Table 2

History and Risk Factor Data Elements and Definitions

Element NameElement Definition
Prior anginaHistory 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 weekAverage 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 wkTotal 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:

  • • Yes

  • • No

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:

  • • Detection of the rise and/or fall of cardiac biomarkers (preferably cTn) with at least 1 value above the 99th percentile and with at least 1 of the following:

  •  - Symptoms of ischemia

  •  - New or presumed new significant ST-T changes or new LBBB

  •  - Development of pathological Q waves on the ECG

  •  - Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.

  •  - Identification of an intracoronary thrombus by angiography or autopsy

  • • Cardiac death with symptoms suggestive of myocardial ischemia and presumed new ischemic electrocardiographic changes or new LBBB, but death occurred before cardiac biomarkers were obtained or before cardiac biomarker values would be increased.

  • • PCI-related MI is arbitrarily defined by elevation of cTn values (>5 times the 99th percentile URL) in patients with normal baseline values (≤99th percentile URL) or a rise in cTn values ≥20% if baseline values are elevated and stable or falling; in addition, either symptoms suggestive of myocardial ischemia OR NEW ISCHEmic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium or new regional wall motion abnormality.

  • • Stent thrombosis associated with MI when detected by coronary angiography or autopsy in the setting of myocardial ischemia and with a rise and/or fall of cardiac biomarker values with at least 1 value >99th percentile URL.

  • • CABG-related MI is arbitrarily defined by elevation of cardiac biomarker values (>10 times the 99th percentile URL) in patients with normal baseline cTn values (≤99th percentile URL) plus either new pathological Q waves or new LBBB, or angiographically documented new graft or new native coronary artery occlusion, or imaging evidence of new loss of viable myocardium.

  • • The 99th percentile is observed after the procedure in conjunction with symptoms suggestive of myocardial ischemia or new ischemic electrocardiographic changes or angiographic findings consistent with a procedural complication or imaging demonstration of new loss of viable myocardium or in patients with a preprocedure elevated biomarker that is stable or falling, a rise of biomarker values ≥20% in conjunction with the PCI-related criteria stated above.

  • A prior MI can also be documented if the patient has any 1 of the following criteria that meets the diagnosis for prior MI:

  • • Pathological Q waves with or without symptoms in the absence of nonischemic causes

  • • Imaging evidence of a region of loss of viable myocardium that is thinned and fails to contract, in the absence of a nonischemic cause

  • • Pathological findings of a 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:

  • • Class I: patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea.

  • • Class II: patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, or dyspnea.

  • • Class III: patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnea.

  • • Class IV: patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms are present even at rest or minimal exertion. If any physical activity is undertaken, discomfort is increased.

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:

  • • None

  • • Balloon angioplasty

  • • Bare metal stent

  • • Drug-eluting stent

  • • Other

  • Note: Timeframe does NOT include the current admission.

Date of prior PCIIf 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 CABGIf 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:

  • • Ischemic stroke: an acute episode of focal, cerebral, spinal, or retinal dysfunction caused by infarction of the central nervous system tissue

  • • TIA: transient episode of neurological dysfunction caused by focal or global brain, spinal cord, or retinal ischemia without acute infarction

  • • Noninvasive or invasive arterial imaging test demonstrating ≥50% stenosis of any of the major extracranial or intracranial vessels to the brain

  • • Previous cervical or cerebral artery revascularization surgery or percutaneous intervention

  • 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:

  • • Ischemic stroke

  • • Intracerebral hemorrhage

  • • Subarachnoid hemorrhage

  • • Unknown type

  • If ischemic, list the most likely etiologies:

  • • Large artery atherosclerosis of the extracranial vessels (e.g., carotid)

  • • Large artery atherosclerosis of the intracranial vessels (e.g., middle cerebral artery stenosis)

  • • Cardioembolism

  • • Small vessel occlusion (lacunar)

  • • Ischemic stroke of other determined etiology (e.g., arterial dissection)

  • • Ischemic stroke of undetermined etiology

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

  • • Claudication on exertion that is relieved by rest

  • • Amputation for severe arterial vascular insufficiency

  • • Vascular reconstruction, bypass surgery, or percutaneous revascularization in the arteries of the lower and upper extremities

