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SCAI-QIT App Home
App authored by Kalon Ho, MD, MSc, FACC, FACP, FSCAI, FAHA; May 2013
v2 Sept 2014
© The Society for Cardiovascular Angiography and Interventions April 2014.
Acknowledgements
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Patient Name:
MRN:
DOB:
Enter DOB for patient identification and/or for automatic computation of patient age
Age:
Enter Age here, or Enter DOB above to compute age automatically
years
Sex:
Indicate the patient's sex at birth.
Height (cm):
Enter cm if known, otherwise enter inches for computation of cm
Height     [ft]:
If cm value was entered, the feet value is ignored.
  [in]:
If cm value was entered, the inches value is ignored
cm
Weight (kg):
Enter kg if known, otherwise enter lbs for computation of kg
Weight [lbs]:
If kg value was entered, the lbs value is ignored
kg
Race:
Indicate if the patient is Black or African American as determined by the patient/family (having origins in any of the black racial groups of Africa). Terms such as "Haitian" or "Negro" can be used in addition to "Black or African American."
BMI:
kg/m2
Admission Source:
Indicate the source of admission for the patient to your facility. "ED" excludes transfers from other facilities.
Health Insurance:
Indicate the patient's primary insurance payor for this admission.
History and Risk Factors
Hypertension:
Hypertension is defined by any one of the following:
1. History of hypertension diagnosed and treated with medication, diet and/or exercise
2. Prior documentation of blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic for patients without diabetes mellitus or chronic kidney disease, or prior documentation of blood pressure greater than 130 mm Hg systolic and/or 80 mm Hg diastolic on at least two occasions for patients with diabetes mellitus or chronic kidney disease
3. Currently on pharmacologic therapy for treatment of hypertension.
Prior Heart Failure:
Indicate if there is a previous history of heart failure between birth and arrival at this facility. Heart failure is defined as physician documentation or report of any of the following clinical symptoms of heart failure described as unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or the description of rales, jugular venous distension, pulmonary edema on physical exam, or pulmonary edema on chest x-ray presumed to be due to cardiac dysfunction. A low ejection fraction alone, without clinical evidence of heart failure does not qualify as heart failure.
Prior PCI:
Indicate if the patient had a previous percutaneous coronary intervention prior to arrival at this facility
Prior CABG:
Indicate if the patient had a previous coronary artery bypass graft (CABG) surgery prior to arrival at this facility.
Currently on Dialysis:
Indicate if the patient is currently undergoing either hemodialysis or peritoneal dialysis on an ongoing basis as a result of renal failure. If a patient is on receiving continuous veno-venous hemofiltration (CVVH) as a result of renal failure (and not as treatment to remove fluid for heart failure), code "yes."
Cerebrovascular Disease:
Cerebrovascular Disease documented by any one of the following:
1. Cerebrovascular Accident (CVA): Patient has a history of stroke, i.e., loss of neurological function with residual symptoms at least 24 hrs after onset, presumed to be from vascular etiology.
2. Transient Ischemic Attack (TIA): Patient has a history of loss of neurological function that was abrupt in onset but with complete return of function within 24 hrs, presumed to be due to vascular etiology
3. Non-invasive/invasive carotid test with >79% occlusion.
4. Previous carotid artery surgery/intervention for carotid artery stenosis.
This does not include neurological disease processes such as metabolic and/or anoxic ischemic encephalopathy.
Peripheral Arterial Disease:
Indicate if the patient has a history of peripheral arterial disease (PAD; includes upper and lower extremity, renal, mesenteric, and abdominal aortic systems). This includes:
1. Claudication, either with exertion or at rest.
2. Amputation for arterial vascular insufficiency.
3. Vascular reconstruction, bypass surgery, or percutaneous intervention to the extremities (excluding dialysis fistulas and vein stripping).
4. Documented aortic aneurysm with or without repair.
5. Positive non-invasive test (e.g., ankle brachial index ≤0.9); ultrasound, magnetic resonance, computed tomography, or angiographic imaging of >50% diameter stenosis in any peripheral artery (e.g., renal, subclavian, femoral, iliac).
For these purposes, peripheral arterial disease excludes disease in the carotid and cerebrovascular arteries.
Chronic Lung Disease:
A history of chronic inhalation reactive disease (asbestosis, mesothelioma, black lung disease or pneumoconiosis) qualifies as chronic lung disease. Radiation induced pneumonitis or radiation fibrosis also qualifies as chronic lung disease. A history of atelectasis is a transient condition and does not qualify. Chronic lung disease can include patients with chronic obstructive pulmonary disease, chronic bronchitis, or emphysema. It can also include a patient who is currently being chronically treated with inhaled or oral pharmacological therapy (e.g., beta-adrenergic agonist, anti-inflammatory agent, leukotriene receptor antagonist, or steroid). Patients with asthma or seasonal allergies are not considered to have chronic lung disease.
Diabetes Mellitus:
Indicate if the patient has a history of diabetes mellitus regardless of duration of disease or need for antidiabetic agents. Diabetes mellitus is diagnosed by a physician or can be defined as a fasting blood sugar greater than 7 mmol/l or 126 mg/dL. It does not include gestational diabetes.
Patients placed on a pre-procedure diabetic pathway of insulin drip after arrival but were not on insulin therapy (treated by diet or oral method) are not coded as insulin treatment.
