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Acute Coronary Syndromes (ACS)

Dataset

These are standards current on 10th May 2007

National Clinical Dataset Development Programme (NCDDP) Support Team Information Services Area 54E Gyle Square 1 South Gyle Crescent Edinburgh EH12 9EB Tel: 0131 275 7053 Email to: [email protected] Website: www.show.scot.nhs.uk/clinicaldatasets/

mailto:[email protected]

http://www.show.scot.nhs.uk/clinicaldatasets/

Acute Coronary Syndromes Dataset 2

PATIENT DETAILS .................................................................................................... 4

Patient Identification and Demographics Table ....................................................... 4 General Practice Details Table................................................................................ 5

Ambulance Incident Number................................................................................ 5 ADMISSION DETAILS ............................................................................................... 6

Date/ Time of Symptom Onset {ACS}.................................................................. 6 Date/ Time Call for Help {ACS}............................................................................ 7 Date/ Time Arrival at Hospital {ACS} ................................................................... 7 Admitted/ Transfer from – location....................................................................... 8 Patient Admin Status ........................................................................................... 8 Initial Diagnosis {ACS} ......................................................................................... 8 Method of Admission {ACS}................................................................................. 9 Admission Ward {ACS} ...................................................................................... 10 Admitting Consultant Identifier ........................................................................... 11 Admitting Consultant Type {ACS} ...................................................................... 11 Seen by Cardiologist.......................................................................................... 11

ADMISSION TREATMENT....................................................................................... 13 Where was Aspirin / other Anti platelet Given?.................................................. 13 Reason Aspirin Not Given.................................................................................. 14 Aspirin Contraindications ................................................................................... 14 Clopidogrel......................................................................................................... 15 Reason Clopidogrel Not Given .......................................................................... 15 Clopidogrel Contraindications ............................................................................ 15 Heparin (Low Molecular Weight Heparin or Intravenous Heparin) .................... 16 Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given.................................................................................................................. 16 Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Contraindications ............................................................................................... 17

THROMBOLYSIS ..................................................................................................... 18 ECG Determining Reperfusion Treatment ......................................................... 18 Date/ Time of 1st ECG....................................................................................... 19 Date/ Time of ECG Determining Reperfusion Treatment .................................. 19 Place First ECG Performed ............................................................................... 20 Was Reperfusion Attempted .............................................................................. 20 Reason Thrombolytic Treatment Not Given....................................................... 21 Thrombolytic Drug.............................................................................................. 21 Date/ Time of Reperfusion Treatment................................................................ 22 Reason if Delay Before Thrombolytic Treatment ............................................... 22 Where was Initial Reperfusion Treatment Given ............................................... 23 Bleeding Complications as a Result of Reperfusion Therapy............................ 23 Reperfusion Outcome........................................................................................ 24

BLOOD RESULTS ................................................................................................... 25 Serum Total Cholesterol (Admission) {ACS} ..................................................... 25 Cardiac Enzymes/ Markers Raised.................................................................... 25 Peak Serum Creatinine Kinase.......................................................................... 26 Peak Troponin.................................................................................................... 26 Troponin Assay.................................................................................................. 26

CHD RISK FACTORS .............................................................................................. 28 Smoking Status.................................................................................................. 28 Family History of CHD ....................................................................................... 29


Previous Myocardial Infarction........................................................................... 29 Previous Angina................................................................................................. 29 Hypertension...................................................................................................... 30 Chronic Kidney Disease..................................................................................... 30 Diabetes Management....................................................................................... 31 Previous Percutaneous Coronary Intervention (PCI)......................................... 32 Previous Coronary Artery Bypass Graft (CABG) ............................................... 32

INVESTIGATIONS DURING ADMISSION ............................................................... 33 Exercise Tolerance Test .................................................................................... 33 Reason for no Exercise Tolerance Test............................................................. 34 Echocardiography.............................................................................................. 35 LV Function as Result of Echocardiogram......................................................... 35 Reason for No Echocardiography...................................................................... 36 Referral for Coronary Angiography .................................................................... 36 Date of Referral for Coronary Angiogram .......................................................... 37 Coronary Angiography During This Admission {ACS} ....................................... 37 Date of Coronary Angiogram ............................................................................. 38

INTERVENTIONS DURING ADMISSION ................................................................ 39 Referral for Revascularisation............................................................................ 39 Date of Referral for Revascularisation ............................................................... 39 Revascularisation {ACS}.................................................................................... 40 Date of Revascularization .................................................................................. 40

COMPLICATIONS DURING ADMISSION ............................................................... 41 Heart Failure {ACS} ........................................................................................... 41 Angina {ACS}..................................................................................................... 41 Reinfarction........................................................................................................ 42 Cardiac Arrest .................................................................................................... 42 Date/ Time of 1st Cardiac Arrest........................................................................ 42 Outcome of 1st Cardiac Arrest........................................................................... 43

CARDIAC REHABILITATION .................................................................................. 44 Referral to Cardiac Rehabilitation Service ......................................................... 44 Date of Referral to Cardiac Rehabilitation Service ............................................ 44 Reason for No Referral to Cardiac Rehabilitation.............................................. 45

DISCHARGE DETAILS ............................................................................................ 46 Discharge Date {ACS} ....................................................................................... 46 Discharge Diagnosis {ACS} ............................................................................... 47 Discharged on Aspirin / other Antiplatelet.......................................................... 48 Discharged on Warfarin ..................................................................................... 49 Discharged on Clopidogrel................................................................................. 49 Discharged on Beta Blocker .............................................................................. 50 Discharged on Angiotensin Inhibitor .................................................................. 50 Discharged on Statin.......................................................................................... 50 Discharge Destination {ACS} ............................................................................. 51 Discharge / transfer to - location ........................................................................ 51 Cause of Death in Hospital {ACS} ..................................................................... 52 Person Death Date ............................................................................................ 52 Episode Sign Off ................................................................................................ 52


PATIENT DETAILS

Patient Identification and Demographics Table Generic Data Items Data Item Definition Format Location Code G This is the reference number of any building

or set of buildings where events pertinent to NHS Scotland take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patient/client’s home.

5 characters

Health Record Identifier G

A Patient Health Record Identifier is a code (set of characters) used to uniquely identify a patient within a health register or a HEALTH RECORDS SYSTEM, e.g. PAS.

14 characters

CHI Number G The Community Health Index (CHI) is a population register, which is used in Scotland for health care purposes. The CHI number uniquely identifies a person on the index.

10 characters

Surname G That part of a person's name which is used to describe family, clan, tribal group, or marital association.

35 characters

Forename G The forename or given name of a person 35 characters Person Birth Date G The date on which a person was born or is

officially deemed to have been born, as recorded on the Birth Certificate.

10 characters (CCYY-MM-DD)

Person Current Gender G

A statement by the individual about the gender they currently identify themselves to be (i.e. self-assigned).

1 character

Ethnic Group (Self Assigned) G

A statement made by the service user about their current ethnic group

Up to 6 characters (2 + 4)

Postcode G The code allocated by the Post Office to identify a group of postal delivery points.

8 characters

G The above data items have already been approved and are available in the Health & Social Care Data Dictionary.


General Practice Details Table Generic Data Items Data Item Definition Format Registered GP Practice Code G

General Medical Practitioners provide general medical services to the population either in partnership with other GMPs or on a single-handed basis. The term GP practice covers both partnerships and single-handed practices. Each GP practice in Scotland is identified by a unique GP practice code. The practice code is a four-digit code plus a check digit with ranges of codes allocated to each Health Board.

