Appendix 2. Definitions and Technical Specifications of NCRI Data Elements.
The elements are listed here with specifications developed in the Cardiovascular Domain
Analysis Model (CV-DAM) version 3. The order follows the section headings shown in Table 2.
Available at www.hl7.org/implement/standards/product_brief.cfm?product_id=133.
Medical history
1. Hypertension
Hypertension
Type:
Class
Package:
Cardiology CDE Library
Alias:
Hypertension
Class Definition: C0020538 Hypertensive disease: NCI/PT | Pathological increase in blood pressure; a
repeatedly elevated blood pressure exceeding 140 over 90 mmHg.
Attributes
Attribute
Notes
Attribute Definition: Hypertension (HTN) diagnosis is the current or
Name:
HTNDiagnosticIndicator previous diagnosis of a systolic or diastolic blood pressure that consistently
exceeds 140/90.
Datatype: Enum
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Hypertension
Enumerations:
Selections: No, Yes
2. Diabetes
3. Diabetes Therapy
Diabetes
Type:
Package:
Alias:
Class
Cardiology CDE Library
Diabetes
Class Definition: Diabetes mellitus is diagnosed by a physician or can be defined by any one of the
following:
1. A1C>=6.5%.
2. FPG >=126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.* 3. Two-hour
plasma glucose >= 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described
by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous
glucose dissolved in water.
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose
>=200 mg/dl (11.1 mmol/l).
*Does not include gestational diabetes.
Attributes
Attribute
Name:
diabetesMellitusType
Datatype: Enum
Alias: Diabetes Mellitus
Name:
diabetesTherapy
Datatype: Enum
Alias: Diabetes Therapy
Notes
Attribute Definition: Current or previous history of diabetes. *Does not
include gestational diabetes.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Type 1
Type II
No Diabetes
Attribute Definition: Indicate the therapy method the patient presented with.
Choose the most aggressive therapy. Note(s):
Patients placed on a pre-procedure diabetic pathway of insulin drip at admission
but were controlled by diet or oral method are not coded as insulin treated. If a
patient had a pancreatic transplant, code "Other", since the insulin from the new
pancreas is not exogenous insulin. Target Value: The value on arrival at this
facility.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 None
2 Diet
3 Oral
4 Insulin
Attribute
Notes
5 Other
4. Dyslipidemia.
Dyslipidemia
Type:
Package:
Alias:
Class
Cardiology CDE Library
Dyslipidemia
Class Definition: Abnormally high levels of cholesterol and other fats in the blood. Defined as any 1 of
the following:
• Total cholesterol greater than 200 mg/dl (5.18 mmol/l)
• Low-density lipoprotein (LDL) greater than or equal to 130 mg/dl (3.37 mmol/l)
• High-density lipoprotein (HDL) less than 40 mg/dl (1.04 mmol/l) in men and less than 50 mg/dl (1.30
mmol/l) in women
• Yes
Source: ACC/AHA Cardiac Imaging DS/ ACC Top 100
Attributes
Attribute
Name:
dyslipidemiaIndicator
Datatype: Enum
Alias: Dyslipidemia
Notes
Attribute Definition: Indicate current or previous diagnosis of dyslipidemia
per the National Cholesterol Education Program (12) criteria.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
5. Tobacco Use.
6. Tobacco Use-Smoked Tobacco Type.
7. Smokeless Tobacco.
88. Illicit Drug Use.
89. Illicit Drug Use Type – Cocaine.
SubstanceAbuse
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: HHC/DX Definition: Excessive use of harmful bodily materials. Substance abuse
problem
Attributes
Attribute
Name:
coccaineUseIndicator
Datatype: Enum
Alias: Illicit Drug Use
Type_ Coccaine Use
Name:
IllicitDrugUseIndicator
Datatype: Enum
Alias: Illicit Drug Use
Name:
smokedTobaccoType
Datatype: Enum
Alias: Smoked Tobacco
Type
Name:
smokelessTobaccoIndicat
or
Datatype: Enum
Alias: Smokeless Tobacco
Notes
Attribute Definition: Indicate if the patient reports cocaine use within the
last 72 hours or has a urine test that is positive for cocaine.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Documented history of current, recent, or remote
abuse of any illicit drug (e.g., cocaine, methamphetamine, marijuana) or
controlled substance.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the type of smoked tobacco.
Type is a collection of values used in the enumerated, menu of choices or
pick-list.
Enumerations:
Cigars
Cigarettes
Pipe
Attribute Definition: Indicate smokeless tobacco.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute
Name: tobaccoUseType
Datatype: Enum
Alias: Tobacco Use
Notes
Attribute Definition: Current or previous use of any tobacco product,
including cigarettes, cigars, pipes, and chewing tobacco.
Type is a collection of values used in the enumerated, menu of choices or
pick-list.
Enumerations:
-current every day smoker
-current some day smoker -former smoker
-never smoker
-smoker, current statusunknown
-unknown if ever
8. Heart Failure
13. NYHA Class
HeartFailure
Type:
Package:
Alias:
Class
Cardiology CDE Library
Heart Failure
Class Definition: 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 distension,
pulmonary edema on physical exam, or pulmonary edema on chest x-ray presumed to be cardiac
dysfunction. A low ejection fraction without clinical evidence of heart failure does not qualify as heart
failure. Source: Acute Coronary Syndromes Data Standards (JACC 2001 38: 2114 - 30), The Society of
Thoracic Surgeons.
Attributes
Attribute
Name: HFIndicator
Datatype: Enum
Alias: Heart Failure
Name:
NYHAClassType
Datatype: Enum
Alias: NYHA Class
Notes
Attribute Definition: Indicate current or previous history of heart failure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Heart failure class [New York Heart Association
(NYHA)] For symptoms or signs in patients with defined or presumed cardiac
disease per the New York Heart Association classification scale.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
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.
Value Domain/PV:
I
II
III
IV
Source: ACC/AHA
Attribute
Notes
Citation: 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, Mass: Little, Brown & Co.; 1994: 253-256.
9. Heart Failure Hospital Timeframe.
10. CHF Hospitalization.
Heart Failure Hospitalization
Type:
Package:
Alias:
Class
Cardiology CDE Library
CHF Hospitalization
Class Definition: Admission to acute care facility (hospital) to treat/manage condition in which heart is
unable to pump blood at an adequate rate to meet tissue metabolic requirements or has the ability to do so
only at an elevated filling pressure.
Attributes
Attribute
Name:
hospitalizationIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient has been hospitalized for heart
failure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: CHF Hospitalization Enumerations:
Selections: No, Yes
Name:
recentHospitalizationTi
meframeType
Datatype: Enum
Alias: Heart Failure
Hospital Timeframe
Attribute Definition: Indicate the timeframe of the most recent
hospitalization for heart failure.
Type is a collection of values used in the enumerated, menu of choices or
pick-list.
Enumerations:
<= 6 months
> 6 months
11. Prior cardiac transplant.
Prior Intervention
Type:
Package:
Alias:
Class
Cardiology CDE Library
Prior Intervention
Class Definition: Course of action utilized before the current admission/encounter (or current course of
action) was initiated
Attributes
Attribute
Name:
priorCardiacTranspla
ntIndicator
Datatype: Enum
Alias: Prior cardiac
transplant
Name:
priorValveProcedureIn
dicator
Datatype: Enum
Alias: Prior Valve
Surgery/Procedure
Notes
Attribute Definition: Indicate if the patient has had previous heart transplant
surgery. Source: NCDR (ICD 2.1).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient had a previous surgical
replacement and/or repair of a cardiac valve, by any approach prior to arrival.
Note(s): This also includes percutaneous valve procedures and valvuloplasty.
Source: NCDR (Cath PCI).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
12. Heart transplant waiting list.
Cardiac Transplant Wait List
Type:
Package:
Alias:
Class
Cardiology CDE Library
Heart transplant waiting list
Class Definition: Listing of people with end-stage heart failure who are in need of a heart transplant
procedure/are waiting on a donor heart to become available for transplant.
Attributes
Attribute
Name:
heartTransplantWaitList
Indicator
Datatype: Enum
Alias: Heart transplant
waiting list
Notes
Attribute Definition: Indicate if the patient is currently on a waiting list to
receive a heart transplant. Target Value: The last value between birth and the
first generator procedure in this admission. Source: NCDR (ICD 2.1).
Enumerations:
Selections: 0-No,1-Yes
14. Chronic Kidney Disease.
Chronic Kidney Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Chronic Kidney Disease
Class Definition: Chronic kidney disease is defined as either kidney damage or GFR less than 60
ml/min/1.73 m2 for greater than or equal to 3 months. Kidney damage is defined as pathologic
abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies.
Attributes
Attribute
Name:
chonicrenalDiseaseTyp
e
Datatype: Enum
Alias: Chronic Kidney
Disease
Notes
Attribute Definition: Current or previous history of chronic kidney disease,
captured as current status.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Indicate the patient's stage of disease (13):
• Stage 0 - No known kidney disease
• Stage 1 - Kidney damage with normal or high GFR greater than or equal to 90
ml/min/1.73 m2
• Stage 2 - Kidney damage with mildly decreased GFR 60 to 89 ml/min/1.73
m2
• Stage 3 - Moderately decreased GFR 30 to 59 ml/min/1.73 m2
• Stage 4 - Severely decreased GFR 15 to 29 ml/min/1.73 m2
• Stage 5 - Kidney failure GFR less than 15 ml/min/1.73 m2 or on dialysis.
Type is a collection of values used in the enumerated, menu of choices or picklist.menu of choices or pick-list.
15. Dialysis.
Dialysis
Type:
Package:
Alias:
Class
Cardiology CDE Library
Dialysis
Class Definition: A procedure to remove toxic substances from the blood that is used in patients with
end-stage chronic kidney disease or acute kidney failure. Source: NCI (C15221).
Attributes
Attribute
Name:
requirementIndicator
Datatype: Enum
Alias: Dialysis required
Notes
Attribute Definition: Requirement for dialysis treatment, including
hemodialysis and peritoneal dialysis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
16. Chronic Lung Disease.
Chronic Lung Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Chronic Lung Disease
Class Definition: Long-term obstructive or inflammatory condition of the lungs. Chronic lung disease
can include patients with chronic obstructive pulmonary disease, chronic bronchitis, or emphysema. It can
also include a patient who is currently being chronically treated with inhaled or oral pharmacological
therapy (e.g., beta-adrenergic agonist, anti-inflammatory agent, leukotriene receptor antagonist, or
steroid). Source: NCDR
Attributes
Attribute
Name: CLDIndicator
Datatype: Enum
Alias: Chronic Lung
Disease (CLD)
Notes
Attribute Definition: Indicate if the patient has chronic lung disease. Patients
with asthma or seasonal allergies are not considered to have chronic lung
disease (CLD).
Note: A history of chronic inhalation reactive disease (asbestosis,
mesothelioma, black lung disease or pneumoconiosis) qualifies as chronic lung
disease. Radiation induced pneumonitis or radiation fibrosis also qualifies as
chronic lung disease. A history of atelectasis is a transient condition and does
not qualify.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
17. Chronic Lung Disease – Home Oxygen Therapy.
O2Therapy
Type:
Class
Package:
Cardiology CDE Library
Alias:
Home O2 Therapy
Class Definition: Use of supplemental oxygen outside of the acute care setting to maintain normal
oxygenation levels.
Attributes
Attribute
Name:
home.O2TherapyIndicat
or
Datatype: Enum
Alias: Home O2 Therapy
Notes
Attribute Definition: Indicate if, prior to the current procedure, the patient
has been receiving home oxygen therapy for treatment of chronic lung
disease.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
18. Coronary Artery Disease.
22. PCI.
23. CABG Surgery.
Coronary Artery Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Artery Disease
Class Definition: Condition in which atherosclerotic plaque accumulates in the coronary arteries to the
point where coronary circulation is compromised. Documented history of any of the following: (ACC)
• Documented coronary artery stenosis greater than or equal to 50% (by cardiac catheterization or other
modality of direct imaging of the coronary arteries)
• Previous coronary artery bypass surgery (CABG)
• Previous percutaneous coronary intervention (PCI)
• Previous myocardial infarction.
Attributes
Attribute
Name: CADIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate current or previous history of coronary artery
disease.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Coronary artery
Enumerations:
disease
Selections: No, Yes
Attribute Definition: Indicate the patient's coronary artery disease (CAD)
Name:
CADPresentationType presentation. Choose the worst status. Note(s): If the patient presents with
Datatype: Enum
atypical symptoms of myocardial ischemia (i.e. only shortness of breath, upper
abdominal pain, left arm pain, etc.) that is known and documented to be
Alias: CAD Presentation myocardial ischemia, and is considered to be an anginal equivalent, code the
selection that fits their presentation. If these symptoms are not thought to be or
have not been proven to be the anginal equivalent, code "Symptom unlikely to
be ischemic."
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
No symptom, no angina
Symptom unlikely to be ischemic
Stable Angina
Unstable Angina
NSTEMI
STEMI
19. One epicardial artery >= 70% confirmed by angiography.
Coronary Artery Angiography Result
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Artery Angiography Result
Class Definition: C0085532 Coronary Angiography MSH/MH | Radiography of the vascular system of
the heart muscle after injection of a contrast medium.
Attributes
Attribute
Name:
epicardialArteryObstr
uctionIndicator
Datatype: Enum
Alias: One epicardial
artery > = 70%
confirmed by
angiography
Notes
Attribute Definition: Indicate if ischemic heart disease is confirmed with at
least one epicardial artery with >= 70% obstruction by angiography (or the left
main coronary artery >=50%).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
20. Myocardial Infarction.
Myocardial Infarction History
Type:
Package:
Alias:
Class
Cardiology CDE Library
Myocardial Infarction
Class Definition: Documented history of previous myocardial infarction (MI), typically with objective
evidence via positive biomarkers of myocardial necrosis.
Attributes
Attribute
Name:
HxMyocardialInfarctio
nIndicator
Datatype: Enum
Alias: History of
Myocardial Infarction
Notes
Attribute Definition: Previous history of myocardial infarction. Documented
history of previous myocardial infarction (MI), typically with objective
evidence via positive biomarkers of myocardial necrosis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
21. Myocardial infarction timeframe.
Myocardial Infarction Timeframe
Type:
Package:
Alias:
Class
Cardiology CDE Library
Myocardial Infarction timeframe
Class Definition: Period of time within which a myocardial infarction occurred.
Attributes
Attribute
Name:
MITimeframeType
Datatype: Enum
Alias: Myocardial
Infarction timeframe
Notes
Attribute Definition: Indicate the timeframe of the myocardial infarction.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
<=40 Days
> 40 Days
24. Cardiac Arrest.
25. Cardiac Arrest Date.
26. Cardiac Arrest Due to Arrhythmia.
58. Bradycardia Arrest.
62. VT/VF Arrest.
Cardiac Arrest
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Arrest
Class Definition: *Sudden" cardiac arrest is the sudden cessation of cardiac activity so that 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.
Source: ACC/AHA/HRS 2006 Key Data Elements and Definitions for Electrophysiological Studies and
Procedures
Attributes
Attribute
Name:
arrhythmiaArrestIndic
ator
Datatype: Enum
Alias: Cardiac Arrest
Due to Arrhythmia
Notes
Attribute Definition: Indicate if the patient experienced cardiac arrest due to
arrhythmia. Note(s): If a patient experienced ventricular fibrillation caused by
lead manipulation during the procedure, and it required defibrillation, code no.
No Yes
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the cardiac arrest was a result of bradycardia
which is an excessive slowness in the action of the heart, usually with a heart
rate below 60 beats per minute.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Bradycardia arrest Enumerations:
Selections: No, Yes
Attribute Definition: Current or previous history of cardiac arrest.
Name:
historyOfArrestIndicat Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
or
Datatype: Enum
Enumerations:
Selections: No, Yes
Alias: History of Cardiac
Arrest
Name:
bradycardiaArrestIndi
cator
Datatype: Enum
Attribute
Name:
VTVFArrestIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the cardiac arrest was a result of ventricular
tachycardia or ventricular fibrillation. Ventricular tachycardia is three or more
fast heart beats (greater than 100 bpm) that originates in one of the ventricles.
Ventricular fibrillation occurs when the heart's electrical activity becomes
disordered and the ventricles contract in a rapid, unsynchronized way.
Alias: Ventricular
Tachycardia/Ventricular Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Fibrillation Arrest
Enumerations:
Selections: No, Yes
27. Previous ICD Implant site.
28. Previous ICD reason.
29. Previous ICD type.
Procedure ICD Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
ICD Characteristics
Class Definition: Distinguishing properties of current or prior internal cardiac defibrillator pacemakers
including but not limited to indication for placement, device type, implant site and placement dates.
Attributes
Attribute
Name:
ICDImplantSiteType
Datatype: Enum
Notes
Attribute Definition: Indicate the location in the body where the ICD was
implanted.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: ICD Implant site Enumerations:
-Pectoral The ICD was implanted in the pectoral wall.
-Abdominal The ICD was implanted in the abdominal wall. Source: NCDR
(ICD 2.1)
Attribute Definition: Indicate if the reason the previous ICD was implanted for
Name:
secondary prevention was that the patient had an episode of cardiac arrest or
ICDReasonIndicator
Datatype: Enum
arrhythmia where the etiology was unknown. This includes a sudden loss of
consciousness requiring cardioversion or defibrillation to restore hemodynamic
Alias: Initial ICD reason stability.
Indicator is a selection of No/Yes values used in the enumerated, menu of
is Cardiac
choices or pick-list.
Arrest/arrhythmia
Enumerations:
Etiology Unknown
Selections: No, Yes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was not documented in the medical record.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Initial ICD reason Selections: No, Yes
is Not Documented
Name:
ICDReasonNotDocume
ntedIndicator
Datatype: Enum
Name:
ICDReasonSyncopeHig
hRiskIndicator
Datatype: Enum
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was that the patient had an episode of syncope (sudden
loss of consciousness with loss of postural tone not related to anesthesia) with
high risk characteristics. High risk characteristics include non-ischemic dilated
cardiomyopathy, or ischemic heart disease with significant ventricular
Attribute
Alias: Initial ICD reason
is Syncope with High
Risk Characteristics
Notes
dysfunction, hypertrophic cardiomyopathy, Brugada Syndrome, or Long QT
Syndrome.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
Name:
ICDReasonSyncopeInd secondary prevention was that the patient had an episode of syncope (sudden
loss of consciousness with loss of postural tone not related to anesthesia) while
ucibleVTIndicator
Datatype: Enum
ventricular tachycardia (VT) was induced during an electrophysiological study
that induced VT.
Alias: Initial ICD reason Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
is Syncope with
Enumerations:
Inducible VT
Selections: No, Yes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was that the patient had an episode of ventricular
fibrillation (VF). VF is a rapid, usually more than 300 beats per minute (cycle
length 180 msec or less) grossly irregular ventricular rhythm with marked
variability in cycle length, lack of discernible discreet QRS complex.
Alias: Initial ICD reason Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
is Ventricular
Enumerations:
Fibrillation
Selections: No, Yes
Name:
ICDReasonVFIndicato
r
Datatype: Enum
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was that the patient had an episode of ventricular
tachycardia (VT) that started spontaneously. Spontaneous VT lasts >30 seconds
in duration or requires termination due to hemodynamic compromise in <30
seconds.
Alias: Initial ICD reason Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
is Spontaneous
Enumerations:
Sustained VT
Selections: No, Yes
Name:
ICDReasonVTIndicato
r
Datatype: Enum
Name: ICDType
Datatype: Enum
Alias: ICD Type
Attribute Definition: Indicate the type of implantable cardioverter defibrillator
(ICD).
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Single chamber A single-chamber ICD defibrillates the ventricle and paces the
ventricle.
Dual chamber A dual-chamber ICD defibrillates the ventricle and paces the
atrium and ventricle.
CRT-D A cardiac resynchronization therapy device and defibrillator (CRT-D)
has dual capabilities. It is a biventricular pacemaker that sends electrical signals
Attribute
Notes
to both ventricles as well as a defibrillator. It may or may not have an atrial
pacing wire. Source: NCDR (ICD 2.1)
Name:
previousICDDate
Datatype: Date
Attribute Definition: Indicate the date the patient had a previous ICD. Note(s):
If month or day is unknown, enter "01". Source: NCDR
Alias: Date of Previous
ICD Date
Name:
previousICDReasonTy
pe
Datatype: Enum
Alias: Previous ICD
reason
Attribute Definition: Indicate the reason the previous ICD was implanted.
Note(s): If the patient originally presented with an indication of primary
prevention, then had an event that categorized them as secondary prevention,
code the patient as secondary prevention.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Primary prevention Primary Prevention is an indication for an ICD to prevent
sudden cardiac death. It refers to use of ICDs in individuals who are at risk for
but have not yet had an episode of sustained ventricular tachycardia, ventricular
fibrillation, or resuscitated cardiac arrest.
Secondary prevention Secondary prevention refers to an indication for ICD
exclusively for patients who have survived one or more cardiac arrests or
sustained ventricular tachycardia. Patients with cardiac conditions associated
with a high risk of sudden death who have unexplained syncope that is likely to
be due to ventricular arrhythmias are considered to have a secondary indication.
Supporting Definitions: Primary Prevention: Primary Prevention is an
indication for an ICD to prevent sudden cardiac death. It refers to use of ICDs
in individuals who are at risk for but have not yet had an episode of sustained
ventricular tachycardia, ventricular fibrillation, or resuscitated cardiac arrest.
Source: ACC/AHA//HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities
Secondary Prevention: Secondary prevention refers to an indication for ICD
exclusively for patients who have survived one or more cardiac arrests or
sustained ventricular tachycardia. Patients with cardiac conditions associated
with a high risk of sudden death who have unexplained syncope that is likely to
be due to ventricular arrhythmias are considered to have a secondary indication.
Source: ACC/AHA//HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities
30. Cardiogenic Shock.
Cardiogenic Shock
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiogenic Shock
Class Definition: Cardiogenic shock is defined as a sustained (>30 minutes) episode of systolic blood
pressure <90 mm Hg, and/or cardiac index <2.2 L/min/m2 determined to be secondary to cardiac
dysfunction, and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support
(e.g., Intra-aortic balloon pump (IABP), extracorporeal circulation, ventricular assist devices) to maintain
blood pressure and cardiac index above those specified levels.
Note: Transient episodes of hypotension reversed with IV fluid or atropine do not constitute cardiogenic
shock. The hemodynamic compromise (with or without extraordinary supportive therapy) must persist for
at least 30 minutes. Source: ACC/AHA Acute Coronary Syndromes Data Standards (JACC 2001 38:
2114 -30).
Attributes
Attribute
Name: shockIndicator
Datatype: Enum
Alias: Cardiogenic
Shock
Notes
Attribute Definition: Current or previous history of cardiogenic shock.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
31. Cerebral Artery Disease.
Cerebral Artery Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cerebral Artery Disease
Class Definition: Buildup of atherosclerotic plaque in the intracranial or cerebral arteries.
Attributes
Attribute
Name:
cerebroarterialDiseaseI
ndicator
Datatype: Enum
Alias: Cerebral Artery
Disease
Notes
Attribute Definition: Current or previous history of any of the following:
• Ischemic Stroke: infarction of central nervous system tissue whether
symptomatic or silent (asymptomatic)
• Transient ischemic attack (TIA): transient episode of neurological dysfunction
caused by focal brain, spinal cord, or retinal ischemia without acute infarction.
• Noninvasive or invasive carotid imaging test demonstrating greater than or
equal to 50% stenosis of any of the major vessels to the brain
• Previous carotid artery surgery or percutaneous carotid intervention for carotid
artery stenosis.
This does not include chronic (non-vascular) neurological diseases or other
acute neurological insults such as metabolic and anoxic ischemic
encephalopathy.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
32. Transient Ischemic Attack.
TIA
Type:
Package:
Alias:
Class
Cardiology CDE Library
TIA (Transient ischemic attack)
Class Definition: Transient ischemic attack (TIA) is defined as a transient episode of focal neurological
dysfunction caused by brain, spinal cord, or retinal ischemia, without acute infarction
Attributes
Attribute
Name: TIAIndicator
Datatype: Enum
Alias: TIA
Notes
Attribute Definition: Current or previous history of Transient Ischemic Attack
(TIA).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
33. Ischemic Stroke.
Ischemic Stroke
Type:
Package:
Alias:
Class
Cardiology CDE Library
Ischemic Stroke
Class Definition: Ischemic stroke is defined as an acute episode of focal cerebral, spinal, or retinal
dysfunction caused by infarction of central nervous system tissue.
Attributes
Attribute
Notes
Name: strokeIndicator Attribute Definition: Current or previous history of ischemic stroke.
Datatype: Enum
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Ischemic Stroke
Selections: No, Yes
34. Hemorrhagic Stroke.
Hemorrhagic Stroke
Type:
Package:
Alias:
Class
Cardiology CDE Library
Hemorrhagic Stroke
Class Definition: Hemorrhagic stroke is defined as an acute episode of focal or global cerebral or
spinal dysfunction caused by nontraumatic intraparenchymal, intraventricular or subarachnoid
hemorrhage.
Attributes
Attribute
Name:
hemorrhagicStrokeInd
icator
Datatype: Enum
Alias: Hemorrhagic
Stroke Indicator
Notes
Attribute Definition: Indicate a hemorrhagic stroke.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
35. Undetermined Stroke.
Undetermined Stroke
Type:
Package:
Alias:
Class
Cardiology CDE Library
Undetermined Stroke
Class Definition: Defined as a stroke with insufficient information to allow categorization as an ischemic
or hemorrhagic stroke.
Attributes
Attribute
Name:
underterminedStrokeI
ndicator
Datatype: Enum
Alias: Undetermined
Stroke Indicator
Notes
Attribute Definition: Indicate undetermined stroke.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
36. Syndromes at risk for sudden death.
Sudden Death Syndrome
Type:
Package:
Alias:
Class
Cardiology CDE Library
Sudden Death Syndrome
Class Definition: A syndrome that puts a patient at risk for sudden death. Source: NCDR
Attributes
Attribute
Name:
syndromeIndicator
Datatype: Enum
Alias: Indicator of
Syndromes at Risk for
Sudden Death
Name: syndromeType
Datatype: Enum
Alias: Sudden death
syndrome type
Notes
Attribute Definition: Indicate if the patient has a special syndrome that puts
him/her at risk for sudden death.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Specify the type of syndrome that puts the patient at risk
for sudden death.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
 Long QT syndrome -History of ECG findings of prolonged QT interval.
