ICD) Prior pacemaker Other cardiovascular intervention or cardiac surgery Type: Indication: PRE-OPERATIVE CARDIAC STATUS Prior Myocardial Infarction (MI) hours or less 9 greater than 6 hours but less than 12 hours 9 greater than 12 hours but less than 24 hours days days 9 greater than 21 days 9 within 8 weeks ANGINAL CLASSIFICATION 1 (within 2 weeks) CARDIAC PRESENTATION ON ADMISSION No symptoms/no Angina CCS I: Ordinary physical activity (i.e., walking or climbing stairs) does not cause angina; angina occurs with strenuous or rapid prolonged exertion at work or recreation CCS II: Slight limitation or ordinary activity (i.e., angina occurs while walking or climbing stairs after meals, in cold, in wind, under emotional stress, or only during a few hours after awakening; walking more than 2 blocks on the level or climbing more than 1 flight of ordinary stairs at a normal pace; and in normal conditions) CCS III: Marked limitation of ordinary activity (i.e., angina occurs with walking 1 or 2 blocks on level or climbing 1 flight of stairs in normal conditions and at a normal pace) CCS IV: Inability to perform any physical activity without discomfort; angina syndrome may be present at rest No symptoms/no angina Shortness of breath/dyspnea on exertion Unstable angina Prior Heart Failure: 9 ischemic 9 nonischemic 9 unknown Type: 9 systolic 9 diastolic 9 unknown New York State Association of Heart Failure Classification: 9 I 9 II 9 III 9 IV Duration of symptoms since initial onset: 9 within 2 weeks 9 greater than 3 months months 9 greater than 9 months Heart Failure within 2 weeks

3 down PATIENT ASSESSMENT GUIDE 3 of 5 CARDIAC PRESENTATION ON ADMISSION Cardiogenic shock History of Cardiac Arrest: Date: Cardiac Arrythmia: 9 none 9 remote 9 recent Arrythmia type: 9 ventricular tachycardia/fibrillation 9 sick sinus syndrome 9 atrial fibrillation/flutter Atrial fibrillation type: 9 paroxysmal 9 continuous EJECTION FRACTION % (60% - normal; 50% - good function; 45% - mildly reduced; 40% - fair function; 30% - moderately reduced; 25% - poor function; 20% - severely reduced) By: 9 Angiogram 9 2 dimensional echocardiogram 9 Transesophageal echocardiogram (TEE) 9 Multiple gated acquisition (MUGA) FUNCTIONAL STATUS Five Meter Walking Test Completed: Times (seconds): Frailty as indicated by average gait speed greater than 6 seconds Average PRE-OPERATIVE MEDICATIONS Beta Blockers: 9 Contraindication Reason: Angiotensin converting enzyme (ACE) or Angiotensin II receptor blocker (ARB) within 24 hours Calcium channel blockers Nitrates (intravenous) Inotropes Thrombolytics within 24 hours Lipid Lowering: 9 Statin 9 Non-Statin 9 Both ANTIPLATELET MEDICATIONS Taken within 5 days of surgery Indication: Last dose: Cyclooxygenase Inhibitors: 9 Aspirin Adenosine Diphosphate (ADP) Receptor Inhibitors: 9 Clopidogrel (Plavix) 9 Prasugrel (Effient) 9 Ticagrelor (Brilanta) 9 Ticlopidine (Ticlid) Phosphodiesterase Inhibitors: 9 Cilostazol (Pletal) 9 Glycoprotein llb/llla Inhibitors (intravenous use only) 9 Abciximab (ReoPro) 9 Eptifibatide (Integrelin) 9 Tirofiban (Aggrastat) Adenosine Reuptake Inhibitors: 9 Dipyridamole PRE-OPERATIVE LABORATORY STUDIES STANDARD PRE-OPERATIVE WORK-UP DIAGNOSTIC STUDIES Complete Blood count (CBC): White Blood Cells (WBC): Hematocrit (Hct): Hemoglobin (Hgb): Platelets: Comprehensive Metabolic Panel (CMP): Blood Urea Nitrogen (BUN): Creatinine: Sodium (Na): Potassium (K): Bilirubin: Albumin: Glomerular Filtration Rate (GFR): Cardiac Markers: Beta Natriuretic Peptide (BNP): Troponin I (peak): Creatine Kinase (CK)/CK-Muscle & Brain (MB) [peak]: Urinalysis: WBC: Nitrates: Leukocyte esterase: Protein: Hgb A1c : Methicillin Resistant Staphylococcus Aureus (MRSA) Nasal Culture: Date obtained: Date Mupirocin Started: Results : 9 Positive 9 Negative Lipid Panel Type & Cross: Date: (valid for 21 days) Room Air Oxygen (O 2 ) Saturation: (obtain arterial blood gas [ABG] if po 2 is less than 94%) ABG (on room air): ph: po 2 pco 2 O 2 saturation: WNL 3 Chest X-ray (to rule out active pulmonary disease): Date done: Concerns:

