Admission Date/Time : Patient Restriction 3036 C. HISTORY AND RISK FACTORS. Weight : Heart Failure : Prior PCI 4495 :

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1 A. DEMGRAPHICS Last Name 2000 : First Name 2010 : Middle Name 2020 : SSN 2030 : - - SSN N/A 2031 Patient ID 2040 : (auto) ther ID 2045 : Birth Date 2050 : Race: Sex 2060 : Male Female Patient Zip Code 2065 : Zip Code N/A 2066 White 2070 Black/African American 2071 American Indian/Alaskan Native 2073 Asian 2072 If Yes, Asian Indian 2080 Chinese 2081 Filipino 2082 Japanese 2083 Korean 2084 Vietnamese 2085 ther 2086 Native Hawaiian/Pacific Islander 2074 If Yes, Native Hawaiian 2090 Guamanian or Chamorro 2091 Samoan 2092 ther Island 2093 Hispanic or Latino Ethnicity 2076 : No Yes If Yes, Ethnicity Type: B. EPISDE F CARE Mexican, Mexican-American, Chicano 2100 Puerto Rican 2101 Cuban 2102 ther Hispanic, Latino or Spanish rigin 2103 Arrival Date/Time 3001 : Admission Date/Time : ED Provider s Name, NPI 12202,12201,12203,12204 : Admitting Provider s Name, NPI 3050,3051,3052,3053 : Attending Provider s Name, NPI 3055,3056,3057,3058 :,, Health Insurance 3005 : No Yes If Yes, Payment Source 3010 : HIC # 3015 : Research Study 3020 : No Yes If Yes, Study Name 3025, Patient ID 3030 :, Patient Restriction 3036 C. HISTRY AND RISK FACTRS Private Health Insurance Medicare Medicaid Military Health Care State-Specific Plan (non-medicaid) Indian Health Service Non-US Insurance MBI # : Height : cm Weight : kg Atrial Fibrillation : No Yes Heart Failure : No Yes Atrial Flutter : No Yes Prior PCI 4495 : No Yes Hypertension 4615 : No Yes If Yes, Most Recent PCI Date : Dyslipidemia 4620 : No Yes Prior CABG 4515 : No Yes Currently on Dialysis : No Yes If Yes, Most Recent CABG Date 4520 : Cancer : No Yes Cerebrovascular Disease 4551 : No Yes Prior MI : Diabetes Mellitus : Tobacco Use 4625 : No No Yes Yes If Yes, Stroke : If Yes, TIA : Peripheral Arterial Disease 4610 : Never Former Current - Every Day Current - Some Days Current - Frequency Unknown Unknown if ever smoked If any Current, Tobacco Type 4626 : If Current - Every Day and Cigarettes, Amount 4627 : Cigarettes Cigars Pipe Smokeless Light tobacco use (<10/day) No No No Heavy tobacco use (>=10/day) Yes Yes Yes HME FUNCTINING Walking : Unassisted Assisted Wheelchair/Non-ambulatory Unknown Cognition : Normal Mildly impaired Moderately Impaired Severely Impaired Unknown Basic ADLs : (includes bathing, eating, dressing and toileting) Independent of all ADLs Full assist >=1 ADL Partial assist >=1 ADL Unknown , American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 1 of 10

