Submitter DataSubmitter Name * Submitter Email * Submitter Mobile * Hospital Name * Patient DataPatient Name * ID card Number * Patient Tel * Dossier no. in the hospital * Sex *MF Age * Weight * Height * Past History * Yes NoHTNDMDyslipidemiaFamily history of CADSmokingThyroid dysfunctionCerebro vascular StrokePeripheral vascular diseaseAuto immune diseaseMalignancyBlood disorders Renal impairment *NoMildModerateSevere CAD NoYes CADPrevious PCI NoYes Previous CABG *NoYes Current medications Yes NoB blockerACE- inhibitorsARBsNitratesDiureticsAldosterone antagonistsStatins Other medications Previous investigations ECG Changes *NoYes T-wave changes (leads) IIIIIIIIIaVRaVLaVFV1V2V3V4V5V6 Q (leads) IIIIIIaVRaVLaVFV1V2V3V4V5V6 EchoDilated LV NoYes EF 10%15%20%25%30%35%40%45%50%55%60%65%70%75% MR NoMildModerateSevere Arrival To HospitalName of the Hospital * The onset of chest painDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM 1st Medical Contact (Time to Arrive to ER)Date Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM ECG to establish diagnosisDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Site AnteriorLateralInferiorPosteriorRight Ventricular Initial Medications * Yes NoAspirinHeparinLow Molecular Weight HeparinGlycoprotein IIb/IIIa inhibitorsStatinsClopidogrelTicagrelorB blockerACE- inhibitorsARBs Other Initial Medications Thrombolytic *NoYes Thrombolytic *StreptokinaseRTPA Referring Hospital *NoYes Referral Hospital DataName of Hospital * Date Medications * Yes No N/AStreptokinaseGlycoprotein IIb/IIIa inhibitorsHeparinLow molecular Weight HeparinAspirinClopidogrelTicagrelor 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 NowAdmission to Cath-Lab *NoYes Cause of not Admitting to Cath-Lab * Admission to Cath-LabDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Time to Wire less than 15 Minutes15 - 30 Minutes31 - 45 Minutes46 - 60 MinutesMore than 60 Minutes Exit from Cath-labDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM PCI procedurePTCA NoYes Largest balloon Diameter(mm) Apsiration *NoYes Stent NoYes Stent Type *BMSDESMixed Number * Procedure Outcome : TIMI 0IIIIII Dye usedType *IonizedNon-ionized Volume *50100150200250300350400450500 ComplicationsPerforation NoYes Degree * Thrombosis *NoYes Dissection *NoYes Death *NoYes Death *In the procedureWithin 24 hours Hospital Staying days number * Admission to CCU *NoYes Admission to CCUDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Thrombolytic therapy *StreptokinasertPANo Thrombolytic Criteria of reperfusion *NonRelieve painST resolution Duration in CCU * Complications * Yes NoPost infarction anginaRe-infarctionHFTachyarrhythmiaBradyarrhythmiaCerebrovascular strokeBleeding Other Complications Hospital Discharge Date * Time *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Admission to Cath-Lab... NoYes Cause of not Admitting to CCU * Admission to Cath-LabDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Time to Wire less than 15 Minutes15 - 30 Minutes31 - 45 Minutes46 - 60 MinutesMore than 60 Minutes Exit from Cath-lab Date Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM PCI procedure PTCA NoYes Largest balloon Diameter(mm) Apsiration *NoYes Stent NoYes Number * Procedure Outcome : TIMI 0IIIIII Dye used Type *IonizedNon-ionized Dye used Volume *50100150200250300350400450500 Exit from Cath-lab Complications Perforation NoYes Degree * Thrombosis *NoYes Dissection *NoYes Death... *NoYes Death *In the procedureWithin 24 hours Hospital Staying days number * PCI Capability not 24/7 and Cath. Lab. is Inactive NowReferred to 24/7 Hospital *YesNo Date Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Admission to CCUDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Thrombolytic Therapy *NoYes Thrombolytic therapy *StreptokinasertPA Criteria of reperfusion *NonRelieve painST resolution Duration in CCU * Complications * Yes NoPost infarction anginaRe-infarctionHFTachyarrhythmiaBradyarrhythmiaCerebrovascular strokeBleeding Other Complications Hospital Discharge Date * Time *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Admission to Cath-lab later on *NoYes Admission to Cath-labDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM PCI procedure PTCA *NoYes Largest balloon Diameter (mm) *1.51.511.521.531.541.551.561.571.581.591.61.611.621.631.641.651.661.671.681.691.71.711.721.731.741.751.761.771.781.791.81.811.821.831.841.851.861.871.881.891.91.911.921.931.941.951.961.971.981.9922.012.022.032.042.052.062.072.082.092.12.112.122.132.142.152.162.172.182.192.22.212.222.232.242.252.262.272.282.292.32.312.322.332.342.352.362.372.382.392.42.412.422.432.442.452.462.472.482.492.52.512.522.532.542.552.562.572.582.592.62.612.622.632.642.652.662.672.682.692.72.712.722.732.742.752.762.772.782.792.82.812.822.832.842.852.862.872.882.892.92.912.922.932.942.952.962.972.982.9933.013.023.033.043.053.063.073.083.093.13.113.123.133.143.153.163.173.183.193.23.213.223.233.243.253.263.273.283.293.33.313.323.333.343.353.363.373.383.393.43.413.423.433.443.453.463.473.483.493.53.513.523.533.543.553.563.573.583.593.63.613.623.633.643.653.663.673.683.693.73.713.723.733.743.753.763.773.783.793.83.813.823.833.843.853.863.873.883.893.93.913.923.933.943.953.963.973.983.9944.014.024.034.044.054.064.074.084.094.14.114.124.134.144.154.164.174.184.194.24.214.224.234.244.254.264.274.284.294.34.314.324.334.344.354.364.374.384.394.44.414.424.434.444.454.464.474.484.494.54.514.524.534.544.554.564.574.584.594.64.614.624.634.644.654.664.674.684.694.74.714.724.734.744.754.764.774.784.794.84.814.824.834.844.854.864.874.884.894.94.914.924.934.944.954.964.974.984.9955.015.025.035.045.055.065.075.085.095.15.115.125.135.145.155.165.175.185.195.25.215.225.235.245.255.265.275.285.295.35.315.325.335.345.355.365.375.385.395.45.415.425.435.445.455.465.475.485.495.55.515.525.535.545.555.565.575.585.595.65.615.625.635.645.655.665.675.685.695.75.715.725.735.745.755.765.775.785.795.85.815.825.835.845.855.865.875.885.895.95.915.925.935.945.955.965.975.985.996 Apsiration NoYes Stent NoYes Number * Outcome : TIMI *IIIIII Dye used Type IonizedNon-ionized Complications Perforation *NoYes Degree * Thrombosis *NoYes Flow *NoYes No reflow *NoYes Hospital Staying days number * Non-PCI CapabilityReferred to 24/7 Hospital YesNo Referred to 24/7 HospitalDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Admission to CCUDate Time 010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Thrombolytic *NoYes Thrombolytic therapy *StreptokinasertPA Criteria of reperfusion *NonRelieve painST resolution Duration in CCU * Complications * Yes NoPost infarction anginaRe-infarctionHFTachyarrhythmiaBradyarrhythmiaCerebrovascular strokeBleeding Other Complications Hospital Discharge Time *010203040506070809101112HH000510152025303540455055MMAMPMAM/PM Date * Sent to PCI Capability hospital NoYes Text Text Text Last stepPlease enter any two Numbers *Example: 48This box is for spam protection - please leave it blank