4 down PATIENT ASSESSMENT GUIDE 4 of 5 Electrocardiogram (EKG) Baseline: Rate: Rhythm: Concerns: Pulmonary Function Tests: Date done: Predicted FEV1 (%): Predicted DLCO 2 (%): (Predicted FEV1: 60-75% = mild; 50-59% = moderate; less than 50% = severe; Predicted DLCO 2 : greater than 60% = normal) Carotid Dopplers: Date done: 9 Carotid Stenosis (%): Right Left 9 Symptomatic carotid disease Radial Artery Studies: Date done: 9 Allen Test Results: Right Left Ankle Brachial Index (ABI): Result: Bilateral Venous Mapping (for prior vein strippings, ligations, or distal vascular reconstructive procedures): Results: Date done: Stress Test/Imaging Studies Performed 9 Standard exercise stress testing without imaging 9 Stress testing with SPECT myocardial perfusion imaging 9 Stress testing with cardiac magnetic resonance (CMR) 9 Stress echocardiogram 9 Cardiac computerized tomograph angiography (CTA) Results: 9 positive 9 negative 9 indeterminate 9 unknown If positive, extent of ischemia: 9 low 9 intermediate 9 high 9 unknown Coronary Angiogram: 9 Right Heart Catheter Significant Findings: 9 Left Heart Catheter Significant Findings: Echocardiography: 9 Ejection Fraction (%): 9 Diastolic Dysfunction: 9 Right Ventricular Function: 9 Valve function: 9 Left Atrial Size: 9 Wall motion abnormalities: Cardiovascular Surgery Risk Score Assessment: Society thoracic Surgery (STS) Risk Score Assessment: CONSULTS Pulmonary: Date: Reason: Renal: Date: Reason: Vascular: Date: Reason: Other: Date: Reason: Surgical Note and Consent in Chart Score: Score: OTHER Pre-Operative Cardiac Teaching: Date Started: 9 Viewed Cardiac Surgery Pre-Operative Video Date: 9 Gave Education Booklet to Patient & Family Date: 9 Smoking Cessation Counseling Date: 9 Patient/Family Questions Asked & Answered Date: Date Time Print Name/Title Signature 1 DOCUMENTATION DEFINITIONS FROM THE AMERICAN COLLEGE OF CARDIOLOGY (ACC)/NATIONAL CARDIAC DATA REGISTRY (NCDR): ANGINAL CLASSIFICATION/CANDIAN CARDIOVASCULAR SOCIETY CLASSIFICATION SYSTEM (CCS) The highest value between 2 weeks prior to current procedure and current procedure (Name: Anginal Classification within 2 Weeks). The anginal classification or symptom status is classified as the highest grade of angina or chest pain by the CCS. No symptoms, no angina The patient has no symptoms, no angina. CCS I Ordinary physical activity does not cause angina; for example walking or climbing stairs, angina occurs with strenuous or rapid or prolonged exertion at work or recreation. CCS II Slight limitation of ordinary activity; for example, angina occurs walking or stair climbing after meals, in cold, in wind, under emotional stress or only during the few hours after awakening, walking more than two blocks on the level or climbing more than one flight of ordinary stairs at a normal pace and in normal conditions. CCS III Marked limitation of ordinary activity; for example, angina occurs walking one or two blocks on the level or climbing one flight of stairs in normal conditions and at a normal pace. CCS IV Inability to carry on any physical activity without discomfort angina syndrome may be present at rest. CARDIOGENIC SHOCK Cardiogenic shock is defined as a sustained (greater than 30 minutes) episode of systolic blood pressure less than 90 mmhg, and/or cardiac index less than 2.2 liters/minute/m 2 determined to be secondary to cardiac dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g., Intra aortic balloonpump (IABP), extracorporeal circulation, ventricular assist devices) to maintain blood pressure and cardiac index above those specified levels.