6 characters (right justified)

Data Items Data Item Definition Format Ambulance Incident Number

A record of the ambulance incident number as per the Scottish Ambulance Service Patient Record Form (PRF).

12 characters

Ambulance Incident Number Definition: A record of the ambulance incident number as per the Scottish Ambulance Service Patient Record Form (PRF). Format: 12 characters Codes and values: N/A Further Information: The ambulance incident number is comprised of 2 letters - 7 digits - 3 digits.


ADMISSION DETAILS Data Items Data Item Definition Format Date/ Time of Symptom Onset {ACS}

A record of the time to within 10 minutes, if possible, when symptoms began.

25 characters (CCYY-MM-DDThh:mmTZD)

Date/ Time Call for Help {ACS}

A record of the time of the initial call by patient, relative or attendant.


Date/ Time Arrival at Hospital {ACS}

Date/time patient first arrives at hospital.


Admitted/ Transfer from – location

The type of location from which a patient is admitted or transferred for care.

ISD reference file

Patient Admin Status A record of the patients administration status

2 characters

Initial Diagnosis {ACS} A record of a working diagnosis at the time of admission.

2 characters

Method of Admission {ACS}

A record of the process by which the patient was admitted to hospital.

2 characters

Admission Ward {ACS} Refers to the unit to which the patient is admitted either from A&E or directly by ambulance service and where patient will spend majority of first 24 hours in hospital.

2 characters

Admitting Consultant Identifier

A record of the unique identifier for the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital

7 characters

Admitting Consultant Type {ACS}

A record of the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital

2 characters

Seen by Cardiologist A record of whether the patient is seen by a cardiologist or other physician with a specialist interest in cardiology, at any time during this admission.

2 characters

Date/ Time of Symptom Onset {ACS} Definition: A record of the time to within 10 minutes, if possible, when symptoms began. Format: 25 characters (CCYY-MM-DDThh:mmTZD)


Codes and values: N/A Sub-data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known

Further information: Where there is a prodrome of intermittent pain the time recorded should be the time of onset of those symptoms which led the patient to call for help. Routine ambulance data should be used to provide symptom onset information. Where admission followed an out of hospital cardiac arrest with no better information available use the time if arrest for onset of symptoms. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Date/ Time Call for Help {ACS} Definition: A record of the time of the initial call by patient, relative or attendant. Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Sub-data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known

Further information: This may be to a GP, NHS 24, or the ambulance service. This time may be available from the ambulance service record as the time of the emergency call but may only be correct when a 999 call is made to the Ambulance service. Make sure you know to whom the initial call was made. If the call was to a GP (or deputising service), or NHS 24 you will have to establish this time as accurately as possible from the patient. The call time should be taken from the ambulance patient report form (PRF) and is when the caller's telephone number, exact location of the incident and nature of chief complaint are known. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Date/ Time Arrival at Hospital {ACS} Definition: A record of the date/time patient first arrives at hospital Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A


Sub-data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known

Further information: Either A&E, CCU, MAU, or assessment unit. Routine ambulance data. It is recommended that this be used by all as the time of arrival rather than time of registration or time of first ECG. Use A&E registration time if self presented or time of ambulance arrival at hospital if direct admission. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Admitted/ Transfer from – location Definition: The type of location from which a patient is admitted or transferred for care. Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Further information: ISD Reference File. This is only relevant for those patients who are admitted/transferred directly from another NHS Location for revascularisation or inpatient angiography with a view to revascularisation. This is not relevant for those patients admitted from home. This is the location of where a patient has been admitted or transferred from. A location is any building or set of buildings where events pertinent to the NHSSCOTLAND take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patients/clients’ home.

Patient Admin Status Definition: A record of the patient’s administration status Format: 2 characters Codes and values: Code Value Explanatory Notes 01 NHS 02 Private 03 Amenity NHS patient but procedure carried out in private hospital. 04 Visitor Any patient that does not live in the local catchment area,

includes holiday makers and overseas tourists 99 Not known

Initial Diagnosis {ACS} Definition: A record of a working diagnosis at the time of admission.


Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Definite myocardial

infarction Diagnosis based on unequivocal changes of infarction on admission ECG (ST elevation) and appropriate history.

02 Probable myocardial infarction

Should be used where there is strong likelihood of infarction on history and an abnormal ECG without ST elevation or LBBB. This is a working diagnosis needing confirmation by further ECGs and/or biochemical markers. See 'Reason if delay before thrombolytic treatment’ for advice on what to enter when first ECGs are not diagnostic and a subsequent ECG is diagnostic and results in reperfusion treatment being given. Includes appearance at admission of non Q wave (subendocardial) infarction.

03 Acute coronary syndrome

Covers all other suspected acute coronary syndromes where confirmation of diagnosis subject to troponin results

04 Chest pain of uncertain cause

Single episode of cardiac sounding chest pain with admission thought appropriate to exclude ischaemic event.

05 Other initial diagnosis Other (usually non-cardiac) diagnosis such as acute aortic dissection, pancreatitis, etc subsequently found to be an infarction. Also to be used where patient is already in hospital.

99 Not known Further information: The primary purpose is to identify those patients who are admitted with a diagnosis of definite MI (ST elevation MI). Do not change initial diagnosis on the basis of further ECGs or enzymes/markers. Note: This standard will be updated when a new definition of Acute Coronary Syndrome is available.

Method of Admission {ACS} Definition: A record of the process by which the patient was admitted to hospital. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Called GP who saw patient

before calling emergency services

Use also when patient sees GP at surgery, drop in night time clinic etc.

02 Called GP who called emergency service before seeing patient

In some instances the GP may not actually see the patient.


03 Called GP, told to make own way to hospital

04 Called 999 05

Made own way to hospital (did not call anyone)

06 Patient admitted from outpatient setting

This includes Rapid Access Chest Pain Clinics

07 Patient already in hospital If the patient is already in hospital with another diagnosis it is only necessary to enter the date of symptom onset and the date of arrival at hospital.

08 Transferred in for PCI/Surgery Use when admitted by transfer from another hospital for consideration of primary or rescue angioplasty or surgical procedure.

09 Transferred in for primary treatment

Use this option for transfer from any other hospital for primary treatment (e.g. thrombolysis) or where split management of acute coronary events takes place. If transfer is for primary or rescue angioplasty use option 8.

98 Other Includes other routes of entry to hospital (became ill visiting hospital etc)

99 Not known Further Information: In every case the caller refers to the patient or other non-professional in attendance.

Admission Ward {ACS} Definition: A record of the unit to which the patient is admitted either from A&E or directly by ambulance service and where patient will spend majority of first 24 hours in hospital. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Coronary care unit A unit specified for this purpose including those

with shared facilities with ITU, or HDU, or a dedicated CCU which is part of a general medical ward or a dedicated cardiac ward and where the major part of early management takes place.

02 Acute admissions unit A unit for the assessment of non-specific acute medical admissions.

03 General medical ward Where this is separate from a CCU. 04 Intensive therapy unit Where this is separate from a CCU, and is not

the usual place of care for early infarction (post-arrest or when CCU is full, etc).

05 Cardiac ward (non CCU)

A cardiac ward without a specific CCU function

06 Stepdown ward A facility normally used primarily for patients after initial care on CCU


07 Died in A&E Very important for interpretation of mortality data.

98 Other To record patients admitted to non-medical wards or who had infarction while already in hospital.

99 Not known Further Information: If patient admitted direct to Catheter Lab, enter facility to which patient admitted on leaving lab.

