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Heart Failure Hospital Record Abstraction Form

OMB# 0925-0491

EXPIRATION DATE XX/XXXX

FORM CODE: : H F A

Version A.: 02-16-2007

ID NUMBER: CONTACT YEAR NUMBER:

FORM SEQUENCE NUMBER:

LAST NAME: INITIALS:

General Instructions:

The Heart Failure hospital Record Abstraction Form is completed for heart failure-eligible Community Surveillance hospitalizations. See Surveillance Procedure manual for sampling rules. It should also be completed for all heart failure-eligible cohort hospitalizations. Refer to this form’s question by question instructions for detailed information on each data item.

0. a. Hospital code number:

0. b. Medical Record Number:

0. c. Date of discharge (for nonfatal case) or death:

Month Day Year

0. d. What was the disposition of the patient on discharge?

Deceased ………D

Alive …………….A

0. e. Was an autopsy performed?

Yes………Y

No……….N

0. f. Was the patient either dead on arrival or did he/she die in the emergency room?

Yes………Y

No……….N

SECTION I. SCREENING FOR DECOMPENSATION OR NEW ONSET

1. Was there evidence of the following conditions? Yes No/Not Recorded

a. Increasing or new onset shortness of breath

b. Increasing or new onset edema

c. Increasing or new onset paroxysmal nocturnal dyspnea

d. Increasing or new onset orthopnea

e. Increasing or new onset hypoxia

2 . Was there evidence in the doctor's notes that the reason for this

hospitalization was heart failure?

3. Is this a cohort participant?

If any response to items 1-3 is YES, go to item 4. If all are NO or not recorded, go to item 77.

Yes No/Not Recorded

4. Did the patient have new onset or progressive symptoms/signs of

heart failure:

a. At the time of admission to the hospital?

b. During this hospitalization?

5 . Date of new onset or progression of symptoms/signs known (mm-dd-yyyy):

a. If exact date unknown, estimate weeks prior to this hospitalization:

6. Did the physician’s note or discharge summary indicate any of the following specific types of

heart failure? (check all that apply)

Yes No/ Not Recorded

a . Ischemic cardiomyopathy

b . Idiopathic/dilated cardiomyopathy

c . Hypertensive heart failure

d . Hypertrophic cardiomyopathy

e . Restrictive cardiomyopathy

f . Infiltrative cardiomyopathy

g . Cor pulmonale

8. D iastolic heart failure

i. Valvular cardiomyopathy

j. Other cardiomyopathy/systolic heart failure If No/Not Recorded, go to item 7.

j.1. If other cardiomyopathy, specify _____________________________________________________

SECTION II: HISTORY OF HEART FAILURE

7. Prior to this hospitalization was there a history of any of the following:

Yes No/Not Recorded Unsure

a. Diagnosis of heart failure

b. Prior hospitalization for heart failure

c. Treatment for heart failure

8 . Was cardiac imaging performed prior to this hospitalization? Yes No/Unk

Go to item 9.

8. a. Lowest Ejection Fraction recorded: %

8. a.1. Qualitative description:

Normal………………………….. N

Decreased mildly………………. D

Decreased moderately…………M

Decreased severely…………… S

None of the above………………O

8. b. Year of lowest ejection fraction (yyyy) :

8.c. Type of imaging:

1. MUGA

2. ECHO

3. Cath/LV gram

4. CT

5. MRI

6. Other

7. Unknown

SECTION Ill: MEDICAL HISTORY AND PRECIPITATING FACTORS

9. General

History of?
Yes No/NR

a. AIDS/HIV

2. Excess alcohol use

3. Illicit drug use

4. A nemia

5. C ancer (excluding skin cancer)

6. C onnective tissue disease

7. E x-smoker

8. C urrent smoker

9. T hyroid disease

Respiratory

a . Asthma ^G

2. C hronic bronchitis/COPD ^G

3. O ther chronic lung disease

4. P ulmonary embolus

5. C oughing, phlegm, wheezing ^G

6. Sleep apnea

11. Cardiovascular

a. Angina ^G

2. Arrhythmia

1 ) Atrial fibrillation/atrial flutter

2) Heart block or other bradycardia

3) Ventricular fibrillation or tachycardia

SECTION Ill: MEDICAL HISTORY AND PRECIPITATING FACTORS (continued)

11. Cardiovascular (continued)

History of?
Yes No/NR

c. Infectious/bacterial endocarditis

d. cardiac arrest

5. Cardiac procedures

   1. C ABG

   2. PCI

   3. V alve surgery

   4. P acemaker

   5. Defibrillator

f

If Yes, go to item 11.i.