5 down PATIENT ASSESSMENT GUIDE 5 of 5 Note: Transient episodes of hypotension reversed with intravenous fluid or atropine do not constitute cardiogenic shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30 minutes. The Left Ventricular Ejection Fraction can be assessed via invasive (i.e. LV gram) or non-invasive (i.e. Echo, MR, CT or Nuclear) testing. HYPERTENSION a. History of hypertension diagnosed and treated with medication, diet and/or exercise. b. Prior documentation of blood pressure greater than 140 mmhg systolic and/or 90 mmhg diastolic for patients without diabetes or chronic kidney disease, or prior documentation of blood pressure greater than 130 mmhg systolic and/or 80 mmhg diastolic on at least two occasions for patients with diabetes or chronic kidney disease. c. Currently on pharmacologic therapy for treatment of hypertension. DYSLIPIDEMIA National Cholesterol Education Program criteria include documentation of the following: 1. Total cholesterol greater than 200 mg/ dl (5.18 mmol/liter); or 2. Low-density lipoprotein (LDL) greater than or equal to 130 mg/dl (3.37 mmol/liter); or 3. High-density lipoprotein (HDL) less than 40 mg/dl (1.04 mmol/liter). For patients with known coronary artery disease, treatment is initiated if LDL is greater than 100 mg/dl (2.59 mmol/liter), and this would qualify as hypercholesterolemia. Source: Acute Coronary Syndromes Data Standard (JACC : ), The Society of Thoracic Surgeons FAMILY HISTORY PREMATURE CAD DIRECT RELATIVES Family history includes any direct blood relatives (parents, siblings, children) who have had any of the following diagnosed at age less than 55 years for male relatives or less than 65 years for female relatives: 1. Angina 2. Acute myocardial infarction 3. Sudden cardiac death without obvious cause 4. Coronary artery bypass graft surgery 5. Percutaneous coronary intervention Source: NCDR, The Society of Thoracic Surgeons MYOCARDIAL INFARCTION (MI) Prior MI, A myocardial infarction is evidenced by any of the following: 1. A rise and fall of cardiac biomarkers (preferably troponin) with at least one of the values in the abnormal range for that laboratory [typically above the 99th percentile of the upper reference limit (URL) for normal subjects] together with at least one of the following manifestations of myocardial ischemia: a. Ischemic symptoms. b. EKG changes indicative of new ischemia (new ST-T changes, new left bundle branch block, or loss of R wave voltage). c. Development of pathological Q waves in 2 or more contiguous leads in the EKG (or equivalent findings for true posterior MI). d. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. e. Documentation in the medical record of the diagnosis of acute myocardial infarction based on the cardiac biomarker pattern in the absence of any items enumerated in a-d due to conditions that may mask their appearance (e.g., peri-operative infarct when the patient cannot report ischemic symptoms; baseline left bundle branch block or ventricular pacing). 2. EKG changes associated with prior myocardial infarction can include the following (with or without prior symptoms): a. Any Q-wave in leads V2- V3 is 0.02 seconds or more -or- QS complex in leads V2 and V3. b. Q-wave is 0.03 seconds or more and 0.1 mv or more deep or QS complex in leads I, II, avl, avf, or V4-V6 in any two leads of a contiguous lead grouping (I, avl, V6; V4-V6; II, III, and avf). c. R-wave is 0.04 seconds or more in V1-V2 and R/S is 1 or more with a concordant positive T-wave in the absence of a conduction defect. 