  • • Positive noninvasive test (e.g., ankle brachial index ≤0.9, ultrasound, MR imaging or CT scanning of >50% diameter stenosis in any peripheral artery [i.e., subclavian, femoral, iliac]) or angiographic imaging

Aorta diseaseCurrent or previous history of disease of the thoracic, thoracoabdominal, or abdominal aorta (typically aneurysm)
Renal artery diseaseCurrent 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:

  • • None

  • • ≤1 alcoholic drink per week

  • • 2–7 alcoholic drinks per week

  • • ≥8 alcoholic drinks per week

  • Specify alcohol dependency history. Choose all that apply:

  • • Documented alcohol dependency

  • • Medical sequelae of alcohol consumption (alcoholic hepatitis, cirrhosis, alcohol neuropathy, Wernicke-Korsakoff syndrome)

  • • Treatment for alcohol dependency

  • 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:

  • • Yes

  • • No

  • • Unknown

  • • N/A

DepressionCurrent or previous diagnosis of depression or documentation of a depressed mood or affect
Diabetes
  • History of diabetes diagnosed and/or treated by a healthcare provider. The American Diabetes Association criteria (33) include documentation of the following:

  • 1. Hemoglobin A1c ≥6.5%; or

  • 2. Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L); or

  • 3. 2-h Plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test; or

  • 4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L)

  • 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

  • • Insulin: insulin treatment (includes any combination with insulin)

  • • Other subcutaneous medications (e.g., GLP-1 agonist)

  • • Oral: treatment with oral agent (includes oral agent with or without diet treatment)

  • • Diet only: Treatment with diet only

  • • None: no treatment for diabetes

  • • Other: other adjunctive treatment, non-oral/insulin/diet

Hypertension
  • Indicate if the patient has a current diagnosis of hypertension defined by any 1 of the following:

  • • History of hypertension diagnosed and treated with medication, diet, and/or exercise

  • • Prior documentation of blood pressure ≥140 mm Hg systolic and/or 90 mm Hg diastolic for patients without diabetes or chronic kidney disease, or prior documentation of blood pressure ≥130 mm Hg systolic or 80 mm Hg diastolic on at least 2 occasions for patients with diabetes or chronic kidney disease

  • • Currently undergoing pharmacological therapy for treatment of hypertension

Tobacco use (34)
  • Current or previous use of any tobacco product, including cigarettes, cigars, pipes, and chewing tobacco, captured as smoking status:

  • • Current everyday smoker

  • • Current some day smoker

  • • Former smoker

  • • Never smoker

  • • Smoker, current status unknown

Illicit drug useDocumented 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:

  • • Total cholesterol >200 mg/dL (5.18 mmol/L); or

  • • LDL ≥130 mg/dL (3.37 mmol/L);

  • • HDL <40 mg/dL (1.04 mmol/L) in men and <50 mg/dL (1.30 mmol/L) in women;

  • • Currently receiving antilipidemic treatment

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:

  • • Angina

  • • Acute MI

  • • Sudden cardiac death without obvious cause

  • • CABG surgery

  • • PCI

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 immunizationIndicate if the patient has a history of influenza immunization. The month and year of the most recent immunization should be noted.
History of pneumococcal immunizationIndicate if the patient has a history of pneumococcal immunization. The month and year of the most recent immunization should be noted.
Current dialysisIndicate 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):

  • • Class I: ordinary physical activity, such as walking or climbing stairs, does not cause angina. Angina occurs with strenuous, rapid, or prolonged exertion at work or recreation.

  • • Class II: slight limitation of ordinary activity. Angina occurs on walking or climbing stairs rapidly, walking uphill, walking or climbing stairs after meals, or in cold, in wind, or under emotional stress, or only during the few hours after awakening. Angina occurs on walking >2 blocks on the level and climbing >1 flight of ordinary stairs at a normal pace and in normal conditions.

  • • Class III: marked limitation of ordinary physical activity. Angina occurs on walking 1 to 2 blocks on the level and climbing 1 flight of stairs in normal conditions and at a normal pace.

  • • Class IV: inability to perform any physical activity without discomfort—angina symptoms may be present at rest.

Amount of sublingual nitroglycerin consumedRecord 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.