SSL-Case-STEMI – ICOM Forms Manager

Submitter Data

Submitter Name *
Submitter Email *
Submitter Mobile *
Hospital Name *

Patient Data

Patient Name *
ID card Number *
Patient Tel *
Dossier no. in the hospital *
Sex *
Age *
Weight *
Height *
Past History *
Yes No
HTN
DM
Dyslipidemia
Family history of CAD
Smoking
Thyroid dysfunction
Cerebro vascular Stroke
Peripheral vascular disease
Auto immune disease
Malignancy
Blood disorders
Renal impairment *
CAD

CAD

Previous PCI

Previous CABG *

Current medications

Other medications

Previous investigations

ECG Changes *

Echo

Dilated LV

Arrival To Hospital

Name of the Hospital *

The onset of chest pain

Date

Time HHMMAM/PM

1st Medical Contact (Time to Arrive to ER)

Date

Time HHMMAM/PM

ECG to establish diagnosis

Date

Time HHMMAM/PM

Site

AnteriorLateralInferiorPosteriorRight Ventricular

Initial Medications *
Yes No
Aspirin
Heparin
Low Molecular Weight Heparin
Glycoprotein IIb/IIIa inhibitors
Statins
Clopidogrel
Ticagrelor
B blocker
ACE- inhibitors
ARBs
Other Initial Medications
Thrombolytic *
Thrombolytic *
Referring Hospital *

Referral Hospital Data

Name of Hospital *

Date

Medications *

Other Medications

Facilities of the hospital *
PCI Capability 24/7PCI Capability not 24/7 but Cath. Lab. is Active NowPCI Capability not 24/7 and Cath. Lab. is Inactive NowNon PCI Capability

PCI Capability 24/7 / PCI Capability not 24/7 but Cath. Lab. is Active Now

Admission to Cath-Lab *
Cause of not Admitting to Cath-Lab *

Admission to Cath-Lab

Date

Time HHMMAM/PM

Exit from Cath-lab

Date

Time HHMMAM/PM

PCI procedure

PTCA

Largest balloon Diameter(mm)

Apsiration *

Stent

Stent Type *

Number *

Procedure Outcome : TIMI

Dye used

Type *

Volume *

Complications

Perforation

Degree *

Thrombosis *

Dissection *

Death *

Hospital Staying days number *

Admission to CCU *

Admission to CCU

Date

Time HHMMAM/PM

Thrombolytic therapy *

Criteria of reperfusion *

Duration in CCU *

Complications *

Other Complications

Hospital Discharge

Date *

Time *HHMMAM/PM

Admission to Cath-Lab...

NoYes

Cause of not Admitting to CCU *

Admission to Cath-Lab

Date

Time HHMMAM/PM

Time to Wire

less than 15 Minutes15 - 30 Minutes31 - 45 Minutes46 - 60 MinutesMore than 60 Minutes

Exit from Cath-lab

Date

Time HHMMAM/PM

PCI procedure

PTCA

Largest balloon Diameter(mm)

Apsiration *

Stent

Number *

Procedure Outcome : TIMI

Dye used Type *

Dye used Volume *

Exit from Cath-lab

Complications Perforation

Degree *

Thrombosis *

Dissection *

Death... *

Death *

Hospital Staying days number *

PCI Capability not 24/7 and Cath. Lab. is Inactive Now

Referred to 24/7 Hospital *
YesNo

Date

Time HHMMAM/PM

Admission to CCU

Date

Time HHMMAM/PM

Thrombolytic Therapy *

Thrombolytic therapy *

Criteria of reperfusion *

Duration in CCU *

Complications *

Other Complications

Hospital Discharge

Date *

Time *HHMMAM/PM

Admission to Cath-lab later on *

Admission to Cath-lab

Date

Time HHMMAM/PM

PCI procedure

PTCA *

Largest balloon Diameter (mm) *

Apsiration

Stent

Number *

Outcome : TIMI *

Dye used

Type

Complications

Perforation *

Degree *

Thrombosis *

Flow *

No reflow *

Hospital Staying days number *

Non-PCI Capability

Referred to 24/7 Hospital
YesNo

Referred to 24/7 Hospital

Date

Time HHMMAM/PM

Admission to CCU

Date

Time HHMMAM/PM

Thrombolytic *

Thrombolytic therapy *

Criteria of reperfusion *

Duration in CCU *

Complications *

Other Complications

Hospital Discharge

Time *HHMMAM/PM

Date *

Sent to PCI Capability hospital

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	Yes	No
Post infarction angina
Re-infarction
HF
Tachyarrhythmia
Bradyarrhythmia
Cerebrovascular stroke
Bleeding

	Yes	No
Post infarction angina
Re-infarction
HF
Tachyarrhythmia
Bradyarrhythmia
Cerebrovascular stroke
Bleeding

	Yes	No
Post infarction angina
Re-infarction
HF
Tachyarrhythmia
Bradyarrhythmia
Cerebrovascular stroke
Bleeding

	Yes	No
HTN
DM
Dyslipidemia
Family history of CAD
Smoking
Thyroid dysfunction
Cerebro vascular Stroke
Peripheral vascular disease
Auto immune disease
Malignancy
Blood disorders

	Yes	No
B blocker
ACE- inhibitors
ARBs
Nitrates
Diuretics
Aldosterone antagonists
Statins

	Yes	No
Aspirin
Heparin
Low Molecular Weight Heparin
Glycoprotein IIb/IIIa inhibitors
Statins
Clopidogrel
Ticagrelor
B blocker
ACE- inhibitors
ARBs

	Yes	No	N/A
Streptokinase
Glycoprotein IIb/IIIa inhibitors
Heparin
Low molecular Weight Heparin
Aspirin
Clopidogrel
Ticagrelor