Page of 7 Patient Details Hidden Show Show/Hide Annotations Stickies: Toggle All Toggle Open Toggle Resolved 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 b 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 a 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
Page of 7 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 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 %) L Main = Left Main Coronary Artery LAD = Left Anterior Descending LCx = Left Circumflex RCA = Right Coronary Artery PDA = Posterior Descending
Page of 7 Ectasia 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 5 Fractional Flow Reserve Performed 5a 5a.iii 5a.i 5a.ii Vessels Studied Check all that apply. Left Main Coronary Artery (L Main) Left Anterior Descending (LAD) Left Circumflex (LCx) LAD LCx Left Main RCA 5a.iv Right Coronary Artery (RCA) 6 Coronary Flow Reserve (CFR) Performed 6a If CFR Performed, CFR abnormal (Abnormal is defined as:. Maximal Flow: Resting Flow) Intravascular Ultrasound
Page of 7 7 Intravascular Ultrasound Performed 7a Vessels Studied LAD LCx Left Main RCA 7a.v 7a.vi 7a.i 7a.ii 7a.iii 7a.iv 7a.vii If Left Main, Maximal Intimal Thickness (MIT) If Left Main, If LAD, Maximal Intimal Thickness (MIT) If LAD, If LCx, Maximal Intimal Thickness (MIT) If LCx, If RCA, Maximal Intimal Thickness (MIT) <. mm >=.mm t Done <. mm >=.mm t Done <. mm >=.mm t Done <. mm >=.mm
Page 5 of 7 7a.viii If RCA, t Done Left Ventricular Function Evaluation Left Ventricular Function Evaluation 8 Nearest to coronary angiogram 8a Date of study t Done 8b Method of Interpretation Contrast ventriculogram Echocardiogram MRI Radionuclide angiogram (MUGA) 8c 8d Left Ventricular Ejection Fraction Echo Shortening Fraction t Done t Done 8e Wall Motion Akinesis Dyskinesis Hypokinesis rmal t interpreted for wall motion abnormalities 8e.iii 8e.i Hypokinesis Akinesis
Page 6 of 7 8e.ii Dyskinesis Dobutamine or Exercise Stress Echo 9 Was Dobutamine or Exercise Stress Echo performed? 9a Date 9b Maximum Dobutamine Dose mcg/kg/min t Done 9c 9c.ii Baseline Is there segmental hypokinesis and if so, how many segments? Akinesis/dyskinesis Hypokinesis rmal 9c.i Is there segmental Akinesis/dyskinesis and if so, how many segments? less than 9d Stress New Akinesis/dyskinesis New Hypokinesis rmal 9d.ii 9d.i If Stress is New Hypokinesis If Stress is New Akinesis/dyskinesis
Page 7 of 7 9e Maximum Heart Rate Achieved 9f LV Dilatation with Stress 7 PHTS [PHTS]