Form 4: Coronary Evaluation

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Gervase Craig
5 years ago
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1 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 a Injection sites Check all that apply. Aorta Left Ventricle INJAORTA INJLV

2 Selective Left Coronary Selective Right Coronary INJSLC INJSRC INJUNK b c Method of Interpretation (Pertains to the angiogram) Check only one. Pre angiogram nitroglycerin Caliper Computer Assisted Visual Estimate Angiography Results a a Angiography Results If abnormal, indicate ISHLT CAV score (J Heart Lung Transplant July ;9(7):77 7) Abnormal rmal 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) Left Main Coronary Artery (L Main) Mild Stenosis (% to 5%) Moderate Stenosis (5% to 7%) rmal t Visualized Severe Stenosis (7% to %) _LM_ABS _LM_ECT _LM_MLD _LM_MOD NORLMA _LM_NV _LM_PRN _LM_SEV _LM_UN Left Anterior Descending (LAD) Mild Stenosis (% to 5%) Moderate Stenosis (5% to 7%) _LAD_ABS _LAD_ECT _LAD_MLD _LAD_MOD

3 rmal NORLAD t Visualized Severe Stenosis (7% to %) _LAD_NV _LAD_PRN _LAD_SEV _LAD_UN Left Circumflex (LCx) Mild Stenosis (% to 5%) Moderate Stenosis (5% to 7%) rmal t Visualized Severe Stenosis (7% to %) _LCX_ABS _LCX_ECT _LCX_MLD _LCX_MOD NORLCX _LCX_NV _LCX_PRN _LCX_SEV _LCX_UN _RCA_ABS Right Coronary Artery (RCA) Mild Stenosis (% to 5%) Moderate Stenosis (5% to 7%) rmal t Visualized Severe Stenosis (7% to %) _RCA_ECT _RCA_MLD _RCA_MOD NORRCA _RCA_NV _RCA_PRN _RCA_SEV _RCA_UN Posterior Descending (PDA) _PDA_ABS Mild Stenosis (% to 5%) Moderate Stenosis (5% to 7%) rmal t Visualized Severe Stenosis (7% to %) _PDA_ECT _PDA_MLD _PDA_MOD NORPDA _PDA_NV _PDA_PRN _PDA_SEV _PDA_UN 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 FFRLAD FFRLCX FFRLM FFRRCA FFRUNK

4 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 Vessels Studied LAD LCx Left Main RCA IULAD IULCX IULMAIN IURCA IUUNK If Left Main, Maximal Intimal If Left Main, <. mm >=.mm t Done

5 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 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)

6 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 WMAK WMDY WMHY WMNORMAL ECHONIWM WMUNK Hypokinesis Akinesis Dyskinesis 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 BEAKDY BEHY BENORMAL

7 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 SEAKDY SEHY SENORMAL If Stress is New Hypokinesis If Stress is New Akinesis/dyskinesis Maximum Heart Rate Achieved Missing Reason: LV Dilatation with Stress PHTS [test]

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