. Congenital heart disease

g . Coronary heart disease (within year) ^G

h. Coronary heart disease (ever) ^G

i . Electrocardioversion/defibrillation

j. Hypertension

k . Myocardial infarction

l. Pulmonary hypertension

m . Peripheral vascular disease

n. Rheumatic heart disease

o . Valvular heart disease

12. Gastrointestinal / Endocrine

a . Diabetes

b. Hyperlipidemia

c . Liver disease

13. Renal

a . Dialysis

SECTION Ill: MEDICAL HISTORY AND PRECIPITATING FACTORS (continued)

1 4. Neurology

History of?
Yes No/NR

a . Stroke/TIA

b . Depression

15. Other significant medical condition: _______________________________________

16. Were any of the following medical problems listed as precipitating factors (i.e. precipitated the onset of

this event)?

Yes No/NR

a . Postpartum state

b . Excess alcohol intake

c . Excess fluid intake/administration

d. Noncompliance with diet

e . Noncompliance with medication

f. Infection

g . Pneumonia

h. Infectious/ bacterial endocarditis

i . Pulmonary embolus

j. Angina

k . Atrial fibrillation/flutter

l . Heart block

m. Ventricular fibrillation/flutter

n . Cardiac arrest

o. Myocardial infarction

p . Valvular heart disease

q. Stroke/TIA

SECTION lV: PHYSICAL EXAM – VITAL SIGNS

At hospital admission At hospital discharge

(or at onset of event) (or last recorded)

17. Blood pressure: a. / b. mmHg c. / d.

1 8. Heart rate: ^{B, F, N} a. bpm

1 9. Height: a. a.1. cm/ in (c=cm, i=in)

2

0. Weight: ^F a. . a.1. lbs/ kg b. . . b.1. lbs\ kg

(l=lbs, k=kg) (l=lbs, k=kg)

21. Respiration rate a. /min b. /min

SECTION V: PHYSICAL EXAM AND SYMPTOMS - FINDINGS

2 2. Did the patient have any of the following GENERAL signs or symptoms?

Anytime during hospitalization At hospital discharge

or at admission

Yes No/NR Yes No/NR

1. L ower extremity edema ^{G, F, N} a.1.

b . Jugular venous distension (JVD) ^{B, F, N} b.1.

c . Hepatojugular reflux ^F

d . Hepatomegaly ^{F, N, B}

e. Leg fatigue on walking ^B

23. Did the patient have any of the following RESPIRATORY signs or symptoms?

Anytime during hospitalization At hospital discharge

or at admission

Yes No/NR Yes No/NR

1. C ough ^F a.1.

If Yes, go to item 23g.

2. D yspnea (Rest) ^B b.1.

3. D yspnea (Walking) ^{B, F, N} c.1.

4. D yspnea (Climbing or exertion) ^{B, F, N} d.1.

5. S tops for breath when walking ^N e.1.

6. Stops for breath after 100 yards ^N

7. R honchi ^G

8. P aroxysmal nocturnal dyspnea ^B,F,G h.1.

i . Orthopnea ^B i.1.

j . Pulmonary basilar rales ^{B, G, F, N} j.1.

k . Rales (more than basilar) ^{B, G, F, N} k.1.

l . Wheezing ^B l.1

m. Vital capacity (decreased 1/3) ^F

SECTION V: PHYSICAL EXAM AND SYMPTOMS - FINDINGS (continued)

2 4. Did the patient have any of the following CARDIOVASCULAR signs or symptoms?