Long QT Syndrome includes prolongation of the corrected QT interval
beyond 440 ms for adult males, 460 ms for adult females and 50 ms in the
presence of ventricular depolarization abnormalities (i.e., bundle branch
blocks or IVCB more than 120 ms. Note: A normal QT interval in a resting
ECG with a failure to shorten with an increase in heart rate qualifies as
Long QT Syndrome.
 Short QT syndrome-History of ECG findings of short QT interval. Short
QT Syndrome is characterized by a QT interval of <=300 ms.
 Brugada syndrome -Polymorphic ventricular tachycardia in the absence of
structural heart disease, associated with a baseline ECG pattern during sinus
rhythm showing right bundle branch block with ST segment elevation in
leads V1 through V3. It can also be characterized by documentation of ECG
patterns associated with Brugada Syndrome, some of which may be
unmasked when provoked with drugs. The most common genetic mutations
identified for Brugada syndrome are in a sodium channel gene (SCN5A).
Sodium channel blocking drugs, therefore, may exacerbate the
electrocardiographic features and clinical presentation. Brugada syndrome
typically presents before the age of 50 years.
 Catecholaminergic polymorphic VT- Ventricular Tachycardia associated
with syncope and/or cardiac arrest
 VT triggered by emotion or exercise in patients whose baseline ECG is
normal.
Attribute
Notes
 Idiopathic/primary VT/VF -Ventricular tachycardia or ventricular
fibrillation whose cause is unknown.
 Other -The patient has a special syndrome with risk of sudden death which
is not specified above.
38. Syncope.
39. Syncope Date.
40. Syncope – Frequency of Episodes.
41. Syncope – Number of Episodes.
Syncope
Type:
Package:
Alias:
Class
Cardiology CDE Library
Syncope
Class Definition: Sudden loss of consciousness with loss of postural tone, not related to anesthesia, with
spontaneous recovery as reported by patient or observer. Patient may experience syncope when supine.
Source: ACC/AHA CV EHR Data Standards
Attributes
Attribute
Name: episodeDate
Datatype: Date
Notes
Attribute Definition: Date of syncope. Indicate the date of the most recent
event if there is a history of more than one.
Alias: Date of Syncope
Attribute Definition: Specify frequency if multiple syncopal episodes have
Name:
episodeFrequencyType occurred.
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: Frequency of
days
syncopal episodes
weeks
years
Attribute Definition: Indicate current or previous history of syncope.
Name:
Indicator is a selection of No/Yes values used in the enumerated, menu of
episodeIndicator
Datatype: Enum
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Syncope
Name:
numberOfEpisodes
Datatype: Integer
Alias: Number of
syncopal episodes
Attribute Definition: Specify number of syncopal episodes. If multiple
episodes have occurred, provide frequency. ACC/AHA EP DS.
42. Sleep Apnea.
43. Sleep Apnea – Sleep Study Diagnosis.
Sleep Study Diagnosis
Type:
Package:
Alias:
Class
Cardiology CDE Library
Sleep Study Diagnosis
Class Definition: Cessation of breathing for short periods during sleep. It is classified as obstructive,
central, or mixed obstructive-central. It can occur at any age but it is more frequent in people over forty.
Risk factors include male sex and obesity. Source: NCI (C26884)
Attributes
Attribute
Name:
sleepApneaStudyDiagn
osisIndicator
Datatype: Enum
Alias: Sleep Apnea_
Sleep Study Diagnosis
Name:
sleepApneaType
Datatype: Enum
Alias: Sleep Apnea
Notes
Attribute Definition: Indicate if the sleep apnea was diagnosed by a sleep
study.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if patient has a history of sleep apnea as defined
below:
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
- Obstructive sleep apnea: recurrent collapse of the pharynx during sleep
- Central sleep apnea: transient cessation of neural drive to respiratory muscles
- Mixed
44. Aorta Disease.
Aorta Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Aorta Disease
Class Definition: Current or previous history of disease of the thoracic, thoracoabdominal, or abdominal
aorta (typically aneurysm).
Attributes
Attribute
Name:
aortaDiseaseIndicator
Datatype: Enum
Alias: Aorta Disease
Indicator
Notes
Attribute Definition: Indicate current or previous history of disease of the
thoracic, thoracoabdominal, or abdominal aorta (typically aneurysm).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
45. Peripheral Arterial Disease.
Peripheral Arterial Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Peripheral Arterial Disease
Class Definition: Impaired peripheral arterial circulation evidenced by any 1 of the following:
• Claudication, either with exertion or at rest
• Amputation for arterial vascular insufficiency
• Vascular reconstruction, bypass surgery, or percutaneous intervention to the extremities
• Documented aortic aneurysm with or without repair
• Vascular angiography demonstrating a 50% or greater stenosis of a major peripheral arterial vessel
• Positive noninvasive test for peripheral arterial disease, including an ankle-brachial index less than or
equal to 0.9, ultrasound, magnetic resonance or computed tomography imaging demonstrating a 50% or
greater stenosis of a major peripheral arterial vessel Source: ACC Top 100
Attributes
Attribute
Name: PADIndicator
Datatype: Enum
Notes
Attribute Definition: Current or previous history of peripheral arterial disease,
including upper and lower extremity, renal, mesenteric, and aortic; but
excluding cerebrovascular arterial disease).
Alias: Peripheral Arterial Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Disease
Enumerations:
Selections: No, Yes
46. Renal Artery Disease.
Renal Artery Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Renal Artery Disease
Class Definition: Current or previous history of disease of the main renal arteries or extrarenal branches.
Attributes
Attribute
Name:
renalArteryDiseaseIndi
cator
Datatype: Enum
Alias: Renal Artery
Disease Indicator
Notes
Attribute Definition: Indicate current or previous history of disease of the
main renal arteries or extrarenal branches.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
47. Deep Venous Thrombosis.
Deep Venous Thrombosis
Type:
Package:
Alias:
Class
Cardiology CDE Library
Deep Venous Thrombosis
Class Definition: A blood clot (thrombus) in a deep vein in the thigh or leg. Source: NCI (C49343).
Attributes
Attribute
Name: DVTIndicator
Datatype: Enum
Alias: Deep Venous
Thrombosis
Notes
Attribute Definition: Current or previous history of deep venous thrombosis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
48. Venous Thromboembolism.
Thromboembolism
Type:
Package:
Alias:
Class
Cardiology CDE Library
Venous thromboembolism
Class Definition: Occlusion of the lumen of a vessel by a thrombus that has migrated from a distal site
via the blood stream Source: NCI (C28195)
Attributes
Attribute
Name: VTEIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate current or previous history of deep venous
thrombosis or pulmonary embolism.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Alias: Yes/No indicator choices or pick-list.
Enumerations:
for Venous
Thromboembolism (VT) Selections: No, Yes
49. Pulmonary Embolism.
Pulmonary Embolism
Type:
Package:
Alias:
Class
Cardiology CDE Library
Pulmonary Embolism
Class Definition: The closure of the pulmonary artery or one of its branches by an embolus, sometimes
associated with infarction of the lung. Source: NCI (C50713).
Attributes
Attribute
Name: PEIndicator
Datatype: Enum
Alias: Pulmonary
Embolism
Notes
Attribute Definition: Current or previous history of pulmonary embolism.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
50. Primary Valvular Disease.
Cardiac Valve Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Primary Valvular Disease
Class Definition: Primary Valvular Disease: Primary valvular heart disease is defined by heart disease
that is primarily due to a valvular defect or abnormality, and is classified as:
1 Moderately severe or severe, or 3+ or 4+ aortic insufficiency.
2 Moderately severe or severe, or 3+ or 4+ mitral insufficiency with echocardiographic evidence that
mitral insufficiency is a primary abnormality and not secondary to ventricular dilation.
3 Moderately severe or severe aortic stenosis defined by estimated aortic valve area by catheterization or
Doppler echocardiography of <=1.0 cm2.
4 Moderately severe or severe mitral stenosis defined by estimated mitral valve area by catheterization or
Doppler echocardiography of <1.0 cm2.
5 Moderately severe or severe pulmonic or tricuspid valve disease that is known to be a primary
abnormality.
Source: ACC/AHA/HRS 2006 Key Data Elements and Definitions for Electrophysiological Studies and
Procedures.
Attributes
Attribute
Name:
primaryValvularDiseas
eType
Datatype: Enum
Alias: Primary Valvular
Disease
Notes
Attribute Definition: Indicate if the patient has a history of primary valvular
heart disease that is moderately severe or severe. Note(s):
Valve disease that is felt to be significant but does not fulfill the definition for
primary valvular heat disease is considered contributory valvular heart disease,
and should be coded as 'No.'
An example of primary valvular heart disease is severe aortic stenosis that
caused heart failure or cardiomyopathy. Aortic stenosis is the primary problem.
An example of secondary valvular heart disease is a patient who had a
myocardial infarction that caused a valve defect, thus the valve disease is not
primary.
Target Value: Any occurrence between birth and the first generator procedure in
this admission.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Moderately severe or severe, or 3+ or 4+ aortic insufficiency.
2 Moderately severe or severe, or 3+ or 4+ mitral insufficiency with
echocardiographic evidence that mitral insufficiency is a primary abnormality
and not secondary to ventricular dilation.
3 Moderately severe or severe aortic stenosis defined by estimated aortic valve
area by catheterization or Doppler echocardiography of <=1.0 cm2.
Attribute
Notes
4 Moderately severe or severe mitral stenosis defined by estimated mitral valve
area by catheterization or Doppler echocardiography of <1.0 cm2.
5 Moderately severe or severe pulmonic or tricuspid valve disease that is known
to be a primary abnormality.
51. Prior Valve Surgery/Procedure.
Prior Intervention
Type:
Package:
Alias:
Class
Cardiology CDE Library
Prior Intervention
Class Definition: Course of action utilized before the current admission/encounter (or current course of
action) was initiated
Attributes
Attribute
Name:
priorCardiacTranspla
ntIndicator
Datatype: Enum
Alias: Prior cardiac
transplant
Name:
priorValveProcedureIn
dicator
Datatype: Enum
Alias: Prior Valve
Surgery/Procedure
Notes
Attribute Definition: Indicate if the patient has had previous heart transplant
surgery. Source: NCDR (ICD 2.1).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient had a previous surgical
replacement and/or repair of a cardiac valve, by any approach prior to arrival.
Note(s): This also includes percutaneous valve procedures and valvuloplasty.
Source: NCDR (Cath PCI).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
52. Sinus Node Function.
53. Permanent Pacemaker.
Permanent Cardiac Pacemaker
Type:
Package:
Alias:
Class
Cardiology CDE Library
Permanent Cardiac Pacemaker
Class Definition: An electronic device that is implanted in the body to monitor heart rate and rhythm. It
gives the heart electrical stimulation when it does not beat normally. It runs on batteries and has long, thin
wires that connect it to the heart. Source: NCI (C94198)
Attributes
Attribute
Name:
permanentPacemakerI
ndicator
Datatype: Enum
Alias: Permanent
Pacemaker
Name:
permanentPacemaker
Type
Datatype: Enum
Alias: Permanent
Pacemaker type
Name:
sinusNodeFunctionTyp
e
Datatype: Enum
Alias: Sinus Node
Function
Notes
Attribute Definition: Indicate if the patient currently has a permanent
pacemaker or had a permanent pacemaker that was implanted at any time prior
to this procedure. This includes patients that had a permanent pacemaker
previously, but the device is no longer in place.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate type of permanent pacemaker.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
• Single chamber (atrial)
• Single chamber (ventricular)
• Dual chamber (both atrial and ventricular, but not biventricular)
• Biventricular of any type
Attribute Definition: Indicate the patient's medical history with respect to
sinus node function.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
- Normal sinus rhythm (60 to 100 bpm and the cycle length does not vary by
more than 10% or 120 ms)
- Sinus arrhythmia
- Wandering atrial pacemaker
- Sinus bradycardia
- Sinoatrial exit block
- Mobitz I
- Mobitz II
- Sinus arrest/pause
Attribute
Notes
- Sinus node dysfunction (bradycardia)
- Sick sinus syndrome
- Sinus node dysfunction following cardiac surgery (transient or permanent)
- Ectopic atrial rhythm
- Other (specify)
Specify date of first documented arrhythmia, number of episodes, and
frequency.
54. Atrial arrhythmias.
55. Atrial Fibrillation.
56. Atrial Fibrillation Classification.
57. Atrial Flutter.
Atrial Arrhythmia
Type:
Package:
Alias:
Class
Cardiology CDE Library
Atrial Arrhythmia
Class Definition: Irregular heart beat resulting from a pathologic process in the cardiac atria. Source:
NCI (C80503).
Attributes
Attribute
Name:
afibrillationClassificati
onType
Datatype: Enum
Alias: afibrillation
Classification
Notes
Attribute Definition: Indicate the classification of atrial fibrillation or flutter.
Note(s): If a patient fits in more than one category choose their most recent and
most frequent presentation. For example, first detected atrial fibrillation (AF)
can be either paroxysmal or persistent. A patient may have several episodes of
paroxysmal AF and occasional persistent AF (code as paroxysmal) or the
reverse (code as persistent).
If a patient had permanent atrial fibrillation that was ablated, then it reoccurred
and is now paroxysmal, code paroxysmal.
Termination with pharmacological therapy or direct-current cardioversion does
not alter designation.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Paroxysmal The arrhythmia terminates spontaneously (without pharmacological
therapy or electrical cardioversion).
Persistent (> 7 days) The arrhythmia is sustained beyond seven days (and is not
self-terminating). This category also includes cases of long-standing atrial
fibrillation (e.g. greater than one year), cases where atrial fibrillation terminates
with pharmacological therapy or electrical cardioversion, or cases where
cardioversion is not indicated, not attempted, or unsuccessful.
Permanent (> 1 year) The arrhythmia has persisted for greater than one year,
where pharmacological therapy and/or cardioversion has failed or has been
foregone.
Secondary (reversible cause) Secondary atrial fibrillation occurs when atrial
fibrillation is transient and due to an unrelated, reversible cause. It is not the
primary problem and treatment of the underlying disorder usually terminates the
arrhythmia. It occurs in the setting of acute myocardial infarction, cardiac
surgery, pericarditis, myocarditis, hyperthyroidism, or acute pulmonary disease.
Conversely, when it is known that atrial fibrillation occurs in the course of a
Attribute
Notes
concurrent disorder like well-controlled hypothyroidism, it is not considered
secondary.
Unknown The patient has a history of atrial fibrillation but the classification is
not known or not specified. Source: NCDR (ICD
Attribute Definition: Current of previous history of atrial arrhythmia.
Name:
atrialArrhythmiaType (The assessed type of atrial arrhythmia of the patient.)
Datatype: Enum
Enumerations:
 First detected AF
Alias: Atrial arrhythmias  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
 AFlutter
 ATach
 SSS
 Paroxysmal Supraventricular Tachycardia
ACC/AHA CHF DS
Type is a collection of values used in the enumerated, menu of choices or picklist.
Attribute Definition: Indicate current or previous history of atrial fibrillation.
Name:
atrialFibrillationIndica Atrial Fibrillation is a supraventricular tachyarrhythmia characterized by
uncoordinated atrial activity with consequent deterioration of atrial mechanical
tor
Datatype: Enum
function. On the electrocardiogram (ECG), atrial fibrillation is characterized by
the replacement of consistent P waves with rapid oscillations or fibrillation
Alias: Atrial fibrillation waves that vary in amplitude, shape and timing, associated with an irregular,
frequently rapid ventricular response when atrioventricular conduction is intact.
Indicator
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate current or previous history of atrial flutter. Atrial
Name:
atrialFlutterIndicator Flutter is characterized by a sawtooth pattern of regular atrial activation called
Datatype: Enum
flutter waves on the Electrocardiogram (ECG), particularly visible in leads II,
III, aVF and v1.
Enumerations:
Alias: Atrial Flutter
Selections: No, Yes
Indicator
59. Ventricular arrhythmias.
Ventricular Arrhythmia
Type:
Package:
Alias:
Class
Cardiology CDE Library
Vtach/Vfib Arrest
Class Definition: Irregular heart beat resulting from a pathologic process in the cardiac ventricles.
Source: NCI (C26924)
Attributes
Attribute
Name: VAType
Datatype: Enum
Alias: Ventricular
Arrhythmias (VF) type
Notes
Attribute Definition: Indicate the current or previous history of ventricular
arrhythmias.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Current or previous history of ventricular arrhythmias.(The assessed type of
ventricular arrhythmia of the patient.)
• Ventricular tachycardia, sustained
• Ventricular tachycardia, non-sustained
• Ventricular fibrillation
No. Can choose any of the VT/VF choices. No is exclusive. ACC/AHA CHF
DS
60. Ventricular Tachycardia.
61. Ventricular Tachycardia Type.
Ventricular Tachycardia
Type:
Package:
Alias:
Class
Cardiology CDE Library
Ventricular tachycardia
Class Definition: Ventricular tachycardia is three or more fast heart beats (greater than 100 bpm) that
originates in one of the ventricles.
Attributes
Attribute
Name: VTIndicator
Datatype: Enum
Alias: Ventricular
Tachycardia Indicator
Name: VTType
Datatype: Enum
Alias: Ventricular
Tachycardia Type
Notes
Attribute Definition: Current or previous history of ventricular tachycardia.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the type of ventricular tachycardia. Target
Value: The highest value between birth and the first generator procedure in this
admission.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
 Non-sustained VT Nonsustained or unsustained ventricular tachycardia
(VT) is three or more beats in duration, terminating spontaneously in <30
seconds. Non-sustained VT can be monomorphic or polymorphic.
 Sustained monomorphic VT Sustained monomorphic ventricular
tachycardia (VT) is VT >30 seconds in duration or requiring termination
due to hemodynamic compromise in <30 seconds that has a stable, single
QRS morphology.
 Sustained polymorphic VT Sustained polymorphic ventricular tachycardia
(VT) is VT >30 seconds in duration or requiring termination due to
hemodynamic compromise in <30 seconds that has a changing or multiform
QRS morphology at cycle length >180 milliseconds.
 Sustained monomorphic and polymorphic VT. The patient has a history of
both sustained monomorphic and sustained polymorphic VT polymorphic
ventricular tachycardia.
 Unknown The patient has a history of ventricular tachycardia but the
specific type is not known.
62. VT/VF Arrest.
Cardiac Arrest
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Arrest
Class Definition: *Sudden" cardiac arrest is the sudden cessation of cardiac activity so that 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.
Source: ACC/AHA/HRS 2006 Key Data Elements and Definitions for Electrophysiological Studies and
Procedures
Attributes
Attribute
Name:
arrhythmiaArrestIndic
ator
Datatype: Enum
Alias: Cardiac Arrest
Due to Arrhythmia
Notes
Attribute Definition: Indicate if the patient experienced cardiac arrest due to
arrhythmia. Note(s): If a patient experienced ventricular fibrillation caused by
lead manipulation during the procedure, and it required defibrillation, code no.
No Yes
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the cardiac arrest was a result of bradycardia
which is an excessive slowness in the action of the heart, usually with a heart
rate below 60 beats per minute.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Bradycardia arrest Enumerations:
Selections: No, Yes
Attribute Definition: Current or previous history of cardiac arrest.
Name:
historyOfArrestIndicat Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
or
Datatype: Enum
Enumerations:
Selections: No, Yes
Alias: History of Cardiac
Arrest
Name:
bradycardiaArrestIndi
cator
Datatype: Enum
Name:
VTVFArrestIndicator
Datatype: Enum
Attribute Definition: Indicate if the cardiac arrest was a result of ventricular
tachycardia or ventricular fibrillation. Ventricular tachycardia is three or more
fast heart beats (greater than 100 bpm) that originates in one of the ventricles.
Ventricular fibrillation occurs when the heart's electrical activity becomes
Attribute
Alias: Ventricular
Tachycardia/Ventricular
Fibrillation Arrest
Notes
disordered and the ventricles contract in a rapid, unsynchronized way.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
63. Hemodynamic Instability associated with Ventricular Tachycardia.
Hemodynamic Instability
Type:
Package:
Alias:
Class
Cardiology CDE Library
Hemodynamic Instability associated with Ventricular Tachycardia
Class Definition: Hemodynamic instability can include periods of reduced, unstable, or abnormal blood
pressure with near syncope, or episodes of syncope. It creates a state of hypoperfusion that does not
support normal organ perfusion or function.
Attributes
Attribute
Name:
VTWithHemodynamic
InstabilityIndicator
Datatype: Enum
Alias: Hemodynamic
Instability associated
with Ventricular
Tachycardia
Notes
Attribute Definition: Indicate if the patient demonstrated hemodynamic
instability while having episodes of sustained or non-sustained ventricular
tachycardia.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
64. ICD.
Implantable Cardioverter Defibrillator
Type:
Package:
Alias:
Class
Cardiology CDE Library
ICD Indicator
Class Definition: A small device used to correct a heartbeat that is abnormal (too fast, too slow, or
irregular). The device is placed by surgery in the chest or abdomen. Wires are passed through a vein to
connect the device to the heart. When it detects abnormal heartbeats, it sends an electrical shock to the
heart to restore the heartbeat to normal. Source: NCI (C93238)
Attributes
Attribute
Name: ICDIndicator
Datatype: Enum
Alias: ICD
Notes
Attribute Definition: Indicate if the patient had an implantable cardioverter
defibrillator (ICD).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
65. Initial ICD reason is Cardiac Arrest/arrhythmia Etiology Unknown.
66. Initial ICD reason is Not Documented.
67. Initial ICD reason is Spontaneous Sustained VT.
68. Initial ICD reason is Syncope with High Risk Characteristics.
69. Initial ICD reason is Syncope with Inducible VT.
70. Initial ICD reason is Ventricular Fibrillation.
Procedure ICD Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
ICD Characteristics
Class Definition: Distinguishing properties of current or prior internal cardiac defibrillator pacemakers
including but not limited to indication for placement, device type, implant site and placement dates.
Attributes
Attribute
Name:
ICDImplantSiteType
Datatype: Enum
Notes
Attribute Definition: Indicate the location in the body where the ICD was
implanted.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: ICD Implant site Enumerations:
-Pectoral The ICD was implanted in the pectoral wall.
-Abdominal The ICD was implanted in the abdominal wall. Source: NCDR
(ICD 2.1)
Attribute Definition: Indicate if the reason the previous ICD was implanted for
Name:
secondary prevention was that the patient had an episode of cardiac arrest or
ICDReasonIndicator
Datatype: Enum
arrhythmia where the etiology was unknown. This includes a sudden loss of
consciousness requiring cardioversion or defibrillation to restore hemodynamic
Alias: Initial ICD reason stability.
Indicator is a selection of No/Yes values used in the enumerated, menu of
is Cardiac
choices or pick-list.
Arrest/arrhythmia
Enumerations:
Etiology Unknown
Selections: No, Yes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was not documented in the medical record.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Initial ICD reason Selections: No, Yes
is Not Documented
Name:
ICDReasonNotDocume
ntedIndicator
Datatype: Enum
Attribute
Name:
ICDReasonSyncopeHig
hRiskIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was that the patient had an episode of syncope (sudden
loss of consciousness with loss of postural tone not related to anesthesia) with
high risk characteristics. High risk characteristics include non-ischemic dilated
cardiomyopathy, or ischemic heart disease with significant ventricular
Alias: Initial ICD reason dysfunction, hypertrophic cardiomyopathy, Brugada Syndrome, or Long QT
Syndrome.
is Syncope with High
Indicator is a selection of No/Yes values used in the enumerated, menu of
Risk Characteristics
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
Name:
ICDReasonSyncopeInd secondary prevention was that the patient had an episode of syncope (sudden
loss of consciousness with loss of postural tone not related to anesthesia) while
ucibleVTIndicator
Datatype: Enum
ventricular tachycardia (VT) was induced during an electrophysiological study
that induced VT.
Alias: Initial ICD reason Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
is Syncope with
Enumerations:
Inducible VT
Selections: No, Yes
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was that the patient had an episode of ventricular
fibrillation (VF). VF is a rapid, usually more than 300 beats per minute (cycle
length 180 msec or less) grossly irregular ventricular rhythm with marked
variability in cycle length, lack of discernible discreet QRS complex.
Alias: Initial ICD reason Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
is Ventricular
Enumerations:
Fibrillation
Selections: No, Yes
Name:
ICDReasonVFIndicato
r
Datatype: Enum
Attribute Definition: Indicate if the reason the previous ICD was implanted for
secondary prevention was that the patient had an episode of ventricular
tachycardia (VT) that started spontaneously. Spontaneous VT lasts >30 seconds
in duration or requires termination due to hemodynamic compromise in <30
seconds.
Alias: Initial ICD reason Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
is Spontaneous
Enumerations:
Sustained VT
Selections: No, Yes
Name:
ICDReasonVTIndicato
r
Datatype: Enum
Name: ICDType
Datatype: Enum
Alias: ICD Type
Attribute Definition: Indicate the type of implantable cardioverter defibrillator
(ICD).
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Single chamber A single-chamber ICD defibrillates the ventricle and paces the
Attribute
Name:
previousICDDate
Datatype: Date
Notes
ventricle.
Dual chamber A dual-chamber ICD defibrillates the ventricle and paces the
atrium and ventricle.
CRT-D A cardiac resynchronization therapy device and defibrillator (CRT-D)
has dual capabilities. It is a biventricular pacemaker that sends electrical signals
to both ventricles as well as a defibrillator. It may or may not have an atrial
pacing wire. Source: NCDR (ICD 2.1)
Attribute Definition: Indicate the date the patient had a previous ICD. Note(s):
If month or day is unknown, enter "01". Source: NCDR
Alias: Date of Previous
ICD Date
Name:
previousICDReasonTy
pe
Datatype: Enum
Alias: Previous ICD
reason
Attribute Definition: Indicate the reason the previous ICD was implanted.