2 HME MEDICATINS CATEGRY MEDICATIN CDE MEDICATIN PRESCRIBED N YES ACE INHIBITRS (ANGITENSIN CNVERTING ENZYME) ACE (Any) ARB (ANGITENSIN RECEPTRS BLCKERS) ARB (Any) ABA (ALDSTERNE BLCKING ANTAGNIST) ABA (Any) ANTICAGULANT Warfarin ANTIPLATELET Aspirin (Any) BETA-BLCKER Beta Blocker (Any) NEPRILYSIN INHIBITR AND ANGITENSIN II RECEPTR BLCKER Sacubitril and Valsartan NN-STATIN Ezetimibe Fenofibrate INSULIN Insulin (Any) Apixaban NN-VITAMIN K DEPENDENT RAL ANTICAGULANT Dabigatran Edoxaban Rivaroxaban DPP-4 Inhibitor GLP-1 Receptor Agonist Metformin RAL ANTI-GLYCEMICS ther ral Hypoglycemic Pioglitazone SGLT2 Inhibitor Sulfonylurea Clopidogrel P2Y12 INHIBITRS Prasugrel Ticagrelor PCSK9 INHIBITRS Alirocumab Evolocumab STATIN Statin (Any) D. CARDIAC STATUS N PRESENTATIN Patient Type : Low-Risk Chest Pain NSTEMI STEMI Unstable Angina If STEMI, STEMI Setting : Pre-Arrival In-Hospital Means of Transport to First Facility : If Ambulance or Air, Self/Family Ambulance Air EMS First Medical Contact Date and Time : Non-System Reason for Delay , American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 2 of 10

3 D. CARDIAC STATUS N PRESENTATIN Heart Failure : No Yes Cardiogenic Shock : No Yes Heart Rate : bpm Systolic BP : mmhg Cardiac Arrest ut of Hospital 4630 : If Yes, Arrest Witnessed 4631 : If Yes, Arrest after Arrival of EMS 4632 : If Yes, Bystander CPR : No No No No Yes Yes Yes Yes If Yes, First Cardiac Arrest Rhythm 4633 : If Yes, Resuscitation Date/Time : Shockable Not Shockable Unknown 4634 Cardiac Arrest at Transferring Facility 4635 : No Yes Location of First Evaluation : If ED, Transfer ut Date/Time : ED Cath Lab bservation Direct Admit ther If ED, ED Disposition : bservation Inpatient If bservation, bservation rder Date/Time : Acute Coronary Syndrome Symptom Date/Time 12277,12276 : Electrocardiogram Counter : 1 2 ECG Date/Time : STEMI or STEMI Equivalent : If Yes, ECG Findings : If No, ther ECG Findings : Risk Score Documented : No If TIMI Performed, TIMI Score : ST elevation Isolated posterior MI Left bundle branch block ST depression (New or Presumed New) T-Wave inversion (New or Presumed New) Transient ST elevation (Lasting < 20 minutes) ld LBBB None Yes If Yes, Name of Risk Score Performed : TIMI GRACE HEART SYNTAX Score EDACS No Yes No Yes ther ST elevation Isolated posterior MI Left bundle branch block ST depression (New or Presumed New) T-Wave inversion (New or Presumed New) Transient ST elevation (Lasting < 20 minutes) ld LBBB None If GRACE Performed, GRACE Score : Ischemic Symptoms Resolved Before Testing : Chest X-ray Performed : No No Yes Yes Non-Invasive Test Performed : Yes No No Reason No Medical Reason No Pt. Reason If Yes, Non-Invasive Test Performed Type : If Echocardiogram, Nuclear, R Imaging w/cmr, Test Method : Exercise Stress Test (w/o imaging) Echocardiogram Nuclear with SPECT Imaging w/ CMR Cardiac CTA Rest Rest Rest Stress Stress Stress If No No Reason, Planned for After Discharge : No Yes 2017, American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 3 of 10