Admitting Consultant Identifier Definition: A record of the unique identifier for the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital Format: 7 characters Codes and values: N/A Further Information: This is not the A&E consultant. The admitting consultant identifier has the same format as the General Medical Council number.

Admitting Consultant Type {ACS} Definition: A record of the clinician having primary rather than advisory care of the patient immediately (first 24 hours) after admission to hospital Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Cardiologist Cardiologist or physician with a major interest

in cardiology. 02 Other general physician All other physicians. 98 Other Patient admitted under another discipline, e.g.

surgeon. 99 Not known Further Information: This is not the A&E consultant

Seen by Cardiologist Definition: A record of whether the patient is seen by a cardiologist or other physician with a specialist interest in cardiology, at any time during this admission. Format: 2 characters Codes and values: Code Value 00 No 01 Yes


02 Discussed with cardiologist but not seen 99 Not known Further Information: Patients may be admitted by a general physician then later seen by a cardiologist.


ADMISSION TREATMENT Data Items Data Item Definition Format Where was Aspirin / other Anti platelet Given?

A record of if and when aspirin or other anti platelet drug was first given to patient.

2 characters

Reason Aspirin Not Given

A record of the reason aspirin/other anti-platelet was not given.

2 characters

Aspirin Contraindications

A record of the reason aspirin/other anti-platelet is contraindicated.

2 characters

Clopidogrel A record of whether Clopidogrel was given on admission.

2 characters

Reason Clopidogrel Not Given

A record of the reason Clopidogrel was not given on admission.

2 characters

Clopidogrel Contraindications

A record of the reason why Clopidogrel is contraindicated.

2 characters

Heparin (Low Molecular Weight Heparin or Intravenous Heparin)

A record of whether Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was given on admission.

2 characters

Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given

A record of the reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was not given.

2 characters

Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Contraindications

A record of the reason why Heparin (Low Molecular Weight Heparin or Intravenous Heparin) is contraindicated.

2 characters

Where was Aspirin / other Anti platelet Given? Definition: A record of if and when aspirin or other antiplatelet drug was first given to patient. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 Not given 01 Already on aspirin / antiplatelet

drug Regular use of aspirin / antiplatelet before this episode. Ignore the administration of additional doses by paramedics.

02 Aspirin / antiplatelet drug given out of hospital

Aspirin or other anti platelet drug started for this episode before admission.


Patient not previously taking any antiplatelet drug.

03 Aspirin / antiplatelet drug given after arrival in hospital

99 Not known

Reason Aspirin Not Given Definition: A record of the reason aspirin/other anti-platelet was not given. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 None No reason given 01 Contraindicated Clinical reason aspirin/other anti-platelet should not

be given 02 Adverse Reaction Patient experienced unwanted effects/allergic to

aspirin/other anti-platelet 03 Not tolerated Patient cannot tolerate aspirin/other antiplatelet 04 Not indicated e.g. person may already be on a similar medication 05 Patient declined Patient chose not to be prescribed aspirin/other anti-

platelet 98 Other 99 Not known

Aspirin Contraindications Definition: A record of the reason aspirin/other anti-platelet is contraindicated. Format: 2 characters Codes and values: Code Value 01 Allergic 02 GI Bleed 03 Dyspepsia 04 Severe liver abnormalities 05 Intolerant 06 Cerebral haemorrhage 07 Haemoptysis 08 Pregnant 99 Not known Further Information: Contra-indication in pregnancy should be supported by clinical data (teratogenicity or foetotoxicity) or by strong pre-clinical data such as teratogenicity, mutagenicity and carcinogenicity at low doses. (European Medicines Agency Evaluation of Medicines for Human Use - Doc. Ref.: EMEA/CHMP/64302/2005 (CHMP))


Clopidogrel Definition: A record of whether Clopidogrel was given on admission. Format: 2 characters Codes and values: Code Value 00 No 01 Yes 99 Not known Further Information: This is relevant for only those patients who are deemed as Acute Coronary Syndrome patients on admission.

Reason Clopidogrel Not Given Definition: A record of the reason Clopidogrel was not given on admission. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 None No reason given 01 Contraindicated Clinical reason Clopidogrel should not be given 02 Adverse Reaction Patient experienced unwanted effects/allergic

to Clopidogrel 03 Not tolerated Patient cannot tolerate Clopidogrel 04 Not indicated Patient may already be on a similar medication 05 Patient declined Patient chose not to be prescribed Clopidogrel 98 Other 99 Not known Further information: Where clinical guidelines recommend the prescription of a specific drug or class of drug for a particular condition, this data item allows the recording of the reason why that guidance was not followed. It is intended to support the clinical governance agenda

Clopidogrel Contraindications Definition: A record of the reason why Clopidogrel is contraindicated. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 None None 01 Specific clinical

diagnosis

02 Co-morbidities This includes concomitant diseases 03 Demographic factors e.g. gender, age


04 Predispositions This includes metabolic or immunological factors and prior adverse reactions

05 Pregnancy 06 Lactation 07 Strong theoretical

reasons e.g. on grounds of pharmacokinetics, pharmacodynamics, or common state of knowledge in medicine

99 Not known

Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Definition: A record of whether Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was given on admission. Format: 2 characters Codes and values: Code Value 00 No 01 Yes 99 Not known Further Information: This is relevant for only those patients who are deemed as Acute Coronary Syndrome patients on admission.

Reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Not Given Definition: A record of the reason Heparin (Low Molecular Weight Heparin or Intravenous Heparin) was not given. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 None No reason given 01 Contraindicated Clinical reason Heparin should not be given 02 Adverse Reaction Patient experienced unwanted effects/allergic

to Heparin 03 Not tolerated Patient cannot tolerate Heparin 04 Not indicated Patient may already be on a similar medication 05 Patient declined Patient chose not to be prescribed Heparin 98 Other 99 Not known


Heparin (Low Molecular Weight Heparin or Intravenous Heparin) Contraindications Definition: A record of the reason why Heparin (Low Molecular Weight Heparin or Intravenous Heparin) is contraindicated. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 None None 01 Specific clinical

diagnosis

02 Co-morbidities This includes concomitant diseases 03 Demographic factors e.g. gender, age 04 Predispositions This includes metabolic or immunological

factors and prior adverse reactions 05 Pregnancy 06 Lactation 07 Strong theoretical

reasons e.g. on grounds of pharmacokinetics, pharmacodynamics, or common state of knowledge in medicine

99 Not known


THROMBOLYSIS Data Items Data Item Definition Format ECG Determining Reperfusion Treatment

A record of the ECG appearances upon which a decision to offer reperfusion treatment including angioplasty, was based.

2 characters

Date/ Time of 1st ECG A record of the date and time of the first ECG recorded after the start of symptoms.


Date/ Time of ECG Determining Reperfusion Treatment

A record of the date and time the ECG that determined the reperfusion treatment, was taken.


Place First ECG Performed

A record of where the first ECG was performed.

2 characters

Was Reperfusion Attempted

A record of whether or not reperfusion was attempted on this patient.

2 characters

Reason Thrombolytic Treatment Not Given

A record of the explanation of why thrombolysis was not performed where it might be expected to be performed.

2 characters

Thrombolytic Drug A record of the agent for first thrombolytic treatment.

2 characters

Date/ Time of Reperfusion Treatment

A record of the date and time of start of reperfusion treatment whether by bolus or infusion.