Note(s): If the patient originally presented with an indication of primary
prevention, then had an event that categorized them as secondary prevention,
code the patient as secondary prevention.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Primary prevention Primary Prevention is an indication for an ICD to prevent
sudden cardiac death. It refers to use of ICDs in individuals who are at risk for
but have not yet had an episode of sustained ventricular tachycardia, ventricular
fibrillation, or resuscitated cardiac arrest.
Secondary prevention Secondary prevention refers to an indication for ICD
exclusively for patients who have survived one or more cardiac arrests or
sustained ventricular tachycardia. Patients with cardiac conditions associated
with a high risk of sudden death who have unexplained syncope that is likely to
be due to ventricular arrhythmias are considered to have a secondary indication.
Supporting Definitions: Primary Prevention: Primary Prevention is an
indication for an ICD to prevent sudden cardiac death. It refers to use of ICDs
in individuals who are at risk for but have not yet had an episode of sustained
ventricular tachycardia, ventricular fibrillation, or resuscitated cardiac arrest.
Source: ACC/AHA//HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities
Secondary Prevention: Secondary prevention refers to an indication for ICD
exclusively for patients who have survived one or more cardiac arrests or
sustained ventricular tachycardia. Patients with cardiac conditions associated
with a high risk of sudden death who have unexplained syncope that is likely to
be due to ventricular arrhythmias are considered to have a secondary indication.
Source: ACC/AHA//HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities
71. Structural Abnormality Type – Amyloidosis.
Amyloidosis
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormalities - Amyloidosis
Class Definition: Amyloidosis is a rare and potentially fatal disease that occurs when substances called
amyloid proteins
build up in organs, including the heart. Source: NCDR
Attributes
Attribute
Name:
accumulatorIndicator
Datatype: Enum
Alias: Structural
Abnormality Type Amyloidosis
Notes
Attribute Definition: Indicate if the patient has a history of amyloidosis.
Note(s): Code yes if the patient has a documented history of amyloidosis. A
biopsy of the heart to confirm involvement is not required to code yes.
Enumerations:
Selections: No, Yes
72. Structural Abnormality Type – Atrial Septal Defect.
Atrial Septal Defect
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type -Atrial Septal Defect
Class Definition: An Atrial Septal Defect (ASD) is a hole in the wall between the two upper chambers of
the heart. Note(s): Code no if the patient has an iatrogenic ASD (e.g. after trans-septal approach for a cath
or EP study). Source: NCDR.
Attributes
Attribute
Name: ASDIndicator
Datatype: Enum
Alias: Indicator for
Structural Abnormality
of Type -Atrial Septal
Defect (ASD)
Notes
Attribute Definition: Indicate if the patient has a history of an atrial septal
defect (ASD). Note(s): Code no if the patient has an iatrogenic ASD (e.g. after
trans-septal approach for a cath or EP study).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
73. Structural Abnormality Type – Chagas Disease.
Chagas Disease
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality - Chagas Disease History
Class Definition: Chagas disease is an inflammatory, infectious condition caused by a parasite called the
reduviid bug
and which is transmitted to humans. Also called American trypanosomiasis, may become chronic, and
can result in serious heart and digestive problems. Source: NCDR
Attributes
Attribute
Notes
Name: chagasIndicator Attribute Definition: Documented history of Chagas disease.
Datatype: Enum
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Structural
Selections: No, Yes
Abnormality Type Chagas Disease
indicator
74. Structural Abnormality Type – Common Ventricle.
Common Ventricle
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type - Common Ventricle
Class Definition: Common ventricle is an umbrella term used to describe several very different complex
congenital heart defects that share the same problem: the heart has only one functional ventricle
(anatomically right or left or indeterminate) supplying the systemic circulation. These defects include
tricuspid atresia, hypoplastic left or right heart syndrome, double outlet right ventricle, double inlet left
ventricle, and other forms of single ventricle defects.
Attributes
Attribute
Name:
commonVentricleIndic
ator
Datatype: Enum
Alias: Indicator for
Common Ventricle,
congenital heart defects
that share the same
problem
Notes
Attribute Definition: Indicate if the patient has a history of a common
ventricle (CV).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
75. Structural Abnormality Type – Ebstein’s Anomaly.
Ebstein's Anomaly
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type - Ebstein's Anomaly
Class Definition: Ebstein's anomaly is a rare congenital heart defect that primarily involves the right
ventricle and the tricuspid valve. Blood leaks back through the valve and into the right atrium which can
lead to cardiomyopathy, and tachyarrhythmias. Source: NCDR.
Attributes
Attribute
Name:
ebsteinHistoryIndicato
r
Datatype: Enum
Alias: Indicator for
history of Ebstein's
anomaly (EB)
Notes
Attribute Definition: Indicate if the patient has a history of Ebstein's anomaly.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
76. Structural Abnormality Type - Giant Cell Myocarditis.
Giant Cell Myocarditis
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type - Giant Cell Myocarditis
Class Definition: Giant cell myocarditis (GCM) is a type of myocarditis (or inflammation of the
myocardium) that is diagnosed by endocardial biopsy and thought to be mediated by T lymphocytes.
Source: NCDR.
Attributes
Attribute
Name: GCMIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient has a history of giant cell
myocarditis (GCM).
Enumerations:
Alias: Indicator for giant Selections: No, Yes
cell myocarditis (GCM)
77. Structural Abnormality Type – Hypertrophic Cardiomyopathy.
Hypertrophic Cardiomyopathy
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Hypertrophic Cardiomyopathy (HCM)
Class Definition: Hypertrophic Cardiomyopathy (HCM) is a disease in which the heart muscle
(myocardium) becomes abnormally thick or hypertrophied. Source: NCDR.
Attributes
Attribute
Name: HCMIndicator
Datatype: Enum
Alias: Structural
Abnormality Type Hypertrophic
Cardiomyopathy
Notes
Attribute Definition: Indicate if the patient has a history of hypertrophic
cardiomyopathy (HCM).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
78. Structural Abnormality Type - Left Ventricular Aneurysm.
Left Ventricular Aneurysm
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Left Ventricular Aneurysm
Class Definition: A left ventricular aneurysm is a bulge or ballooning in the left ventricle of the heart.
Source: NCDR (ICD 2.1).
Attributes
Attribute
Name: LVAIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient has a history of a left ventricular
aneurysm (LVA).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Structural
Abnormality Type - Left Enumerations:
Selections: No, Yes
Ventricular Aneurysm
(LVA)
79. Structural Abnormality Type – LV-Non-compaction Syndrome.
Left Ventricular Noncompaction
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type- LV Non-compaction Syndrome
Class Definition: This is an uncommon congenital abnormality where the left ventricular myocardium
fails to compact during embryonic development, leading to cardiomyopathy with a variable degree of
ventricular dysfunction. There is genetic heterogeneity and phenotypic variability. Characteristically,
there are typically deep trabeculations in the noncompacted area, with varying proportions of the LV
myocardium compacted. LV noncompaction is associated with rhythm abnormalities including WolffParkinson-White syndrome, conduction defects, and ventricular tachyarrhythmias. Source: NCDR (ICD
2.1).
Attributes
Attribute
Notes
Name: LVNSIndicator Attribute Definition: Indicate if the patient has a history of left ventricular
Datatype: Enum
non-compaction syndrome (LVNS).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Structural
Abnormality Type- LV Enumerations:
Selections: No, Yes
Non-compaction
Syndrome
80. Structural Abnormality Type – Other.
Other Structural Abnormality
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Other Structural Abnormality
Class Definition: These conditions are frequently found in imaging reports such as echo, MRI, CAT
scan, MUGA or other imaging studies. Source: NCDR (ICD 2.1).
Attributes
Attribute
Name:
otherAbnormalityIndic
ator
Datatype: Enum
Alias: Presence of other
structural abnormality
Notes
Attribute Definition: Indicate if the patient has any other structural
abnormality of the heart, ventricles or great vessels (excluding primary valvular
heart disease).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: 0-No,1-Yes
81. Structural Abnormality Type – Right Ventricular Dysplasia (ARVD).
Arrhythmia Right Ventricular Dysplasia
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type - Right Ventricular Dysplasia (ARVD)
Class Definition: Arrhythmia Right Ventricular Dysplasia is an inherited cardiomyopathy characterized
by ventricular arrhythmia and right ventricular dysfunction. Source : NCDR (ICD 2.1).
Attributes
Attribute
Name:
arrhythmiaRVDysplasi
aIndicator
Datatype: Enum
Alias: Indicator for
arrhythmia right
ventricular dysplasia
(ARVD)
Notes
Attribute Definition: Indicate if the patient has a history of arrhythmia right
ventricular (RV) dysplasia.
Enumerations:
Selections: No, Yes
82. Structural Abnormality Type – Sarcoidosis.
Sarcoidosis
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type - Sarcoidosis
Class Definition: Sarcoidosis is a disease characterized by the development and growth of tiny clumps of
inflammatory cells in different areas of the body, including the heart. Note(s): Code yes if the patient has
a documented history of sarcoidosis. A biopsy of the heart to confirm involvement is not required to code
yes. Source : NCDR (ICD 2.1).
Attributes
Attribute
Name:
sarcoidIndicator
Datatype: Enum
Alias: Indicator for
Structural Abnormality
Type - Sarcoidosis
(Sarcoid)
Notes
Attribute Definition: Indicate if the patient has a history of sarcoidosis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
83. Structural Abnormality Type – Transposition of Great Vessels.
Transposition Great Vessels
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type - Transposition of Great Vessels
Class Definition: Transposition of the great vessels (TGV) is a congenital heart defect in which the two
main arteries leaving the heart are reversed (transposed). Source: NCDR (ICD 2.1).
Attributes
Attribute
Name: TGVIindicator
Datatype: Enum
Alias: Yes/No indicator
for history of
transposition of great
vessels (TGV)
Notes
Attribute Definition: Indicate if the patient has a history of transposition of
great vessels.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
84. Structural Abnormality Type – Tetralogy of Fallot.
Tetralogy Fallot
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type -Tetralogy of Fallot
Class Definition: Tetralogy of Fallot is a congenital heart defect characterized by a large ventricular
septal defect, pulmonary stenosis; right ventricular hypertrophy and an overriding aorta. Source: NCDR.
Attributes
Attribute
Name: TOFIndicator
Datatype: Enum
Alias: Indicator for
Tetralogy of Fallot
(TOF)
Notes
Attribute Definition: Indicate if the patient has a history of Tetralogy of Fallot
(TOF).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
85. Structural Abnormality Type – Ventricular Septal Defect.
Ventricular Septal Defect
Type:
Package:
Alias:
Class Structural Abnormality
Cardiology CDE Library
Structural Abnormality Type -Ventricular Septal Defect
Class Definition: A ventricular septal defect (VSD) is a hole in the wall between the two lower chambers
of the heart. Note(s): The VSD can be congenital or acquired. Source: NCDR.
Attributes
Attribute
Name: VSDIndicator
Datatype: Enum
Alias: Yes/No indicator
for ventricular septal
defect (VSD)
Notes
Attribute Definition: Indicate if the patient has a history of a ventricular septal
defect (VSD).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
86. Depression.
Depression
Type:
Package:
Alias:
Class
Cardiology CDE Library
Depression
Class Definition: Diagnosis of depression, or documentation of a depressed mood or affect.
Attributes
Attribute
Name:
depressionIndicator
Datatype: Enum
Alias: Depression
Notes
Attribute Definition: Current or previous diagnosis of depression, or
documentation of a depressed mood or affect.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
87. HIV Infection
HIV Infection
Type:
Package:
Alias:
Class
Cardiology CDE Library
HIV Infection
Class Definition: 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.
Attributes
Attribute
Name: HIVIndicator
Datatype: Enum
Alias: HIV Infection
Indicator
Notes
Attribute Definition: Indicate HIV infection diagnosed by a physician or
qualified medical-care provider documented in a medical record.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
90. Patient Life Expectancy of >= 1 year.
Patient Life Expectancy
Type:
Package:
Alias:
Class
Cardiology CDE Library
Patient Life Expectancy of > = 1 year
Class Definition: The length of time a patient may be expected to live.
Attributes
Attribute
Name:
lifeExpectancyType
Datatype: Enum
Alias: Patient Life
Expectancy of > = 1
year.
Notes
Attribute Definition: Indicate if, by physician estimate, the patient is expected
to live for one or more years.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
-No
-Yes
-Not Documented
91. Clinical Trial.
Clinical Trial Participant
Type:
Package:
Alias:
Class
Cardiology CDE Library
Clinical Trial Participant
Class Definition: NCI/PT | Consent by a patient to a surgical or medical procedure or participation in a
clinical study after achieving an understanding of the relevant medical facts and the risks involved.
C0021430 (Informed Consent)
Attributes
Attribute
Name:
clinicalTrialConsentIn
dicator
Datatype: Enum
Alias: Clinical Trial
Informed Consent
Notes
Attribute Definition: Indicate if the patient signed an informed consent to
participate in a clinical trial during his/her hospitalization, even if the
investigational medication, device, or procedure was never initiated.
Note(s): This element is referenced in The Joint Commission AMI Core
Measures, AMI-1 through AMI-9.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Family history
92. Coronary artery disease.
Familial Coronary Artery Disease
Type:
Package:
Alias:
Class
Cardiology CDE Library
Familial Coronary Artery Disease
Class Definition: A record of a patient's background regarding health and disease events of blood
relatives includes the diagnosis of coronary artery disease. A patient's family medical history may be
important in diagnosing existing conditions Source: NCI (C17726)
Attributes
Attribute
Name:
familialCADIndicator
Datatype: Enum
Alias: Family history of
Coronary artery disease
(CAD)
Notes
Attribute Definition: A first-degree relative (parent, sibling, child)
documented to have had any of the following at age less than 55 years for male
relatives or less than 65 years for female relatives: :
- Coronary artery disease (CAD) -Myocardial infarction (MI)
- Coronary artery bypass graft surgery (CABG)
- Percutaneous coronary intervention (PCI)
- Sudden cardiac death without obvious cause.
Enumerations:
Selections: No, Yes
93. Sudden Cardiac Death.
Familial Sudden Cardiac Death
Type:
Package:
Alias:
Class
Cardiology CDE Library
Sudden Cardiac Death
Class Definition: Family history (parent or sibling) of sudden cardiac death, defined as natural death due
to cardiac causes,
heralded by abrupt loss of consciousness. The time and mode of death are unexpected even though
preexisting heart disease may have been known to be present (26). Sudden death without obvious cause is
considered sudden cardiac death. Traumatic death subsequently proven to be due to sudden loss of
control due to a cardiac problem is included. Source: ACC/AHA CHF Data Standards.
Attributes
Attribute
Name:
familialSCDIndicator
Datatype: Enum
Alias: Family history of
Sudden cardiac death
(SCD)
Notes
Attribute Definition: A first-degree relative (parent, sibling, child)
documented to have died of suddenly of presumed cardiac etiology without
other obvious cause.
ACC/AHA Cardiac Imaging DS.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Physical exam
94. Height.
95. Weight.
96. Systolic Blood Pressure.
97. Diastolic Blood Pressure.
100. Waist Circumference.
104. Killip Class.
Physical Exam
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: This class supports the collection of information resulting from the physical exam of a
patient. It includes information for the period prior to the encounter, e.g., CHF current status, as well as
information collected within the context of the encounter, e.g., Admission Sx Presentation.
Attributes
Attribute
Notes
Attribute Definition: Diastolic blood pressure in millimeters mercury.
Name:
diastolicBloodPressure
Datatype: Integer
Alias: Diastolic Blood
Pressure
Name: height
Datatype: Integer
Attribute Definition: Height in cm. To be converted from English units if
needed.
Alias: Height
Name: killipClass
Datatype: Enum
Alias: killip Class
Attribute Definition: In patients presenting with an acute ST elevation
myocardial infarction, physical exam findings at the initial evaluation:
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Class 1: absence of rales over the lung fields and absence of S3
Class 2: rales over 50% or less of the lung fields or the presence of an S3
• Class 3: rales over more than 50% of the lung fields
• Class 4: cardiogenic shock (systolic BP <90 mm Hg greater than or equal to
30 minutes, not responsive to fluid resuscitation alone, and felt to be secondary
Attribute
Notes
to cardiac) dysfunction. ACC/AHA ACS Data Standards.
Name:
systolicBloodPressure
Datatype: Integer
Attribute Definition: Systolic blood pressure in millimeters mercury.
Alias: Systolic Blood
Pressure
Name:
waistCircumference
Datatype: Integer
Attribute Definition: Measured actual waist dimensions at the level of the
umbilicus, in cm.
Alias: Waist
circumference
Name: weight
Datatype: Integer
Alias: Weight
Attribute Definition: Measured actual weight in kg. To be converted from
English units if needed.
98. Heart Rate.
99. Heart Rate Date/Time.
Pulse
Type:
Package:
Alias:
Class
Cardiology CDE Library
Pulse
Class Definition: Number of heart beats over a period of one minute.
Attributes
Attribute
Name: heartRate
Datatype: Integer
Notes
Attribute Definition: Indicate the number of heart beats over a period of one
minute.
Alias: Heart Rate
Name:
heartRateDateTime
Datatype: DateTime
Alias: Heart Rate
Date/Time
Attribute Definition: The date/time that the Heart Rate was taken.
101. Chest Pain: Angina or Anginal Equivalent.
102. Anginal classification.
103. Anginal Classification Date.
Angina Pectoris
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: Chest pain, other discomfort, dyspnea, or other sign or symptom possibly, probably, or
definitely consistent with myocardial ischemia or infarction. ACC/AHA Cardiac Imaging DS.
Attributes
Attribute
Notes
Attribute Definition: Date of the Canadian Cardiovascular Society (CCS)
Name:
CCSAnginalClassificat Anginal Classification.
ionDate
Datatype: Date
Alias: Anginal
Classification Date
Name:
CCSAnginalClassificat
ionType
Datatype: Enum
Alias: Anginal
Classification
Attribute Definition: Type is a collection of values used in the enumerated,
menu of choices or pick-list. For symptoms or signs in patients suspected or
consistent with myocardial ischemia per the Canadian Cardiovascular Society
(CCS) grading scale:
Enumerations:
• 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 more than 2 blocks on the level and
climbing more than 1 flight of ordinary stairs at a normal pace and in normal
conditions.
• Class III: Marked limitations 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.
I
II
III
IV
Attribute
Notes
ACC/AHA Campeau L. Circulation 1976;54:522. Letter.
105. New York Heart Association Class.
HeartFailure
Type:
Package:
Alias:
Class
Cardiology CDE Library
Heart Failure
Class Definition: 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 distension,
pulmonary edema on physical exam, or pulmonary edema on chest x-ray presumed to be cardiac
dysfunction. A low ejection fraction without clinical evidence of heart failure does not qualify as heart
failure. Source: Acute Coronary Syndromes Data Standards (JACC 2001 38: 2114 - 30), The Society of
Thoracic Surgeons.
Attributes
Attribute
Name: HFIndicator
Datatype: Enum
Alias: Heart Failure
Name:
NYHAClassType
Datatype: Enum
Alias: NYHA Class
Notes
Attribute Definition: Indicate current or previous history of heart failure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Heart failure class [New York Heart Association
(NYHA)] For symptoms or signs in patients with defined or presumed cardiac
disease per the New York Heart Association classification scale.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
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.
Value Domain/PV:
I
II
III
IV
Source: ACC/AHA
Citation: The Criteria Committee of the New York Heart Association. In
Nomenclature and Criteria for Diagnosis of Diseases of the Heart and Great
Attribute
Notes
Vessels, 9th ed. Boston, Mass: Little, Brown & Co.; 1994: 253-256.
Laboratory values
Reported in standard laboratory units.
106. Blood urea nitrogen.
107. Creatinine.
108. Hematocrit.
109. Hemoglobin.
110. Glucose, any.
111. Glucose, fasting.
112. Hemoglobin A1c.
113. Total cholesterol.
114. LDL cholesterol.
115. HDL cholesterol.
116. Triglycerides.
117. Brain naturemic peptide (BNP).
118. NT-proBNP.
119. Prothrombin International Normalized Ratio (INR).
120. Sodium.
121. Potassium.
122. Creatinine kinase (CK).
123. Creatinine kinase MB (CK-MB).
124. Troponin.
125. Troponin I.
126. Troponin T.
Diagnostic Procedures
127. Cardiac diagnostic procedure.
128. Date of cardiac diagnostic procedure.
Cardiac Diagnostic Procedure
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Diagnostic Procedure
Class Definition:
Attributes
Attribute
Name:
diagnosticProcedureTy
pe
Datatype: Enum
Alias: Cardiac
Diagnostic Procedure
Notes
Attribute Definition: Indicate the type of cardiac diagnostic procedure. This
lexicon emphasizes common names for procedure concepts even when various
sub-procedures comprise the concept (e.g., transthoracic echocardiogram, left
heart catheterization), rather than an unbundled listing of the sub-procedures
that comprise the procedure (e.g., CPT code listing). The procedure of greater
complexity should be chosen when the concept of greater complexity is
inclusive of the one of lesser complexity (e.g., Stress echo is inclusive of TTE).
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
ECG
Holter monitor
Event monitor
TTE
TEE
Stress ECG
Stress echo
Stress nuclear
MR
Stress MR
CTA
PET
RHC
RvBx
LHC
EPS
Coronary Angiography
[Except for cardiac catheterization and RV biopsy, tests are mutually exclusive
events]
129. 12 Lead ECG.
130. 12 Lead ECG Date/Time.
131. ECG (any).
132. ECG (any) date/Time.
Lead ECG Performed
Type:
Package:
Alias:
Class
Cardiology CDE Library
Lead ECG Performed
Class Definition: The patient had a 12 lead electrocardiogram (ECG) with automated measurements.
Attributes
Attribute
Name:
12LeadECGPerformed
Indicator
Datatype: Enum
Alias: 12 Lead EG
Performed indicator
Notes
Attribute Definition: Indicate if the patient had a 12 lead electrocardiogram
(ECG) with automated measurements.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
133. ECG Timing with STEMI or STEMI Equivalent.
134. ECG Findings for NSTEMI.
135. ECG Findings for STEMI.
ECG Findings
Type:
Package:
Alias:
Class
Cardiology CDE Library
ECG Findings
Class Definition: Interpretations of measurements from an electrocardiogram.
Attributes
Attribute
Name:
abnormalIVCIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction
Name:
leftAnteriorFascicular
BlockIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction Type - Left
Anterior Fascicular
Block
Name:
leftBundleBranchBlock
Indicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction Type - Left
Bundle Branch Block
Notes
Attribute Definition: Indicate if the patient has Abnormal intraventricular
conduction, with fascicular blocks, bundle branch blocks, non-specific
conduction delays or ventricular pacing.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient has left anterior fascicular block.
Left anterior fascicular block is characterized by all of the following: Left-axis
deviation with frontal QRS axis between -45 degrees and -90 degrees; Q wave
in lead aVL; rS in inferior leads ; QRS duration is <120 ms ACC/AHA/HRS
2006 Key Data Elements and Definitions for Electrophysiological Studies and
Procedures.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient has left bundle branch block. .
Supporting def (if any): Left Bundle Branch is characterized by QRS duration
120 ms or longer, delayed onset of intrinsicoid deflection in 1, V5, and V6 >60
ms, Broad and notched or slurred R waves in I, aVL, V5, and V6, rS or QS
complexes in right precordial leads, ST-segment and T waves in opposite
polarity to the major QRS deflection ACC/AHA/HRS 2006 Key Data Elements
and Definitions for Electrophysiological Studies and Procedures.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute
Name:
leftPosteriorFascicular
BlockIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction Type - Left
Posterior Fascicular
Block
Notes
Attribute Definition: Indicate if the patient has left posterior fascicular block.
Selections: 0-No,1-Yes, Supporting def (if any):Left Posterior Fascicular Block
is characterized by all of the following: Right-axis deviation with frontal QRS
axis between +90 degrees and +180 degrees; rS in leads I and aVL and qR in
inferior leads (Q waves 40 ms) QRS duration <120 ms; Exclude other causes of
Right Axis deviation ACC/AHA/HRS 2006 Key Data Elements and Definitions
for Electrophysiological Studies and Procedures.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient has an intraventricular conduction
delay that was nonspecific. Selections: 0-No,1-Yes, Supporting def (if
any):Non-Specific abnormal Intraventricular conduction delays are
characterized by a QRS duration of 110 ms or more with morphology different
from LBBB or RBBB ACC/AHA/HRS 2006 Key Data Elements and
Definitions for Electrophysiological Studies and Procedures.
Alias: Abnormal
Indicator is a selection of No/Yes values used in the enumerated, menu of
Intraventricular
choices or pick-list.
Conduction Type Enumerations:
Delay, Nonspecific
Selections: No, Yes
Name: NSTEMIType Attribute Definition: Indicate if the findings from the electrocardiogram
Datatype: Enum
demonstrated evidence on NSTEMI., code the findings on which treatment was
based.
Alias: ECG Findings for Type is a collection of values used in the enumerated, menu of choices or picklist.
NSTEMI
Enumerations:
1 New or Presumed New ST
Depression
Indicate if there was new or presumed
new horizontal or down-sloping ST
depression >=0.5 mV in two contiguous
leads below the isoelectric line on the
electrocardiogram (ECG) within the first
24 hours of presentation. If no exact
ST- depression measurement is
recorded in the medical chart,
physician’s written documentation of
ST- depression is acceptable.
2 New or Presumed New T Wave
Inversion
Indicate if there was a new or
presumed new T-wave inversion of at
least 0.1 mV in two contiguous leads
Name:
nonspecificIVCDelayIn
dicator
Datatype: Enum
Attribute
Name: PRInterval
Datatype: Integer
Notes
with prominent R-wave or R/S ratio >1
within the first 24 hours of
presentation. If no exact T-wave
inversion measurement is recorded in
the medical chart, physician’s written
documentation of T-wave inversion is
acceptable.
3 Transient ST Elevation
Lasting < 20 Minutes
Indicate if there was new or presumed
new ST- segment elevation at the J point
in two contiguous
electrocardiogram (ECG) leads with the
cut-off points: >=0.2 mV in men or >=
0.15mV in women in leads V2-V3
and/or >= 0.1 mV in other leads, and
lasting less than 20 minutes, within the
first 24 hours of presentation. If no
exact ST- elevation measurement is
recorded in the medical chart,
physician’s written documentation of
transient ST- elevation is acceptable.
