Table 2.
Element Name | Element Definition |
---|---|
Prior angina | History of angina before the current admission. “Angina” refers to evidence or knowledge of symptoms before this acute event described as chest pain or pressure, jaw pain, arm pain, or other equivalent discomfort suggestive of cardiac ischemia. Indicate if angina existed >2 wk before admission and/or within 2 wk before admission. |
Average number of episodes of angina in the prior week | Average number of distinct episodes of anginal pain that occurred in the last week before hospital admission or this visit |
Number of angina episodes in the prior 6 wk | Total number of distinct episodes of anginal pain that occurred in the last 6 wks before hospital admission or visit should be recorded. Duration of each episode and requirement for sublingual nitroglycerin are also documented. |
Intermittent claudication | History of claudication that typically
presents as exertional fatigue, cramping, or aching in the muscles of
the legs that is reproducible and resolves promptly with rest. Choose 1
of the following:
|
Prior MI | Indicate if the patient has had at least one
documented previous myocardial infarction. Any occurrence between birth
and arrival at first facility. The term acute MI should
be used when there is evidence of myocardial necrosis in a clinical
setting consistent with myocardial ischemia. Under these conditions, any
1 of the following criteria meets the diagnosis for MI:
|
A prior MI can also be documented if the
patient has any 1 of the following criteria that meets the diagnosis for
prior MI:
| |
Previous history of heart failure | Indicate if there is a previous history of heart failure before this care encounter. A previous hospital admission with the principal diagnosis of heart failure is considered evidence of a history 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 distention, pulmonary edema on physical examination, or pulmonary edema on chest x-ray. A low ejection fraction without clinical evidence of heart failure does not qualify as heart failure. | |
NYHA functional class | If heart failure is present, indicate the NYHA functional class. |
Choose 1 of the following:
| |
Prior PCI | Indicate if the patient had a previous PCI (even if unsuccessful) of any type (balloon angioplasty, stent, or other), performed before the current admission. |
Check all that apply:
| |
Note: Timeframe does NOT include the current admission. | |
Date of prior PCI | If the patient had a previous PCI of any type (balloon angioplasty, stent, or other) performed before the current admission, indicate the date of the most recent PCI. If month or day is unknown, year is sufficient. |
Prior CABG | Indicate whether the patient had a previous CABG surgery before the current admission. |
Note: Timeframe does NOT include the current admission. | |
Date of prior CABG | If the patient had a previous CABG before the current admission, indicate the date of the most recent CABG. If month or day is unknown, year is sufficient. |
Prior catheterization with stenosis ≥50% | The patient has documented CAD at coronary angiography at any time before the current admission, with at least a 50% stenosis in the diameter of a major coronary artery. If the patient had a cardiac catheterization before the index event that demonstrated a stenosis of 90% that was successfully stented to a 0% residual, this should be coded as “yes,” because a stenosis ≥50% diameter was documented. |
Cerebral artery disease | Current or previous history of any of the
following:
|
This does not include chronic (nonvascular) neurological diseases or other acute neurological insults such as metabolic and anoxic ischemic encephalopathy. | |
Prior stroke | Indicate whether the patient has a history of stroke, which is defined as an acute episode of neurological dysfunction caused by focal or global brain, spinal cord, or retinal vascular injury as a result of hemorrhage or infarction. |
If present, record type of stroke:
| |
If ischemic, list the most likely etiologies:
| |
PAD | Current or previous history of PAD (includes
lower extremity from iliac to tibials and upper extremity with
subclavian and brachials. Excludes renal, coronary, cerebral, and
mesenteric vessels and aneurysms.) This can include
|
Aorta disease | Current or previous history of disease of the thoracic, thoracoabdominal, or abdominal aorta (typically aneurysm) |
Renal artery disease | Current or previous history of disease of the main renal arteries or extrarenal branches |
History of alcohol consumption/dependency | Specify alcohol consumption history. Choose
from the following categories:
|
Specify alcohol dependency history. Choose all
that apply:
| |
For patients with alcohol dependency, note treatment for dependency, cessation of use, or continued use. | |
Erectile dysfunction | Indicate if the patient has a history of erectile dysfunction. |
Choose 1 of the following:
| |
Depression Diabetes | Current or previous diagnosis of depression or documentation of a depressed mood or affect |
History of diabetes diagnosed and/or treated
by a healthcare provider. The American Diabetes Association criteria
(33) include documentation of
the following:
| |
This does not include gestational diabetes. | |
Diabetes control | Indicate the patient’s diabetes control method as presented on admission. Patients placed on a preprocedure diabetic pathway of insulin drip at admission but whose diabetes was controlled by diet or oral methods are not coded as being treated with insulin. |
Choose the most aggressive therapy from the
order below
| |
Hypertension | Indicate if the patient has a current
diagnosis of hypertension defined by any 1 of the following:
|
Tobacco use (34) | Current or previous use of any tobacco
product, including cigarettes, cigars, pipes, and chewing tobacco,
captured as smoking status:
|
Illicit drug use | Documented history of current, recent, or remote abuse of any illicit drug (e.g., cocaine, methamphetamine, marijuana) or controlled substance. |
Dyslipidemia | Indicate if the patient has a history of
dyslipidemia that was diagnosed and/or treated by a physician. NCEP
criteria include documentation of the following:
|
Family history of premature CAD | Indicate if the patient has any direct blood
relatives (parents, siblings, children) who have had any of the
following at age <55 y for male relatives or <65 y for
female relatives:
|
Previous implantation of a pacemaker or ICD | Indicate if the patient had a pacemaker or ICD implanted before the current encounter. Information about the type of device (pacemaker, biventricular/resynchronization/CRT, ICD, combination), cardiac chamber(s) involved, and year of implantation may be helpful. |
Prior atrial fibrillation or flutter | Indicate whether atrial fibrillation or flutter is present within 2 wk before admission. |
Whether or not the patient is currently experiencing atrial fibrillation or flutter should also be noted. | |
History of influenza immunization | Indicate if the patient has a history of influenza immunization. The month and year of the most recent immunization should be noted. |
History of pneumococcal immunization | Indicate if the patient has a history of pneumococcal immunization. The month and year of the most recent immunization should be noted. |
Current dialysis | Indicate if the patient currently requires dialysis treatment, including hemodialysis or peritoneal dialysis. |
Angina grade | Indicate grade symptoms or signs in patients
with suspected or presumed stable angina (or anginal equivalent)
according to the CCS grading scale (35):
|
Angina occurs on walking >2 blocks on
the level and climbing >1 flight of ordinary stairs at a normal
pace and in normal conditions.
| |
Amount of sublingual nitroglycerin consumed | Record the number of sublingual nitroglycerin tablets or spray used each week for symptomatic episodes. Record prophylactic usage also. Average the total number of sublingual uses over the 6-wk interval and record the weekly range. |
CABG indicates coronary artery bypass graft; CAD, coronary artery disease; CCC, Canadian Cardiovascular Society; cTn, cardiac troponins; CRT, cardiac resynchronization therapy; CT, computed tomography; ECG, electrocardiogram; GLP-1, glucagon peptide-like-1; HDL, high-density lipoprotein; ICD, implantable cardioverter-defibrillator; LBBB, left bundle-branch block; LDL, low-density lipoprotein; MI, myocardial infarction; MR, magnetic resonance; N/A, not available; NCEP, National Cholesterol Education Program; NYHA, New York Heart Association; PAD, peripheral artery disease; PCI, percutaneous coronary intervention; TIA, transient ischemic attack; and URL, upper reference limit.