Reason if Delay Before Thrombolytic Treatment

A record of the reason for delay, if any, before thrombolytic treatment is given.

2 characters

Where was Initial Reperfusion Treatment Given

A record of where the initial reperfusion treatment was given

2 characters

Bleeding Complications as a Result of Reperfusion Therapy

A record of bleeding complications due to reperfusion therapy

2 characters

Reperfusion Outcome A record of the result of primary thrombolytic treatment prior to any further reperfusion treatment

2 characters

ECG Determining Reperfusion Treatment Definition: A record of the ECG appearances upon which a decision to offer reperfusion treatment including angioplasty, was based. Format: 2 characters Codes and values:


Code Value Explanatory Notes 01 ST segment elevation Appearances considered typical of acute

myocardial infarction. 02 Left bundle branch

block New LBBB. Whether or not LBBB is 'new' causes practical difficulties. In order to confirm this it is necessary to have evidence that it did not exist before this event, by comparing with previous ECGs. It follows that unless there is definite ST segment elevation in addition to LBBB, the admission diagnosis for a patient with LBBB of uncertain duration has to be 'Probable MI'. Can be used to calculate TIMI risk score for Acute MI.

03 ST segment depression Any degree of ST segment depression involving more than one lead without any ST elevation (except a VR).

04 T wave changes only Includes non Q wave infarction. 05 Other abnormality All other abnormalities thought potentially

relevant to this admission e.g. arrhythmias, conduction disturbances.

06 Normal ECG 99 Not known Further information: This can include any 12 lead ECG performed in the pre hospital setting. If ST Elevation consistent with infarction is recorded on any ECG during the episode, regardless of treatment, the final diagnosis should be Myocardial Infarction (ST Elevation).

Date/ Time of 1st ECG Definition: A record of the date and time of the first ECG recorded after the start of symptoms Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known

Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Date/ Time of ECG Determining Reperfusion Treatment Definition: A record of the date and time the ECG that determined the reperfusion treatment, was taken Format: 25 characters (CCYY-MM-DDThh:mmTZD)


Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known

Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Place First ECG Performed Definition: A record of where the first ECG was performed. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Ambulance An ECG performed in any location by

ambulance paramedic staff as a result of an emergency call

02 In hospital In this hospital 98 Other healthcare facility Includes general practice or care home where

the ECG was performed by a non paramedic 99 Not known Further Information: This refers to the first ECG recorded, not necessarily the diagnostic ECG.

Was Reperfusion Attempted Definition: A record of whether or not reperfusion was attempted on this patient. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Thrombolytic drug Includes one or more doses of any thrombolytic

agent, although only timing of the first dose to be recorded. Use even if there was reason for delay before treatment.

02 Primary PCI Either as an elective decision or because thrombolytic treatment contraindicated.

03 Facilitated PCI PCI performed in the acute setting as soon as possible after thrombolysis for acute STEMI (or new LBBB) with a clear history of MI, provided as a routine treatment in addition to thrombolysis. Where, as a part of an agreed protocol, thrombolysis is given before a PCI is


performed. 99 Not known Further information: This data item only refers to the initial reperfusion strategy. Reperfusion therapy implies either lytic therapy (thrombolytic drug) or mechanical treatment (PCI) or both.

Reason Thrombolytic Treatment Not Given Definition: A record of the explanation of why thrombolysis was not performed where it might be expected to be performed. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No reasons No reason why thrombolysis not performed. This

should include any administration failures 01 Contraindicated Generally acknowledged clinical contraindication

to performing thrombolysis exists. This should include too late, risk of haemorrhage, uncontrolled hypertension, previous stroke, recent surgery etc

02 Not indicated No clinical indication for thrombolysis 03 Clinical Decision Clinical judgement of inappropriateness of

thrombolysis in an individual patient due to their specific set of circumstances

04 Not available Thrombolysis not available 05 Not applicable 06 Patient declined Patient chose not to have thrombolysis 07 Diagnostic uncertainty 08 Primary PCI 98 Other 99 Not known Further Information: Thrombolytic therapy may be expected when clinical guidelines recommend thrombolysis should be performed.

Thrombolytic Drug Definition: A record of the agent given for thrombolytic treatment. Format: Characters Field length: 2 Codes and values: Code Value 01 Alteplase 02 Reteplase 03 Streptokinase 04 Tenecteplase


05 Urokinase 98 Other 99 Not known Related data items: Thrombolysis Status, Date / Time of Reperfusion Treatment, Reason for no Thrombolysis {CHD}

Date/ Time of Reperfusion Treatment Definition: A record of the date and start time of reperfusion treatment whether by bolus or infusion. Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known

Further information: Required for calculation of time of arrival to time of thrombolysis. Required for time from onset symptoms to time of thrombolysis. Required for time from onset symptoms to time of thrombolysis. Recording Guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock

Reason if Delay Before Thrombolytic Treatment Definition: A record of the reason for delay, if any, before thrombolytic treatment is given. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No delay This means that there was no operational delay

regardless of the time to treatment. 01 Sustained hypertension As defined by local protocol. 02 Clinical concern about

recent cerebrovascular event or surgery

If delay results from need to check on significance of recent cerebrovascular event or operative procedure.

03 Delay obtaining consent If patient requests delay - use only when the patient wishes to take time to consider use of a conventional (non trial) thrombolytic drug. Other delays obtaining consent, or arranging randomisation for a therapeutic study should be recorded under 98 Other.


04 Cardiac arrest Cardiac arrest includes an arrest occurring before arrival in hospital.

05 Obtaining consent for a therapeutic trial

Consent for a therapeutic trial. Use only for an approved study

06 Hospital Administrative Failure

Includes any valid procedural reason why thrombolytic treatment was delayed in hospital including portering delay.

07 Ambulance procedural delay

This includes e.g. incorrect address or difficulty finding address, unable to gain entry to patient’s house, patient reasons e.g. initial refusal to go to hospital or extended domestic arrangements, or adverse weather conditions.

08 Ambulance 12 lead ECG not diagnostic of STEMI

When initial ambulance ECG is not diagnostic of STEMI.

09 Consideration for primary PCI

Where consideration for primary PCI led to a delay in providing thrombolysis.

10 No identifiable reason for delay

On review of clinical case no valid reason for delay is obvious (retrospective data entry)

98 Other 99 Not known Further Information: NHSQIS require 50% of patients to receive thrombolysis within 30 minutes of admission

Where was Initial Reperfusion Treatment Given Definition: A record of where the initial reperfusion treatment was given. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Ambulance This includes the patient's home. 02 GP / Out of Hours 03 Community hospital 04 In A&E Regardless of who initiated treatment there. 05 In CCU (direct

admission) A patient who enters CCU directly from an ambulance without assessment by hospital clinical staff before arrival.

06 In CCU (slowtrack) Implies admission via A&E or other assessment unit where a diagnosis of definite infarction was made, followed by transfer to CCU where thrombolytic treatment was initiated.

07 Elsewhere in hospital Includes acute admission units, general medical wards and catheter laboratories.

99 Not known

Bleeding Complications as a Result of Reperfusion Therapy Definition: A record of bleeding complications due to reperfusion therapy.