4 None Indicate if the first electrocardiogram
(ECG) did not reveal ST depression,
transient ST-elevation or T-wave inversion
Attribute Definition: Indicate the PR interval, in milliseconds, on the
electrocardiogram.
Alias: PR Interval
Name:
PRIntervalObtainableI
ndicator
Datatype: Enum
Alias: PR Interval not
Obtainable
Name: QRSDuration
Datatype: Integer
Alias: QRS Duration
(Non-ventricular Paced
Complexes)
Attribute Definition: Indicate if the PR interval on the electrocardiogram was
not obtainable.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the duration of the non-ventricular paced or
intrinsic QRS complex, in milliseconds, that was derived from the surface
electrocardiogram (ECG). Surface ECGs are obtained from the surface of the
body and do not include intracardiac ECGs.
Attribute
Notes
Attribute Definition: Indicate if the patient has right bundle branch block.
Selections: 0-No,1-Yes. Right Bundle Branch Block is characterized by a QRS
duration of 120 ms, rsR' or rSR' complexes in V1 and V2, Delayed onset of
intrinsicoid, deflection in V1 and V2 >50 ms, Broad, slurred S wave in 1, V5,
and V6
Secondary ST-T wave changes ACC/AHA/HRS 2006 Key Data Elements and
Alias: Abnormal
Definitions for Electrophysiological Studies and Procedures.
Intraventricular
Conduction Type - Right Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Bundle Branch Block
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the ECG findings demonstrated either new or
Name:
STEMIECGFindingsT presumed new ST segment elevation, new left bundle branch block, or isolated
posterior myocardial infarction. Code the findings on which treatment was
ype
Datatype: Enum
based.
Type is a collection of values used in the enumerated, menu of choices or pickAlias: ECG Findings for list.
Enumerations:
STEMI
1 ST Elevation ST-segment elevation is defined by
new or presumed new sustained ST segment
elevation at the J-point in two
contiguous electrocardiogram (ECG)
leads with the cut-off points: >=0.2 mV
in men or >= 0.15mV in women in leads
V2-V3 and/or >= 0.1 mV in other leads
and lasting greater than or equal to 20
minutes. If no exact ST-elevation
measurement is recorded in the
medical chart, physician’s written
documentation of ST-elevation or Q waves
is acceptable. If only one ECG
is performed, then the assumption that
the ST elevation persisted at least the
required 20 minutes is acceptable.
2 LBBB Left bundle branch block (LBBB) refers
to LBBB that was not known to be old
on the initial ECG.
3 Isolated Posterior MI Isolated Posterior Myocardial Infarction refers to
infarction of the posterobasal wall of the left ventricle. The use of posterior
leads V7 to V9 will show ST segment elevation in patients with posterior
infarction. If posterior leads were not applied, ST segment depression that is
Name:
rightBundleBranchBlo
ckIndicator
Datatype: Enum
Attribute
Notes
maximal in leads V1-V3, without ST-segment elevation in other leads, may be
considered as indicative of posterior ischemia or infarction.
Attribute Definition: Indicate if a STEMI or STEMI equivalent was noted on
either the first ECG or a subsequent ECG. Note(s): Code "Subsequent ECG" if
the ECG on arrival does not indicate STEMI or STEMI equivalent.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: ECG Timing with Enumerations:
1 First ECG
STEMI or STEMI
2 Subsequent ECG
Equivalent
Name:
STEMIECGTimingTy
pe
Datatype: Enum
Alias: Only Ventricular
Paced QRS Complexes
Attribute Definition: Indicate if there were only ventricular paced QRS
complexes present. Note(s): If the patient has some intrinsic ventricular
complexes present, code 'No.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Name:
ventricularPacedQRS
Duration
Datatype: Integer
Attribute Definition: Indicate the duration of the ventricular paced QRS
complex, in milliseconds, that was derived from the surface electrocardiogram
(ECG). Surface ECGs are obtained from the surface of the body and do not
include intracardiac ECGs.
Name:
ventricularPacedQRS
ComplexesIndicator
Datatype: Enum
Alias: Ventricular Paced
QRS Duration
Name:
VentricularPacedRhyt
hmIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction Type Ventricular Paced
Rhythm
Attribute Definition: Indicate if the patient has a ventricular paced rhythm. If,
on the ECG closest to the procedure, the patient is not paced 100% of the time,
code no., Target value: The last value between birth and the first generator
procedure in this admission.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
136. Electrophysiology Study.
Electrophysiology Study Performed
Type:
Package:
Alias:
Class
Cardiology CDE Library
Electrophysiology Study Performed
Class Definition: The patient had an electrophysiology study (EPS). One or more catheters capable of
recording and pacing are placed in one or more of the cardiac chambers. The catheters may be used to
measure conduction of the impulse from the sinus node to the ventricle; induce a tachycardia; and/or
localize (map) the location where the tachycardia originates. NCDR
Attributes
Attribute
Name:
EPSPerformedIndicato
r
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient had an electrophysiology study
(EPS).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Electrophysiology Selections: No, Yes
study (EPS) Performed
Indicator
137. Ventricular Arrhythmias Induced.
Ventricular Arrhythmia Induced
Type:
Package:
Alias:
Class
Cardiology CDE Library
Ventricular Arrhythmias Induced
Class Definition: Arrhythmias that are induced through programmed ventricular stimulation, or delivery
of external energy, such as radiofrequency current. ACC/AHA/HRS 2006 Key Data Elements and
Definitions for Electrophysiological Studies and Procedures.
Attributes
Attribute
Name:
inducedIndicator
Datatype: Enum
Alias: Ventricular
Arrhythmias Induced
Notes
Attribute Definition: Indicate if ventricular arrhythmias were induced during
the electrophysiology study.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
138. Non-Invasive Stress Testing.
NonInvasive Stress Test
Type:
Package:
Alias:
Class
Cardiology CDE Library
Non-Invasive Stress Testing
Class Definition: Patient underwent exercise or pharmacologic stress testing with or without
echocardiographic or nuclear imaging.
Attributes
Attribute
Name:
nonInvasiveStressTestI
ndicator
Datatype: Enum
Alias: Non-Invasive
Stress Test Indicator
Notes
Attribute Definition: Indicate if the patient underwent exercise or
pharmacologic stress testing with or without echocardiographic or nuclear
imaging.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
139. Stress Test Result.
Stress Test Result
Type:
Package:
Alias:
Class
Cardiology CDE Library
Stress or Exercise Stress Test Results
Class Definition: A recording of cardiac electrical activity during stress or exercise. Source: NCI
(C80406)
Attributes
Attribute
Name:
exceriseStressResultType
Datatype: Enum
Notes
Attribute Definition: Indicate the results of the exercise stress test.
Type is a collection of values used in the enumerated, menu of choices or
pick-list.
Enumerations:
Alias: Exercise Stress Test Negative: A stress test is negative when the electrocardiogram (ECG) is
normal or not suggestive of ischemia. ECGs are not suggestive of ischemia
Results
when < 1 mm of horizontal or downsloping ST-segment depression or
elevation for >= 60-80 milliseconds after the end of the QRS complex, either
during or after exercise.
Positive: A stress test is positive when the electrocardiogram (ECG) suggests
ischemia. ECGs suggestive of ischemia can be described as having >= 1
mm of horizontal or downsloping ST-segment depression or elevation for >=
60-80 milliseconds after the end of the QRS complex, either during or after
exercise. It is also suggestive of ischemia if the patient had symptoms of
ischemia (i.e., chest pain), arrhythmias, and/or a fall in blood pressure during
or immediately after the procedure.
If more than one study was performed with conflicting results and one study
suggested coronary artery disease, code yes.
Indeterminant: The results of the stress test were in determinant. They cannot
be considered positive or negative.
Unavailable: The results of the stress test are not available.
Attribute Definition: Result of functional cardiac testing evaluating for
Name:
evidence of myocardial ischemia.
stressTestResultType
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or
pick-list.
Enumerations:
Alias: Stress Test Result
Normal
Abnormal
Indeterminate
140. Exercise Stress Test Results.
Ischemia Risk Score Stress
Type:
Package:
Alias:
Class
Cardiology CDE Library
Ischemia Risk Stress
Class Definition: The risk score is derived by the Duke Treadmill score which is an exercise treadmill
score that predicts prognosis in coronary artery disease. It is calculated as follows: Treadmill score =
exercise time -(5 x ST-segment deviation in millimeters*) -(4 x treadmill angina index**) * ST-segment
deviation can be measured at 60 to 80 ms after the J point. If the amount of exercise-induced ST-segment
deviation is less than 1 mm, the value entered into the score for ST deviation is 0. ** The treadmill
anginal index has a value of 0 if there was no exercise angina, 1 if exercise angina occurred, and 2 if
angina was the reason the patient stopped exercising. Exercise time is based on a standard Bruce protocol.
The Duke Treadmill Score was published by Daniel, Mark, et. al, in the Annals of Internal Medicine, June
1987, Vol 106, #6.
Attributes
Attribute
Name:
riskExtentIschemiaStr
essType
Datatype: Enum
Alias: Risk/Extent of
Ischemia (Stress Test)
Notes
Attribute Definition: Indicate the risk score of the standard exercise stress test.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Target Value: The last value between 6 months prior to procedure and current
procedure.
Enumerations:
 Low Risk: Low-risk treadmill score (score >=5). Low risk equates with a
less than 1% annual mortality rate.
 Intermediate Risk: Intermediate risk treadmill score (-11 < score < 5).
Intermediate risk equates with a 1-3% annual mortality rate.
 High Risk: High risk treadmill score (score <= -11). High risk equates with
a greater than 3% annual mortality rate.
 Unavailable: The results of the stress test are unavailable.
Supporting Definitions: (none)
141. SPECT/MPI Imaging Results.
SPECT MPI Result
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: C0040399 SPECT NCI/PT | A type of tomography in which gamma photon-emitting
radionuclides are administered to the patient and then detected by one or more gamma cameras rotated
around the patient. From the series of two-dimensional images produced, a three-dimensional image can
be created by computer reconstruction.
Attributes
Attribute
Name: SMResultType
Datatype: Enum
Notes
Attribute Definition: Indicate the imaging results of the SPECT MPI study.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: SPECT/MPI
Imaging Results SPECT 1 Negative The results of the imaging study revealed no myocardial perfusion
MPI imaging result (it’s defects.
an appropriate acronym) 2 Positive The result of the imaging study revealed one or more stress-induced
myocardial perfusion defects.
3 Indeterminant The results of the study were uninterpretable. They cannot be
considered positive or negative.
4 Unavailable The results of the study were not available.
Supporting Definitions: (none)
142. Risk/Extent of Ischemia (SPECT/MPI).
Ischemia Risk SPECT MPI
Type:
Package:
Alias:
Class
Cardiology CDE Library
Ischemia Risk Nuclear
Class Definition: The percentage of myocardial tissue which exhibits characteristics of inadequate blood
flow as measured by cardiac nuclear imaging procedure/study. Source: NCI (C80494).
Attributes
Attribute
Name:
riskExtentIschemiaSpe
ctMPIType
Datatype: Enum
Alias: Risk/Extent of
Ischemia (SPECT/MPI)
Notes
Attribute Definition: Indicate the risk or extent of ischemia as evidenced by
the results of a stress testing with SPECT MPI.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
 Low Risk
1. Low-risk treadmill score (score >=5).
2. Normal or small myocardial perfusion defect at rest or with stress.*
*Although the published data are limited, patients with these findings will
probably not be at low risk in the presence of either a high-risk treadmill
score or severe resting left ventricular dysfunction (LVEF <35%).
Low risk equates with a less than 1% annual mortality rate.
 Intermediate Risk
1. Mild/moderate resting left ventricular dysfunction (LVEF=35% to 49%).
2. Intermediate-risk treadmill score (-11 < score < 5)
3. Stress-induced moderate perfusion defect without LV dilation or
increased lung intake (thallium-201)
Intermediate risk equates with a 1%-3% annual mortality rate.
 High Risk
1. Severe resting left ventricular dysfunction (exercise LVEF <35%)
2. High-risk treadmill score (score <= -11)
3. Severe exercise left ventricular dysfunction (exercise LVEF <35%)
4. Stress-induced large perfusion defect (particularly if anterior)
5. Stress-induced multiple perfusion defects of moderate size
6. Large, fixed perfusion defect with LV dilation or increased lung update
(thallium-201)
7. Stress-induced moderate perfusion defect with LV dilation or increased lung
uptake (thallium-201)
High risk equates with a greater than 3% annual mortality rate.
Unavailable The results of the study were not available.
143. Stress Echo Imaging Results.
Echo Stress Test Result
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: An image of the heart produced by ultrasonography during exercise or while
pharmacologic stressors are in use. (C37945)
Attributes
Attribute
Name:
stressEchoResultType
Datatype: Enum
Alias: Stress Echo
Imaging Results
Notes
Attribute Definition: Indicate the imaging results of the stress echocardiogram.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumeration
Negative: The imaging study was normal. There was no change in wall motion
during the procedure.
Positive: The imaging study was abnormal. There were changes that reflected
wall motion abnormalities during the procedure.
Indeterminant: The results of the study were uninterpretable. They cannot be
considered positive or negative.
Unavailable: The results of the imaging study was not available.
144. Risk/Extent of Ischemia (Stress Echo).
Ischemia Risk Stress Echo
Type:
Package:
Alias:
Class
Cardiology CDE Library
Risk/Extent of Ischemia (Stress Echo)
Class Definition: Type is a collection of values used in the enumerated, menu of choices or pick-list.
Enumerations:
Indicate the risk or extent of ischemia of the stress echocardiogram.
Low risk
1. Low-risk treadmill score (score >=5).
2. Normal stress echocardiographic wall motion or no change of limiting
resting wall motion abnormalities during stress*. *Although the published data are limited,
patients with these findings will probably not be at low risk in the presence of either a high-risk
treadmill score or severe resting left ventricular dysfunction (LVEF <35%). Low risk equates with
a less than 1% annual mortality rate
Intermediate risk 1. Mild/moderate resting left ventricular dysfunction (LVEF=35% to 49%) 2.
Intermediate-risk treadmill score (-11 < score < 5). 3. Limited stress echocardiographic ischemia
with a wall motion abnormality only at higher doses of dobutamine involving less than or equal to
two segments. Intermediate risk equates with a 1%-3% annual mortality rate.
High risk 1. Severe resting left ventricular dysfunction (exercise LVEF <35%). 2. High-risk
treadmill score (score <= -11). 3. Severe exercise left ventricular dysfunction (exercise LVEF
<35%). 4. Echocardiographic wall motion abnormality (involving greater than two segments)
developing at low dose of dobutamine (<=10 mg/kg/min) or at a low heart rate (<120 beats/min). 5.
Stress echocardiographic evidence of extensive ischemia.
High risk equates with a greater than 3% annual mortality rate.
Unavailable Results of test not available.
Attributes
Attribute
Name:
ischemiaRiskStressEch
oIndicator
Datatype: Enum
Alias: Ischemia Risk
Stress Echo Indicator
Notes
Attribute Definition: Indicate the risk or extent ischemia as evidenced by the
results of a stress echocardiogram.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
 Low risk
1. Low-risk treadmill score (score >=5).
2. Normal stress echocardiographic wall motion or no change of limiting
resting wall motion abnormalities during stress*. *Although the published data
are limited, patients with these findings will probably not be at low risk in the
presence of either a high-risk treadmill score or severe resting left ventricular
dysfunction (LVEF <35%). Low risk equates with a less than 1% annual
mortality rate
Attribute
Notes
 Intermediate risk 1. Mild/moderate resting left ventricular dysfunction
(LVEF=35% to 49%) 2. Intermediate-risk treadmill score (-11 < score < 5).
3. Limited stress echocardiographic ischemia with a wall motion
abnormality only at higher doses of dobutamine involving less than or equal
to two segments. Intermediate risk equates with a 1%-3% annual mortality
rate.
 High risk 1. Severe resting left ventricular dysfunction (exercise LVEF
<35%). 2. High-risk treadmill score (score <= -11). 3. Severe exercise left
ventricular dysfunction (exercise LVEF <35%). 4. Echocardiographic wall
motion abnormality (involving greater than two segments) developing at
low dose of dobutamine (<=10 mg/kg/min) or at a low heart rate (<120
beats/min). 5. Stress echocardiographic evidence of extensive ischemia.
High risk equates with a greater than 3% annual mortality rate.
 Unavailable Results of test not available.
145. Stress Test with CMR Imaging.
Cardiac Magnetic Resonance Result
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Magnetic Resonance Result
Class Definition: Findings from a cardiac magnetic resonance imaging procedure performed to evaluate
cardiac function, structure or morphology.
Attributes
Attribute
Name:
CMRResultType
Datatype: Enum
Alias: CMR Imaging
Results
Notes
Attribute Definition: Indicate the imaging results of the cardiac magnetic
resonance (CMR) imaging study performed to evaluate cardiac perfusion.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Negative: The results of the imaging study revealed no myocardial perfusion
defects.
Positive: The result of the imaging study revealed one or more stress-induced
myocardial perfusion defects.
Indeterminant: The results of the study were uninterpretable. They cannot be
considered positive or negative.
Unavailable: The results of the study were not available.
146. Risk/Extent of Ischemia (Stress Test with CMR).
Ischemia Risk CMR
Type:
Package:
Alias:
Class
Cardiology CDE Library
Risk/Extent of Ischemia (Stress Test with CMR)
Class Definition: Indicate the risk or extent of ischemia as evidenced by the results of a stress test with
cardiac magnetic resonance (CMR).
Attributes
Attribute
Name:
ischemicRiskType
Datatype: Enum
Notes
Attribute Definition: Indicate the risk or extent of ischemia as evidenced by
the results of a stress test with cardiac magnetic resonance (CMR).
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: Type Risk/Extent of Ischemia 1 Low Risk 1. Low-risk treadmill score (score >=5).
(Stress Test with CMR) 2. Normal or small myocardial perfusion defect at rest or with stress.*
*Although the published data are limited, patients with these findings will
probably not be at low risk in the presence of either a high-risk treadmill score
or severe resting left ventricular dysfunction (LVEF <35%).
Low risk equates with a less than 1% annual mortality rate.
2 Intermediate Risk 1. Mild/moderate resting left ventricular dysfunction
(LVEF=35% to 49%).
2. Intermediate-risk treadmill score (-11 < score < 5)
3. Stress-induced moderate perfusion defect without LV dilation or increased
lung intake (thallium-201)
Intermediate risk equates with a 1%-3% annual mortality rate.
3 High Risk 1. Severe resting left ventricular dysfunction (exercise LVEF
<35%)
2. High-risk treadmill score (score <= -11)
3. Severe exercise left ventricular dysfunction (exercise LVEF <35%)
4. Stress-induced large perfusion defect (particularly if anterior)
5. Stress-induced multiple perfusion defects of moderate size
6. Large, fixed perfusion defect with LV dilation or increased lung update
(thallium-201)
7. Stress-induced moderate perfusion defect with LV dilation or increased lung
uptake (thallium-201)
High risk equates with a greater than 3% annual mortality rate.
4 Unavailable The results of the study were not available.
147. Cardiac CTA.
148. Cardiac CTA Results.
Cardiac CTA
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac CTA
Class Definition: Cardiac computerized tomographic angiography (CTA) was performed.
Attributes
Attribute
Name: CTAIndicator
Datatype: Enum
Alias: Cardiac CTA
Indicator
Notes
Attribute Definition: Indicate if a cardiac computerized tomographic
angiography (CTA) was performed.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the results of the cardiac computerized
tomographic angiography (CTA). Note(s): For purposes of coding the results of
a cardiac CTA, a coronary artery is defined as one of the 3 major vessels of the
heart. These vessels are the right coronary artery, the left anterior descending
Alias: CTA Result Type. coronary artery and the circumflex coronary artery and their associated
branches. A left main coronary artery with stenosis >=50% is considered two
vessel disease because it feeds both the left anterior descending and circumflex
arteries.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
0 No disease There was <50% stenosis in all coronary artery branches.
1 1 Vessel disease There was >=50% stenosis in one coronary artery.
2 2 Vessel disease There was >=50% stenosis in two coronary arteries (or
>=50% stenosis in
the left main coronary artery).
3 3 Vessel disease There was >=50% stenosis in three coronary arteries (or
>=50% stenosis
in the left main coronary artery and >=50% stenosis in the right coronary
artery).
4 Indeterminant The results of the study were uninterpretable due to technical or
patientrelated issues.
5 Unavailable The results of the study were unavailable.
Name:
CTAResultType.
Datatype: Enum
149. Pre-Test Probability of coronary artery disease.
Medical Risk Factor
Type:
Package:
Alias:
Class
Cardiology CDE Library
Medical Risk Factor
Class Definition: Any aspect of an individual's life, behavior, an environmental exposure, or an inborn or
inherited characteristic that increases the likelihood of a disease, condition or injury. Source:
NCI(C17103)
Attributes
Attribute
Name:
pretestProbabilityOfCAD
Type
Datatype: Enum
Notes
Attribute Definition: For procedures evaluating for the presence of
obstructive coronary disease (e.g., stress tests, CT angiography, left heart
cardiac catheterization), indicate(or specify) the pre-test probability estimate
of the presence of obstructive CAD. If presence of CAD is known, select
‘Known CAD’.
Alias: Pre-test probability of Type is a collection of values used in the enumerated, menu of choices or
pick-list.
coronary artery disease
Enumerations:
Permissible values: Low (<10%)
Intermediate (10% to 90%)
High (>90%
Known CAD
Source: ACC/AHA CV EHR DS and Cardiac Imaging DS.
150. Left Ventricular Ejection Fraction (qualitative).
151. Left Ventricular Ejection Fraction (quantitative).
Left Ventricular Ejection Fraction
Type:
Package:
Alias:
Class
Cardiology CDE Library
Ejection Fraction
Class Definition: Amount of blood ejected during a ventricular contraction of the heart.
Attributes
Attribute
Notes
Name: qualLVEFType Attribute Definition: The estimated resting left ventricular ejection fraction
Datatype: Enum
(LVEF), as a qualitative score.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: Left Ventricular
Enumerations:
Ejection Fraction
Hyperdynamic: greater than 70%
(LVEF) (qualitative)
Normal: 50% to 70% (midpoint 60%)
Mild dysfunction: 40% to 49% (midpoint 45%)
Moderate dysfunction: 30% to 39% (midpoint 35%)
Severe dysfunction: less than 30% (midpoint 20%)
Attribute Definition: The calculated resting left ventricular ejection fraction
Name: quantLVEF
Datatype: Integer
(LVEF), as either a percentage value or the midpoint value when a range is
reported.
Alias: Left Ventricular
Ejection Fraction
(quantLVEF)
152. Left ventricle size, end-diastole (quantitative).
153. Left ventricle size, end-systole (quantitative).
Left Ventricular Size
Type:
Package:
Alias:
Class
Cardiology CDE Library
Left Ventricle
Class Definition: Measurements of lower left chamber of heart obtained during radiographic imaging.
Attributes
Attribute
Name:
qualitativeSizeType
Datatype: Enumeration
Notes
Attribute Definition: Qualitative estimate of the chamber size of the left
ventricle.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: Left Ventricle size Enumerations:
Normal
(Qualitative)
Enlarged
Reduced
Attribute Definition: Short axis measurement of the left ventricular chamber
Name:
quantatativeSizeDiasto size at end-diastole, in cm.
le
Datatype: Integer
Alias: Left ventricle size,
end-diastole
(quantitative)
Attribute Definition: Short axis measurement of the left ventricular chamber
Name:
quantitativeSizeSystole size at end-systole, in cm.
Datatype: Integer
Alias: Left Ventricular
Size, end-Systole
(quantitative)
154. Left atrium size (quantitative).
Left Atrium Size
Type:
Package:
Alias:
Class
Cardiology CDE Library
Left Atrium
Class Definition: Measurements obtained from radiographic image of the left cardiac atrium. Source:
NCI(C80422).
Attributes
Attribute
Name: LAQuantSize
Datatype: Integer
Alias: Left atrium size
(quantitative)
Notes
Attribute Definition: Size of the left atrium, in cm.
155. Aortic valve stenosis severity.
156. Aortic valve area.
Stenosis Severity
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: Degree to which the orifice of the cardiac valves are narrowed or strictured resulting in
restriction of blood flow through the valves.
Attributes
Attribute
Name:
aorticValveArea
Datatype: Integer
Notes
Attribute Definition: Severity of stenosis of the aortic valve in cm2.
Alias: Aortic valve area
Name:
aorticValveStenosisSev
erityType
Datatype: Enum
Alias: Aortic valve
stenosis severity
Name:
mitralValveArea
Datatype: Integer
Attribute Definition: Severity of stenosis of the aortic valve.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
None
Mild
Moderate
Severe
Attribute Definition: Severity of stenosis of the mitral valve, in square
centimeters.
Alias: Mitral valve area
Name:
mitralValveStenosisSev
erityType
Datatype: Enum
Alias: Mitral valve
stenosis severity
Attribute Definition: Severity of stenosis of the mitral valve.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
None
Mild
Moderate
Severe
157. Aortic valve regurgitation severity.
Regurgitation Severity
Type:
Package:
Alias:
Class
Cardiology CDE Library
Regurgitation Severity
Class Definition: Degree to which blood flows in the opposite direction than expected owning to
imperfect closing, insufficiency, or incompetency of the valves. Blood may flow into the heart or across
chambers of the heart inappropriately.
Attributes
Attribute
Name:
aorticValveSeverityTy
pe
Datatype: Enum
Notes
Attribute Definition: Severity of regurgitation through the aortic valve.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
None
Mild
Alias: Aortic valve
Moderate
regurgitation severity
Severe
Attribute Definition: Severity of regurgitation through the mitral valve.
Name:
mitralValveSeverityTy Type is a collection of values used in the enumerated, menu of choices or picklist.
pe
Datatype: Enum
Enumerations:
None
Mild
Alias: Mitral valve
Moderate
regurgitation severity
Severe
158. Mitral valve stenosis severity.
159. Mitral valve area.
Stenosis Severity
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: Degree to which the orifice of the cardiac valves are narrowed or strictured resulting in
restriction of blood flow through the valves.
Attributes
Attribute
Name:
aorticValveArea
Datatype: Integer
Notes
Attribute Definition: Severity of stenosis of the aortic valve in cm2.