4 ARRIVAL MEDICATINS CATEGRY MEDICATIN CDE MEDICATIN ADMINISTERED N YES CNTRAINDICATED If Yes, DSE If Yes, START DATE/TIME ANTIPLATELET Aspirin (Any) BETA-BLCKER Beta Blocker (Any) Clopidogrel mg P2Y12 INHIBITRS Prasugrel mg Ticagrelor mg E. ARRIVAL INFRMATIN (CMPLETE IF PATIENT TYPE IS STEMI AND STEMI SETTING IS PRE-ARRIVAL ) Thrombolytic : Yes No No Reason No Medical Reason No Pt. Reason If Yes, Thrombolytic Therapy Date and Time : CMPLETE IF MEANS F TRANSPRT T FIRST FACILITY IS 'AMBULANCE' R 'AIR' EMS Dispatch Date/Time : EMS Leaving Scene Date/Time : EMS Agency Number : EMS Run Number : 12-Lead ECG Performed : If Yes, EMS STEMI Activation Alert : TRANSFERS Transferred from utside Facility : No No No Yes Yes Yes If Yes, Means of Transfer : Ambulance Air Wheelchair Stretcher If Yes, Arrival at utside Facility Date/Time : If Yes, Transfer from utside Facility Date/Time : If Yes, Name and ID of Transferring Facility 12402,12161 : Name, ID Unavailable , American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 4 of 10

5 F. LABS CARDIAC MARKERS Troponin Counter : 1 2 Troponin Collected Date/Time : If any value,troponin Result Date/Time : Troponin Test Location : Lab PC Lab PC If Lab, Troponin Assay, URL : Lab Assay, URL Lab Assay, URL If PC, Troponin Assay, URL : PC Assay, URL PC Assay, URL Troponin Value : ng/ml ng/l µg/l ng/ml ng/l µg/l Initial Creatinine Value : mg/dl Peak Creatinine Value : mg/dl Initial Hemoglobin Value : g/dl Lowest Hemoglobin Value : g/dl Initial Hemoglobin A1c Value : % Not Drawn Not Drawn If any Value, Date/Time : Not Drawn Not Drawn If any Value, Date/Time : Not Drawn Initial INR Value : Not Drawn If any Value, Date/Time : LIPIDS Total Cholesterol : HDL : LDL : Triglycerides : mg/dl Not Drawn mg/dl Not Drawn mg/dl Not Drawn mg/dl Not Drawn G. PRCEDURE INFRMATIN LVEF Assessed : No Yes If Yes, LVEF Measurement : % If No, Planned for after discharge : No Yes Coronary Angiography : Yes No No Reason No Medical Reason No Pt. Reason No System Reason If Yes, Cath Lab Arrival Date/Time : If Yes, Diagnostic Cath perator s Name, NPI 7046,7047,7048,7049 : If Yes, Angiography Date/Time : If Yes, Native Vessel with Stenosis >= 50% 7505 : No NATIVE VESSEL Yes If Yes, Specify Segment(s): SEGMENT 7507 MEASUREMENT (FR EACH SELECTED) Native Stenosis 7508 : Native Stenosis 7508 : % % If Yes, AND Prior CABG 4515 IS Yes, Graft Vessel with Stenosis >= 50% 7525 : No Yes If Yes, Specify Segment(s): GRAFT VESSEL MEASUREMENT (FR EACH SELECTED) SEGMENT 7527 Graft Stenosis 7528 : % Graft Vessel 7529 : LIMA RIMA SVG Radial Graft Stenosis 7528 : % Graft Vessel 7529 : LIMA RIMA SVG Radial CABG : No Yes If Yes, Date/Time : Unknown 7530 Unknown , American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 5 of 10