If a patient had a pancreatic transplant, code "not on insulin", since the insulin from the new pancreas is not exogenous insulin.
Hemoglobin (g/dL):
Indicate the most recent hemoglobin level in g/dL.
Serum Creatinine (mg/dL):
Indicate the patient's most recent creatinine level in mg/dL (last value between 1 month prior to arrival and current procedure)
GFR:
ml/min/1.73m2
Clinical Evaluation
CAD Presentation:
Indicate the patient's coronary artery disease (CAD) presentation. Choose the worst status between 7 days prior to arrival and current procedure.
If this is a repeat visit to the cath lab after an earlier PCI during the same episode of care, code the CAD presentation based on the patient's clinical status prior to the subsequent PCI procedure. If this is a repeat visit to the cath lab wthout an earlier PCI during the same episode of care, code the CAD presentation based the worst patient clinical status prior to this or prior diagnostic catheterization procedures.
If this is a subsequent episode of care (within 7 days), do not code the CAD Presentation from the previous episode of care.
CCS Angina Class (last 2 weeks):
No ischemic symptoms: The patient has no symptoms, no angina.
CCS I: Ordinary physical activity does not cause angina; for example walking or climbing stairs, angina occurs with strenuous or rapid or prolonged exertion at work or recreation.
CCS II: Slight limitation of ordinary activity; for example, angina occurs walking or stair climbing after meals, in cold, in wind, under emotional stress or only during the few hours after awakening, walking more than two blocks on the level or climbing more than one flight of ordinary stairs at a normal pace and in normal conditions.
CCS III: Marked limitation of ordinary activity; for example, angina occurs walking one or two blocks on the level or climbing one flight of stairs in normal conditions and at a normal pace.
CCS IV: Inability to carry on any physical activity without discomfort – angina syndrome may be present at rest.
NYHA Heart Failure Class (last 2 weeks):
Indicate the patient's worst dyspnea or functional class within the past 2 weeks with physician documentation or report that the patient has been in a state of heart failure. Heart failure is defined as physician documentation or report of any of the following clinical symptoms of heart failure described as unusual dyspnea on light exertion, recurrent dyspnea occurring in the supine position, fluid retention; or the description of rales, jugular venous distension, pulmonary edema on physical exam, or pulmonary edema on chest x-ray presumed to be cardiac dysfunction. A low ejection fraction alone, without clinical evidence of heart failure does not qualify as heart failure.
The New York Heart Association (NYHA) classification:
Class I: Patient has cardiac disease but without resulting limitations of ordinary physical activity. Ordinary physical activity (e.g., walking several blocks or climbing stairs) does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Limiting symptoms may occur with marked exertion.
Class II: Patient has cardiac disease resulting in slight limitation of ordinary physical activity. Patient is comfortable at rest. Ordinary physical activity such as walking more than two blocks or climbing more than one flight of stairs results in limiting symptoms (e.g., fatigue, palpitation, dyspnea, or anginal pain).
Class III: Patient has cardiac disease resulting in marked limitation of physical activity. Patient is comfortable at rest. Less than ordinary physical activity (e.g., walking one to two level blocks or climbing one flight of stairs) causes fatigue, palpitation, dyspnea, or anginal pain.
Class IV: Patient has symptoms at rest that increase with any physical activity. Patient has cardiac disease resulting in inability to perform any physical activity without discomfort. Symptoms may be present even at rest. If any physical activity is undertaken, discomfort is increased.
Cardiogenic Shock within 24 hrs:
Indicate if the patient has been in a state of cardiogenic shock within 24 hrs of procedure. Cardiogenic shock is defined as a sustained (>30 minutes) episode of systolic blood pressure <90 mm Hg, and/or cardiac index <2.2 L/min/m2 determined to be secondary to cardiac dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g., Intra aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices) to maintain blood pressure and cardiac index above those specified levels. Note: Transient episodes of hypotension reversed with IV fluid or atropine do not constitute cardiogenic shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30 minutes.
Cardiac Arrest within 24 hrs:
Indicate if the patient has had an episode of cardiac arrest within 24 hours of procedure. Cardiac arrest includes pulseless clinical scenarios that can be brady arrests or tachy arrests requiring cardiopulmonary resuscitation (requiring two or more chest compressions, or open chest massage) and/or requiring emergency defibrillation.
Procedural Details
IABP:
Indicate if the patient required the use of an Intra-Aortic Balloon Pump (IABP) between start of procedure and end of procedure.
PCI Status:
Indicate the status of the PCI. The status is determined at the time the operator decides to perform a PCI.
Elective: The procedure can be performed on an outpatient basis or during a subsequent hospitalization without significant risk of infarction or death. For stable inpatients, the procedure is being performed during this hospitalization for convenience and ease of scheduling and NOT because the patient's clinical situation demands the procedure prior to discharge. If the diagnostic catheterization was elective and there were no complications, the PCI would also be elective.