Alias: Aortic valve area
Name:
aorticValveStenosisSev
erityType
Datatype: Enum
Alias: Aortic valve
stenosis severity
Name:
mitralValveArea
Datatype: Integer
Attribute Definition: Severity of stenosis of the aortic valve.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
None
Mild
Moderate
Severe
Attribute Definition: Severity of stenosis of the mitral valve, in square
centimeters.
Alias: Mitral valve area
Name:
mitralValveStenosisSev
erityType
Datatype: Enum
Alias: Mitral valve
stenosis severity
Attribute Definition: Severity of stenosis of the mitral valve.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
None
Mild
Moderate
Severe
160. Mitral valve regurgitation severity.
Regurgitation Severity
Type:
Package:
Alias:
Class
Cardiology CDE Library
Regurgitation Severity
Class Definition: Degree to which blood flows in the opposite direction than expected owning to
imperfect closing, insufficiency, or incompetency of the valves. Blood may flow into the heart or across
chambers of the heart inappropriately.
Attributes
Attribute
Name:
aorticValveSeverityTy
pe
Datatype: Enum
Notes
Attribute Definition: Severity of regurgitation through the aortic valve.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
None
Mild
Alias: Aortic valve
Moderate
regurgitation severity
Severe
Attribute Definition: Severity of regurgitation through the mitral valve.
Name:
mitralValveSeverityTy Type is a collection of values used in the enumerated, menu of choices or picklist.
pe
Datatype: Enum
Enumerations:
None
Mild
Alias: Mitral valve
Moderate
regurgitation severity
Severe
161. Diagnostic Catheterization.
Cardiac Diagnostic Procedure
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Diagnostic Procedure
Class Definition: Procedure to evaluate the structure and / or function of the heart.
Attributes
Attribute
Name:
diagnosticProcedureTy
pe
Datatype: Enum
Alias: Cardiac
Diagnostic Procedure
Notes
Attribute Definition: Indicate the type of cardiac diagnostic procedure. This
lexicon emphasizes common names for procedure concepts even when various
sub-procedures comprise the concept (e.g., transthoracic echocardiogram, left
heart catheterization), rather than an unbundled listing of the sub-procedures
that comprise the procedure (e.g., CPT code listing). The procedure of greater
complexity should be chosen when the concept of greater complexity is
inclusive of the one of lesser complexity (e.g., Stress echo is inclusive of TTE).
\
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
ECG
Holter monitor
Event monitor
TTE
TEE
Stress ECG
Stress echo
Stress nuclear
MR
Stress MR
CTA
PET
RHC
RvBx
LHC
EPS
Coronary Angiography
[Except for cardiac catheterization and RV biopsy, tests are mutually exclusive
events]
162. Diagnostic Catheterization Status.
163. Reason for Diagnostic Catheterization_Cardiac Transplantation.
164. Reason for Diagnostic Catheterization_Cardiac Transplant Evaluation Type
165. Reason for Diagnostic Catheterization_Cardiomyopathy or Left ventricular systolic
dysfunction evaluation.
166. Reason for Diagnostic Catheterization_Pre-operative evaluation for noncardiovascular surgery.
Diagnostic Cath Indication
Type:
Package:
Alias:
Class
Cardiology CDE Library
Diagnostic Cardiac Catheterization Indication
Class Definition: Reasons for performing diagnostic cardiac catheterization procedures.
Attributes
Attribute
Name:
cardiomyopathyIndicat
or
Datatype: Enum
Notes
Attribute Definition: Indicate if a reason for the cath lab visit is evaluation of
cardiomyopathy and/or evaluation of left ventricular systolic dysfunction (i.e.
depressed LV ejection fraction).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Cath lab
reason_Cardiomyopathy Selections: No, Yes
or Left ventricular
systolic dysfunction
evaluation
Attribute Definition: Indicate if a reason for the cath lab visit is pre-operative
Name:
preopSurgeryIndicator evaluation before non-cardiac surgery.
Datatype: Enum
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Cath Lab
Selections: No, Yes
reason_Pre-operative
evaluation for noncardiovascular surgery
Name: statusType
Datatype: Enum
Alias: Diagnostic Cath
Status
Attribute Definition: Indicate the status of the diagnostic catheterization.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-Elective
2-Urgent
Attribute
Notes
3-Emergency
4-Salvage
Name:
transplantReasonIndic
ator
Datatype: Enum
Attribute Definition: Indicate if a reason for the cath lab visit is evaluation for,
or routine follow-up after an organ transplant.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Reason for
Catheterization_Cardiac
Transplantation
Attribute Definition: Indicate if the reason for the cath lab visit is evaluation
Name:
transplantReasonType for, or routine follow-up after a cardiac transplant. Target Value: Any
Datatype: Enum
occurrence between arrival and current procedure Selections: Selection Text
Definition Donor for cardiac transplant Candidate to receive a cardiac transplant
Post-cardiac transplant follow-up Supporting Definitions: (none).
Alias: Reason for
Catheterization_Cardiac Type is a collection of values used in the enumerated, menu of choices or picklist.
Transplant Evaluation
Enumerations:
Type
1 Donor for cardiac transplant
2 Candidate to receive cardiac transplant
3 Post-cardiac transplant follow-up
167. Left heart catheterization.
Left Heart Catheterization
Type:
Package:
Alias:
Class
Cardiology CDE Library
Left Heart Catheterization
Class Definition: Defined as the passage of a catheter into the left ventricle for the purposes of
angiography or measurement of ventricular pressures and/or oxygen saturation.
Attributes
Attribute
Name:
LHCatheterizationIndi
cator
Datatype: Enum
Alias: Left Heart(LH)
Catheterization
Notes
Attribute Definition: Indicate if the patient had a left heart (LH)
catheterization procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
168. Diagnostic Coronary Angiography.
Diagnostic Coronary Angiography
Type:
Package:
Alias:
Class
Cardiology CDE Library
Diagnostic Coronary Angiography
Class Definition: Diagnostic coronary angiography is defined as the passage of a catheter into the aortic
root or other great vessels for the purpose of angiography of the native coronary arteries or bypass grafts
supplying native coronary arteries. NCDR.
C0085532 Coronary Angiography MSH/MH | Radiography of the vascular system of the heart muscle
after injection of a contrast medium.
Attributes
Attribute
Name:
coronaryAngiographyI
ndicator
Datatype: Enum
Alias: Diagnostic
Coronary Angiography
Notes
Attribute Definition: Indicate if the patient had a diagnostic coronary
angiography procedure.
Enumerations:
Selections: No, Yes
169. Coronary Anatomy Dominance.
Coronary Artery Dominance
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Artery Dominance
Class Definition: Whether the posterior descending artery comes from the right or left vessel system.
Source: NCDR. Location from which posterior descending artery originates as defined by coronary
angiography or other radiologic study.
Attributes
Attribute
Notes
Name: dominanceType Attribute Definition: Indicate the dominance of the coronary anatomy.
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: Coronary
1 Left The posterior descending artery (PDA) and posterolateral artery (PLA)
Anatomy Dominance
arises from the left circumflex artery.
2 Right The posterior descending artery (PDA) and posterolateral artery (PLA)
arises from the right coronary artery.
3 Co-dominant The right coronary artery supplies the posterior descending
artery (PDA) and the circumflex supplies the posterolateral artery (PLA). Thus,
there is approximately equal contribution to the inferior surface of the left
ventricle from both the left circumflex and right coronary arteries.
170. Coronary artery: number of diseased vessels (excludes left main disease).
Diseased Epicardial Vessels
Type:
Package:
Alias:
Class
Cardiology CDE Library
Diseased Vessels
Class Definition: Number of major epicardial vessels, and major branches of the epicardial vessels, with
70% or greater luminal obstruction.
Attributes
Attribute
Name: CANumber
Datatype: Integer
Alias: Coronary artery
(CA) number of diseased
vessels (excludes left
main disease)
Notes
Attribute Definition: Coronary artery (CA) number of diseased vessels
(excludes left main disease).
171. Stenosis location.
172. Stenosis severity.
Coronary Artery Stenosis
Type:
Package:
Alias:
Class
Cardiology CDE Library
Stenosis
Class Definition: Stenosis represents the percentage diameter reduction, from 0 to 100, associated with
the identified vessels. Percent stenosis at its maximal point is estimated to be the amount of reduction in
the diameter of the "normal" reference vessel proximal to the lesion. Source: NCDR.
Attributes
Attribute
Name:
percentCIRCOMLPD
AGraftStenosis
Datatype: Integer
Notes
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in a graft supplying the circumflex coronary artery territory as determined by
angiography. If no stenosis, enter 0%. In instances where multiple lesions are
present, enter the single highest percent stenosis noted.
Alias: CIRCUMFLEX,
Obtuse marginals, Left
posterior descending
artery, Left
Posterolateral Branches
Graft Stenosis Percent
Name:
percentCIRCOMLPD
AStenosis
Datatype: Integer
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in the circumflex (CIRC), obtuse marginals (OMs), and depending on
dominance, the left posterolateral (LPL) and left posterior descending artery
(LPDA) branches of >= 2.0 mm in diameter as determined by angiography.
Alias: Circumflex,
Obtuse marginals, left
posterolateral and left
posterior descending
artery branches percent
stenosis
Name:
percentLADDiagonalG
raftStenosis
Datatype: Integer
Alias: Mid/Distal Left
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in a graft supplying the mid/distal left anterior descending (LAD) coronary
artery territory, including all diagonal branches, as determined by angiography.
In instances where multiple lesions are present, enter the single highest percent
stenosis noted.
Attribute
Anterior Descending,
Diag Branches Graft
Stenosis Percent
Notes
Name:
percentLADStenosis
Datatype: Integer
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in the mid/distal left anterior descending (LAD), including all diagonal
coronary artery branches that are >= 2.0 mm in diameter as determined by
angiography.
Alias: Mid/Distal left
anterior descending
coronary artery and all
diagonal coronary
branches percent
stenosis
Attribute Definition: Left main coronary artery stenosis: Percent luminal
Name:
percentLMCAStenosis narrowing of the left main coronary artery, at the point of maximal stenosis of
Datatype: Integer
the left main.
Alias: Left Main
Stenosis Percent
Name:
percentProximalLADG
raftStenosis
Datatype: Integer
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in a graft supplying the proximal left anterior descending (LAD) coronary
artery branch territory as determined by angiography. If no stenosis, enter 0%.
In instances where multiple lesions are present, enter the single highest percent
stenosis noted.
Alias: Proximal Left
Anterior Descending
Graft Stenosis Percent
Attribute Definition: Proximal left anterior descending coronary artery
Name:
percentProximalLADS stenosis: Percent luminal narrowing of the proximal left anterior descending
artery, at the point of maximal stenosis of the LAD.
tenosis
Datatype: Integer
Alias: Proximal Left
anterior descending
(LAD)coronary artery
percent stenosis
Attribute
Notes
Attribute Definition: Indicate the best estimate of most severe percent stenosis
Name:
percentRamusGraftSte supplying a graft to the ramus coronary artery as determined by angiography.
nosis
Datatype: Integer
Alias: Ramus graft
stenosis percent
Attribute Definition: Indicate the best estimate of most severe percent stenosis
Name:
percentRamusStenosis in the ramus artery (if present) of >= 2.0 mm in diameter as determined by
Datatype: Integer
angiography.
Alias: Ramus artery
percent stenosis
Name:
percentRCAAMRPDA
Stenosis
Datatype: Integer
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in the right coronary artery (RCA), acute marginal (AM) branches, and
depending on dominance, the right posterior descending artery (RPDA), and
right posterolateral (RPL) branches of >= 2.0 mm in diameter as determined by
angiography.
Alias: Right coronary
artery, acute marginal
branches, right posterior
descending artery and
right posterolateral
branches percent
stenosis
Name:
percentRCARPDARP
LAStenosis
Datatype: Integer
Alias: Right coronary
artery, right posterior
descending, right
posterolateral and acute
marginal branches
stenosis percent
Attribute Definition: Indicate the best estimate of most severe percent stenosis
in a graft supplying the right coronary artery territory as determined by
angiography. In instances where multiple lesions are present, enter the single
highest percent stenosis noted.
173. Intravascular Ultrasound (IVUS).
Intravascular Ultrasound
Type:
Package:
Alias:
Class
Cardiology CDE Library
Intravascular Ultrasound (IVUS)
Class Definition: C0041618 Ultrasonography NCI/NCI-GLOSSPT | A procedure in which sound
waves (called ultrasound) are bounced off tissues and the echoes produce a picture (sonogram).
Attributes
Attribute
Name:
CAUltrasoundIndicato
r
Datatype: Enum
Alias: Intravascular
Ultrasound (IVUS) of
Coronary arteries
Notes
Attribute Definition: Indicate if intravascular ultrasound of coronary arteries
was performed to confirm the percent stenosis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
174. Fractional Flow Reserve.
Fractional Flow Reserve
Type:
Package:
Alias:
Class
Cardiology CDE Library
Fractional Flow Reserve
Class Definition: Myocardial fractional flow reserve is a lesion-specific index of stenosis severity.
Attributes
Attribute
Name:
FFReserveIndicator
Datatype: Enum
Alias: Fractional Flow
(FF) Reserve
Notes
Attribute Definition: Indicate if fractional flow (FF) reserve was performed to
confirm the percent stenosis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
175, Fractional Flow Reserve Ratio.
Fractional Flow Reserve Ratio
Type:
Package:
Alias:
Class
Cardiology CDE Library
Fractional Flow Reserve Ratio
Class Definition: The ratio of maximum blood flow to the MYOCARDIUM with CORONARY
STENOSIS present, to the maximum equivalent blood flow without stenosis. The measurement is
commonly used to verify borderline stenosis of CORONARY ARTERIES.
C1721077 Fractional Flow Reserve, Myocardial
Attributes
Attribute
Notes
Attribute Definition: Indicate the fractional flow reserve ratio. (Lowest value).
Name:
fractionalFlowReserve
Ratio
Datatype: Integer
Alias: Fractional Flow
Reserve Ratio
176. Cardiac Rhythm – Sinus Rhythm.
Cardiac Rhythm
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Rhythm
Class Definition: The recurrent, measured movements (rhythm) of a beating heart. Source: NCI
(C87081)
Attributes
Attribute
Name:
pacemakerRhythmIndi
cator
Datatype: Enum
Alias: Cardiac RhythmPaced
Name:
pacingRhythmType
Datatype: Enum
Notes
Attribute Definition: Attribute Definition: The cardiac rhythm originates
from a pacemaker. Note(s): Indicate the patient's cardiac rhythm. It is
acceptable to code the patient's cardiac rhythm based on cardiac Indicator is a
selection of No/Yes values used in the enumerated, menu of choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Attribute Definition: Indicate the type of pacing noted
in the cardiac rhythm
Enumerations:
Atrial pacing -The patient's pacemaker is firing to create an atrial contraction or
a "p
wave".
Ventricular pacing- The patient's pacemaker is firing to create a ventricular
contraction or a
"QRS complex".
Both -The patient's pacemaker is firing to create both atrial and ventricular
contractions
Attribute Definition: The cardiac rhythm originates from the sinoatrial node.
Name:
sinusRhythmIndicator Indicator is a selection of No/Yes values used in the enumerated, menu of
Datatype: Enum
choices or pick-list.
Enumerations:
Alias: Cardiac Rhythm- Selections: No, Yes
Sinus Rhythm
Alias: Pacing Type
Name:
underlyingatrialRhyth
mIndicator
Datatype: Enum
Attribute Definition: Attribute Definition: Indicate, for the paced rhythm, the
underlying atrial rhythm
Enumerations:
Sinus rhythm -The atrial rhythm originates from the sinoatrial node.
Atrial fibrillation/atrial flutter -There are no consistent P waves. With atrial
Attribute
Notes
Alias: Underlying Atrial flutter, in the place of P
waves, there is uncoordinated atrial activity with rapid oscillations or
Rhythm
fibrillation waves that vary in amplitude, shape, timing, and are associated
with an irregular ventricular response (if atrioventricular conduction is
intact). With atrial flutter, there is a sawtooth pattern of regular atrial
activation.
Sinus arrest -The patient has no conduction through the sinoatrial node with a
pause for
a minimum of 3 seconds.
Unknown- The underlying atrial rhythm is unknown
177. Cardiac Rhythm – Atrial Tachycardia.
178. Cardiac Rhythm – Junctional.
179. Cardiac Rhythm – Idioventricular.
Cardiac Rhythm Abnormality
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: CSP/PT | Any variation from the normal rhythm or rate of the heartbeat. Cardiac
Arrhythmia C0003811
Attributes
Attribute
Name:
afibFlutterIndicator
Datatype: Enum
Alias: Cardiac RhythmAfib/Flutter
Notes
Attribute Definition: The cardiac rhythm is atrial fibrillation or atrial flutter.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: The cardiac rhythm is greater than 100 beats per minute
that originates from the atria or sinoatrial node. Note(s): Indicate the patient's
cardiac rhythm. It is acceptable to code the patient's cardiac rhythm based on
cardiac rhythm strips (as opposed to 12 lead ECGs) that are interpreted by a
qualified professional. If more than one is available, code the rhythm based on
Alias: Cardiac Rhythm- the rhythm strip or ECG closest to the start of the procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Atrial Tachycardia
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Attribute Definition: Indicate the presence of a first
Name:
firstDegreeHeartBlock degree heart block characterized by a PR interval greater than 200 ms
Indicator
Enumerations:
Datatype: Enum
Selections: No, Yes
Name:
atrialTachycardiaIndic
ator
Datatype: Enum
Alias: Cardiac RhythmFirst Degree Heart Block
Name:
idioventricularIndicato
r
Datatype: Enum
Attribute Definition: The cardiac rhythm originates in the ventricles. The heart
rate is usually regular and ranging between 30-40 beats per minute (the intrinsic
ventricular rate), but can be higher or lower. If atrial activity is present, there is
usually no relationship between the atrial and ventricular complexes.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Attribute
Alias: Cardiac RhythmIdioventricular
Notes
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: The cardiac rhythm arises from the atrioventricular (AV)
junction. Note(s): Indicate the patient's cardiac rhythm. It is acceptable to code
the patient's cardiac rhythm based on cardiac rhythm strips (as opposed to 12
lead ECGs) that are interpreted by a qualified professional. If more than one is
Alias: Cardiac Rhythm- available, code the rhythm based on the rhythm strip or ECG closest to the start
of the procedure.
Junctional
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Characterized by one of the following: Mobitz I:
Name:
secondDegreeHeartBlo progressive PR prolongation and shortening of RR interval until P wave is
blocked. Pause after blocked P wave is less than twice the PP interval. PR
ckIndicator
Datatype: Enum
following block is shorter than PR immediately preceding block. Mobitz II:
regular sinus/atrial rhythm with intermittent nonconducted P waves. Constant
Alias: Cardiac Rhythm- PR interval in the conducted beats.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Second Degree Heart
choices or pick-list.
Block
Enumerations:
Selections: No, Yes
Attribute Definition: Characterized by independent atrial and ventricular
Name:
thirdDegreeHeartBloc complexes with the atrial rate usually exceeding ventricular rate. Also known as
complete heart block.
kIndicator
Datatype: Enum
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Cardiac Rhythm- Enumerations:
Selections: No, Yes
Third Degree Heart
Block
Name:
junctionalIndicator
Datatype: Enum
180. Cardiac Rhythm – Afib/Flutter.
Atrial Arrhythmia
Type:
Package:
Alias:
Class
Cardiology CDE Library
Atrial Arrhythmia
Class Definition: Irregular heart beat resulting from a pathologic process in the cardiac atria. Source:
NCI (C80503).
Attributes
Attribute
Name:
afibrillationClassificati
onType
Datatype: Enum
Alias: afibrillation
Classification
Notes
Attribute Definition: Indicate the classification of atrial fibrillation or flutter.
Note(s): If a patient fits in more than one category choose their most recent and
most frequent presentation. For example, first detected atrial fibrillation (AF)
can be either paroxysmal or persistent. A patient may have several episodes of
paroxysmal AF and occasional persistent AF (code as paroxysmal) or the
reverse (code as persistent).
If a patient had permanent atrial fibrillation that was ablated, then it reoccurred
and is now paroxysmal, code paroxysmal.
Termination with pharmacological therapy or direct-current cardioversion does
not alter designation.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Paroxysmal The arrhythmia terminates spontaneously (without pharmacological
therapy or electrical cardioversion).
Persistent (> 7 days) The arrhythmia is sustained beyond seven days (and is not
self-terminating). This category also includes cases of long-standing atrial
fibrillation (e.g. greater than one year), cases where atrial fibrillation terminates
with pharmacological therapy or electrical cardioversion, or cases where
cardioversion is not indicated, not attempted, or unsuccessful.
Permanent (> 1 year) The arrhythmia has persisted for greater than one year,
where pharmacological therapy and/or cardioversion has failed or has been
foregone.
Secondary (reversible cause) Secondary atrial fibrillation occurs when atrial
fibrillation is transient and due to an unrelated, reversible cause. It is not the
primary problem and treatment of the underlying disorder usually terminates the
arrhythmia. It occurs in the setting of acute myocardial infarction, cardiac
surgery, pericarditis, myocarditis, hyperthyroidism, or acute pulmonary disease.
Conversely, when it is known that atrial fibrillation occurs in the course of a
concurrent disorder like well-controlled hypothyroidism, it is not considered
secondary.
Unknown The patient has a history of atrial fibrillation but the classification is
Attribute
Notes
not known or not specified. Source: NCDR (ICD
Attribute Definition: Current of previous history of atrial arrhythmia.
Name:
atrialArrhythmiaType (The assessed type of atrial arrhythmia of the patient.)
Datatype: Enum
Enumerations:
 First detected AF
Alias: Atrial arrhythmias  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
 AFlutter
 ATach
 SSS
 Paroxysmal Supraventricular Tachycardia
ACC/AHA CHF DS
Type is a collection of values used in the enumerated, menu of choices or picklist.
Attribute Definition: Indicate current or previous history of atrial fibrillation.
Name:
atrialFibrillationIndica Atrial Fibrillation is a supraventricular tachyarrhythmia characterized by
uncoordinated atrial activity with consequent deterioration of atrial mechanical
tor
Datatype: Enum
function. On the electrocardiogram (ECG), atrial fibrillation is characterized by
the replacement of consistent P waves with rapid oscillations or fibrillation
Alias: Atrial fibrillation waves that vary in amplitude, shape and timing, associated with an irregular,
frequently rapid ventricular response when atrioventricular conduction is intact.
Indicator
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate current or previous history of atrial flutter. Atrial
Name:
atrialFlutterIndicator Flutter is characterized by a sawtooth pattern of regular atrial activation called
Datatype: Enum
flutter waves on the Electrocardiogram (ECG), particularly visible in leads II,
III, aVF and v1.
Enumerations:
Alias: Atrial Flutter
Selections: No, Yes
Indicator
181. Cardiac Rhythm – Paced.
182. Pacing Type.
183. Underlying Atrial Rhythm.
Cardiac Rhythm
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Rhythm
Class Definition: The recurrent, measured movements (rhythm) of a beating heart. Source: NCI
(C87081)
Attributes
Attribute
Name:
pacemakerRhythmIndi
cator
Datatype: Enum
Alias: Cardiac RhythmPaced
Name:
pacingRhythmType
Datatype: Enum
Notes
Attribute Definition: Attribute Definition: The cardiac rhythm originates
from a pacemaker. Note(s): Indicate the patient's cardiac rhythm. It is
acceptable to code the patient's cardiac rhythm based on cardiac Indicator is a
selection of No/Yes values used in the enumerated, menu of choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Attribute Definition: Indicate the type of pacing noted
in the cardiac rhythm
Enumerations:
Atrial pacing -The patient's pacemaker is firing to create an atrial contraction or
a "p
wave".
Ventricular pacing- The patient's pacemaker is firing to create a ventricular
contraction or a
"QRS complex".
Both -The patient's pacemaker is firing to create both atrial and ventricular
contractions
Attribute Definition: The cardiac rhythm originates from the sinoatrial node.
Name:
sinusRhythmIndicator Indicator is a selection of No/Yes values used in the enumerated, menu of
Datatype: Enum
choices or pick-list.
Enumerations:
Alias: Cardiac Rhythm- Selections: No, Yes
Sinus Rhythm
Alias: Pacing Type
Attribute
Name:
underlyingatrialRhyth
mIndicator
Datatype: Enum
Notes
Attribute Definition: Attribute Definition: Indicate, for the paced rhythm, the
underlying atrial rhythm
Enumerations:
Sinus rhythm -The atrial rhythm originates from the sinoatrial node.
Atrial fibrillation/atrial flutter -There are no consistent P waves. With atrial
Alias: Underlying Atrial flutter, in the place of P
waves, there is uncoordinated atrial activity with rapid oscillations or
Rhythm
fibrillation waves that vary in amplitude, shape, timing, and are associated
with an irregular ventricular response (if atrioventricular conduction is
intact). With atrial flutter, there is a sawtooth pattern of regular atrial
activation.
Sinus arrest -The patient has no conduction through the sinoatrial node with a
pause for
a minimum of 3 seconds.
Unknown- The underlying atrial rhythm is unknown
184. Only Ventricular Paced QRS Complexes.
185. QRS Duration (Non-ventricular Paced Complexes).
186. Ventricular Paced QRS Duration.
187. PR Interval.
188. PR Interval not obtainable.
189. Cardiac Rhythm - Second Degree Heart Block.
190. Cardiac Rhythm – Third Degree Heart Block.
191. Abnormal Intraventricular Conduction
192. Abnormal Intraventricular Conduction Type – Delay, Nonspecific.
193. Abnormal Intraventricular Conduction Type – Left Anterior Fascicular Block.
194. Abnormal Intraventricular Conduction Type – Left Posterior Fascicular Block.
195. Abnormal Intraventricular Conduction Type – Left Bundle Branch Block.
196. Abnormal Intraventricular Conduction Type – Right Bundle Branch Block.
197. Abnormal Intraventricular Conduction Type – Ventricular Paced Rhythm.
ECG Findings
Type:
Package:
Alias:
Class
Cardiology CDE Library
ECG Findings
Class Definition: Interpretations of measurements from an electrocardiogram.