6 H. PCI PRCEDURE PCI : No Yes If Yes, PCI perator s Name, NPI 7051,7052,7053,7054 : If Yes, Stent Placed : No Yes If Yes, Stent Type : BMS DES Bioabsorbable Unknown If Yes, Arterial Access Site 7320 : Femoral Brachial Radial ther If Yes, PCI Indication : STEMI Primary PCI for Acute STEMI STEMI Rescue (after unsuccessful lytics) STEMI Stable ( <= 12 hrs from Sx) New nset Angina <= 2 months STEMI Stable ( > 12 hrs from Sx) NSTE ACS STEMI Unstable ( >12 hrs from Sx) STEMI (after successful lytics) If No, AND Patient Type is STEMI, Reason Primary PCI Not Performed : No No Reason No Medical Reason Mechanical Ventricular Support 7422 : No Yes If Yes, Device 7423 : CMPLETE IF PCI INDICATIN IS STEMI PRIMARY PCI FR ACUTE STEMI Cath Lab Activated : No Yes If Yes, Cath Lab Activation Date/Time : If Yes, Cath Lab Activation Canceled : No Yes First Device Activation Date/Time 7845 : Patient Centered Reason for Delay in PCI 7850 : No Yes If Yes, Reason 7851 : Difficult Vascular Access Difficulty crossing the culprit lesion Cardiac arrest and/or need for intubation before PCI PCI PRCEDURE MEDICATINS (CMPLETE IF PCI IS 'YES') CATEGRY MEDICATIN CDE 7990 Patient delays in providing consent for PCI Emergent placement of LV support device before PCI ther MEDICATIN ADMINISTERED 7995 N YES Bivalirudin Fondaparinux ANTICAGULANT Heparin Derivative Low Molecular Wt Heparin Unfractionated Heparin Warfarin ANTIPLATELET Vorapaxar GLYCPRTEIN (GP) IIB/IIIA INHIBITRS GP IIb/IIIa Inhibitors (Any) Apixaban NN-VITAMIN K DEPENDENT RAL ANTICAGULANT Dabigatran Edoxaban Rivaroxaban Cangrelor P2Y12 INHIBITRS Clopidogrel Prasugrel Ticagrelor 2017, American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 6 of 10

7 I. EPISDE EVENTS (ALL PATIENT TYPES) (NTE 1: RECRD EACH EVENT SEPARATELY INDICATING THE DATE AND TIME) EVENT(S) EVENT(S) CCURRED IF YES, EVENT DATE/TIME(S) Atrial Fibrillation No Yes Bleeding Access Site No Yes Bleeding Gastrointestinal No Yes Bleeding Genitourinary No Yes Bleeding ther No Yes Bleeding Retroperitoneal No Yes Bleeding Surgical Procedure or Intervention Required No Yes Cardiac Arrest No Yes Cardiogenic Shock No Yes Heart Failure No Yes Intubation No Yes Myocardial Infarction No Yes New Requirement for Dialysis No Yes Stroke Hemorrhagic No Yes Stroke Ischemic No Yes Stroke Undetermined No Yes Transient Ischemic Attack (TIA) No Yes Ventricular Fibrillation No Yes Ventricular Tachycardia No Yes THER EVENTS RBC Transfusion : No Yes If Yes, Transfusion Date : If Yes, CABG Related Transfusion : No Yes NSAID Administered : No Yes CMPLETE IF CARDIAC ARREST UT F HSPITAL 4630 IS YES R CARDIAC ARREST AT TRANSFERRING FACILITY 4635 IS YES R (EVENT(S) IS CARDIAC ARREST AND EVENT(S) CCURRED IS YES ) Hypothermia Induced : Yes No No Reason No Medical Reason If Yes, Hypothermia Induced Date/Time : If Yes, Location of Hypothermia Induction : ED Cath Lab ICU/CCU Level of Consciousness : (A) Alert (V) Verbal (P) Pain (U) Unresponsive Unable to assess 2017, American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 7 of 10

