Table 1

History and Physical Examination Elements

Data Field	Definition	Value Domain	Notes	Source
Current Status
Chest pain (angina) or anginal equivalent	Chest 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).
Syncope	Sudden 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 syncope	Indicate date of the most recent event if there is a history of >1 event.	Date [null]	Minimum data: year	ACCF/AHA Electrophysiology Data Standards (16)
Past History (“History of …”)
Hypertension^⁎	Current 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)
Dyslipidemia	Current 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)
Diabetes	History 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 use^⁎	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	Current everyday smoker Current some day smoker Former smoker Never smoker Smoker, current status Unknown [null]		CMS Meaningful Use (29)
Chronic lung disease	Documented 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 disease	Current 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).
Dialysis	Requirement for dialysis treatment, including hemodialysis and peritoneal dialysis	Yes [No] [null]
Illicit drug use	Documented 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 infection	HIV 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 arrhythmias	Current 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 exclusive	ACCF/AHA Electrophysiology Data Standards (16)
Paroxysmal supraventricular tachycardia	Current 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 exclusive	ACCF/AHA Chronic Heart Failure Data Standards (20)
Venous thromboembolism	Current or previous history of DVT or pulmonary embolism	Yes—DVT Yes—Pulmonary embolism [No] [null]
Depression	Current 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 disease^⁎	Current 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 disease	Current 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 disease	Current 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 disease	Current or previous history of disease of the thoracic, thoracoabdominal, or abdominal aorta (typically aneurysm)	Yes [No] [null]		Nomenclature for Vascular Diseases (32)
Renal artery disease	Current or previous history of disease of the main renal arteries or extrarenal branches	Yes [No] [null]		Nomenclature for Vascular Diseases (32)
Myocardial infarction	The 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 infarction	Date of documented MI. Indicate the date of most recent MI if there is a history of more than one.	Date [null]	Minimum data is year	ACCF/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 arrest	Date of documented resuscitated cardiac arrest	Date [null]	Minimum data is year	ACCF/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 disease	Indicate 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 death	A 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 pressure	Systolic blood pressure in millimeters mercury		Numeric (mm Hg)
Diastolic blood pressure	Diastolic blood pressure in millimeters mercury		Numeric (mm Hg)
Weight	Measured actual weight in kilograms. To be converted from conventional units if needed.		Numeric (kg)
Waist circumference	Average 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)
Height	Measured in centimeters. To be converted from conventional units if needed.	Numeric (cm)
Heart rate	Number 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).