Submitter DataSubmitter Name * Submitter Email * Submitter Mobile * Hospital/ Center Name * Patient DataPatient ID (Emirates ID or any official ID number) * Nationality * Race *CapoidMongoloidCaucasianNegroidAustralian Dossier no. in the hospital * Sex *MaleFemale Age * Weight in kg * Height in cm * Past HistoryHTN *YesNoNA Dyslipidemia *YesNoNA Family history of premature CAD (Male: before age of 50, Female: before age of 60) *YesNoNA Cerebro vascular Stroke *YesNoNA Peripheral vascular disease *YesNoNA Malignancy *YesNoNA Blood disorders *YesNoNA DM *YesNoNA DM *Insulin dependentNon Insulin dependent How long? * Smoking *YesNoNA Smoking CigaretteElectronic CigarettesShishaMedwakh how long? * Renal impairment *Moderate renal impairment GFR less than 60. Severe renal impairment GFR less than 30YesNoNA EGFR * CAD YesNoNA Please specify * Previous MI YesNoNA Please Specify * Previous PCI YesNoNA Please Specify * Previous CABG *YesNoNA Please specify * Is there any previous Medications *YesNoNA Current medications * Yes No NAB blockerACE- inhibitors – ARBs – ARNINitratesDiureticsAldosterone antagonistsStatinsPSCK9Aspirin – ADBInsulin – Oral AntidiabeticAntidiabetic Medication ECG Changes (Old) *YesNoNA Previous investigations Sinus RhythmAFLBBBRBBBLBBBPacingComplete Heart BlockST DepressionT inversionQ Waves Echo (Old) *YesNo ECHODilated LV YesNo EF Normal (Above 55%)Mild impairment (55% – 45%)Moderate impairment (45% – 30%)Severe Impairment (Less than 30%) MR NoMildModerateSevere RSWMA YesNo Please specify * THE ONSET OF MOST SEVERE CHEST PAINDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM 1ST MEDICAL CONTACT (TIME TO ARRIVE TO ER) *Hospital (ER)Primary Care CenterPrivate ClinicAmbulance ER *PCI equipped facilityNon PCI equipped facility Was patient transferred ? YesNo Date Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Thrombolytic needle time: 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Primary PCI wire: ECG TO ESTABLISH DIAGNOSIS OF STEMIDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Site of STEMI AnteriorLateralInferiorPosteriorRight Ventricular 1ST RESULT FOR CARDIAC ENZYMESDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Type of cardiac enzymes used: *TroponinHS TroponinCPKCKMB PositiveNegative Level of Cardiac Enzymes * 2ND RESULT FOR CARDIAC ENZYMESDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Level of Cardiac Enzymes * Vital signsBlood pressure: Heart rate: Chest: Echo pre-repurfusion: YesNo Please specify * Modality of reperfusion *ThrombolatyicPrimary PCIConcretive (Late presentation) Thrombolytic type *StreptokinaseRTPA TIME TO NEEDLE less than 15 Minutes15 – 30 Minutes31 – 45 Minutes46 – 60 Minutes60 – 90 Minutes90 – 120 MinutesMore than 120 Minutes Chest pain to needle time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Time of admission to cathlab *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Door to wire time *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Chest pain to wire time *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Angiographic findings: *single vessel disease2 vessel diseasemulti vessel disease EXIT FROM CATH-LABDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM PCI PROCEDUREPTCA YesNo Largest balloon Diameter(mm) Door to balloon 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Apsiration *YesNo Stent *YesNo Add number of stents *123 Procedure Outcome : TIMI 0IIIIII Treated Coronary vessels YesNo Admission Medications * Yes No NAAspirinHeparinLow Molecular Weight HeparinGlycoprotein IIb/IIIa inhibitorsStatinsClopidogrelTicagrelorB blockerACE- inhibitorsARBs Admission to CCU *YesNo DYE USEDType *IonizedNon-ionized Volume *50100150200250300350400450500 COMPLICATIONSComplications *YesNo Only infarction rated arteryOther vessels *No reflowDissectionLeathal arrithmiaThrombos migrationDeath Perforation YesNo Degree * Thrombosis *YesNo Dissection *YesNo Death *YesNo Admission to CCU *YesNo Hospital Staying days number * ADMISSION TO CCUDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Duration in CCU * Complications * Yes NoPost infarction anginaRe-infarctionHFTachyarrhythmiaBradyarrhythmiaCerebrovascular strokeBleeding Other Complications HOSPITAL DISCHARGEDeath during hospitalization *YesNo SectionDate * Time *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Cause * Cause of referral * REFERRAL HOSPITAL DATAName of Hospital * Date * Number * THERAPYPCI *YesNo Date * Number * Number of stents * Type of stents Thrombolytic *Yes HOSPITAL DISCHARGEDate * Number * Complications * Yes NoACSHFTachyarrhythmiaBradyarrhythmiaCerebrovascular StrokeBleeding Other Complications Death during hospitalization *YesNo Date * Time * Cause * VerificationPlease enter any two digitsExample: 12This box is for spam protection – please leave it blank