Table 1

History and Physical Examination Elements

Data FieldDefinitionValue DomainNotesSource
Current Status
Chest pain (angina) or anginal equivalentChest pain, other discomfort, dyspnea, or other sign or symptom possibly, probably, or definitely consistent with myocardial ischemia or infarction:
  •  • Noncardiac: signs/symptoms inconsistent with myocardial ischemia

  •  • Atypical: signs/symptoms possibly consistent with myocardial ischemia but not typical of classical angina pectoris (or anginal equivalent)

  •  • Stable angina: angina pectoris (or anginal equivalent) without a recent change in frequency or pattern. Angina is relieved by rest and/or sublingual/transdermal medications.

  •  • Variant (synonym: Prinzmetal angina, coronary vasospasm): angina pectoris (or anginal equivalent) that usually occurs spontaneously and, unlike typical angina, nearly always occurs at rest and does not require physical exertion. It is frequently associated with transient ST-segment elevation.

  •  • Unstable angina/NSTEMI: angina pectoris (or anginal equivalent) with any of the following features:

    •   – Symptoms at rest and prolonged, usually >20 min

    •   – New-onset symptoms of CCS grade III or grade IV severity

    •   – Recent acceleration of symptoms with an increase in severity of at least 1 CCS grade to CCS grade III or grade IV severity

    •   – Symptoms associated with positive biomarkers for myocardial necrosis but without ST elevation on ECG

    •  • Acute STEMI

  • Noncardiac

  • Atypical

  • Stable angina

  • Variant

  • Unstable angina/NSTEMI

  • Acute STEMI

  • [null]

ACCF/AHA Cardiac Imaging Data Standard (18)
Angina grade [CCS]To grade symptoms or signs in patients with suspected or presumed stable angina (or anginal equivalent) according to the CCS grading scale:
  •  • 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–anginal symptoms may be present at rest.

  • 1

  • 2

  • 3

  • 4

  • [null]

ACCF/AHA Acute Coronary Syndrome Data Standards (17), Campeau L. Letter: grading of angina pectoris. Circulation. 1976;54:522–3 (26).
Heart failure class [NYHA]To classify symptoms or signs in patients with suspected or presumed heart failure according to the NYHA classification scale:
  •  • Class I: without limitations of physical activity. Ordinary physical activity does not cause undue fatigue, palpitations, or dyspnea.

  •  • Class II: slight limitation of physical activity. The patient is comfortable at rest. Ordinary physical activity results in fatigue, palpitations, or dyspnea.

  •  • Class III: marked limitation of physical activity. The patient is comfortable at rest. Less than ordinary activity causes fatigue, palpitations, or dyspnea.

  •  • Class IV: inability to carry on any physical activity without discomfort. Heart failure symptoms are present even at rest or with minimal exertion.

  • 1

  • 2

  • 3

  • 4

  • [null]

The Criteria Committee of the New York Heart Association. In Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great Vessels. 9th ed. Boston, MA: Little, Brown & Co; 1994:253–6 (27).
SyncopeSudden loss of consciousness with loss of postural tone, not related to anesthesia, with spontaneous recovery as reported by patient or observer. Patients may experience syncope when supine.
  • Yes

  • [No]

  • [null]

ACCF/AHA Electrophysiology Data Standards (16)
Date of syncopeIndicate date of the most recent event if there is a history of >1 event.
  • Date

  • [null]

Minimum data: yearACCF/AHA Electrophysiology Data Standards (16)
Past History (“History of …”)
HypertensionCurrent or previous diagnosis of hypertension, defined as any of the following:
  •  • History of hypertension diagnosed and treated with medication, diet, and/or exercise

  •  • On at least 2 separate occasions, documented blood pressure >140 mm Hg systolic and/or 90 mm Hg diastolic in patients without diabetes or chronic kidney disease, or blood pressure >130 mm Hg systolic or 80 mm Hg diastolic in patients with diabetes or chronic kidney disease

  •  • Currently on pharmacological therapy for treatment of hypertension

  • Yes

  • [No]

  • [null]

ACCF/AHA Cardiac Imaging Data Standards (18)
DyslipidemiaCurrent or previous diagnosis of dyslipidemia according to National Cholesterol Education Program criteria, defined as any 1 of the following:
  •  • Total cholesterol >200 mg/dL (5.18 mmol/L)

  •  • 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

  • Yes

  • [No]

  • [null]

ACCF/AHA Cardiac Imaging Data Standards (18)
DiabetesHistory of diabetes diagnosed and/or treated by a physician. American Diabetes Association criteria include documentation of the following:
  •  • Hemoglobin A1c ≥6.5%; or

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

  •  • 2-Hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during oral glucose tolerance test; or

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

  •  This does not include gestational diabetes.