Format: 2 characters Codes and values: Code Value 00 None 01 Intracranial bleed 02 Retroperitoneal bleed 03 Any other spontaneous bleed with Hb fall >= 5g or Hct > 15% 04 Bleed from any non-intracranial or non-retroperitoneal site with Hb fall > 3g

and < 5 g 05 Bleed from any non-intracranial or non-retroperitoneal site with Hb fall <=3 g 99 Not known Further Information: This can be used for both thrombolytic treatment and any bleed post PCI. Options are listed in order of precedence: use the highest item that applies. Use if any antiplatelet/ anticoagulant/ fibrinolytic drug is thought to be responsible for bleeding.

Reperfusion Outcome Definition: A record of the result of primary thrombolytic treatment prior to any further reperfusion treatment Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Successful Reduction in ST Segment elevation by >50% within 90

minutes 02 Unsuccessful Persistent ST Segment elevation despite thrombolysis

after 90 minutes 03 Not applicable Record if thrombolytic treatment is not administered 99 Not known Further Information: An example of primary thrombolytic therapy is an additional dose of thromboytic drug.


BLOOD RESULTS Data Items Data Item Definition Format Serum Total Cholesterol (Admission) {ACS}

A record of a fasting sample serum total cholesterol level taken within 24 hours of admission

nn.nn (mmol/L)

Cardiac Enzymes/ Markers Raised

A record of whether or not the patient has raised cardiac enzymes / markers

2 characters

Peak Serum Creatinine Kinase

The highest serum creatinine kinase level in a series of measurements.

nnn (units)

Peak Serum Troponin The highest serum troponin level in a series of measurements, during this admission.

nnn.nn (units)

Troponin Assay A record of the specific type of troponin assay used

2 characters

Serum Total Cholesterol (Admission) {ACS} Definition: A record of a fasting sample serum total cholesterol level taken within 24 hours of admission Format: nn.nn (mmol/L) Codes and values: N/A Further Information: Cholesterol levels change within 24 hrs of an MI and do not return to normal levels for up to 3 months

Cardiac Enzymes/ Markers Raised Definition: A record of whether or not the patient has raised cardiac enzymes / markers Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No Enzyme activity (CK, CKMB or other cardiac

enzyme) on a single sample NOT greater than twice the upper limit of normal for the hospital laboratory. For other markers e.g. troponin, use local normal range for infarction.

01 Yes Enzyme activity (CK, CKMB or other cardiac enzyme) on a single sample greater than twice


the upper limit of normal for the hospital laboratory. For other markers e.g. troponin, use local normal range.

02 Test not done 98 Test done but results

not available

99 Not known If the patient dies before bloods are taken enter 'Not known'.

Peak Serum Creatinine Kinase Definition: The highest serum creatinine kinase level in a series of measurements. Format: nnn (units) Codes and values: N/A Further information: The biochemical definition of acute infarction and acute coronary syndromes has to take account of proposed changes of biochemical criteria which have not yet gained widespread agreement or acceptance. Entry of the peak value for the two markers allows either or both to be recorded. This allows for the reality that some Trusts are using different cut off points for troponin for the definition of infarction. The rest are likely still to be using creatine kinase (CK). Where serial CK levels are measured, the peak (highest) value should be recorded, but in situations where a single CK level is measured, this should be used.

Peak Troponin Definition: The highest serum troponin level in a series of measurements. Format: nnn.nn (units) Codes and values: N/A Further information: These values are presently collected for future analysis when standardisation of troponin assay is feasible. Where serial troponin levels are measured, the peak (highest) value should be recorded, but in situations where a single troponin level is measured, this should be used. This data item should record the highest level during this admission.

Troponin Assay Definition: A record of the specific type of troponin assay used. Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Troponin I 02 Troponin T


99 Not known Further information: It is important to know which assay type is used to measure troponin since different assays will have different reference ranges.


CHD RISK FACTORS Data Items Data Item Definition Format Smoking Status A record of tobacco

consumption at date of contact. 2 characters

Family History of CHD A record of family history of premature CHD by diagnosis.

2 characters

Previous Myocardial Infarction

A record of whether or not an individual has had a confirmed diagnosis of MI in the past confirmed by abnormal ECG findings e.g. Q-wave (and/or ETT and angiography results). Option for >1 with attached dates.

2 characters

Previous Angina A record of whether the patient has previously been diagnosed with angina.

2 characters

Hypertension A record of whether or not an individual is already receiving treatment (drug, dietary, or lifestyle) for hypertension, or has a record of BP > 140/90

2 characters

Chronic Kidney Disease A record of whether or not the individual has chronic kidney disease.

2 characters

Diabetes Management The type(s) of management of a patient’s diabetes.

2 characters

Previous Percutaneous Coronary Intervention (PCI)

A record of whether or not reperfusion of coronary arterial blood-flow by PTCA was performed prior to this admission.

2 characters

Previous Coronary Artery Bypass Graft (CABG)

A record of whether or not reperfusion of coronary arterial blood-flow by CABG was performed at any time prior to this admission.

2 characters

Smoking Status Definition: A record of tobacco consumption at date of contact. Format: 2 characters Codes and values:


Code Value Explanatory Notes 10 Never smoked May have tried smoking once or twice 11 Ex smoker Has not smoked for at least 12 months 12 Current non-smoker Has stopped smoking within the past 12

months 13 Current smoker 97 Patient declined Patient chose not to disclose this information 99 Not known Further Information: Includes all types of tobacco consumption.

Family History of CHD Definition: A record of family history of premature CHD by diagnosis. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further Information: A family history of CHD is pertinent in father or brother before 55 and mother or sister before 65.

Previous Myocardial Infarction Common name: Previous MI, personal history of MI Definition: Record of whether or not an individual has had a confirmed diagnosis of MI in the past proven by ECG, cardiac enzymes or heart perfusion scan or other reliable methodology, but not on clinical features alone. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further information: Confirmed by history and/ or abnormal investigative findings e.g. Q-wave on ECG (and/or ETT and angiography results) indicative of STEMI. Recording guidance: Systems must allow for recording of multiple previous MI’s, with associated dates.

Previous Angina


Definition: A record of whether the patient has previously been diagnosed with angina. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further Information: Symptoms thought to be indicative of ischaemic cardiac pain either at rest or on exertion existing at least two weeks prior to this admission. Symptoms indicative of ischaemic heart disease include chest pain of cardiac nature at rest or on exertion which may be relieved by rest and/or medical therapy e.g. administration of nitrates. Note: This standard will be updated when a new definition of Acute Coronary Syndrome is available

Hypertension Common name: HBP Definition: A record of whether or not an individual is already receiving treatment (drug, dietary, or lifestyle) for hypertension, or has a record of BP > 140/90 Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further information: The patient must have a BP >140/90 on two occasions prior to admission. Note: The definition of 'hypertension' is subject to periodic revision. The prevailing definition at the time of data recording should be used. This definition complies with current WHO-ISH and SIGN guidelines and will be updated to comply with new SIGN guidelines when they are available.

Chronic Kidney Disease Common name: CKD Main source of standard: US National Kidney Foundation Definition: Record of whether or not the individual has chronic kidney disease.


Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further information: CKD is defined as either kidney damage or Glomerular Filtration Rate (GFR) <60mL/min/1.73m2 for ≥3 months, where kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. This is the US National Kidney Foundation definition for Chronic Kidney Disease as published in “Kidney Disease Outcomes Quality Initiative (K/DOQI) Clinical Practice Guidelines for Chronic Kidney Disease: Evaluation, Classification, and Stratification” which can be found at: US National Kidney Foundation - K/DOQI guidelineshttp://www.kidney.org/professionals/doqi/kdoqi/p9_approach.htm. This definition will almost certainly be adopted by renal services and registries in both Scotland and England. The formula for calculation of estimated GFR is: e GFR = 186.3 x SCr-1.154 x age-0.203 x 0.742 (if female) x 1.212 (if black) e GFR is reported in mL/min/1.73 m2 SCr: serum creatinine in mg/dL (divide by 88.4 to convert from mol/L)

CKD Stage

Description eGFR (ml/min/1.73m2)

1 Kidney damage + normal or ↑GFR >90 2 Kidney damage + mild ↓GFR 60-89 3 Moderate ↓GFR 30-59 4 Severe ↓GFR 15-29 5 Kidney failure <15 (or dialysis)

Diabetes Management Definition: The type(s) of management of a patient’s diabetes Format: 2 characters Codes and values: Code Value Explanatory Notes 00 None 01 Dietary Control 02 Oral Hypoglycaemic 03 Insulin 04 Not yet established Newly diagnosed diabetes for which definitive

management has not yet been established 99 Not known

http://www.kidney.org/professionals/kdoqi/index.cfm

http://www.kidney.org/professionals/kdoqi/index.cfm

http://www.kidney.org/professionals/doqi/kdoqi/p9_approach.htm


Previous Percutaneous Coronary Intervention (PCI) Definition: A record of whether or not reperfusion of coronary arterial blood-flow by PTCA was performed prior to this admission. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known

Previous Coronary Artery Bypass Graft (CABG) Definition: A record of whether or not reperfusion of coronary arterial blood-flow by CABG was performed at any time prior to this admission. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known


INVESTIGATIONS DURING ADMISSION Data Items Data Item Definition Format Exercise tolerance test

A record of whether or not an individual has undergone an exercise tolerance test.

2 characters

Reason for no Exercise tolerance test

An explanation of why an exercise tolerance test was not performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed

2 characters

Echocardiography A record of whether or not echocardiographic investigation has been performed

2 characters

LV function as result of echocardiogram

A high level report on the findings of an echocardiography investigation, with reference to abnormalities which may be related to ischaemic heart disease and/or valvular disease.

2 characters

Reason for not performing echocardiogram

An explanation of why no echocardiogram was performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed

2 characters

Referral for coronary angiography

A record of referral for coronary angiography in another hospital

2 characters

Date of referral for coronary angiogram

A record of the date a patient was referred for coronary angiogram


Coronary angiography during this admission {ACS}

A record of whether or not coronary angiography investigation has been performed for delineation of coronary arterial blood-flow during this admission

2 characters

Date of coronary angiogram

A record of the date when a coronary angiogram was performed.


Exercise Tolerance Test Common name: ETT, Exercise ECG Definition: A record of whether or not an individual has undergone an exercise tolerance test.


Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No ETT not performed 01 Yes 02 Planned Includes ‘requested’ and ‘referred for’ 99 Unknown Related data items: Reason for no Exercise Tolerance Test Further information: For various clinical conditions, specific clinical guidelines recommended ETT investigation. Whether or not an ETT was performed in line with such guidelines may be needed to assess the quality of clinical care, as in the GMS Quality Outcomes Framework. Exercise tolerance testing (ETT) has been shown to be of value in assessing prognosis of patients with coronary artery disease. An ETT is also helpful in patients at high risk of CHD, where a positive test can provide useful prognostic information. (Ref. SIGN 51)

Reason for no Exercise Tolerance Test Common name: Reason for no ETT, Reason for no exercise ECG Definition: An explanation of why an exercise tolerance test was not performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No reason No reason why ETT not performed 01 Contraindicated Generally acknowledged clinical contraindication to

performing ETT exists, e.g. physically incapable of performing the test, may have aortic stenosis or cardiomyopathy

02 Not indicated No clinical indication for ETT e.g. diagnosis of CHD is unlikely or the results of stress testing would not affect management

03 Clinical decision Clinical judgement of inappropriateness of ETT investigation in an individual patient due to their specific set of circumstances

04 Not available ETT investigation not available 05 Not applicable 06 Patient declined Patient chose not to have ETT 99 Not known Related data items: Exercise Tolerance Test


Further information: Exercise tolerance testing (ETT) is used principally to identify patients with reversible myocardial ischaemia who might benefit from revascularisation. (Ref. SIGN 41)

Echocardiography Common name: Echo, Cardiac ultrasound Definition: A record of whether or not echocardiographic investigation has been performed. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No Not performed 01 Yes 02 Planned Includes ‘requested’ and ‘referred for’ 99 Unknown Sub data item: Type of echocardiogram:

1 Transthoracic 2 Transoesophageal 3 Mitral 4 Atrial

Related data items: Echocardiogram Results {CHD} Reason for no Echocardiogram Further information: The Echocardiography must be performed during this admission. Echocardiography is established as the standard means of assessing cardiac structure and function in clinical practice. It permits measurement of left ventricular size, shape, wall thickness, contraction, and relaxation. In addition, valve structure and function can be assessed and thrombus detected. Right ventricular measurements can also be made and pericardial effusion excluded. (Ref. SIGN 35) It is used to assess patient’s post-MI, in those with heart failure, valvular heart disease or congenital heart disease. For various clinical conditions, specific clinical guidelines recommended echo investigation. Whether or not an echo was performed in line with such guidelines may be needed to assess the quality of clinical care.

LV Function as Result of Echocardiogram Common name: Echo Results {CHD} Definition: A high level report on the findings of an echocardiography investigation, with reference to abnormalities which may be related to ischaemic heart disease and/or valvular disease. Format: 3 characters


Codes and values: Code Value Sub

code

Sub value Explanatory Notes

00 Normal Abnormalities detected on echo, but nature of abnormality not specified A LV impairment Echo suggestive of left

ventricular impairment B LV hypertrophy Echo suggestive of left

ventricular hypertrophy C Significant valve

disease Echo suggestive of significant valve disease

D Non-significant valve disease

Echo suggestive of non- significant valve disease

01 Abnormal

E Other abnormality 02 Inconclusive 99 Unknown Related data items: Echocardiogram (Investigation) Recording guidance: Multiple abnormalities may be recorded.

Reason for No Echocardiography Common name: Reason for no Echo Definition: An explanation of why no echocardiogram was performed where it might be expected to be performed, e.g. when clinical guidelines recommend echo should be performed. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No reason No reason why Echo not performed 01 Contraindicated Generally acknowledged clinical contraindication to performing

Echo exists, e.g. physically incapable of performing the test 02 Not indicated No clinical indication for Echo 03 Clinical decision Clinical judgement of inappropriateness of Echo investigation in

an individual patient due to their specific set of circumstances 04 Not available Echo investigation not available 05 Not applicable 06 Patient declined Patient chose not to have Echo 99 Unknown Related data items: Echocardiography (Investigation)

Referral for Coronary Angiography


Definition: A record of referral for coronary angiography in another hospital. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No Not performed 01 Yes 02 Planned Includes ‘requested’ and ‘referred for’ 99 Not known

Date of Referral for Coronary Angiogram Definition: A record of the date a patient was referred for coronary angiogram Format: 10 characters (CCYY-MM-DD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known

Recording guidance: Valid date >1/1/2000 and <= today.

Coronary Angiography During This Admission {ACS} Definition: A record of whether or not coronary angiography investigation has been performed for delineation of coronary arterial blood-flow during this admission Format: 2 characters Codes and values: Code Value Explanatory Notes 00 Not performed 01 Protocol driven

investigation performed in this hospital

Clinician considers angiography necessary for management in the absence of continuing clinical symptoms.