Attributes
Attribute
Name:
abnormalIVCIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction
Name:
leftAnteriorFascicular
BlockIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction Type - Left
Anterior Fascicular
Block
Notes
Attribute Definition: Indicate if the patient has Abnormal intraventricular
conduction, with fascicular blocks, bundle branch blocks, non-specific
conduction delays or ventricular pacing.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient has left anterior fascicular block.
Left anterior fascicular block is characterized by all of the following: Left-axis
deviation with frontal QRS axis between -45 degrees and -90 degrees; Q wave
in lead aVL; rS in inferior leads ; QRS duration is <120 ms ACC/AHA/HRS
2006 Key Data Elements and Definitions for Electrophysiological Studies and
Procedures.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute
Name:
leftBundleBranchBlock
Indicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient has left bundle branch block. .
Supporting def (if any):Left Bundle Branch is characterized by QRS duration
120 ms or longer, delayed onset of intrinsicoid deflection in 1, V5, and V6 >60
ms, Broad and notched or slurred R waves in I, aVL, V5, and V6, rS or QS
complexes in right precordial leads, ST-segment and T waves in opposite
polarity to the major QRS deflection ACC/AHA/HRS 2006 Key Data Elements
Alias: Abnormal
and Definitions for Electrophysiological Studies and Procedures.
Intraventricular
Conduction Type - Left Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Bundle Branch Block
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient has left posterior fascicular block.
Name:
leftPosteriorFascicular Selections: 0-No,1-Yes, Supporting def (if any):Left Posterior Fascicular Block
is characterized by all of the following: Right-axis deviation with frontal QRS
BlockIndicator
Datatype: Enum
axis between +90 degrees and +180 degrees; rS in leads I and aVL and qR in
inferior leads (Q waves 40 ms) QRS duration <120 ms; Exclude other causes of
Right Axis deviation ACC/AHA/HRS 2006 Key Data Elements and Definitions
Alias: Abnormal
for Electrophysiological Studies and Procedures.
Intraventricular
Conduction Type - Left Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Posterior Fascicular
Enumerations:
Block
Selections: No, Yes
Attribute Definition: Indicate if the patient has an intraventricular conduction
delay that was nonspecific. Selections: 0-No,1-Yes, Supporting def (if
any):Non-Specific abnormal Intraventricular conduction delays are
characterized by a QRS duration of 110 ms or more with morphology different
from LBBB or RBBB ACC/AHA/HRS 2006 Key Data Elements and
Definitions for Electrophysiological Studies and Procedures.
Alias: Abnormal
Indicator is a selection of No/Yes values used in the enumerated, menu of
Intraventricular
choices or pick-list.
Conduction Type Enumerations:
Delay, Nonspecific
Selections: No, Yes
Name: NSTEMIType Attribute Definition: Indicate if the findings from the electrocardiogram
Datatype: Enum
demonstrated evidence on NSTEMI., code the findings on which treatment was
based.
Alias: ECG Findings for Type is a collection of values used in the enumerated, menu of choices or picklist.
NSTEMI
Enumerations:
1 New or Presumed New ST
Depression
Indicate if there was new or presumed
new horizontal or down-sloping ST
depression >=0.5 mV in two contiguous
leads below the isoelectric line on the
Name:
nonspecificIVCDelayIn
dicator
Datatype: Enum
Attribute
Name: PRInterval
Datatype: Integer
Notes
electrocardiogram (ECG) within the first
24 hours of presentation. If no exact
ST- depression measurement is
recorded in the medical chart,
physician’s written documentation of
ST- depression is acceptable.
2 New or Presumed New T Wave
Inversion
Indicate if there was a new or
presumed new T-wave inversion of at
least 0.1 mV in two contiguous leads
with prominent R-wave or R/S ratio >1
within the first 24 hours of
presentation. If no exact T-wave
inversion measurement is recorded in
the medical chart, physician’s written
documentation of T-wave inversion is
acceptable.
3 Transient ST Elevation
Lasting < 20 Minutes
Indicate if there was new or presumed
new ST- segment elevation at the J point
in two contiguous
electrocardiogram (ECG) leads with the
cut-off points: >=0.2 mV in men or >=
0.15mV in women in leads V2-V3
and/or >= 0.1 mV in other leads, and
lasting less than 20 minutes, within the
first 24 hours of presentation. If no
exact ST- elevation measurement is
recorded in the medical chart,
physician’s written documentation of
transient ST- elevation is acceptable.
4 None Indicate if the first electrocardiogram
(ECG) did not reveal ST depression,
transient ST-elevation or T-wave inversion
Attribute Definition: Indicate the PR interval, in milliseconds, on the
electrocardiogram.
Alias: PR Interval
Attribute Definition: Indicate if the PR interval on the electrocardiogram was
Name:
PRIntervalObtainableI not obtainable.
Indicator is a selection of No/Yes values used in the enumerated, menu of
ndicator
Attribute
Datatype: Enum
Alias: PR Interval not
Obtainable
Name: QRSDuration
Datatype: Integer
Alias: QRS Duration
(Non-ventricular Paced
Complexes)
Notes
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the duration of the non-ventricular paced or
intrinsic QRS complex, in milliseconds, that was derived from the surface
electrocardiogram (ECG). Surface ECGs are obtained from the surface of the
body and do not include intracardiac ECGs.
Attribute Definition: Indicate if the patient has right bundle branch block.
Selections: 0-No,1-Yes. Right Bundle Branch Block is characterized by a QRS
duration of 120 ms, rsR' or rSR' complexes in V1 and V2, Delayed onset of
intrinsicoid, deflection in V1 and V2 >50 ms, Broad, slurred S wave in 1, V5,
and V6
Secondary ST-T wave changes ACC/AHA/HRS 2006 Key Data Elements and
Alias: Abnormal
Definitions
for Electrophysiological Studies and Procedures.
Intraventricular
Conduction Type - Right Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Bundle Branch Block
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the ECG findings demonstrated either new or
Name:
STEMIECGFindingsT presumed new ST segment elevation, new left bundle branch block, or isolated
posterior myocardial infarction. Code the findings on which treatment was
ype
Datatype: Enum
based.
Type is a collection of values used in the enumerated, menu of choices or pickAlias: ECG Findings for list.
Enumerations:
STEMI
1 ST Elevation ST-segment elevation is defined by
new or presumed new sustained ST segment
elevation at the J-point in two
contiguous electrocardiogram (ECG)
leads with the cut-off points: >=0.2 mV
in men or >= 0.15mV in women in leads
V2-V3 and/or >= 0.1 mV in other leads
and lasting greater than or equal to 20
minutes. If no exact ST-elevation
measurement is recorded in the
medical chart, physician’s written
documentation of ST-elevation or Q waves
is acceptable. If only one ECG
is performed, then the assumption that
Name:
rightBundleBranchBlo
ckIndicator
Datatype: Enum
Attribute
Notes
the ST elevation persisted at least the
required 20 minutes is acceptable.
2 LBBB Left bundle branch block (LBBB) refers
to LBBB that was not known to be old
on the initial ECG.
3 Isolated Posterior MI Isolated Posterior Myocardial Infarction refers to
infarction of the posterobasal wall of the left ventricle. The use of posterior
leads V7 to V9 will show ST segment elevation in patients with posterior
infarction. If posterior leads were not applied, ST segment depression that is
maximal in leads V1-V3, without ST-segment elevation in other leads, may be
considered as indicative of posterior ischemia or infarction.
Attribute Definition: Indicate if a STEMI or STEMI equivalent was noted on
Name:
STEMIECGTimingTy either the first ECG or a subsequent ECG. Note(s): Code "Subsequent ECG" if
the ECG on arrival does not indicate STEMI or STEMI equivalent.
pe
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: ECG Timing with Enumerations:
1 First ECG
STEMI or STEMI
2 Subsequent ECG
Equivalent
Alias: Only Ventricular
Paced QRS Complexes
Attribute Definition: Indicate if there were only ventricular paced QRS
complexes present. Note(s): If the patient has some intrinsic ventricular
complexes present, code 'No.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Name:
ventricularPacedQRS
Duration
Datatype: Integer
Attribute Definition: Indicate the duration of the ventricular paced QRS
complex, in milliseconds, that was derived from the surface electrocardiogram
(ECG). Surface ECGs are obtained from the surface of the body and do not
include intracardiac ECGs.
Name:
ventricularPacedQRS
ComplexesIndicator
Datatype: Enum
Alias: Ventricular Paced
QRS Duration
Name:
VentricularPacedRhyt
hmIndicator
Datatype: Enum
Alias: Abnormal
Intraventricular
Conduction Type -
Attribute Definition: Indicate if the patient has a ventricular paced rhythm. If,
on the ECG closest to the procedure, the patient is not paced 100% of the time,
code no., Target value: The last value between birth and the first generator
procedure in this admission.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute
Ventricular Paced
Rhythm
Notes
Therapeutic Procedures
198. Cardiac Therapeutic Procedure.
199. Date of Cardiac Therapeutic Procedure.
Procedure
Type:
Package:
Alias:
Class
Cardiology CDE Library
Procedure
Class Definition: An activity that produces an effect, or that is intended to alter the course of a disease in
a patient or population. This is a general term that encompasses the medical, social, behavioral, and
environmental acts that can have preventive, therapeutic, or palliative effects. Source: NCI C25218
Attributes
Attribute
Name:
cardiacDiagnosticProc
edureType
Datatype: Enum
Notes
Attribute Definition: Procedure to evaluate the structure and / or function of
the heart. This lexicon emphasizes common names for procedure concepts even
when various sub-procedures comprise the concept (e.g., transthoracic
echocardiogram, left heart catheterization), rather than an unbundled listing of
the sub-procedures that comprise the procedure (e.g., CPT code listing). The
Alias: Cardiac diagnostic procedure of greater complexity should be chosen when the concept of greater
complexity is inclusive of the one of lesser complexity (e.g., Stress echo is
procedure type
inclusive of TTE). Selected results data (listed in the next section below) are to
be linked to the study.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
ECG
Holter monitor
Event monitor
TTE
TEE
Stress ECG
Stress echo
Stress nuclear
MR
Stress MR
CTA
PET
RHC
RvBx
LHC
Attribute
Notes
EPS
[Except for cardiac catheterization and RV biopsy, tests are mutually exclusive
events]
Name:
cardiacTherapeuticPro
cedureType
Datatype: Enum
Attribute Definition: Indicate the procedure to treat pathologic
structural/pathophysiological functional disorder of the heart. This lexicon
emphasizes common names for procedure concepts even when various
subprocedures make up the concept (e.g., CRT, PCI) rather than an unbundled
listing of the subprocedures that make up the procedure (e.g., CPT code listing).
The procedure of greatest complexity should be chosen when the concept of
greater complexity is inclusive of the one of lesser complexity (e.g., ICD is
inclusive of pacemaker). Type is a collection of values used in the enumerated,
menu of choices or pick-list.
Enumerations:
• Ablation, atrial (e.g., for AF)
• Ablation, ventricular (e.g., for VT)
• Ablation, other (e.g., reciprocating tachycardia ablation)
• Pacemaker
• ICD
• CRT
• Lead extraction
• Electrical cardioversion
• Chemical cardioversion
• PCI
• Septal ablation
• Transcatheter aortic valve implant
• Closure device, atrial
• Closure device, ventricular
• CABG
• Aortic balloon valvotomy
• Aortic valve replacement
• Mitral valve repair
• Mitral valve replacement
• Mitral balloon valvotomy
• Mitral commissurotomy
• Percutaneous mitral repair
• Tricuspid valve repair
• Tricuspid valve replacement
• Pulmonic valvuloplasty
• Pulmonary valve replacement
• Surgical maze
• Pericardiocentesis
• Pericardial window
• Pericardial stripping
• Left atrial appendage occlusion
Alias: Cardiac
Therapeutic Procedure
Attribute
Notes
• Ventricular aneurysm resection
• Left VAD
• Right VAD
• Heart transplant
Attribute Definition: Indicate if the patient died during the procedure/ in the
Name:
deathDuringProcedure lab
Indicator is a selection of No/Yes values used in the enumerated, menu of
Indicator
Datatype: Enum
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Death During
Procedure
Attribute Definition: Indicate the implanted cardiac device type.
Name:
implantedCardiacDevi Type is a collection of values used in the enumerated, menu of choices or picklist.
ceType
Datatype: Enum
Enumerations:
• Single-chamber pacemaker
Alias: Implanted Cardiac • Dual-chamber pacemaker
• Biventricular pacemaker
Device Type
• Cardioverter-defibrillator
• Cardioverter-defibrillator with resynchronization
• Atrial lead, right
• Atrial lead, left
• Ventricular lead, right
• Ventricular lead, left
• Bare metal stent
• Drug-eluting stent
• Closure device, atrial
• Closure device, ventricular
• Aortic valve, mechanical
• Aortic valve, tissue
• Aortic valve, transcutaneous
• Mitral valve, mechanical
• Mitral valve, tissue
• Left VAD
• Right VAD
• Total artificial heart
Attribute Definition: Indicate if the procedure was performed at your facility.
Name:
procedureLocationIndi Enumerations: Yes, No
cator
Datatype: Enum
Alias:
200. Coronary Artery Bypass Graft Surgery.
Coronary Artery Bypass Graft
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Artery Bypass Graft
Class Definition: Surgery performed to bypass partially or completely occluded coronary arteries,
thereby increasing the blood supply of the heart. Source: NCI (C51998).
Attributes
Attribute
Notes
Name: CABGIndicator Attribute Definition: Indicate if the patient had a coronary artery bypass graft
Datatype: Enum
(CABG) surgery. Source : NCDR/ STS
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: CABG
Enumerations:
Selections: No, Yes
201. Coronary Bypass Graft Surgery Status.
CABG Status
Type:
Package:
Alias:
Class
Cardiology CDE Library
CAGB Status
Class Definition: No definition!
Attributes
Attribute
Name: statusType
Datatype: Enum
Alias: CABG Status
Notes
Attribute Definition: The status of the Coronary Artery Bypass Graft surgery.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Elective The patient's cardiac function has been
stable in the days or weeks prior to the
operation. The procedure could be
deferred without increased risk of
compromised cardiac outcome.
2 Urgent Procedure required during same
hospitalization in order to minimize
chance of further clinical deterioration.
Examples include but are not limited to:
worsening sudden chest pain, CHF,
acute myocardial infarction (AMI),
anatomy, IABP, unstable angina (UA)
with intravenous (IV) nitroglycerin
(NTG) or rest angina
3 Emergency Patients requiring emergency operation
will have ongoing refractory (difficulty,
complicated, and unmanageable)
unrelenting cardiac compromise, with or
without hemodynamic instability, and
not responsive to any form of therapy
except cardiac surgery. An emergency
operation is one in which there should
be no delay in providing operative
intervention. The patient's clinical
status includes any of the following:
a. Ischemic dysfunction (any of the
following):
1. Ongoing ischemia including rest
angina despite maximal medical
Attribute
Notes
therapy (medical or IABP).
2. Acute Evolving Myocardial Infarction
with 24hours before surgery.
3. Pulmonary edema requiring
intubation.
b. Mechanical dysfunction (either of the
following):
1. Shock with circulatory support
2. Shock without circulatory support.
4 Salvage The patient is undergoing CPR in route
to the operating room or prior to
anesthesia induction.
202. Coronary Graft Anastomoses.
Coronary Graft Anastomosis
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Graft Anastomosis
Class Definition: The anastomoses that were made during a coronary artery bypass grafting procedure.
Source: NCI (C80476). Site/location where graft was attached to native coronary artery during CABG.
Attributes
Attribute
Name:
anastomosesLocationT
ype
Datatype: Enum
Alias: Coronary graft
anastomoses
Notes
Attribute Definition: Per the CASS coronary artery segment map, indicate the
anastomoses placed during a CABG procedure.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Proximal right coronary artery conduit segment - pRCA
2 Mid-right coronary artery conduit segment - mRCA
3 Distal right coronary artery conduit segment - dRCA
4 Right posterior descending artery segment - rPDA
5 Right posterior atrioventricular segment - rPAV
6 First right posterolateral segment - 1st RPL
7 Second right posterolateral segment - 2nd RPL
8 Third right posterolateral segment - 3rd RPL
9 Posterior descending septal perforators segment - pDSP
10 Acute marginal segment(s) - aMarg
11 Left main coronary artery segment - LM
12 Proximal LAD artery segment - pLAD
13 Mid-LAD artery segment - mLAD
14 Distal LAD artery segment - dLAD
15 First diagonal branch segment - 1st Diag
15a Lateral first diagonal branch segment - Lat 1st Diag
16 Second diagonal branch segment - 2nd Diag
16a Lateral second diagonal branch segment - Lat 2nd Diag
17 LAD septal perforator segments - LAD SP
18 Proximal circumflex artery segment - pCIRC
19 Mid-circumflex artery segment - mCIRC
19a Distal circumflex artery segment - dCIRC
20 First obtuse marginal branch segment - 1st OM
20a Lateral first obtuse marginal branch segment - Lat 1st OM
21 Second obtuse marginal branch segment - 2nd OM
21a Lateral second obtuse marginal branch segment - Lat 2nd OM
22 Third obtuse marginal branch segment - 3rd OM
Attribute
Notes
22a Lateral third obtuse marginal branch segment - Lat 3rd OM
23 Circumflex artery AV groove continuation segment - CIRC AV
24 First left posterolateral branch segment - 1st LPL
25 Second left posterolateral branch segment - 2nd LPL
26 Third posterolateral descending artery segment - 3rd LPL
27 Left posterolateral descending artery segment - LPDA
28 Ramus intermedius segment - Ramus
28a Lateral ramus intermedius segment - Lat Ramus
29 Third diagonal branch segment - 3rd Diag
29a Lateral third diagonal branch segment - Lat 3rd Diag
203. Percutaneous Coronary Intervention.
204. PCI Indication.
205. PCI Status.
214. Guidewire Across Lesion.
Percutaneous Coronary Intervention
Type:
Package:
Alias:
Class
Cardiology CDE Library
PCI
Class Definition: A percutaneous coronary intervention (PCI) is the placement of an angioplasty guide
wire, balloon, or other device (e.g. stent, atherectomy, brachytherapy, or thrombectomy catheter) into a
native coronary artery or coronary artery bypass graft for the purpose of mechanical coronary
revascularization.
Source: NCDR (Cath PCI).
Attributes
Attribute
Name:
guidewireSucessIndicat
or
Datatype: Enum
Notes
Attribute Definition: Indicate if a guidewire successfully crossed the lesion.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Guidewire Across
Lesion
Name: PCIIndicator
Datatype: Enum
Alias: PCI
Name:
PCIRationaleType
Datatype: Enum
Alias: PCI Indication
Attribute Definition: Indicate current or previous Percutaneous Coronary
Intervention.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the reason the PCI is being performed.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Immediate PCI for patient with STEMI (or STEMI equivalent).
 PCI for STEMI (or STEMI equivalent) more than 12 hours from symptom
onset with recurrent or persistent symptoms, symptoms of heart failure or
ventricular arrhythmia.
 (PCI for) Patient with STEMI (or STEMI equivalent) who is stable, and is
more than 12 hours from symptom onset. The patient does not have any
symptoms of recurrent or persistent ischemia, symptoms of heart failure, or
electrical instability.
 PCI for STEMI (or STEMI equivalent) who is stable after receiving full-
Attribute
Notes
dose thrombolysis.
 Rescue PCI for STEMI (or STEMI equivalent) after failed full-dose lytics.
Incudes patients with unstable angina or N-STEMI who have high risk features
for short-term risk of death or nonfatal MI. High risk features includes at least
one of the following:
1. History -accelerating tempo of ischemic symptoms in preceding 48 hours.
2. Character of pain -prolonged ongoing (greater than 20 minutes) rest pain.
3. Clinical findings:
A. Pulmonary edema, most likely due to ischemia
B. New or worsening mitral regurgitation murmur
C. S3 or new worsening rales
D. Hypotension, bradycardia, tachycardia
E. Age greater than 75 years
4. ECG
A. Angina at rest with transient ST-segment changes greater than or equal to
0.5 mm
B. Bundle-branch block, new or presumed new
C. Sustained ventricular tachycardia
5. Cardiac markers -NSTEMI patients with elevated cardiac TnT, Tnl, or
CK-MB.
 The second PCI of a planned, staged procedure (the first PCI could have
been during a prior admission, or during this admission).Includes patients
that don't fit into any of the above categories. This can include patients with
elective or urgent status, status/post cardiac arrest or cardiogenic shock but
without ECG or biomarker evidence of acute infarction (put this text in
context document only – remove from all attributes on report view).
Name: statusType
Datatype: Enum
Alias: PCI Status
Attribute Definition: Type is a collection of values used in the enumerated,
menu of choices or pick-list.
Elective: The procedure can be performed on an outpatient basis or during a
subsequent hospitalization without significant risk of infarction or death. For
stable inpatients, the procedure is being performed during this hospitalization
for convenience and ease of scheduling and NOT because the patient's clinical
situation demands the procedure prior to discharge. If the diagnostic
catheterization was elective and there were no complications, the PCI would
also be elective.
Urgent The procedure should be performed on an inpatient basis and prior to
discharge because of significant concerns that there is risk of ischemia,
infarction and/or death. Patients who are outpatients or in the emergency
department at the time that the cardiac catheterization is requested would
warrant an admission based on their clinical presentation.
Emergency The procedure should be performed as soon as possible because of
substantial concerns that ongoing ischemia and/or infarction could lead to
death. "As soon as possible" refers to a patient who is of sufficient acuity that
Attribute
Notes
you would cancel a scheduled case to perform this procedure immediately in the
next available room during business hours, or you would activate the on-call
team were this to occur during off-hours. Salvage The procedure is a last resort.
The patient is in cardiogenic shock when the PCI begins (i.e. at the time of
introduction into a coronary artery or bypass graft of the first guidewire or
intracoronary device for the purpose of mechanical revascularization). Within
the last ten minutes prior to the start of the case or during the diagnostic portion
of the case, the patient has also received chest compressions for a total of at
least sixty seconds or has been on unanticipated extracorporeal circulatory
support (e.g. extracorporeal mechanical oxygenation, or cardiopulmonary
support).
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-Elective
2-Urgent
3-Emergency
4-Salvage
Attribute Definition: Indicate whether an intracoronary stent was used during
Name:
stentPreviousPCIIndic the previous Percutaneous Cardiac Intervention (PCI).
Indicator is a selection of No/Yes values used in the enumerated, menu of
ator
Datatype: Enum
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Stent Placed in
Previous PCI
206. Coronary Lesions Treated.
209. Chronic Total Occlusion.
Segment Treated
Type:
Class
Package:
Cardiology CDE Library
Alias:
PCI Segment
Class Definition: Portion of coronary artery that is manipulated or altered during an attempt to improve
coronary.
Attributes
Attribute
Name:
chronicTotalOcclusion
Indicator
Datatype: Enum
Alias: Chronic Total
Occlusion
Name:
coronaryLesionTreate
dType
Datatype: Enum
Alias: Coronary lesions
treated
Notes
Attribute Definition: Indicate if the segment with 100% pre-procedure stenosis
was presumed to be 100% occluded for at least 3 months previous to this
procedure AND not related to a clinical event prompting (or leading to) this
procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Per the CASS coronary artery segment map, the lesion(s)
treated during a PCI procedure.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Proximal right coronary artery conduit segment - pRCA
2 Mid-right coronary artery conduit segment - mRCA
3 Distal right coronary artery conduit segment - dRCA
4 Right posterior descending artery segment - rPDA
5 Right posterior atrioventricular segment - rPAV
6 First right posterolateral segment - 1st RPL
7 Second right posterolateral segment - 2nd RPL
8 Third right posterolateral segment - 3rd RPL
9 Posterior descending septal perforators segment - pDSP
10 Acute marginal segment(s) - aMarg
11 Left main coronary artery segment - LM
12 Proximal LAD artery segment - pLAD
13 Mid-LAD artery segment - mLAD
14 Distal LAD artery segment - dLAD
15 First diagonal branch segment - 1st Diag
Attribute
Notes
15a Lateral first diagonal branch segment - Lat 1st Diag
16 Second diagonal branch segment - 2nd Diag
16a Lateral second diagonal branch segment - Lat 2nd Diag
17 LAD septal perforator segments - LAD SP
18 Proximal circumflex artery segment - pCIRC
19 Mid-circumflex artery segment - mCIRC
19a Distal circumflex artery segment - dCIRC
20 First obtuse marginal branch segment - 1st OM
20a Lateral first obtuse marginal branch segment - Lat 1st OM
21 Second obtuse marginal branch segment - 2nd OM
21a Lateral second obtuse marginal branch segment - Lat 2nd OM
22 Third obtuse marginal branch segment - 3rd OM
22a Lateral third obtuse marginal branch segment - Lat 3rd OM
23 Circumflex artery AV groove continuation segment - CIRC AV
24 First left posterolateral branch segment - 1st LPL
25 Second left posterolateral branch segment - 2nd LPL
26 Third posterolateral descending artery segment - 3rd LPL
27 Left posterolateral descending artery segment - LPDA
28 Ramus intermedius segment - Ramus
28a Lateral ramus intermedius segment - Lat Ramus
29 Third diagonal branch segment - 3rd Diag
29a Lateral third diagonal branch segment - Lat 3rd Diag
207. Lesion Complexity Description.
208. Bifurcation Lesion.
213. Lesion length.
220. Stent Placed in previous lesion.
221. Stent Place in Previous PCI.
223. Previously Treated Lesion.
224. Previous Treatment Type_Stent.
225. Reason for current treatment of previously treated lesion_In-stent Restenosis.
226. Reason for current treatment of previously treated lesion_In-stent Thrombus.
229. Culprit Lesion.
230. Pre-Procedure TIMI Flow.
231. Post-Procedure TIMI Flow.
PCI Treated Lesion Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
PCI Lesion Treated
Class Definition: Collection of characteristics of lesions treated with percutaneous coronary intervention.