  • Yes–type 1

  • Yes–type

  • 2

  • [No]

  • [null]

ADA Position Statement: Standards of Medical Care in Diabetes–2011 (28)
Tobacco useCurrent 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

  •  Current everyday smoker

  • Current some day smoker

  • Former smoker

  • Never smoker

  • Smoker, current status Unknown

  • [null]

CMS Meaningful Use (29)
Chronic lung diseaseDocumented history of chronic lung disease (e.g., chronic obstructive pulmonary disease, chronic bronchitis) or currently receiving long-term treatment with inhaled or oral pharmacological therapy (e.g., beta-adrenergic agonist, anti-inflammatory agent, leukotriene receptor antagonist, or steroid) for the indication of lung disease.
  • Date of onset (first diagnosis) may be helpful.

  • Yes

  • No

  • [null]

ACCF/AHA Atrial Fibrillation Data Standards (19)
Chronic kidney diseaseCurrent or previous history of chronic kidney disease, captured as current status. Chronic kidney disease is defined as either kidney damage or GFR <60 mL/min/1.73 m2 for ≥3 months. Kidney damage is defined as pathologic abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies:
  •  • Stage 0—No known kidney disease

  •  • Stage 1—Kidney damage with normal or high—GFR ≥90 mL/min/1.73 m2

  •  • Stage 2—Kidney damage with mildly decreased—GFR 60–89 mL/min/1.73 m2

  •  • Stage 3—Moderately decreased—GFR 30–59 mL/min/1.73 m2

  •  • Stage 4—Severely decreased—GFR 15–29 mL/min/1.73 m2

  •  • Stage 5—Kidney failure—GFR <15 mL/min/1.73 m2 or on dialysis

  • 0

  • 1

  • 2

  • 3

  • 4

  • 5

  • [null]

ACCF/AHA, NKF KDOQI Advisory Board. KDOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002;39Suppl 2:S65 (30).
DialysisRequirement for dialysis treatment, including hemodialysis and peritoneal dialysis
  • Yes

  • [No]

  • [null]

Illicit drug useDocumented history of current, recent, or remote abuse of any illicit drug (e.g., cocaine, methamphetamine, marijuana) or controlled substance
  • Yes

  • [No]

  • [null]

ACCF/AHA Atrial Fibrillation Data Standards (19)
HIV infectionHIV infection diagnosed by a physician or qualified medical-care provider documented in a medical record and based on the following laboratory criteria:
  •  • Positive result from an HIV antibody screening test (e.g., reactive EIA) confirmed by a positive result from a supplemental HIV antibody test (e.g., Western blot or indirect immunofluorescence assay test); or

  •  • Positive result or report of a detectable quantity (i.e., within the established limits of the laboratory test) from any of the following HIV virologic (i.e., non-antibody) tests:

    •   – HIV nucleic acid (DNA or RNA) detection test (e.g., PCR)

    •   – HIV p24 antigen test, including neutralization assay

    •   – HIV isolation (viral culture)

    • Oral reports of prior laboratory test results are not acceptable.

  • Yes

  • [No]

  • [null]

CDC–Revised Surveillance Case Definitions for HIV Infection Among Adults, Adolescents, and Children Aged <18 Months and for HIV Infection and AIDS Among Children Aged 18 Months to <13 Years—United States, 2008 (31)
Atrial arrhythmiasCurrent or previous history of any of the following atrial arrhythmias, captured as type of arrhythmia:
  •  • First detected AF

  •  • Paroxysmal AF: AF is self-terminating within 7 days of recognized onset

  •  • Persistent AF: AF is not self-terminating within 7 days or is terminated electrically or pharmacologically

  •  • Permanent AF: cardioversion failed or not attempted

  •  • Atrial flutter

  •  • Atrial tachycardia

  •  • Sick sinus syndrome

  • AF, first detected

  • AF, paroxysmal

  • AF, persistent

  • AF, permanent

  • Atrial flutter

  • Atrial tachycardia

  • Sick sinus syndrome

  • [No]

  • [null]