3. Imaging evidence of a region with new loss of viable myocardium at rest in the absence of a non-ischemic cause. This can be manifest as: a. Echocardiographic, CT, MR, ventriculographic or nuclear imaging evidence of left ventricular thinning or scarring and failure to contract appropriately (i.e., hypokinesis, akinesis, or dyskinesis). b. Fixed (non-reversible) perfusion defects on nuclear radioisotope imaging (e.g., MIBI, thallium). 4. Medical records documentation of prior myocardial infarction. Source: Joint ESC-ACC-AHA-WHF 2007 Task Force consensus document Universal Definition of Myocardial Infarction. DIABETES MELLITUS Diabetes mellitus is diagnosed by a physician or can be defined as a fasting blood sugar greater than 7mmol/l or 126 mg/ dl. It does not include gestational diabetes. Source: Acute Coronary Syndromes Data Standards (JACC : ), The Society of Thoracic Surgeons NON-STEMI The patient was hospitalized for a non-st elevation myocardial infarction (STEMI) as documented in the medical record. Non- STEMIs are characterized by the presence of both criteria: a. Cardiac biomarkers (creatinine kinase-myocardial band, Troponin T or I) exceed the upper limit of normal according to the individual hospital s laboratory parameters with a clinical presentation which is consistent or suggestive of ischemia. EKG changes and/or ischemic symptoms may or may not be present. b. Absence of EKG changes diagnostic of a STEMI (see STEMI ST-ELEVATION MI (STEMI) OR EQUIVALENT The patient presented with a ST elevation myocardial infarction (STEMI) or its equivalent as documented in the medical record. STEMIs are characterized by the presence of both criteria: a. EKG evidence of STEMI: New or presumed new ST-segment elevation or new left bundle branch block not documented to be resolved within 20 minutes. ST-segment elevation is defined by new or presumed new sustained ST-segment elevation at the J-point in two contiguous electrocardiogram (EKG) leads with the cut-off points: 0.2 mv or more in men or 0.15 mv or more in women in leads V2-V3 and/or 0.1 mv or more in other leads and lasting greater than or equal to 20 minutes. If no exact ST-elevation measurement is recorded in the medical chart, physician s written documentation of ST-elevation or Q-waves is acceptable. If only one EKG is performed, then the assumption that the ST elevation persisted at least the required 20 minutes is acceptable. Left bundle branch block (LBBB) refers to new or presumed new LBBB on the initial EKG. b. Cardiac biomarkers (creatinine kinase-myocardial band, Troponin T or I) exceed the upper limit of normal according to the individual hospital s laboratory parameters a clinical presentation which is consistent or suggestive of ischemia. IMMUNOCOMPROMISE PRESENT (This includes, but is not limited to systemic steroid therapy, anti-rejection medications and chemotherapy. Has the patient been administered any form of immunosuppressive therapy within 30 days of surgery or was the patient prescribed steroids for chronic or long term usage? DO NOT include topical creams or inhalers that are steroidal in form. DO NOT include patients who receive a one or two dose of systemic treatment, or a pre-operative/pre-cath protocol. There are four classes of drugs considered to be immunosuppressive. Corticosteroids (only if taken systemically) Cytotoxic drugs, Antabolites and Cyclosporine. Immunosuppression can result from radiation therapy, malnutrition, or removal of the spleen. Immunodeficiency can be inherited or acquired. Examples of conditions causing immunocompromise include Hypogammaglobulinemia and HIV infection.) 2 PERIPHERAL ARTERY DISEASE: excludes carotid, cerebral vascular disease or thoracic aneurysm 3 WNL: within normal limits

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