Anytime during hospitalization At hospital discharge

Yes No/NR Yes No/NR

1. S3 (gallop) ^{B, F} a.1.

2. S 4 (gallop) b.1.

3. C hest Pain ^G c.1.

4. N YHA class: I II III IV not recorded

SECTION VI: DIAGNOSTIC TESTS

2

Go to item 27.

5. Was an electrocardiogram performed during this hospitalization?: Yes No/NR

26. Did the patient have any of the following ECG abnormalities at any time during this hospitalization?

Yes No/Unknown

a. MI (age undetermined)

b. Ischemic changes or ST-T changes

c. Atrial fibrillation / atrial flutter ^G c.1. On telemetry? Yes No

d. Left ventricular hypertrophy

e. Left bundle branch block

f. Ventricular tachycardia f.1. On telemetry? Yes No

Go to item 29.

27. Was a chest X-ray performed during this hospitalization?: Yes No/NR

28. Did the patient have any of the following signs on chest X-ray at any time during this hospitalization?

Yes No/Unknown

a. Alveolar infiltrates

b. Alveolar/pulmonary edema ^{B, F, N}

c. Interstitial pulmonary edema ^{B, F, N}

d. Cardiomegaly ^{B, F}

e. Cephalization/upper zone redistribution ^{B, N}

f. Congestive heart failure

g. Bilateral pleural effusion ^{B, F, N}

h. Unilateral pleural effusion ^{F, N}

i . Pulmonary vascular congestion

j . Kerley B lines

k. Cardiothoracic ratio ≥ 0.5 ^B

SECTION VI: DIAGNOSTIC TESTS (continued)

2

Go to item 30 29.

9. Was a transthoracic echocardiogram performed? Yes No/NR

First transthoracic echocardiogram performed after onset or progression of heart failure.

a. Date (mm-dd-yyyy):

b. Ejection fraction: %

c. Wall thickness: septal: . c.1. units (1=cm, 2=mm)

c.2. posterior: c.3. units (1=cm, 2=mm)

d. Record the following if present on transthoracic echocardiogram:

Mild Moderate Severe None Present NR

1. Left ventricular hypertrophy (LVH)

2. Impaired LV systolic function

3. Impaired RV systolic function

4. Aortic regurgitation

5. Aortic stenosis

6. Tricuspid regurgitation

7. Mitral regurgitation

8. M itral stenosis

9. Estimated RVSP/PASP: mmHg a. TR jet velocity: . m/s

10. Pulmonary hypertension

Yes No/Unknown/NR

1 1. Regional wall motion abnormality

12. Dilated left ventricle

1 3. Dilated right ventricle

14. Diastolic dysfunction

SECTION VI: DIAGNOSTIC TESTS (continued)

3 0. Was a transesophageal echocardiogram performed? Yes No/NR

Go to item 31.

First transesophageal echocardiogram performed after onset or progression of event.

a. Date (mm-dd-yyyy):

b. Ejection fraction: %

c. Record the following if present on transesophageal echocardiogram:

Mild Moderate Severe None Present NR

1. Impaired LV systolic function

2. Impaired RV systolic function

Yes No/Unknown/NR

3. Regional wall motion abnormality

4. Dilated left ventricle

5. Dilated right ventricle

SECTION VI: DIAGNOSTIC TESTS (continued)

3

Go to item 32.

1 Was a right cardiac catheterization performed? Yes No/NR

a. Date (mm-dd-yyyy) :

b. Record the following measurements from the catheterization report::

1. Right atrial pressure (mean): mmHg

2. Pulmonary arterial pressure: / mmHg

3 . Pulmonary wedge pressure: mmHg

4. Cardiac output: . liters/min

5. Cardiac index: . liters/min/m² BSA

3

Go to item 33.

