New Jersey Cardiac Catheterization Data Registry, Version 2.0

(Please report data only for patients 16 years or older.)

A.	ADMINISTRATIVE
1. Facility Code:	2. Facility Name:
3. Procedure Type (Choose only one):

Diagnostic Cath. Only Coronary Intervention Only Diagnostic Cath. and Coronary Intervention
B.	DEMOGRAPHICS
4. Last Name:	5. First Name:	6. MI:
7. SSN:	- -	8. Medical Record No.:
9. Date of Birth:	/ /	10. Gender: Male Female
11. Race (Choose only one):

White Black Asian Native American/Alaska Native Hawaiian/Other Pacific Islander Other
12. Hispanic or Latino Origin? Yes No	13. Patient Zip Code:
C.	ADMISSION
14. Admission Date:	/ /
15. Admission Status:

Outpatient Referral ED Transfer–Acute Care Facility Transfer–Non-Acute Care Facility Other
16. Inpatient Status: Yes No
17. Insurance Payor:

BC/BS	HMO	Medicare	Tricare (CHAMPUS)	Other

Commercial	Medicaid	Self Pay	Uninsured/Indigent

ADMISSION/LAB MEDICATIONS (Administered on admission up to and including all cath. lab visits):
Medication	Yes	No	Medication	Yes	No
18.	Aspirin
25. Platelet Agg. Inhib.
19.	Beta Blocker
26. Renal Adj. Therapy
20.	Coumadin
27. Lipid Lowering Agents
21. Glycoprotein IIbIIIa Inhibitors
28. Thrombin Inhibitors
22.	Heparin Low Molecular Weight
29. Thrombolytics
23.	Heparin Unfract.
30. Other
24.	ACEI/ARB
→ 31. If Other, Specify:

D.	HISTORY AND RISK FACTORS
32. Height:	cm.	33. Weight:	kg.
34. Previous MI (>7 days)? Yes No	35. CHF (Previous History)? Yes No
36. Most recent EF:	%	37. EF Method: Not Done LVG Radionuclide Estimate Echo
38. Diabetes: Yes No	→ 39. If Yes, Diabetes Control: None Insulin Oral Diet
40. Renal Failure (Previous History)?	Yes No	→ 41. If Yes, Dialysis?	Yes No
42. Cerebrovascular Disease?	Yes No
43.	Cerebrovascular Accident?	Yes No	→ 44. If Yes, When? <2 weeks >2 weeks
45. Peripheral Vascular Disease?	Yes No	46. Chronic Lung Disease?	Yes No
47. Dyslipidemia?	Yes No	48. Hypertension?	Yes No
49. Tobacco History? Never Current Former	50. Previous Diagnostic Cath.?	Yes No
51. Previous PCI?	Yes No	→ 52. If Yes, Date of most recent:	/ /
53. Previous CABG?	Yes No	→ 54. If Yes, Date of most recent:	/ /
55. Previous Valve Surgery?	Yes No	56. Previous Cardiac Transplant?	Yes No

E.	CURRENT CLINICAL STATUS
57. CHF (Current Status)?	Yes No	58. NYHA: I II III IV
59. Cardiogenic Shock?	Yes No	60. Hemodynamically Stable?	Yes No
61. Hypotension?	Yes No	62. Last Creatinine:	mg/dl
63. Outcome of Non-Invasive Test: No Test Positive Negative Equivocal
64. Ventilator Support?	Yes No	65. Defibrillation?	Yes No
66. Admission Symptom (Sx) Presentation:	67. If any symptom, Time Period Sx Onset to Admission:
No Sx/No Angina	> 0° - < 6 hrs
Atypical Chest Pain	> 6° - < 12°
Stable Angina	> 12° - < 24°
Unstable Angina	> 24° - < 48°
Non-STEMI	> 48° - < 72°
STEMI	> 72° - < 7d
Silent MI (No Time Period)