Can select any of the above choices; “No” is exclusiveACCF/AHA Electrophysiology Data Standards (16)
Paroxysmal supraventricular tachycardiaCurrent or previous history of paroxysmal supraventricular tachycardia
  • Yes

  • [No]

  • [null]

ACCF/AHA Electrophysiology Data Standards (16)
Ventricular arrhythmias
  • VT, sustained

  • VT, nonsustained

  • VF

  • [No]

  • [null]

Current or previous history of any of the following ventricular arrhythmias, captured as type of arrhythmia:
  •  • VT, sustained

  •  • VT, nonsustained

  •  • VF

Can select any of the VT/VF choices; “No” is exclusiveACCF/AHA Chronic Heart Failure Data Standards (20)
Venous thromboembolismCurrent or previous history of DVT or pulmonary embolism
  • Yes—DVT

  • Yes—Pulmonary embolism

  • [No]

  • [null]

DepressionCurrent or previous diagnosis of depression or documentation of a depressed mood or affect
  • Yes

  • [No]

  • [null]

ACCF/AHA Chronic Heart Failure Data Standards (20)
Coronary artery diseaseCurrent or previous history of any of the following:
  •  • Coronary artery stenosis ≥50% (by cardiac catheterization or other modality of direct imaging of the coronary arteries)

  •  • Previous CABG surgery

  •  • Previous PCI

  •  • Previous MI

  • Yes

  • [No]

  • [null]

ACCF/AHA Cardiac Imaging Data Standards (18)
Cerebral artery diseaseCurrent or previous history of any of the following:
  •  • Ischemic stroke: infarction of central nervous system tissue whether symptomatic or silent (asymptomatic)

  •  • TIA: transient episode of neurological dysfunction caused by focal 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.

  • Yes

  • [No]

  • [null]

ACCF/AHA Cardiac Imaging Data Standards (18); Nomenclature for Vascular Diseases (32); 2009 AHA/ASA Definition and Evaluation of Transient Ischemic Attack (33)
Peripheral artery diseaseCurrent or previous history of peripheral artery disease (lower extremity from iliac to tibials and upper extremity from subclavian to brachials. Excludes renal, coronary, cerebral, and mesenteric vessels and aneurysms). Major symptoms can include
  •  • Claudication relieved by rest

  •  • Amputation for severe arterial vascular insufficiency

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

  •  • Positive noninvasive test (e.g., ankle brachial index ≤0.90, ultrasound, MR or CT imaging of >50% diameter stenosis in any peripheral artery (i.e., subclavian, femoral, iliac) or angiographic imaging

  • Yes

  • [No]

  • [null]

Nomenclature for Vascular Diseases (32)
Aorta diseaseCurrent or previous history of disease of the thoracic, thoracoabdominal, or abdominal aorta (typically aneurysm)
  • Yes

  • [No]

  • [null]

Nomenclature for Vascular Diseases (32)
Renal artery diseaseCurrent or previous history of disease of the main renal arteries or extrarenal branches
  • Yes

  • [No]

  • [null]

Nomenclature for Vascular Diseases (32)
Myocardial infarctionThe term myocardial infarction 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 rise and/or fall of cardiac biomarkers (preferably troponin) with at least 1 value above the 99th percentile of the URL together with evidence of myocardial ischemia with at least 1 of the following:

  •   – Symptoms of ischemia

  •   – ECG changes indicative of new ischemia [new ST-T changes or new LBBB]

  •   – Development of pathological Q waves in the ECG

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

  • Yes

  • [No]

  • [null]

Universal Definition of MI (34)
  •  • Sudden unexpected cardiac death, involving cardiac arrest, often with symptoms suggestive of myocardial ischemia, and accompanied by presumably new ST-segment elevation or new LBBB, and/or evidence of fresh thrombus by coronary angiography a time before the appearance of cardiac biomarkers in the blood.

  •  • For PCI in patients with normal baseline indicative of periprocedural myocardial necrosis. By convention, increases of biomarkers >3×99th percentile URL have been designated as PCI-related MI. A subtype related to a documented stent thrombosis is recognized.

  •  • For CABG in patients with normal baseline troponin values, elevations of cardiac biomarkers above the 99th percentile URL are indicative of periprocedural myocardial necrosis. By convention, increases of biomarkers >5×99th percentile URL plus either new pathological Q waves or new or imaging evidence of new loss of viable myocardium have been designated as defining CABG-related MI.