8 J. DISCHARGE Discharge Date/Time : Discharge Provider Name, NPI 10070,10071,10072,10073 : Comfort Measures nly : No Yes If Yes, Date/Time : Enrolled in Clinical Trial During Hospitalization : No Yes If Yes, Type of Clinical Trial(s) : Precluding the use of aspirin in protocol Related to lipid lowering therapy Related to reperfusion therapy Related to AMI Involving new antiplatelet therapies Related to STEMI Involving renin-angiotensin-aldosterone system inhibitor Discharge Status : Alive Deceased If Alive, Cardiac Rehabilitation Referral : No Reason Not Documented No Health Care System Reason Documented No Medical Reason Documented No Patient riented Reason Yes If Alive, Discharge Location : Home Skilled nursing facility Extended care/transitional care unit/rehab ther ther acute care hospital Left against medical advice (AMA) If ther acute care hospital, Transfer Date/Time : If ther acute care hospital, Transfer for Primary PCI : If ther acute care hospital, Transfer for CABG : No No Yes Yes If Alive, Hospice Care : No Yes If Yes, Date/Time : If Deceased, Cause of Death : Acute myocardial infarction Pulmonary Hemorrhage Sudden cardiac death Renal Non-cardiovascular procedure or surgery Heart failure Gastrointestinal Trauma Stroke Hepatobiliary Suicide Cardiovascular procedure Pancreatic Neurological Cardiovascular hemorrhage Infection Malignancy ther cardiovascular reason Inflammatory/Immunologic ther non-cardiovascular reason 2017, American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 8 of 10

9 DISCHARGE MEDICATINS Medications prescribed at discharge are not required for patients who expired, discharged to ther acute care Hospital, AMA, or are receiving Hospice Care. PRESCRIBED AT DISCHARGE If Yes, DSE CATEGRY MEDICATIN CDE YES N N REASN N MEDICAL REASN N PT. REASN LW MDERATE HIGH ABA (ALDSTERNE BLCKING ANTAGNIST) ABA (Any) ACE INHIBITRS (ANGITENSIN CNVERTING ENZYME) ACE (Any) ANTICAGULANT Warfarin ANTIPLATELET Aspirin (Any) ARB (ANGITENSIN RECEPTRS BLCKERS) ARB (Any) BETA-BLCKER Beta Blocker (Any) NEPRILYSIN INHIBITR AND ANGITENSIN II RECEPTR BLCKER Sacubitril/Valsartan NN-STATIN Non-Statin (Any) Apixaban NN-VITAMIN K DEPENDENT RAL ANTICAGULANT Dabigatran Edoxaban Rivaroxaban Clopidogrel P2Y12 INHIBITRS Prasugrel Ticagrelor STATIN Statin (Any) 2017, American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 9 of 10

10 K. FLLW-UP FLLW-UP T CCUR AT 30 DAYS (+14/- 7 DAYS) AND 1 YEAR (+/- 60 DAYS) AFTER THE ADMISSIN DATE Assessment Date : Reference Admission Date/Time : Reference Discharge Date/Time : Method(s) to Determine Status : ffice Visit Medical Records Letter from Medical Provider Phone Call Social Security Death Master File Hospitalized ther Follow-up Status : If Deceased, Date of Death : If Deceased, Cause of Death : Alive Deceased Lost to Follow-up If Alive, Enrolled in Cardiac Rehabilitation Program : If Yes, Attended Cardiac Rehabilitation Program Date : FLLW-UP EVENTS No Acute myocardial infarction Pulmonary Hemorrhage Sudden cardiac death Renal Non-cardiovascular procedure or surgery Heart failure Gastrointestinal Trauma Stroke Hepatobiliary Suicide Cardiovascular procedure Pancreatic Neurological Cardiovascular hemorrhage Infection Malignancy ther cardiovascular reason Inflammatory/Immunologic ther non-cardiovascular reason Yes EVENT(S) EVENT(S) CCURRED IF YES, EVENT DATE CABG: Planned No Yes CABG: Unplanned No Yes Heart failure No Yes Myocardial Infarction: NSTEMI No Yes Myocardial Infarction: STEMI No Yes PCI Planned No Yes PCI Unplanned No Yes Readmission No Yes Renal failure No Yes Stroke: Hemorrhagic No Yes Stroke: Ischemic No Yes Stroke: Undetermined No Yes 2017, American College of Cardiology Foundation 26-Jun-2018 ( ) Indicates Basic Data Set (BDS) Page 10 of 10