2 Was coronary angiography performed? Yes No/NR

a. Date (mm-dd-yyyy) :

2. Record the following:

1 . Ejection fraction: %

2. Coronary stenosis:

0 1-24 25-49 50-74 75-94 95-99 100 NR

% % % % % % %

a. Left main:

b. Left anterior descending artery and branches:

c. Left circumflex/marginal artery:

d. Right coronary artery and branches:

e. Intermediate ramus:

Go to item 32.b.4.

3 . Were coronary bypass grafts present? Yes No/NR

a. Number of occluded grafts:

4. Mitral regurgitation: mild moderate severe none present NR

SECTION VI: DIAGNOSTIC TESTS (continued)

3

Go to item 34.

3. Was a cardiac radionuclide ventriculogram performed? Yes No/NR

a. Date: b. Ejection fraction: LV: % c. RV: %

mm-dd-yyyy)

3

Go to item 35.

4. Was a cardiac Magnetic Resonance Imaging (MRI) performed? Yes No/NR

a. Date: b. Ejection fraction: LV: % c. RV: %

(mm-dd-yyyy)

3 5. Was a cardiac CT scan performed? Yes No/NR

a. Date: b. Ejection fraction: LV: % c. RV: %

(mm-dd-yyyy)

3 6. Was a stress test performed? Yes No/NR

a. Date:

b. Normal Abnormal Equivocal Not diagnostic

c. Ejection fraction: LV: %

SECTION VII: BIOCHEMICAL ANALYSES

a. Worst* b. Last c. Upper Limit Normal

3 7. Hemoglobin (g/dL)

3 8. Hematocrit (%) .

39. BNP (pg/mL)

40. ProBNP (pg/mL)

41. Troponin T (ng/mL) . . .

42. Troponin I (ng/mL) . . .

43. Sodium (mEq/L)

44. Serum creatinine (mg/dL) . .

45. BUN (mg/dL)

Worst = highest value with exception of hemoglobin, hematocrit, and sodium. For these items

worst is the lowest value (^L )

SECTION Vlll: INTERVENTIONS

Yes No/Unknown/NR

4 6. Cardiac (electrophysiologic) ablation therapy

47. Implantable cardiac defibrillator

48. Cardioversion

49. Pacemaker placement (non-biventricular)

50. Biventricular pacemaker (CRT)

51. Coronary Artery Bypass Graft

5 2. Percutaneous Coronary Intervention (PCI)/stent

5 3. Valve replacement/repair

5 4. Intra Aortic Balloon Pump (IABP)

5 5. Hemofiltration/dialysis

5 6. Listed/received transplant of heart

57. Left ventricular assist device

5 8. Was patient counseled regarding the following?

1. Sodium/cholesterol reduction

2. T obacco cessation N/A

3. Fluid restriction

SECTION lX: MEDICATIONS

Prior to hospitalization or progression At hospital discharge

in hospital

Yes No/NR Yes No/NR

5 9. ACE inhibitors a.

6 0. Angiotensin II receptor blockers a.

61. Antiarrhythmics

a. Amiodarone a. 1.

b. Other b. 1

6 2. Anticoagulants a.

6 3. Anti-inflammatory a.

64. Antiplatelets

a . Aspirin a.1.

b . Other b.1.

6 5. Beta blockers a.

6 6. Calcium channel blockers a.

6 7. Digitalis ^G a.

6 8. Diuretics ^G a.

6 9. Aldosterone Blocker a.

70. Lipid lowering agents

a . Statins a.1.

b . Other b.1.

7 1. Nitrates a.

7 2. Hydralazine a.

S ECTION lX: MEDICATIONS (continued)

73. IV drugs during this hospitalization?

a . IV inotropes: Yes No/NR

b . IV diuretics: Yes No/NR

c . IV vasodilators: Yes No/NR

d . IV antiarrythmics: Yes No/NR

SECTION X: COMPLICATIONS FOLLOWING EVENT

Yes No/Unknown

7 4. Cardiac arrest

7 5. Stroke

7 6. Myocardial infarction

SECTION XI: ADMINISTRATIVE

77. Time taken to abstract (mins):

78. Abstractor number:

79. Date abstract completed (mm-dd-yyyy):

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