Urgent: The procedure should be performed on an inpatient basis and prior to discharge because of significant concerns that there is risk of ischemia, infarction and/or death. Patients who are outpatients or in the emergency department at the time that the cardiac catheterization is requested would warrant an admission based on their clinical presentation.
Emergent: The procedure should be performed as soon as possible because of substantial concerns that ongoing ischemia and/or infarction could lead to death. "As soon as possible" refers to a patient who is of sufficient acuity that you would cancel a scheduled case to perform this procedure immediately in the next available room during business hours, or you would activate the on-call team were this to occur during off-hours.
Salvage: The procedure is a last resort. The patient is in cardiogenic shock when the PCI begins (i.e. at the time of introduction into a coronary artery or bypass graft of the first guidewire or intracoronary device for the purpose of mechanical revascularization). Within the last ten minutes prior to the start of the case or during the diagnostic portion of the case, the patient has also received chest compressions for a total of at least sixty seconds or has been on unanticipated extracorporeal circulatory support (e.g. extracorporeal mechanical oxygenation, or cardiopulmonary support).
LVEF:
Code the best estimate of current left ventricular ejection fraction before the start of the PCI. The Left Ventricular Ejection Fraction can be assessed via invasive (i.e. LV gram) or non-invasive (i.e., echo, MR, CT or Nuclear) testing. If an ejection fraction is not measured during this admission and prior to the PCI, and the clinical status has not changed, it is acceptable to code an ejection fraction that was obtained prior to arrival (i.e., the last value between 6 months prior to current procedure and prior to the intervention). If only a descriptive value is reported (i.e., normal), enter the corresponding percentage value from the list below: Normal = 60%; Good function = 50%; Mildly reduced = 45%; Fair function = 40%; Moderately reduced = 30%; Poor function = 25%; Severely reduced = 20%
Cardiogenic Shock at start of PCI:
Indicate if the patient is in cardiogenic shock at the start of the PCI procedure. Cardiogenic shock is defined as a sustained (>30 minutes) episode of systolic blood pressure <90 mm Hg, and/or cardiac index <2.2 L/min/m2 determined to be secondary to cardiac dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (e.g., Intra aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices) to maintain blood pressure and cardiac index above those specified levels. Note: Transient episodes of hypotension reversed with IV fluid or atropine do not constitute cardiogenic shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for at least 30 minutes.
Primary Arterial Access:
Indicate the primary location of percutaneous arterial entry. Code the site used to perform the majority of the procedure if more than one site was used.
2 vessels with 70% DS:
Indicate if the patient has multivessel CAD.
Number of lesions treated:
Indicate the number of lesions treated during this PCI.
Stent use:
Indicate the types of stents, if any, (to be) deployed during this PCI.
Predicted Outcomes
Predicted risk that the patient will die from any cause following this PCI prior to discharge.
In-hospital mortality (NCDR)
Predicted risk of developing any of the following within 72 hours after PCI or prior to hospital discharge (whichever occurs first): site-reported arterial access site bleeding, which may be either external or a hematoma >10 cm for femoral access, >5 cm for brachial access, or >2 cm for radial access; retroperitoneal, gastrointestinal, or genitourinary bleeding; intracranial hemorrhage; cardiac tamponade; post-procedure hemoglobin decrease of 3 g/dl in patients with a pre-procedure hemoglobin ≤16 g/dl; or post-procedure non-bypass surgery-related blood transfusion for patients with a pre-procedure hemoglobin ≥8 g/dl.
In-hospital bleeding (NCDR)
Predicted risk that the patient will develop prior to discharge a femoral arterial access site complication: access site bleeding requiring tranfusion, access site bleeding causing hematoma >5 cm, retroperitoneal bleeding, other vascular complication requiring diagnostic testing or therapy, or death from a vascular cause.
In-hospital femoral complications (DELTA)
Predicted risk that the patient will develop prior to discharge or within 30 days (whichever comes first) an absolute increase in serum creatinine of ≥0.3 mg/dL or a relative increase in serum creatinine of 50%, or new requirement for dialysis.
In-hospital AKI (NCDR)
Predicted risk that the patient will experience acute or worsening renal failure necessitating renal dialysis (or CVVH for renal failure) prior to discharge or within 30 days (whichever comes first).
In-hospital dialysis (NCDR)
Predicted risk of target vessel revascularization within 1 year following this PCI.
1-year TVR (MassDAC)
  (Target Vessel Revascularization)
Predicted risk of readmission for any reason within 30 days of discharge following this PCI.
30 day Readmission (MassDAC)
© 2014 Society for Cardiovascular Angiography and Interventions
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Age (years):
Height (cm):
Sex:
Weight (kg):
Race:
BMI (kg/m2):
  Admission Source:   Health Insurance:  
History and Risk Factors
Procedural Details
Hypertension:
IABP:
Prior Heart Failure:
PCI Status:
Prior PCI:
LVEF:
Prior CABG:
Cardiogenic Shock at start of PCI:
Currently on Dialysis:
Primary Arterial Access:
  Cerebrovascular Disease:   ≥2 vessels with 70% DS:    
Peripheral Arterial Disease:
Number of lesions treated:
Chronic Lung Disease:
Stent use:
Diabetes Mellitus:
Hemoglobin (g/dL):
Serum Creatinine (mg/dL):
eGFR (mL/min/1.73m2):
Clinical Evaluation
CAD Presentation:
CCS Angina Class (last 2 weeks):
NYHA Heart Failure Class (last 2 weeks):
Cardiogenic Shock within 24 hrs:
Cardiac Arrest within 24 hrs:
  Predicted Chances of a Post-Procedure Event  
       