Attributes
Attribute
Name:
bifurcationLesionIndic
ator
Datatype: Enum
Notes
Attribute Definition: Indicate if the lesion is at a significant bifurcation,
trifurcation or more complex branch point. Note(s): A significant bifurcation or
branch point is a division of a vessel into at least two branches, each of which is
>1.5 mm or greater in diameter. In a bifurcation or branch lesion, the plaque
extends from at least one of the limbs to the branch point; it need not progress
Alias: Bifurcation Lesion down all the proximal and distal branches. Bifurcations or branch point lesions
should be considered one lesion, no matter how many limbs are treated.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the lesion indicated is considered to be
Name:
culpritLesionIndicator responsible for the acute coronary syndrome. Note(s): "No" should be coded if
Datatype: Enum
there is no apparent lesion that could be responsible for evidence of ischemia.
"Unknown" should be coded if the culprit segment was not known. The
physician should use his/her judgment in choosing the primary lesion. In cases
Alias: Culprit Lesion
in which this is difficult to determine (despite correlation of ECG changes and
angiographic data), the lesion supplying the largest territory of myocardium
should be selected.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Attribute
Notes
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the complexity of the lesion as defined in the
selections below.
1 Non-High/Non-C Lesion Non-high/non-C lesions are considered Type A or B
lesions. They can be characterized as follows:
Low Risk or Type A lesions: Discrete (<10 mm length) Concentric Readily
Alias: Lesion
accessible
Non-angulated segment <45 degrees Smooth contour Little or no
Complexity Description
calcification Less than totally occlusive Not ostial in location No major branch
involvement Absence of thrombus
Medium Risk (Type B1) lesions: Tubular (10-20 mm length) Eccentric
Moderate tortuosity of proximal segment Moderately angulated segment, 45-90
degrees Irregular contour Moderate to heavy calcification Ostial in location
Bifurcation lesions requiring double guidewires Some thrombus present Total
occlusion <3 months old
Medium Risk (Type B2 lesions): Two or more "B" characteristics.
2 High/C Lesion Descriptions of a High Lesion Risk (C Lesion): Diffuse
(length > 2cm) Excessive tortuosity of proximal segment Extremely angulated
segments > 90 degrees Total occlusions > 3 months old and/or bridging
collaterals Inability to protect major side branches Degenerated vein grafts with
friable lesions.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Non-High/Non-C lesion
2 High/C lesion.
Attribute Definition: Indicate the post-procedure TIMI flow. Note(s): If a
Name:
postProcedureTIMIFlo lesion spans multiple segments with different TIMI flows, coded the lowest
TIMI flow within the entire lesion.
wType
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: Post-Procedure
1 TIMI - 0 No flow/no perfusion
TIMI Flow
2 TIMI - 1 Slow penetration without perfusion
3 TIMI - 2 Partial flow/partial perfusion (greater
than TIMI-1 but less than TIMI-3.
4 TIMI - 3 Complete and brisk flow/complete
perfusion.
Attribute Definition: Indicate the pre-procedure TIMI flow value. Note(s): If a
Name:
preProcedureTIMIFlo lesion spans multiple segments with different TIMI flows, coded the lowest
TIMI flow within the entire lesion.
wType
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Name:
lesionComplexityType
Datatype: Enum
Attribute
Alias: Pre-Procedure
TIMI Flow
Notes
Enumerations:
1 TIMI - 0 No flow/no perfusion
2 TIMI - 1 Slow penetration without perfusion
3 TIMI - 2 Partial flow/partial perfusion (greater
than TIMI-1 but less than TIMI-3.
4 TIMI - 3 Complete and brisk flow/complete
perfusion.
Attribute Definition: Indicate if the lesion has been treated before in the
Name:
previouslyTreatedLesi current or a prior episode of care.
Indicator is a selection of No/Yes values used in the enumerated, menu of
onIndicator
Datatype: Enum
choices or pick-list.
Enumerations:
Alias: Previously Treated Selections: No, Yes
Lesion
Attribute Definition: Indicate if the previously treated and stented lesion is
being treated because of the presence of a thrombus in the stent.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Reason for current Selections: No, Yes
treatment of previously
treated lesion_in-stent
Thrombus
Name:
previousStentedLesion
ThrombusIndicator
Datatype: Enum
Attribute Definition: Indicate if the previously treated lesion was treated with
any type of stent in the current or prior episode of care.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Previous treatment Selections: No, Yes
type_Stent
Name:
previousTreatmentWit
hStentIndicator
Datatype: Enum
Attribute Definition: Indicate if the previously treated and stented lesion is
being treated for in-stent restenosis. In-stent restenosis is defined as a
previously stented lesion that has 50% or greater stenosis.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Reason for current Enumerations:
treatment of previously Selections: No, Yes
treated lesion_In-stent
Restenosis
Name:
reasonPreviousLesion
RestenosisIndicator
Datatype: String
Attribute
Name:
stentPreviousLesionIn
dicator
Datatype: Enum
Alias: Stent placed in
previous lesion
Notes
Attribute Definition: Indicate if the previously treated lesion was treated with
any type of stent in the current or prior episode of care.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
210. Lesion in Graft.
211. Location in Graft.
Coronary Bypass Graft Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Bypass Graft Characteristics
Class Definition: Properties associated with or defining coronary artery bypass grafts.
Attributes
Attribute
Name:
CABGLesionGraftTyp
e
Datatype: Enum
Notes
Attribute Definition: If the treated lesion is in a coronary artery bypass graft,
indicate the type of graft.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
0 Not in graft Lesion is not in a coronary artery bypass graft.
Alias: Lesion in Graft
1 Vein Lesion is in a vein graft.
2 LIMA graft Lesion is in a left internal mammary artery graft.
3 Other artery Lesion is in an "other" arterial graft (not including LIMA grafts).
Radial artery grafts or other free arterial conduit grafts (e.g. free IMA) should
be coded as an other arterial graft.
Attribute Definition: If the lesion is in a graft, indicate the location of the most
Name:
graftLesionLocationTy severe stenosis in the graft. Target Value: Any occurrence on current procedure.
Type is a collection of values used in the enumerated, menu of choices or pickpe
Datatype: Enum
list.
Enumerations:
Alias: Location of lesion 1 Aortic The most severe stenosis is at the aortic anastomosis of the graft (<= 3
mm from insertion point).
in Graft
2 Body The most severe stenosis is in the body of the graft.
3 Distal The most severe stenosis is at the distal anastomosis of the graft (<= 3
mm from insertion point).
Supporting Definitions: (none).
212. Percent Stenosis.
Lesion Treated Stenosis
Type:
Package:
Alias:
Class
Cardiology CDE Library
Percent Stenosis
Class Definition: Percentage of diameter reduction associated with a coronary vessel containing a lesion
on which a therapeutic intervention is performed.
Attributes
Attribute
Notes
Attribute Definition: Indicate the percent stenosis of vessel containing the
Name:
percentTreatedVesselS treated lesion.
tenosis
Datatype: Integer
Alias: Percent Stenosis
Treated Vessel
215. Intracoronary Device Used.
217. Device Diameter.
218. Device Length.
Intracoronary Device
Type:
Package:
Alias:
Class
Cardiology CDE Library
Intracoronary Device
Class Definition: A class of implements that is used to diagnose, monitor or treat cardiac conditions from
access within the coronary vasculature.
Attributes
Attribute
Notes
Attribute Definition: Indicate the diameter of the intracoronary device in
Name:
coronaryDeviceDiamet millimeters.
er
Datatype: Integer
Alias: Coronary Device
Diameter
Attribute Definition: Indicate the length of the device in millimeters.
Name:
coronaryDeviceLength
Datatype: Integer
Alias: Coronary Device
Length
Name:
coronaryDeviceUsed
Datatype: String
Alias: Coronary Device
Used
Attribute Definition: Intracoronary Device(s) Used Coding Instructions:
Indicate all devices utilized during the current procedure. If a device was
utilized on multiple lesions, specify it only once (e.g., if a balloon was used to
dilate two separate lesions, list it only once). Every treatment and support
device utilized during the procedure should be specified.
216. Device Deployed.
219. Stent Placed in affected coronary artery.
222. Stent Type.
Coronary Artery Stent Device
Type:
Package:
Alias:
Class
Cardiology CDE Library
Stent Placed in affected coronary artery
Class Definition: A device designed to support a tubular structure, especially the small stainless steel
expandable mesh tube inserted within an artery. Source: NCI (C50190)
Attributes
Attribute
Name:
deviceDeploymentIndic
ator
Datatype: Enum
Alias: Device
Deployment
Name:
stentPlacementIndicato
r
Datatype: Enum
Alias: Stent Placed in
affected coronary artery
Name: stentType
Datatype: Enum
Alias: Stent Type
Notes
Attribute Definition: Indicate if a device was deployed during the procedure.
Note(s): If Device Deployed (7220) is 'Yes' for any lesion, at least one
intracoronary device must be specified.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if a stent or stents were placed in the affected
coronary artery.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the type of stent placed.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Drug eluting
Bare Metal
Other
227. Primary reason reperfusion therapy not indicated-Urgent Cardiac Surgery.
Reperfusion Therapy
Type:
Package:
Alias:
Class
Cardiology CDE Library
Reperfusion
Class Definition: Strategy or treatment modality used to restore perfusion through coronary arteries.
Reperfusion therapy includes thrombolysis and primary PCI. Reperfusion therapy also includes prehospital thrombolytics.
Attributes
Attribute
Name:
reasonReperfusionNotI
ndicatedType
Datatype: Enum
Alias: Primary reason
reperfusion therapy not
indicated
Notes
Attribute Definition: Indicate the one primary reason, documented in the
medical record, that reperfusion therapy (thrombolytic therapy or primary PCI)
was not indicated.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Non-compressible vascular puncture(s)
2 Active bleeding on arrival or within 24 hours
3 Known bleeding diathesis
4 Recent bleeding within previous 4 weeks
5 History of Ischemic Stroke
6 Recent surgery/trauma
7 Intracranial neoplasm, AV malformation, or aneurysm
8 Severe uncontrolled hypertension
9 No ST elevation/LBBB
10 ST elevation resolved
11 MI diagnosis unclear
12 MI symptoms onset > 12 hours
13 Chest pain resolved
14 No chest pain
15 Suspected aortic dissection
16 Significant closed head or facial trauma within previous 3 months
17 Prior allergic reaction to thrombolytics or IV contrast
18 Current use of oral anticoagulants
19 Active peptic ulcer
20 Quality of life decision
21 Comorbid disease
22 Traumatic CPR that precludes thrombolytics
23 Anatomy not suitable to primary PCI
24 Spontaneous reperfusion (documented by cath only)
25 Patient/family refusal
Attribute
Name:
reperfusionTherapyIn
dicator
Datatype: Enum
Alias: Reperfusion
Notes
26 DNR at time of treatment decision
27 Ischemic stroke w/in 3 months, except acute ischemic stroke w/in 3 hours
28 Any prior intracranial hemorrhage
29 Pregnancy
30 Other (not listed)
Attribute Definition: Indicate if the patient received reperfusion therapy for
the treatment of STEMI. Reperfusion therapy includes thrombolysis and
primary PCI. Reperfusion therapy also includes pre-hospital thrombolytics.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
228. Non-system reason for Delay in PCI.
PCI Delay
Type:
Package:
Alias:
Class
Cardiology CDE Library
Non-system reason for Delay in PCI
Class Definition: Prolonged elapse of time between presentation in ED to time PCI initiated.
Attributes
Attribute
Name:
nonsystemDelayReason
Type
Datatype: Enum
Alias: Non-system
reason for Delay in PCI
Notes
Attribute Definition: Indicate if there is documentation of a non-system reason
for a delay in performing the percutaneous coronary intervention (PCI).
Documentation must be from a physician/advanced practice nurse/physician
assistant (physician/APN/PA). Note(s): The effect on timing/delay of PCI must
be documented in order to be an acceptable reason for delay. If unable to
determine whether a documented reason is system in nature, or if
physician/APN/PA documentation does not establish a linkage between
event(s)/condition(s) and the timing/delay in PCI/reperfusion/cath/transfer to
cath lab, select "None." System reasons for delay are NOT acceptable.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Difficult vascular access
Cardiac arrest and/or need for intubation before PCI.
Patient delays in providing consent for the procedure.
Difficulty crossing the culprit lesion during the PCI.
Other
None
232. Intra-aortic Balloon Pump (IABP).
233. Intra-aortic Balloon Pump (IABP).
234. Mechanical Ventricular Support –Other.
235. Mechanical Ventricular Support –Other, Timing.
Mechanical Circulatory Support
Type:
Package:
Alias:
Class
Cardiology CDE Library
Mechanical Circulatory Support
Class Definition: Includes use of intra-aortic balloon pump, cardiopulmonary bypass, left ventricular
assist device (LVAD) and/or extracorporeal membrane oxygenation (ECMO).
Attributes
Attribute
Name:
percCircSupportIndica
tor
Datatype: Enum
Alias: Percutaneous
Mechanical Circulator
Support
Notes
Attribute Definition: Indicate if percutaneous mechanical circulatory support
was utilized during the procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the type of mechanical circulatory support used
during the procedure..
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: Percutaneous
Mechanical Circulatory 1 IABP
2 Impella
Support Type
3 Tandem Heart
4 ECMO
Attribute Definition: Attribute Definition: Indicate when the mechanical
Name:
placementTimingCircu circulatory support was placed.
Type is a collection of values used in the enumerated, menu of choices or picklatorySupportType
Datatype: Enum
list.
Enumerations:
Alias: Placement Timing In place at start of procedure-Mechanical circulatory support was in place at the
start of the procedure.
of Mechanical
-Inserted during procedure but prior to PCICirculatory Support
Mechanical circulatory support was inserted during the procedure, but
prior to the Percutaneous Coronary Intervention.
-Inserted during procedure and after PCI started- Mechanical Circulatory
Name:
percCircSupportType
Datatype: Enum
Attribute
Notes
support was placed during the procedure and after the Percutaneous Coronary
Intervention started.
-Inserted during a non PCI procedure- Mechanical circulatory support was
inserted during a non Percutaneous Coronary Intervention Procedure.
Attribute Definition: Indicate if the patient required the use of any mechanical
Name:
ventricularSupportIndi ventricular support.
Indicator is a selection of No/Yes values used in the enumerated, menu of
cator
Datatype: Enum
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Mechanical
Ventricular Support
236. Electrophysiology Procedure.
Electrophysiology Study Performed
Type:
Package:
Alias:
Class
Cardiology CDE Library
Electrophysiology Study Performed
Class Definition: The patient had an electrophysiology study (EPS). One or more catheters capable of
recording and pacing are placed in one or more of the cardiac chambers. The catheters may be used to
measure conduction of the impulse from the sinus node to the ventricle; induce a tachycardia; and/or
localize (map) the location where the tachycardia originates. NCDR
Attributes
Attribute
Name:
EPSPerformedIndicato
r
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient had an electrophysiology study
(EPS).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Electrophysiology Selections: No, Yes
study (EPS) Performed
Indicator
251. VT Ablation Performed.
VT Ablation Performed
Type:
Package:
Alias:
Class
Cardiology CDE Library
VT Ablation Performed
Class Definition: Ventricular tachycardia (VT) ablation was performed. An application of an energy
source delivered through a catheter to eliminate or modify a focus or re-entry circuit that causes an
arrhythmia. NCDR
Attributes
Attribute
Name:
VTAblationPerformed
Indicator
Datatype: Enum
Alias: VT Ablation
Performed Indicator
Notes
Attribute Definition: Indicate if ventricular tachycardia (VT) ablation was
performed. An application of an energy source delivered through a catheter to
eliminate or modify a focus or re-entry circuit that causes an arrhythmia. NCDR
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
252. ATP or Shock Therapy Appropriate.
253. ATP or Shock Therapy Delivered.
Device ICD
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: Implantable cardioverter defibrillator.
Attributes
Attribute
Name:
ATPShockTherapyAp
propriateIndicator
Datatype: Enum
Alias: ATP or Shock
Therapy Appropriate
Name:
ATPShockTherapyDeli
veredIndication
Datatype: Enum
Alias: ATP or Shock
Therapy Delivered
Notes
Attribute Definition: Indicate if, at any point in time, the ICD being removed
had delivered appropriate antitachycardia pacing (ATP) or shock therapy for
spontaneous ventricular tachycardia and/or ventricular fibrillation.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if, at any point in time, the ICD being removed
had delivered antitachycardia pacing (ATP) or shock therapy.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
254. ATP Therapy Successful.
255. Shock Therapy Successful.
VT Treatment Outcome
Type:
Package:
Alias:
Class
Cardiology CDE Library
Shock Therapy Successful
Class Definition: Evaluation undertaken to assess the results or consequences of management and
procedures used in combating (Ventricular Arrhythmias??disease in order to determine the efficacy,
effectiveness, safety, practicability, etc., of these interventions in individual cases or series.
Attributes
Attribute
Name:
ATPTherapySuccessIn
dicator
Datatype: Enum
Alias: ATP Therapy
Successful
Name:
shockTherapySuccessI
ndicator
Datatype: Enum
Alias: Shock Therapy
Successful
Notes
Attribute Definition: Indicate if the antitachycardia pacing (ATP) therapy for
ventricular tachycardia and/or ventricular fibrillation was successful.,
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the shock therapy for ventricular tachycardia
and/or ventricular fibrillation was successful.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
237. ICD
Implantable Cardioverter Defibrillator
Type:
Package:
Alias:
Class
Cardiology CDE Library
ICD Indicator
Class Definition: A small device used to correct a heartbeat that is abnormal (too fast, too slow, or
irregular). The device is placed by surgery in the chest or abdomen. Wires are passed through a vein to
connect the device to the heart. When it detects abnormal heartbeats, it sends an electrical shock to the
heart to restore the heartbeat to normal. Source: NCI (C93238)
Attributes
Attribute
Name: ICDIndicator
Datatype: Enum
Alias: ICD
Notes
Attribute Definition: Indicate if the patient had an implantable cardioverter
defibrillator (ICD).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
238. ICD Procedure Indication.
249. Reason For Malfunction.
250. Reason(s) for Reimplant.
ICD Status Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
ICD Status/Characteristics
Class Definition: Implantable cardiac device (need to clarify acronym ICD(implantable cardiac device vs
implantable cardioverter-defibrillator vs internal cardiac defibrillator/pacer) status and characteristics
including reimplant indication, indication for ICD procedure, ICD malfunction type.
Attributes
Attribute
Name:
ICDMalfunctionReaso
nType
Datatype: Enum
Alias: Reason for
Malfunction
Name:
ICDProcedureType
Datatype: Enum
Alias: ICD Indication
Notes
Attribute Definition: Indicate the reason for malfunction of the ICD.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-Atrial pacing
2-Left ventricular (LV) pacing,
3-Right ventricular (RV) pacing
4-Defibrillation
5-Premature battery depletion
Attribute Definition: Indicate the ICD procedure indication,
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 - Primary prevention
2 - Secondary prevention, Supporting def (if any):Primary Prevention is an
indication for an ICD to prevent sudden cardiac death. It refers to use of ICDs
in individuals who are at risk for but have not yet had an episode of sustained
ventricular tachycardia, ventricular fibrillation, or resuscitated cardiac arrest.
ACC/AHA//HRS 2008 Guidelines for Device-Based Therapy of Cardiac
Rhythm Abnormalities Secondary prevention refers to an indication for ICD
exclusively for patients who have survived one or more cardiac arrests or
sustained ventricular tachycardia. Patients with cardiac conditions associated
with a high risk of sudden death who have unexplained syncope that is likely to
be due to ventricular arrhythmias are considered to have a secondary indication.
mACC/AHA//HRS 2008 Guidelines for Device-Based Therapy of Cardiac
Rhythm Abnormalities.
Attribute
Name:
ICDReimplantReason
Type
Datatype: Enum
Notes
Attribute Definition: Indicate the reason for reimplant
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 End of expected battery life of a previous ICD 2 Generator is being replaced
Alias: Reason(s) for ICD at the time of lead revision 3 Upgrade of a previous device with additional
pacing capabilities (such as an upgrade from a single to a dual chamber device,
Reimplant
or the replacement of a non-CRT with a CRT device) 4 infection in the location
of the previously implanted device 5 previous device has been recognized by
the manufacturer as demonstrating a recurring performance failure resulting in
an advisory letter to physicians. This may or may not reach the level of a food
and drug administration (FDA) designated recall. This also may or may not
have led to device malfunction. 6 faulty connector/header which required
another implant 7 device needed to be relocated because of a medical condition,
or procedure near the original pocket. An example is if the patient was
diagnosed with breast cancer and required treatment or surgery near the original
implant. 8 previous generator has malfunctioned. The device performance is
outside the manufacturer's designated specification and cannot be resolved with
reprogramming, necessitating in the replacement of the device.
239. Device Implanted.
240. Device Explanted.
241. Device Manufacturer.
242. Device Model Name.
243. Device Model Number.
244. Device Returned to Manufacturer.
245. Device Serial Number.
258. Battery Voltage.
Cardiac Device Characteristic
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Device Characteristic
Class Definition: A collection of properties related to cardiac devices.
Attributes
Attribute
Name: batteryVoltage
Datatype: Integer
Notes
Attribute Definition: Indicate the battery voltage (in volts) of the device.
Alias: Battery Voltage
Name:
deviceModelNumber
Datatype: String
Attribute Definition: Indicate the model number of the device
Alias: Device Model
Number
Attribute Definition: Indicate if the device was explanted.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Device Explanted Selections: No, Yes
Name:
explantedIndicator
Datatype: Enum
Attribute Definition: Indicate if the device was implanted.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Device Implanted Selections: No, Yes
Name:
implantedIndicator
Datatype: Enum
Attribute
Name: manufacturer
Datatype: String
Notes
Attribute Definition: Indicate the name of the manufacturer of the device.
Alias: Device
Manufacturer
Name: modelName
Datatype: String
Attribute Definition: Indicate the name of the model of the device.
Alias: Device Model
Name
Name:
returnedToManufactu
rerIndication
Datatype: Enum
Alias: Device Returned
to Manufacturer
Name: serialNumber
Datatype: Integer
Alias: Device Serial
Number
Attribute Definition: Indicate if the explanted generator device was returned to
the manufacturer.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the serial number of the device.
246. Lead Returned to Manufacturer.
259. Conductor Failure.
262. Failed to Shock with Inadequate DFT Safety Margin.
264. Lead Abnormality_Oversensing with Shock or ATP.
265. Lead Abnormality_Oversensing without Shock or ATP.
266. Lead Abnormality_Defibrillation Issues.
267. Lead Abnormality_Extracardiac Stimulation
268. Lead Abnormality_Failure to Capture.
269. Lead Abnormality_Failure to Pace.
270. Lead Abnormality_Oversensing.
271. Lead Abnormality_Undersensing.
278. Existing Lead Status.
Cardiac Pacemaker Lead Function Status
Type:
Package:
Alias:
Class
Cardiology CDE Library
Lead Abnormality (LA)
Class Definition: Conditions under which cardiac pacemaker leads do not conduct electric signals to
myocardium and then conduct myocardial signals back to the generator as expected.
Attributes
Attribute
Name:
conductorFailureIndic
ator
Datatype: Enum
Notes
Attribute Definition: Indicate if the existing lead had abnormal function due to
a lead integrity issue of conductor failure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Conductor Failure Selections: No, Yes
Attribute Definition: Indicate if the existing lead had defibrillation issues such
as oversensing with or without shock/ATP, or failed shocks/inadequate
Defibrillation Threshold (DFT) safety margins.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Lead
Abnormality_Defibrillati Enumerations:
Selections: No, Yes
on Issues
Name:
defibrillationIndicator
Datatype: Enum
Name:
extracardiacStimulatio
nIndicator
Datatype: Enum
Attribute Definition: Indicate if the existing lead was functioning abnormally
because there was extracardiac stimulation. This manifests as stimulation by the
lead of non-cardiac structures such as the diaphragm, chest wall, or pectoral
muscle.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Attribute
Alias: Lead
Abnormality_Extracardi
ac Stimulation
Notes
choices or pick-list.
Enumerations:
Selections: No, Yes
Name:
failedShockIndicator
Datatype: Enum
Attribute Definition: Indicate if the existing lead had defibrillation issues due
to failed shocks or inadequate defibrillation threshold safety margins.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Failed to Shock
with Inadequate DFT
Safety Margin
Name:
failureCaptureIndicato
r
Datatype: Enum
Alias: Lead
Abnormality_Failure to
Capture
Attribute Definition: Indicate if the existing lead was functioning abnormally
because there was failure to capture with acceptable safety margins. This
manifests as a high pacing threshold that results in either intermittent failure to
capture at maximal programmed output.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the existing lead was functioning abnormally
because there was failure to pace. Failure to pace manifests as absence of
pacemaker stimulation artifacts on electrocardiographic recordings despite rates
below pacemaker programmed rate.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Alias: Lead
Abnormality_Failure to choices or pick-list.
Enumerations:
Pace
Selections: No, Yes
Attribute Definition: Indicate if the existing lead had abnormal function due to
Name:
insulationFailureIndica a lead integrity issue of insulation failure. Insulation failure manifests as low
lead impedance either absolutely (below manufacturer's product specifications)
tion
Datatype: Enum
or by a significant decrease from previously stable chronic values.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Alias: Insulation Failure choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the explanted lead was returned to the
Name:
leadReturnedIndicator manufacturer.
Datatype: Enum
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Lead Returned to Enumerations:
Selections: No, Yes
Manufacturer
Name:
failurePaceIndicator
Datatype: Enum
Attribute
Notes
Name: leadStatusType Attribute Definition: Indicate the status of the existing lead.
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: Existing Lead
-Extracted
Status
-Abandoned
-Reused
Attribute Definition: Indicate if the existing lead was functioning abnormally
Name:
due to oversensing. Oversensing manifests as sensing of electrical signals not
oversensingIndicator
Datatype: Enum
related to cardiac depolarization of the lead chamber that cannot be resolved
acceptably by device reprogramming.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Alias: Lead
Abnormality_Oversensi choices or pick-list.