F.	CATH LAB VISIT
68. Procedure Date:	/ /
69. Right Heart Cath?	Yes No
70. Left Heart Cath?	Yes No
71. Coronary Angiography?	Yes No
72. Ventricular Angiography?	Yes No
73. Other Angiography?	Yes No
74. PCI?	Yes No
75. Fluoro Time?	Minutes
HEMODYNAMIC SUPPORT:
76. IABP?	Yes No
→ 77. If Yes, IABP Placement Timing: Before Lab Visit During Lab Visit After Lab Visit
78. Vasopressors/Inotropes: None Before Lab Visit During Lab Visit After Lab Visit
79. Other Clinical Support?	Yes No
LV STATUS:
80. LV Function Assessed?	Yes No
→ 81. If Yes, LV Wall Motion: Normal Abnormal
82. EF?	%
83. Ventilator Support (in Lab)?	Yes No
84. Defibrillation (in Lab)?	Yes No

G.	DIAGNOSTIC CATH PROCEDURE (Skip this section if no diagnostic cath performed)
85. Operator License Number:
86. Operator Last Name:	87. Operator First Name:
88. Cardiac Cath. Status: Elective Urgent Emergency
INDICATIONS:
89. Valvular Heart Disease?	Yes No	90. Arrhythmia?	Yes No
91. Other Cardiac Indications:	None	Congenital Heart Disease	Heart Failure
Cardiomyopathy	Cardiomyopathy/Heart Failure	Other

G.	DIAGNOSTIC CATH PROCEDURE, Continued
INDICATIONS, Continued:
Coronary Anatomy (if assessed, enter percent):
Native Artery:

Percent Stenosis	Grafts (Complete if Previous CABG=Yes):

Percent Stenosis
Left Main:	92.	%
////////////////////////
Prox LAD:	93.	%	98.	%
Mid/Distal LAD:	94.	%	99.	%
Circumflex:	95.	%	100.	%
RCA:	96.	%	101.	%
Ramus:	97.	%	102.	%
VALVE FINDINGS:
103. Mitral Insufficiency: None Grade 1 Grade 2 Grade 3 Grade 4 Not Assessed
104. Aortic Stenosis: Yes No Not Assessed
→ If Yes,	105. Calculated Valve Area:	cm2
106. Doppler Mean Gradient:	mmHg
107. Aortic Insufficiency: None Grade 1 Grade 2 Grade 3 Grade 4 Not Assessed

H.	PCI PROCEDURE (Skip this section if no PCI performed)
108. Operator License Number:
109. Operator Last Name:	110. Operator First Name:
111. PCI Status: Elective Urgent Emergency Salvage
INDICATIONS:
112. Ischemic symptoms compatible with AMI within 12 hours of onset?	Yes No
113. ST segment elevation compatible with AMI?	Yes No
114. Uninterpretable ECG?	Yes No
115. % Stenosis of upstream left main artery?	%
116. Is left main artery unprotected?	Yes No
117. Lesion > 50%:
No Yes-De novo Yes-Restenosis Yes-De Novo/Restenosis Yes-Subacute Thrombosis
118. Acute PCI:
No Yes-Primary PCI for STEMI Yes-Rescue PCI

Yes-Facilitated PCI Yes-Non-STEMI/Unstable Angina
→ If Yes-Primary PCI for STEMI:
Symptom Onset:	119. Date:	/ /	120. Time:	:
Date/Time of Arrival:	121. Date:	/ /	122. Time:	:
123. Transfer in for Primary PCI: Yes No
→ If Yes, ED Presentation at Referring Facility:
124. Date:	/ /	125. Time:	:
Reperfusion Date/Time:	126. Date:	/ /	127. Time:	:
128. Transfer out for Emergency CABG: Yes No
→ If Yes, Call to Surgery Center:	129. Date:	/ /	130. Time:	:
Left Original Hospital:	131. Date:	/ /	132. Time:	:
Arrival at Receiving Hosp.:	133. Date:	/ /	134. Time:	:
Arrival at OR:	135. Date:	/ /	136. Time:	:

I.	LESIONS/DEVICES (Skip this section if no PCI performed. Provide detailed information for the first 3 lesions.))
137.	Total Number of Lesions:	____________
Lesion Counter:	1	2	3
Segment Number:	138.	161.	184.
% Pre-Stenosis:	139.	%	162.	%	185.	%
% Post-Stenosis:	140.	%	163.	%	186.	%
Pre-Proc TIMI Flow:	141.	0No	2Partial

1Slow	3Complete	164.	0No	2Partial

1Slow	3Complete	187.	0No	2Partial

1Slow	3Complete
Post-Proc TIMI Flow:	142.	0No	2Partial

1Slow	3Complete	165.	0No	2Partial

1Slow	3Complete	188.	0No	2Partial

1Slow	3Complete
Prev. Treated Lesion:	143.	Yes	No	166.	Yes	No	189.	Yes	No
If Yes:	Select Multiple:	144.	Balloon

145.	DES or NonDES

146.	Radiation

147.	Other/Unknown	167.	Balloon

168.	DES or NonDES

169.	Radiation

170.	Other/Unknown	190.	Balloon

191.	DES or NonDES

192.	Radiation

193.	Other/Unknown
Prev. Treat Date:	148.	/ /	171.	/ /	194.	/ /
Segment in Graft:	149.	No

Yes-Vein

Yes-Artery	172.	No

Yes-Vein

Yes-Artery	195.	No

Yes-Vein

Yes-Artery
→ If Yes Loc. In Graft:	150.	Aortic

Body

Distal	173.	Aortic

Body

Distal	196.	Aortic

Body

Distal
Lesion Risk:	151.	Non-High/Non-C

High/C	174.	Non-High/Non-C

High/C	197.	Non-High/Non-C

High/C
Lesion Length (mm):	152.	mm	175.	mm	198.	mm
Bifurcation Lesion:	153.	Yes	No	176.	Yes	No	199.	Yes	No
Intracoronary Devices (Note: For each lesion enter either “No Device Deployed” or one of the following):

154.

