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. 2014 Sep 15;14:391. doi: 10.1186/1472-6963-14-391

Table 2.

Description of data elements collection in abstraction tool

Demographic information
Diagnosis at admission (STEMI, NSTEMI, unstable angina), arrival setting (home or facility, etc.), primary language
Presenting symptoms, initial vital signs and tests
Presentation of chest pain, cognitive status
Vitals at admission - pulse, systolic blood pressure, diastolic blood pressure, Respiration, temperature, weight and height
Lab tests - LDL, HDL, HA1c, ALT, AST, Serum creatinine, cardiac troponin level, CK-MB, LVEF, ProBNP\BNP
ECG findings (left/right ventricular hypertrophy, complete bundle branch block, heart block, AF, other arrhythmia) and Chest x-ray findings
Prior history – conditions, procedures, hospitalizations, and status immediately prior to AMI admission
Cardiac conditions and procedures (prior AMI, angina, atrial fibrillation [AF], hypertension, and heart failure [HF]; prior PTCA, coronary artery bypass graft [CABG], stent, or pacemaker,)
Non-cardiac condition (liver disease, diabetes, transient ischemic attack [TIA], stroke, chronic kidney disease [CKD], COPD, asthma, dyslipidemia, and tumor)
Other history (past/current smoking, drug use, difficulty with activities of daily living and other indicators of mobility limitations and frailty, drug allergies)
Medication use - prior to admission and in-hospital
Thrombolytic use, aspirin, clopidogrel/ticlopidine, beta blockers, ACE inhibitors, ARBs, statins, calcium channel blockers, loop diuretic, thiazide diuretics, aldosterone antagonists, digoxin, amiodarone, warfarin, heparin, and other lipid-lowing agents
In-hospital procedures or complications
Procedures - coronary angiography and findings, coronary angioplasty, stent placement, echocardiography, and stress test
Complications – HF, hypotension, cardiogenic shock, renal failure, major bleed, stroke, pneumonia, sepsis, and pulmonary embolism
In-hospital labs and test results, and results prior to discharge
Lab tests (as above), ECG, chest x-ray, stress test, echocardiogram, blood pressure
Discharge instructions including prescribed medications.
Cardiovascular-related discharge medications (as above) discharge disposition – to home, skilled nursing, home health, etc.