     
       
   
     
   
     
_________________________________ _____________________________
______/______/______    ______:______
Printed Name
Signature
Signature Date & Time
Presentation1.jpg
 
   
   
Age (years):
Height (cm):
Sex:
Weight (kg):
Race:
BMI (kg/m2):
  Admission Source:   Health Insurance:  
History and Risk Factors
Procedural Details
Hypertension:
IABP:
Prior Heart Failure:
PCI Status:
Prior PCI:
LVEF:
Prior CABG:
Cardiogenic Shock at start of PCI:
Currently on Dialysis:
Primary Arterial Access:
  Cerebrovascular Disease:   ≥2 vessels with 70% DS:    
Peripheral Arterial Disease:
Chronic Lung Disease:
Diabetes Mellitus:
Hemoglobin (g/dL):
Serum Creatinine (mg/dL):
eGFR (mL/min/1.73m2):
Clinical Evaluation
CAD Presentation:
CCS Angina Class (last 2 weeks):
NYHA Heart Failure Class (last 2 weeks):
Cardiogenic Shock within 24 hrs:
Cardiac Arrest within 24 hrs:
  Predicted Chances of Target Vessel Revascularization within 1 year  
    Minimal nominal stent diameter   Total Stent Length  
      1 Lesion treated    
         
         
         
                 
      2 Lesions treated    
         
         
         
                 
      3 Lesions treated    
         
         
         
_________________________________ _____________________________
______/______/______    ______:______
Printed Name
Signature
Signature Date & Time
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  References  
     
NCDR CathPCI Mortality Model: Brennan, et al. JACC: Cardiovascular Interventions 2013; 6:790-799.
NCDR CathPCI Bleeding Model: Rao, et al. JACC: Cardiovascular Interventions 2013; 6:897-904.
DELTA Femoral Vascular Complications Model: Wimmer, et al. J Am Heart Assoc 2013; 2:e000174
NCDR CathPCI Acute Kidney Injury Model: Tsai, et al. JACC: Cardiovascular Interventions 2014; 7:1-9.
MassDAC 1 year TVR model: Yeh, et al. Circulation. 2011; 124:1557-1564.
MassDAC 30 day Redmission Model: Wasfy, et al. Circulation: Cardiovascular Quality and Outcomes. 2013; 6:429-435.