02 Symptom driven investigation performed in this hospital

Angiography performed for continuing symptoms.

03 Protocol driven investigation performed at another hospital/centre

Clinician considers angiography necessary for management in the absence of continuing clinical symptoms.

04 Symptom driven investigation performed at another hospital/centre

Angiography performed for continuing symptoms.

05 Not indicated


06 Patient declined 99 Not known

Date of Coronary Angiogram Definition: A record of the date when a coronary angiogram was performed. Format: 10 characters (CCYY-MM-DD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known



INTERVENTIONS DURING ADMISSION Data Items Data Item Definition Format Referral for Revascularisation

A record of whether an individual has been referred for revascularistion.

2 characters

Date of Referral for Revascularisation

The date on which a referral for angiography and possible intervention was made, either locally or to another centre.


Revascularisation {ACS} A record of whether the individual has had a revascularistion procedure.

2 characters

Date of Revascularisation

The date on which an individual received revascularization treatment.


Referral for Revascularisation Definition: A record of whether an individual has been referred for revascularisation. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No Referral for revascularisation at another hospital 01 Yes 02 Planned Only use this option when firm arrangements are in place

before discharge. 99 Unknown

Date of Referral for Revascularisation Definition: The date on which a referral for angiography and possible intervention was made, either locally or to another centre. Format: 10 characters (CCYY-MM-DD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known



Revascularisation {ACS} Definition: A record of whether the individual has had a revascularistion procedure. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 Not performed 01 PCI 02 CABG 99 Not known Further Information: Procedure for recurrent symptoms or as an elective procedure.

Date of Revascularization Definition: The date on which an individual received revascularization treatment. Format: 10 characters (CCYY-MM-DD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known



COMPLICATIONS DURING ADMISSION Data Items Data Item Definition Format Heart Failure {ACS}

A record of whether heart failure was documented during this episode

2 characters

Angina {ACS}

A record of whether angina was documented during this episode

2 characters

Reinfarction A record of whether the patient had a subsequent infarction during this episode

2 characters

Cardiac Arrest

A record of whether the patient had a cardiac arrest during this episode.

2 characters

Date/ Time of 1st Cardiac Arrest

A record of the date and time of the patient's first cardiac arrest.


Outcome of 1st Cardiac Arrest

A record of the result of the patient’s cardiac arrest

2 characters

Heart Failure {ACS} Definition: A record of whether heart failure was documented during this episode. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further Information: Heart failure documented during admission, Evidence of oscultatory Rales or raised JVP or CXR evidence of congestion or pulmonary oedema.

Angina {ACS} Definition: A record of whether angina was documented during this episode Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further Information: Ongoing ischaemic cardiac pain despite optimum medical management. Includes post-MI angina and other acute coronary syndromes.


Reinfarction Definition: A record of whether the patient had a subsequent infarction during this episode Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further Information: Ischaemic pain or other symptoms consistent with acute cardiac ischaemia (e.g. sweating, nausea, hypotension) persisting until relieved by analgesia or nitrates, accompanied by new cardiographic changes (new ST elevation or depression or T wave changes in the territory of the initial event) These features must be accompanied by new elevation of CK or other acute marker of cardiac necrosis to more than the upper limit of normal or an increase to a value >= 50% greater than the last recorded value.

Cardiac Arrest Definition: A record of whether the patient had a cardiac arrest during this episode Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes 99 Not known Further information: Cardiac arrest is sudden cessation of cardiac function resulting in loss of effective circulation. FIRST verified arrest only to be reported. Excludes syncope or profound vagally-mediated bradycardia.

Date/ Time of 1st Cardiac Arrest Definition: A record of the date and time of the patient's first cardiac arrest. Format: 25 characters (CCYY-MM-DDThh:mmTZD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Not known


Further information: Date and time of FIRST verified arrest only to be reported. Enter date and time of death if resuscitation not attempted. Recording guidance: Valid date >1/1/2000 and <= today. Use 24 hour clock.

Outcome of 1st Cardiac Arrest Definition: A record of the result of the patient’s cardiac arrest Format: 2 characters Codes and values: Code Value Explanatory Notes 01 No return of circulation Failed resuscitation. 02 Return of spontaneous

circulation but died in hospital

Return of a stable circulation with subsequent death in hospital.

03 Discharged from hospital (with neurological deficit)

04 Discharged from hospital (no neurological deficit)

05 Resuscitation not attempted

This will be a decision normally made in advance of the arrest.

06 Transferred to another hospital

99 Not known Further information: Applies only to outcome of the FIRST arrest. This should include arrests in which resuscitation was deemed to be inappropriate. Please enter the fact that resuscitation was not attempted for whatever reason (such as severe co-morbidity). If further arrests occur the outcome will be recorded in 'Death in hospital'.


CARDIAC REHABILITATION Data Items Data Item Definition Format Referral to Cardiac Rehabilitation Service

A record of whether or not the individual was referred to a cardiac rehabilitation specialist or service.

2 characters

Date of Referral to Cardiac Rehabilitation Service

A record of the date on which a patient was referred to cardiac rehabilitation specialist or service.


Reason for no Referral to Cardiac Rehabilitation Service

An explanation for not referring an individual to cardiac rehabilitation specialist or service as part of ongoing management of ischaemic heart disease.

2 characters

Referral to Cardiac Rehabilitation Service Common name: Referral to Cardiac Rehab Definition: Record of whether or not the individual was referred to a cardiac rehabilitation specialist or service. Format: 2 characters Codes and values: Code Value 00 No 01 Yes 99 Not known

Related data items: Reason for No Referral to Cardiac Rehabilitation Further information: This refers to referral made to cardiac rehabilitation specialist or service as part of the ongoing management of ischaemic heart disease.

Date of Referral to Cardiac Rehabilitation Service Definition: A record of the date on which a patient was referred to cardiac rehabilitation specialist or service. Format: 10 characters (CCYY-MM-DD) Codes and values: N/A Sub data item: Verification Level


Code Value Level 0 Actual Level 1 Estimated Level 2 Not known


Reason for No Referral to Cardiac Rehabilitation Common name: Reason for No Referral to Cardiac Rehab Definition: An explanation for why no referral was made to a cardiac rehabilitation specialist or service. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No reason No reason why cardiac rehab referral not made 01 Contraindicated Generally acknowledged clinical contraindication to

cardiac rehab exists e.g. severe co-morbidity 02 Not indicated No clinical indication for cardiac rehab 03 Clinical decision Clinical judgement of inappropriateness of cardiac rehab

in an individual patient due to their specific set of circumstances

04 Not available Cardiac rehab not available 05 Not applicable 06 Patient declined Patient chose not to have cardiac rehab 99 Unknown Related data items: Referral to Cardiac Rehabilitation Service


DISCHARGE DETAILS Data Items Data Item Definition Format Discharge Date {ACS} A record of the date that the

patient was discharged from hospital


Discharge Diagnosis {ACS}

A record of the patient's discharge diagnosis.