  •  • Pathological findings of an acute MI

Date of myocardial infarctionDate of documented MI. Indicate the date of most recent MI if there is a history of more than one.
  • Date

  • [null]

Minimum data is yearACCF/AHA Cardiac Imaging Data Standards (18)
Sudden cardiac arrest[Sudden] cardiac arrest is the sudden cessation of cardiac activity. The victim becomes unresponsive with no normal breathing and no signs of circulation. If corrective measures are not taken rapidly, this condition progresses to sudden death. Cardiac arrest should be used to signify an event as described above that is reversed, usually by CPR and/or defibrillation or cardioversion or cardiac pacing. Sudden cardiac death should not be used to describe events that are not fatal.
  • Yes

  • No

  • [null]

ACCF/AHA Electrophysiology Data Standards (16)
Date of cardiac arrestDate of documented resuscitated cardiac arrest
  • Date

  • [null]

Minimum data is yearACCF/AHA Electrophysiology Data Standards (16)
Heart failure
  • Indicate if there is physician documentation or a report that the patient has been in a state of heart failure.

  • Heart failure is defined as physician documentation or a 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 presumed to be cardiac dysfunction.

  • A low ejection fraction alone, without clinical evidence of heart failure, does not qualify as heart failure.

  • Yes

  • [No]

  • [null]

ACCF/AHA Acute Coronary Syndrome Data Standards (17); AR-G (22); STS Registry v2.70 (15)
Family History
Coronary artery diseaseIndicate if the patient has/had any direct blood relatives (i.e., parents, siblings, children) who have had any of the following diagnosed at age <55 y for male relatives or <65 y for female relatives:
  •  • Coronary artery disease (i.e., angina, previous CABG or PCI)

  •  • MI

  •  • Sudden cardiac death without obvious cause

  • If the patient is adopted or the family history is unavailable, code “No.”

  • Yes

  • [No]

  • [null]

STS Registry v2.70 (15)
Sudden cardiac deathA first-degree relative (i.e., parent, sibling, child) documented to have died suddenly of presumed cardiac etiology without other obvious cause
  • Yes

  • [No]

  • [null]

ACCF/AHA Cardiac Imaging Data Standards (18)
Patient Assessment
Systolic blood pressureSystolic blood pressure in millimeters mercuryNumeric (mm Hg)
Diastolic blood pressureDiastolic blood pressure in millimeters mercuryNumeric (mm Hg)
WeightMeasured actual weight in kilograms. To be converted from conventional units if needed.Numeric (kg)
Waist circumferenceAverage of 2 measurements in centimeters while subject is standing, one taken after inspiration and one after expiration. Measurement to be taken at the midpoint between the lowest rib and the iliac crest.Numeric (cm)ACCF/AHA Acute Coronary Syndrome Data Standards (17)
HeightMeasured in centimeters. To be converted from conventional units if needed.Numeric (cm)
Heart rateNumber of heartbeats over 1 min.Numeric (bpm)

ACCF indicates American College of Cardiology Foundation; ADA, American Diabetes Association; AF, atrial fibrillation; AHA, American Heart Association; AIDS, acquired immune deficiency syndrome; AR-G, ACTION Registry-Get With the Guidelines; ASA, American Stroke Association; bpm, beats per minute; CABG, coronary artery bypass graft; CCS, Canadian Cardiovascular Society; CDC, Centers for Disease Control and Prevention; CPR, cardiopulmonary resuscitation; CT, computed tomography; DNA, deoxyribonucleic acid; DVT, deep venous thrombosis; ECG, electrocardiogram; EIA, enzyme immunoassay; GFR, glomerular filtration rate; HDL, high-density lipoprotein; HIV, human immunodeficiency virus; KDOQI, Kidney Diseases Outcomes Quality Initiative; LBBB, left bundle-branch block; LDL, low-density lipoprotein; MI, myocardial infarction; MR, magnetic resonance; NKF, National Kidney Fund; NSTEMI, non–ST-segment elevation myocardial infarction; NYHA, New York Heart Association; PCI, percutaneous coronary intervention; PCR, polymerase chain reaction; PQRI, Physician Quality Reporting Initiative; RNA, ribonucleic acid; STEMI, ST-segment elevation myocardial infarction; STS, Society of Thoracic Surgeons; TIA, transient ischemic attack; URL, upper reference limit; VF, ventricular fibrillation; and VT, ventricular tachycardia.

  • The data element/definition is a 2010 PQRI Measures data point (25a).