0	No Device Deployed

1	Balloon Only

2	Drug Eluting Stent Only

3	Bare Metal Stent Only

4	Rotational Atherectomy Only

5	Thrombectomy Only

6	Cutting Balloon Only

7	Balloon and Drug Eluting Stent Only

8	Balloon and Bare Metal Stent Only

9	Other (Specify)

10	Unsuccessful- Balloon Only

11	Unsuccessful- Drug Eluting Stent Only

12	Unsuccessful- Bare Metal Stent Only

13	Unsuccessful - Balloon and Drug Eluting Stent Only

14	Unsuccessful - Balloon and Bare Metal Stent Only

15	Unsuccessful–Other (Specify)	177.

0	No Device Deployed

1	Balloon Only

2	Drug Eluting Stent Only

3	Bare Metal Stent Only

4	Rotational Atherectomy Only

5	Thrombectomy Only

6	Cutting Balloon Only

7	Balloon and Drug Eluting Stent Only

8	Balloon and Bare Metal Stent Only

9	Other (Specify)

10	Unsuccessful- Balloon Only

11	Unsuccessful- Drug Eluting Stent Only

12	Unsuccessful- Bare Metal Stent Only

13	Unsuccessful - Balloon and Drug Eluting Stent Only

14	Unsuccessful - Balloon and Bare Metal Stent Only

15	Unsuccessful–Other (Specify)	200.

0	No Device Deployed

1	Balloon Only

2	Drug Eluting Stent Only

3	Bare Metal Stent Only

4	Rotational Atherectomy Only

5	Thrombectomy Only

6	Cutting Balloon Only

7	Balloon and Drug Eluting Stent Only

8	Balloon and Bare Metal Stent Only

9	Other (Specify)

10	Unsuccessful- Balloon Only

11	Unsuccessful- Drug Eluting Stent Only

12	Unsuccessful- Bare Metal Stent Only

13	Unsuccessful - Balloon and Drug Eluting Stent Only

14	Unsuccessful - Balloon and Bare Metal Stent Only

15	Unsuccessful–Other (Specify)
→ 155. Specify:	→ 178. Specify:	→ 201. Specify:
No Reflow Phenom	156.	Yes	No	179.	Yes	No	202.	Yes	No
Dissection	157.	Yes	No	180.	Yes	No	203.	Yes	No
Acute Closure	158.	Yes	No	181.	Yes	No	204.	Yes	No
→ If Yes:

Successful Reopening	159.	Yes	No	182.	Yes	No	205.	Yes	No
Perforation	160.	Yes	No	183.	Yes	No	206.	Yes	No

J.	ADVERSE OUTCOMES PRIOR TO DISCHARGE (Complete this section for each Admission/Discharge)
GENERAL COMPLICATIONS:	VASCULAR/BLEEDING COMPLICATIONS:
207.	Periprocedural MI	Yes No	220.	Bleeding at Percutaneous Entry Site	Yes No
208.	Cardiogenic Shock	Yes No	221.	Retroperitoneal Bleeding	Yes No
209.	CHF	Yes No	222.	Gastrointestinal Bleeding	Yes No
210.	CVA/Stroke	Yes No	223.	Genito-Urinary Bleeding	Yes No
211.	Tamponade	Yes No	224.	Bleeding - Other/Unknown Cause	Yes No
212.	Thrombocytopenia	Yes No	225.	Access Site Occlusion	Yes No
213.	Contrast Reaction	Yes No	226.	Peripheral Embolization	Yes No
214.	Renal Failure	Yes No	227.	Dissection	Yes No
215.	Emergency PCI	Yes No	228.	Pseudoaneurysm	Yes No
216.	TIA	Yes No	→ 229. If Yes, Treatment:

None Pressure Fibrin Injection Surgery
217.	Sepsis	Yes No
218.	Arrhythmia	Yes No	230.	AV Fistula	Yes No
219.	Ventilator Support	Yes No

K.	DISCHARGE (Complete this section for each Admission/Discharge)
231. CABG Status - During This Admission:
No CABG Elective Urgent Emergency Salvage Transferred for CABG
→ If Yes,232. CAB Date:	/ /
233. Blood products transfused after lab visit: Yes No
234. Discharge Date:	/ /	235. Discharge Status: Alive Dead
236. If Dead, Date of Death:	/ /
237. If Dead, Primary Cause of Death:
Cardiac	Neurologic	Renal	Vascular	Infection
Pulmonary	Valvular	Unknown	Other
238. If Dead, Location of Death:
Died in Cath Lab	Died in Hospital Performing Procedure, but not in Cath Lab
Died in Transit to Cardiac Surgery Center	Died at Cardiac Surgery Center
239. If Alive, Discharge Location:
Not Discharged	Home	Other Acute Care	Rehab/Subacute Care
Nursing Home	Unknown	Other
IF ALIVE AT DISCHARGE, MEDICATIONS (Prescribed at Discharge):
Medication	Medication
240. Aspirin:	Yes No	243. Platelet Agg. Inhib.:	Yes No
241. Beta Blocker:	Yes No	244. Lipid-Lowering Agents:	Yes No
242. Coumadin:	Yes No	245. ACEI/ARB:	Yes No
246. Reserved 1:	247. Reserved 2:	248. Reserved 3:

New Jersey Cardiac Catheterization Data Registry

(Continued)

HCQ-7

MAR 07	Page 5 of 5 Pages.

MAR 07	Page 1 of 5 Pages.

HCQ-7, NJ Cardiac Catheterization Data Registry

HCQ-7, cardiac, catheterization, data registry, cath, health care quality, HCQ, HCQO-25

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2007-02-22

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