2 characters

Discharged on Aspirin / other Antiplatelet

A record of whether a patient is on aspirin when discharged from hospital

2 characters

Discharged on Warfarin A record of whether a patient is on warfarin when discharged from hospital

2 characters

Discharged on Clopidogrel

A record of whether a patient is on clopidogrel when discharged from hospital

2 characters

Discharged on Beta Blocker

A record of whether a patient is on oral beta adrenergic blocker treatment when discharged from hospital

2 characters

Discharged on Angiotensin Inhibitor

A record of whether a patient is on angiotensin converting enzyme inhibitor or angiotensin receptor blocker when discharged from hospital

2 characters

Discharged on Statin A record of whether a patient is on statin when discharged from hospital

2 characters

Discharge Destination {ACS}

A record of the patient's discharge destination

2 characters

Discharge / transfer to - location

A record of the location to where the patient is discharged

Cause of Death in Hospital {ACS}

A record of the cause of death during this admission

2 characters

Person Death Date G The date on which a person died or is officially deemed to have died, as recorded on the Death Certificate


Episode Sign Off A record of the user list

Discharge Date {ACS} Definition: A record of the date that the patient was discharged from hospital Format: 10 characters (CCYY-MM-DD) G The above data items have already been approved and are available in the Health & Social Care Data Dictionary.


Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known


Discharge Diagnosis {ACS} Definition: A record of the patient's discharge diagnosis Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Myocardial infarction

(ST elevation) There will normally be a history consistent with the diagnosis. The diagnosis requires the presence of cardiographic changes of ST elevation consistent with infarction of =>2mm in contiguous chest leads and/or ST elevation of =>1 mm ST elevation in 2 or more standard leads in the opinion of the clinician treating the patient. (New LBBB is included). There will be enzyme or troponin elevation. Where CK is used the peak value should exceed twice the upper limit of the reference range. Where troponin assay is used the locally accepted cut off value should be used. (See Threatened MI) This group includes all patients with STE AMI regardless of whether typical changes were evident on the admission ECG or developed subsequently.

02 Myocardial infarction (non ST elevation)

There will be a history consistent with the diagnosis. There will be cardiographic changes consistent with the diagnosis. These may include new ST or T wave changes (except ST elevation). There will be cardiac enzyme or troponin elevation. Where CK is used the peak value should exceed twice the upper limit of the reference range. Where a troponin assay is used the locally accepted cut off values should be used. This group includes infarctions otherwise known as non Q wave, subendocardial and partial thickness infarction.

03 Myocardial infarction (unconfirmed)

Exceptions must be made for patients who die before enzyme release can occur or samples taken. Clinical judgement, preferably with additional evidence of a history of chest pain or


cardiographic changes, has to be made. If in doubt a diagnosis of Myocardial infarction (unconfirmed) should be recorded. This definition can ONLY apply to patients who die in hospital.

04 Threatened MI After early reperfusion treatment there may be rapid resolution of existing ST elevation associated with a CK rise less than twice the upper limit of normal or a small troponin release. If only troponin has been measured and is elevated, it is a local decision whether this is recorded as 'Definite infarction' or 'Threatened infarction'.

05 Acute coronary syndrome (troponin positive)

Symptoms consistent with cardiac ischaemia with release of troponin. The distinction between non ST elevation infarction and an acute coronary syndrome will depend on locally applied definitions. Use this term when troponin is elevated above the minimum detectable level and less than the locally accepted cut off for AMI or when troponin is elevated with a CK value less than 2x upper limit of normal for your hospital. Synonym unstable angina (troponin positive).

06 Acute coronary syndrome (troponin negative)

Use where there are symptoms consistent with cardiac ischaemia without troponin release. There must be dynamic ECG changes consistent with fluctuating ischaemia. Synonym unstable angina (troponin negative).

07 Acute coronary syndrome (troponin unspecified)

A diagnostic group for hospitals that do not yet have troponin estimations, or where a troponin value is not available although the diagnosis is secure on other criteria

08 Chest pain of uncertain cause

Use in any patient admitted with chest pain not accompanied by significant cardiographic change or enzyme / troponin release, and where no other clear diagnosis emerges. It is likely that at admission there was a high index of clinical suspicion that the pain was cardiac, but this remains unconfirmed.

98 Other Use where a patient is admitted with clinical suspicion of cardiac pain and where any diagnosis other than cardiac ischaemia is confirmed.

Note: This standard will be updated when a new definition of Acute Coronary Syndrome is available.

Discharged on Aspirin / other Antiplatelet Definition: A record of whether a patient is on aspirin when discharged from hospital Format: 2 characters


Codes and values: Code Value Explanatory Notes 00 No 01 Yes If patient was on drug at admission and treatment was

continued while in hospital 02 Contraindicated 03 Not indicated 04 Not tolerated 05 Patient declined 99 Not known If patient is transferred for investigation/intervention.

Patients transferred are not included in analysis of use of secondary prevention drugs.

Discharged on Warfarin Definition: A record of whether a patient is on warfarin when discharged from hospital Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes If patient was on drug at admission and treatment was



Discharged on Clopidogrel Definition: A record of whether a patient is on clopidogrel when discharged from hospital Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes If patient was on drug at admission and treatment was




Discharged on Beta Blocker Definition: A record of whether a patient is on oral beta adrenergic blocker treatment when discharged from hospital. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes If patient was on drug at admission and treatment was



Discharged on Angiotensin Inhibitor Definition: A record of whether a patient is on angiotensin converting enzyme inhibitor or angiotensin receptor blocker.when discharged from hospital. Format: 2 characters Codes and values: Code Value Explanatory Notes 00 No 01 Yes If patient was on drug at admission and treatment was



Discharged on Statin Definition: A record of whether a patient is on statin when discharged from hospital. Format: 2 characters Codes and values:


Code Value Explanatory Notes 00 No 01 Yes If patient was on drug at admission and treatment was



Discharge Destination {ACS} Definition: A record of the patient's discharge destination Format: 2 characters Codes and values: Code Value Explanatory Notes 01 Home Includes nursing home if that is patient's place

of residence 02 Other specialty in same

hospital Where a patient is transferred to another specialty for a specific reason, such as rehabilitation following a CVA, or nephrologists for dialysis. It does NOT include a transfer from cardiologists to general physicians to continue care of the original event before discharge

03 Other hospital 04 Nursing Home If for convalescence only 05 Death 98 Other 99 Not known

Discharge / transfer to - location Definition: A record of the location to where the patient is discharged Format: Codes and values: A valid location code Further information: A location is any building or set of buildings where events pertinent to the NHSSCOTLAND take place. Locations include hospitals, health centres, GP surgeries, clinics, NHS board offices, nursing homes, schools and patients/clients’ home. This is only relevant for those patients who are admitted/transferred directly to another NHS location for inpatient angiography with a view to revascularisation. This is not relevant for those patients admitted from home.


Cause of Death in Hospital {ACS} Definition: A record of the cause of death during this admission Format: 2 characters Codes and values: Code Value Explanatory Notes 01 From MI From all causes attributable to index event;

whether due to VF, or cardiogenic shock. 02 From complication of

treatment Death from haemorrhagic stroke or other bleed as a result of treatment.

03 Other non cardiac related cause

04 Other cardiac related cause

Death due to heart failure or arrhythmia etc where there was NO acute coronary event leading to this admission or during this admission but where the patient was logged in database

99 Not known

Person Death Date Definition: A record of the date on which a person died or is officially deemed to have died, as recorded on the Death Certificate Format: 10 characters (CCYY-MM-DD) Codes and values: N/A Sub data item: Verification Level Code Value Level 0 Actual Level 1 Estimated Level 2 Date not required Level 3 Not known


Episode Sign Off Definition: A record of the user list Format: Codes and values: N/A Further Information: The user list records users registered for clinical management of patient.

acute coronary syndrome acs dataset - ndc.scot.nhs.uk coronary syndrome (acs) dataset.pdf ·...

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