Enumerations:
ng
Selections: No, Yes
Name:
oversensingSansShockI
ndicator
Datatype: Enum
Alias: Lead
Abnormality_
Oversensing without
Shock or ATP
Attribute Definition: Indicate if the existing lead had defibrillation issues due
to oversensing without shock/antitachycardia pacing (ATP). This manifests as
sensing of non-cardiac depolarization signals that did not meet arrhythmia
detection criteria and do not elicit programmed tachyarrhythmia therapy.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the existing lead had defibrillation problems
due to oversensing with shock/antitachycardia pacing (ATP). This manifests as
sensing of non-cardiac depolarization signals that met arrhythmia detection
criteria and elicited programmed tachyarrhythmia therapy.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Lead
Enumerations:
Abnormality_
Oversensing with Shock Selections: No, Yes
or ATP
Name:
oversensingShockIndic
ator
Datatype: Enum
Attribute Definition: Indicate if the existing lead was functioning abnormally
Name:
undersensingIndicator due to undersensing. Undersensing manifests as failure to sense appropriate
Datatype: Enum
cardiac depolarizations that cannot be resolved with reprogramming.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Lead
Abnormality_Undersens Enumerations:
Selections: No, Yes
ing
247. Manufacturer Advisory/Recall.
Product Advisory Recall
Type:
Package:
Alias:
Class
Cardiology CDE Library
Manufacturer Advisory/Recall
Class Definition: C1705180 Recall Activity NCI/FDAPT | Recalls are regulatory actions that enable
FDA to remove a hazardous, potentially hazardous, or a misbranded product from the marketplace.
Recalls are also used to convey additional information to the user concerning the safe use of the product.
Either FDA or the manufacturer can initiate recalls.
Attributes
Attribute
Name:
pacemakerLeadManuf
acturerAdvisoryIndica
tor
Datatype: Enum
Alias: Manufacturer
Advisory/Recall
Notes
Attribute Definition: Indicate if there is a recognized lead problem that has
resulted in a formal advisory or recall from the manufacturer, or the Food and
Drug Administration (FDA).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
248. Non-Lead Related Medical/Surgical Procedure.
Lead Replacement Reason
Type:
Package:
Alias:
Class
Cardiology CDE Library
Non-lead Related Medical/ Surgical Procedure
Class Definition: Rationale (or indication) for changing a cardiac pacemaker lead.
Attributes
Attribute
Name:
nonleadIndicator
Datatype: Enum
Alias: Non-lead Related
Medical/ Surgical
Procedure required
Notes
Attribute Definition: Indicate if a non-lead related medical or surgical
procedure required the existing lead to be replaced.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
256. CS/LV Lead Successful.
257. Reason CS/LV Lead Not Reimplanted.
Coronary Sinus LV Lead
Type:
Package:
Alias:
Class
Cardiology CDE Library
Reason CS/LV Lead Not Implanted
Class Definition: Coronary Sinus Access or Left Ventricular (CS/LV).
Attributes
Attribute
Name:
CSLVLeadImplantSuc
cessType
Datatype: Enum
Alias: CS/LV Lead
Successful
Name:
notImplantedReasonT
ype
Datatype: Enum
Alias: Reason CS/LV
Lead Not Implanted
Notes
Attribute Definition: Indicate if the coronary sinus/left ventricular (CS/LV)
lead was successfully implanted.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-Yes
2-Not implanted
3-Previously implanted
Attribute Definition: Indicate the reason a Coronary Sinus Access or Left
Ventricular (CS/LV) lead was not implanted.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-Vascular access
2-Coronary sinus access
3-Tributary vein access
4-Coronary sinus dissection
5-Unacceptable threshold
6-Diaphragmatic stimulation
260. Defibrillation Threshold/Lowest Energy Tested.
261. Upper Limit of Vulnerability.
ICD Threshold Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
Defibrillation Threshold/ Lowest Energy Tested
Class Definition: Properties or attributes describing or defining parameters required for an implantable
cardioverter-defibrillator to conduct energy through the myocardium and achieve intended outcome.
Attributes
Attribute
Notes
Attribute Definition: Indicate the lowest energy tested (LET) or defibrillation
Name:
defribillationThreshold threshold that demonstrated that the device performs successfully (in joules).
Datatype: Integer
Alias: Defibrillation
Threshold/ Lowest
Energy Tested
Attribute Definition: Indicate the upper limit of vulnerability (ULV) in joules.
Name:
upperLimitVulnerabili
ty
Datatype: Integer
Alias: Upper Limit of
Vulnerability
263. Faulty Connector Header.
Faulty Pacemaker Connector Head
Type:
Package:
Alias:
Class
Cardiology CDE Library
Faulty Connector Header
Class Definition:
Attributes
Attribute
Name:
faultyPacemaker
LeadIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if there was a faulty connector/header in the
existing lead.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Faulty Pacemaker Selections: No, Yes
Connector Lead Head
272. Lead Dislodgement Requiring Reposition/Reoperation.
277. Existing Lead Dislodgement.
Cardiac Pacemaker Lead Dislodgement
Type:
Package:
Alias:
Class
Cardiology CDE Library
Lead Dislodgement Requiring Reposition/Reoperation
Class Definition: Movement (macroscopic or microscopic) of an existing lead within the heart or
vascular tree away from the original implantation site.
Attributes
Attribute
Name:
leadDislodgementIndic
ator
Datatype: Enum
Notes
Attribute Definition: Indicate dislodgement of existing lead.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias:
LeadDislodgementIndic
ator
Name:
pacemakerLeadReoper
ationIndicator
Datatype: Enum
Alias: Lead
Dislodgement Requiring
Reposition/Reoperation
Attribute Definition: Indicate if the patient experienced a lead dislodgement as
documented by movement of a lead that requires repositioning and reoperation.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
273. Lead Erosion.
Cardiac Pacemaker Lead Erosion
Type:
Package:
Alias:
Class
Cardiology CDE Library
Lead Erosion
Class Definition: C1959609 Erosion lesion NCI/PT | An eating away or breakdown of any type of
external or internal human tissue including but not limited to skin, teeth, mucosa, or somatic, which
involves only the outer tissue layer. When tissue surrounds an implanted device, the tissue breakdown
may result in migration and loss of the implant material and may result in further complications such as
infection or abscess.
Attributes
Attribute
Name:
erosionIndicator
Datatype: Enum
Alias: Lead Erosion
Notes
Attribute Definition: Indicate if there was erosion of the existing lead.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
274. Lead Infection.
Cardiac Pacemaker Lead Infection
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Pacemaker Lead Infection
Class Definition: Condition following pacemaker lead procedure resulting in infection evidenced by
positive microbiological cultures/smears or other microbiological evidence indicating infection.
Attributes
Attribute
Name:
documentedLeadInfect
ionIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if there was a documented infection of the
existing lead.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Documented Lead Selections: No, Yes
Infection
Name:
leadInfectionIndicator
Datatype: Enum
Alias: Lead Infection
Attribute Definition: Indicate if there was a suspected or documented infection
of the existing lead.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
275. Lead Perforation.
Cardiac Pacemaker Lead Perforation
Type:
Package:
Alias:
Class
Cardiology CDE Library
Lead Perforation
Class Definition: Penetration of the existing lead through a systemic vein, coronary vein, or the
myocardium.
Attributes
Attribute
Name:
pacemakerLeadPerfor
ationIndication
Datatype: Enum
Alias: Lead Perforation
Notes
Attribute Definition: Indicate if there was penetration of the existing lead
through a systemic vein, coronary vein, or the myocardium.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
276. Lead Location.
Cardiac Pacemaker Lead Location
Type:
Package:
Alias:
Class
Cardiology CDE Library
Lead Location
Class Definition:
Attributes
Attribute
Name:
pacemakerLeadLlocati
onType
Datatype: Enum
Alias: Lead Location
Notes
Attribute Definition: Indicate the location of the lead.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-RA endocardial
2-LV epicardial
3-RV endocardial
4-SVC/subclavian
5-LV via coronary venous system
6-Subcutaneous array
7-Other
279. Existing Lead Function.
Cardiac Pacemaker Lead Function
Type:
Package:
Alias:
Class
Cardiology CDE Library
Existing Lead Function
Class Definition: Status of action performed by cardiac pacemaker lead.
Attributes
Attribute
Name:
pacemakerLeadFuncti
onType
Datatype: Enum
Alias: Existing Lead
Function
Notes
Attribute Definition: Indicate the function of the existing cardiac pacemaker
lead.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1-Normal
2-Abnormal
3-Not assessed
280. Arterial Access Site.
281. Arterial Access Closure Method.
Arterial Access
Type:
Package:
Alias:
Class
Cardiology CDE Library
Arterial Access
Class Definition: Location of percutaneous coronary entry.
Attributes
Attribute
Name: accessSiteType
Datatype: Enum
Alias: Arterial Access
Site
Name: closureMethod
Datatype: String
Alias: Arterial Access
Closure Method
Notes
Attribute Definition: Indicate the primary location of percutaneous entry.
Code the site used to perform the majority of the procedure if more than one
site was used.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 Femoral
2 Brachial
3 Radial
4 Other
Attribute Definition: Indicate the arterial closure methods used in
chronological order regardless of whether or not they provided hemostasis. The
same closure method may be repeated.
Entry values found on the publicly available NCDR Cath PCI website.
http://www.ncdr.com/WebNCDR/ELEMENTS.ASPX
282. Contrast Volume.
Contrast Volume
Type:
Package:
Alias:
Class
Cardiology CDE Library
Contrast Volume
Class Definition: Indicate the volume of contrast (ionic and non-ionic) used in milliliters (ml). The
volume recorded should be the total volume for the lab visit.
Attributes
Attribute
Name:
contrastVolumeTotal
Datatype: Integer
Alias: Contrast Volume
Notes
Attribute Definition: Indicate the volume of contrast (ionic and non-ionic)
used in milliliters (ml). The volume recorded should be the total volume for the
lab visit.
283. Fluoroscopy Dose.
284. Fluoroscopy Time.
Fluoroscopy Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
Fluoroscopy
Class Definition: Properties or attributes of the procedure used to examine the tissues and deep structures
of the body by x-ray, using the fluoroscope, a device that produces an image when x-rays strike a
fluorescent screen. Source: NCI ( C16588)
Attributes
Attribute
Name:
fluoroscopyDose
Datatype: Integer
Notes
Attribute Definition: Indicate the total fluoroscopy dose to the nearest integer
in milligrays (mGy). The value recorded should include the total dose for the
lab visit. Note(s): The dose recorded should include the total dose for the lab
visit. One gray is the absorption of one joule of radiation energy by one
Alias: Fluoroscopy Dose kilogram of matter.
Name:
fluoroscopyTime
Datatype: Integer
Alias: Fluoroscopy Time
Attribute Definition: Indicate the total fluoroscopy time recorded to the
nearest 0.1-minute. The time recorded should include the total time for the lab
visit.
Clinical/Adverse Events.
285. Significant Coronary Dissection.
Coronary Artery Dissection
Type:
Package:
Alias:
Class
Cardiology CDE Library
Significant coronary artery dissection
Class Definition: Dissection of coronary arteries is an opening or tear of the luminal wall as evidenced
by the appearance of contrast materials outside of the expected luminal dimensions of the target vessel
and extending longitudinally beyond the length of the lesion. Significant dissections are grade C
dissections in the presence of ischemia, or grade D-F dissections, all of which are further described as:
type C: persisting contrast medium extravasations; type D: spiral filling defect with delayed but complete
distal flow; type E: persistent filling defect with delayed antegrade flow; type F: filling defect with
impaired flow and total occlusion Supporting Definitions: Dissection is defined as the appearance of
contrast materials outside of the expected luminal dimensions of the target vessel and extending
longitudinally beyond the length of the lesion.
Attributes
Attribute
Name:
significantCADissectio
nIndicator
Datatype: Enum
Alias: Significant
coronary artery
dissection
Notes
Attribute Definition: Indicate if a significant dissection was observed. Note(s):
Typically, dissections described as type A or B are not considered significant
dissections because there is no impairment of flow.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
286. Coronary Artery Perforation.
Coronary Artery Perforation
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Artery Perforation
Class Definition: A coronary artery perforation is a dissection or intimal tear that extends through the full
thickness of the arterial wall.
Attributes
Attribute
Name:
CAPerforationIndicato
r
Datatype: Enum
Alias: Coronary artery
perforation
Notes
Attribute Definition: Indicate if angiographic or clinical evidence of
perforation was observed. Note(s): This does not include pre-existing AV
fistula and other coronary anomalies.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
287. Coronary Thrombus.
Coronary Thrombus
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Thrombus
Class Definition: Blood clot in a coronary artery. Thrombus is suggested by certain angiographic
features: haziness, reduced contrast density or contrast persistence, irregular lesion contours, or globular
filling defects. Source: NCDR
Attributes
Attribute
Name:
bloodClotIndicator
Datatype: Enum
Alias: Coronary
Thrombus
Notes
Attribute Definition: Indicate if a coronary thrombus is present.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
288. Coronary Venous Dissection.
Coronary Venous Dissection
Type:
Package:
Alias:
Class
Cardiology CDE Library
Coronary Venous Dissection
Class Definition: Manipulation of the pacing or defibrillating leads in the coronary sinus which can result
in a tear of the coronary sinus endothelium with dissection into the coronary sinus wall.
Attributes
Attribute
Name:
venousDissectionIndica
tor
Datatype: Enum
Alias: Coronary Venous
Dissection
Notes
Attribute Definition: Indicate if the patient had a coronary venous dissection.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
289. Cardiac Valve Injury.
Cardiac Valve Injury
Type:
Package:
Alias:
Class
Cardiology CDE Library
Valve Injury
Class Definition: Cardiac valve injury results when manipulation of the pacing or defibrillation leads
results in a tear in a valve leaflet or chordae tendinae and manifests as a new regurgitant.
Attributes
Attribute
Name:
valveInjuryIndicator
Datatype: Enum
Alias: Cardiac Valve
Indicator
Notes
Attribute Definition: Indicate if a new cardiac valve injury was documented in
the medical record.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
290. Chamber Thrombus.
Chamber Thrombus
Type:
Package:
Alias:
Class
Cardiology CDE Library
Chamber Thrombus
Class Definition: Clot within the cavities of the cardiac structures. Presence is considered to be definite if
3 of the following 5 criteria are present:: 1. Clear borders, 2. Echogenicity from the surrounding
structures, 3. Independent mobility, 4. Longest diameter 15 mm, 5. Seen in more than one
echocardiographic plane.
Attributes
Attribute
Name:
thrombusIndicator
Datatype: Enum
Alias: Chamber
Thrombus
Notes
Attribute Definition: Indicate if the patient experienced a chamber thrombus.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
291. Conduction Block.
New Conduction Block
Type:
Package:
Alias:
Class
Cardiology CDE Library
Conduction Block
Class Definition: New conduction blocks occur when pacing or defibrillation
leads are manipulated which causes an injury to the specialized cardiac conduction system. It can
manifest as a new right bundle branch block, or a complete heart block in a patient with a pre-existing left
bundle branch block.
Attributes
Attribute
Name:
newAVConductionBloc
kIndicator
Datatype: Enum
Alias: New AV
Conduction Block
Notes
Attribute Definition: Indicate if a new atrial or ventricular conduction block
was documented in the medical record.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
292. Cardiac Perforation.
293. Pericardial Effusion.
Cardiac Perforation
Type:
Package:
Alias:
Class
Cardiology CDE Library
Cardiac Perforation
Class Definition: Hole or opening in the myocardium resulting in pain and/or hypotension cardiac
tamponade.
Attributes
Attribute
Name:
cardiacPerforationIndi
cator
Datatype: Enum
Notes
Attribute Definition: Indicate if cardiac perforation occurred. Cardiac
perforation may or may not be symptomatic and may or may not be self-sealing.
It can be documented by migration of pacing or defibrillator leads to the
epicardial surface, resulting in pain and/or hypotension, pericardial infusion,
cardiac tamponade, failure to capture, capture of the diaphragm, phrenic nerve
or intercostals muscle of sufficient magnitude to require repositioning. Cardiac
Alias: Cardiac
perforation can be caused by leads, guidewires, balloons, or any other device.
Perforation Indicator
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate the location of the cardiac perforation.
Name:
cardiacPerforationLoc Enumerations:
CDISC Anatomical Location Codelist.
ation
Datatype: Enum
Alias: Myocardiac
Perforation Indicator
294. Cardiac Tamponade.
Cardiac Tamponade
Type:
Package:
Alias:
Class
Cardiology CDE Library
Pericardial Tamponade
Class Definition: Accumulation of blood in the pericardial sac.
Attributes
Attribute
Name:
pericardialTamponade
Indicator
Datatype: Enum
Alias: Pericardial
Tamponade
Notes
Attribute Definition: Indicate if the patient experienced fluid in the pericardial
space compromising cardiac filling and requiring intervention.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
295. Luminal/Carotid Thrombus.
Luminal Carotid Thrombus
Type:
Package:
Alias:
Class
Cardiology CDE Library
Luminal/ Carotid Thrombus
Class Definition: A blood clot within the structures of the carotid artery.
Attributes
Attribute
Name:
carotidThrombusIndic
ator
Datatype: Enum
Alias: Luminal/ Carotid
Thrombus
Notes
Attribute Definition: Indicate if a thrombus (blood clot) was present on direct
visual inspection interoperatively during the carotid endarterectomy (CEA)
procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
296. Myocardial infarction.
Acute Myocardial Infarction
Type:
Package:
Alias:
Class
Cardiology CDE Library
Acute Myocardial Infarction
Class Definition: Sudden loss of circulation to the myocardium resulting in ischemia. A myocardial
infarction is evidenced by any of the following:
1. A rise and fall of cardiac biomarkers (preferably troponin) with at least one of the values in the
abnormal range for that laboratory [typically above the 99th percentile of the upper reference limit (URL)
for normal subjects] together with at least one of the following manifestations of myocardial ischemia:
a. Ischemic symptoms.
b. ECG changes indicative of new ischemia (new ST-T changes, new left bundle branch block, or loss of
R- wave voltage).
c. Development of pathological Q- waves in 2 or more contiguous leads in the ECG (or equivalent
findings for true posterior MI).
d. Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality.
e. Documentation in the medical record of the diagnosis of acute myocardial infarction based on the
cardiac biomarker pattern in the absence of any items enumerated in a-d due to conditions that may mask
their appearance (e.g., peri-operative infarct when the patient cannot report ischemic symptoms; baseline
left bundle branch block or ventricular pacing).
2. ECG changes associated with prior myocardial infarction can include the following (with or without
prior symptoms):
a. Any Q-wave in leads V2-V3 >=0.02 seconds or QS complex in leads V2 and V3.
b. Q-wave >=0.03 seconds and >=0.1 mV deep or QS complex in leads I, II, aVL, aVF, or V4-V6 in any
two leads of a contiguous lead grouping (I, aVL, V6; V4-V6; II, III, and aVF).
c. R-wave >=0.04 seconds in V1-V2 and R/S >=1 with a concordant positive T wave in the absence of a
conduction defect.
3. Imaging evidence of a region with new loss of viable myocardium at rest in the absence of a nonischemic cause. This can be manifest as:
a. Echocardiographic, CT, MR, ventriculographic or nuclear imaging evidence of left ventricular thinning
or scarring and failure to contract appropriately (i.e., hypokinesis, akinesis, or dyskinesia).
b. Fixed (non-reversible) perfusion defects on nuclear radioisotope imaging (e.g., MIBI, thallium).
4. Medical record documentation of prior myocardial infarction.
Source: Joint ESC-ACC-AHA-WHF 2007 Task Force Consensus Document "Universal Definition of
Myocardial Infarction".
Attributes
Attribute
Name: AMIDateTime
Datatype: DateTime
Alias: Acute Myocardial
Notes
Attribute Definition: DateTime of the Acute Myocardial Infarction (AMI)
Attribute
Infarction Date and
Time
Notes
Attribute Definition: Indicate whether an Acute Myocardial Infarction (AMI)
occurred.
Enumerations:
Alias: Acute Myocardial Selections: No, Yes
Infarction (AMI)
Indicator
Name: AMIIndicator
Datatype: Enum
297. Urgent Cardiac Surgery.
Urgent Cardiac Surgery
Type:
Package:
Alias:
Class
Cardiology CDE Library
Urgent Cardiac Surgery
Class Definition: Procedure performed on the heart with intent to treat disease, injury or deformity, that
is required during hospitalization in order to minimize chance of further clinical deterioration. Examples
of conditions requiring urgent cardiac surgery include but are not limited to: worsening sudden chest pain,
Congestive Heart Failure (CHF), acute myocardial infarction (AMI),anatomy, IABP, unstable angina
(UA) with intravenous (IV) nitroglycerin (NTG) or rest angina.
Attributes
Attribute
Name: UCSIndicator
Datatype: Enum
Alias: Urgent Cardiac
Surgery (UCS)
Notes
Attribute Definition: Indicate if the patient needed to have urgent, unplanned
cardiac surgery (UCS).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
298. Venous Obstruction.
Venous Obstruction
Type:
Package:
Alias:
Class
Cardiology CDE Library
Venous Obstruction
Class Definition: Swelling, pain and discoloration of an extremity and confirmed by some imaging
technique demonstrating >50% diameter reduction in the affected vein.
Attributes
Attribute
Name:
obstructionIndicator
Datatype: Enum
Alias: Venous
Obstruction
Notes
Attribute Definition: Indicate if the patient experienced a venous obstruction
distal to the vascular access site.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
299. Hematoma at Access Site.
300. Hematoma Size.
301. Hematoma Requiring Re-op.
Hematoma Characteristics
Type:
Package:
Alias:
Class
Cardiology CDE Library
Hematoma Characteristics
Class Definition: C0018944 Hematoma NCI/FDAPT | A localized collection of blood, usually clotted,
in an organ, space, or tissue, due to a break in the wall of a blood vessel.
Attributes
Attribute
Name:
hematomaAccessSiteIn
dicator
Datatype: Enum
Alias: Hematoma at
Access Site
Name:
hematomaRequiringRe
opIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if the patient experienced a hematoma at the
percutaneous entry site.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the patient experienced a hematoma as a result
of the procedure, requiring a reoperation, evacuation or transfusion.
Enumerations:
Selections: 0-No,1-Yes
Alias: Hematoma
Requiring Re-op
Name: hematomaSize
Datatype: Integer
Alias: Hematoma Size
Attribute Definition: Indicate the maximal dimension, in centimeters, of the
hematoma (measured by palpation or imaging).
302. Red blood cell or whole blood transfusion.
RBC Whole Blood Transfusion
Type:
Package:
Alias:
Class
Cardiology CDE Library
RBC /Whole Blood Transfusion
Class Definition: The infusion of whole blood or a blood component directly into the bloodstream.
Source: NCI (C15192)
Attributes
Attribute
Name:
bloodTransfusionIndic
ator
Datatype: Enum
Alias: Red blood cell or
whole blood transfusion
Notes
Attribute Definition: Indicate if there was a transfusion of either whole blood
or packed red blood cells.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
303. Pneumothorax.
Pneumothorax
Type:
Package:
Alias:
Class
Cardiology CDE Library
Pneumothorax
Class Definition: Air in the thorax sufficient to require insertion of a chest tube.
Attributes
Attribute
Name:
pneumoIndicator
Datatype: Enum
Alias: Pneumothorax
Notes
Attribute Definition: Indicate if the patient experienced a pneumothorax as
documented by air in the thorax sufficient to require insertion of a chest tube.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes.
304. Hemothorax.
Hemothorax
Type:
Package:
Alias:
Class
Cardiology CDE Library
Hemothorax
Class Definition: Accumulation of blood in the thorax.
Attributes
Attribute
Name:
hemothoraxIndicator
Datatype: Enum
Alias: Hemothorax
Notes
Attribute Definition: Indicate if the patient experienced presence of blood in
the thoracic cavity.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
305. Peripheral Embolus.
Peripheral Embolus
Type:
Package:
Alias:
Class
Cardiology CDE Library
Peripheral Embolus
Class Definition: Acute occlusion of a peripheral artery resulting from embolization of a cardiac or
proximal arterial thrombus.
Attributes
Attribute
Name:
PeriphEmbIndicator
Datatype: Enum
Alias: Peripheral
Embolus
Notes
Attribute Definition: Indicate if the patient experienced a peripheral embolus
(PE) as documented by acute occlusion of an artery resulting from embolization
of a cardiac or proximal arterial thrombus.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
306. Peripheral Nerve Injury.
Peripheral Nerve Injury
Type:
Package:
Alias:
Class
Cardiology CDE Library
Peripheral Nerve Injury
Class Definition: Sensory or motor loss of peripheral nerve function. This may result from external nerve
compression as a result of positioning during a procedure, internal compression or direct nerve damage.
Attributes
Attribute
Name: PNIIndicator
Datatype: Enum
Alias: Peripheral Nerve
Injury (PNI)
Notes
Attribute Definition: Indicate if the patient experienced a peripheral nerve
injury (PNI) as documented by sensory or motor loss of peripheral nerve
function. This may result from external nerve compression as a result of
positioning during a procedure, internal compression or direct nerve damage.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
307. Infection Requiring Antibiotics.
Infection Requiring Antibiotics
Type:
Package:
Alias:
Class
Cardiology CDE Library
Infection Requiring Antibiotics
Class Definition: Indicate if the patient experienced an infection related to the procedure which required
antibiotics.
Attributes
Attribute
Name:
antibioticsIndicator
Datatype: Enum
Alias: Infection
Requiring Antibiotics
Notes
Attribute Definition: Indicate if antibiotics were required to treat an infection
related to a cardiac procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
308. Set Screw Problem.
Set Screw Problem
Type:
Package:
Alias:
Class
Cardiology CDE Library
Set Screw Problem
Class Definition: Pacing and/or sensing problem associated with high impedance due to a poor
connection between a lead and ICD caused by a loose set screw. Source:NCDR
Attributes
Attribute
Name:
problemIndicator
Datatype: Enum
Alias: Set Screw
Problem
Notes
Attribute Definition: Indicate if the patient had a pacing and/or sensing
problem associated with high impedance due to a poor connection between a
lead and ICD caused by a loose set screw.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
309. Drug Reaction/Serious Substance-related Adverse Event.
310. Drug/Substance Allergy.
Adverse Substance Reaction
Type:
Package:
Alias:
Class
Cardiology CDE Library
Drug Reaction
Class Definition: Unintended, deleterious effects of otherwise licit, therapeutic, properly administered
drugs; for effects of illicit and abused drugs, or of environmental chemicals, see TOXICOLOGY or
POISONING. C0041755
Attributes
Attribute
Name:
substanceReactionIndi
cator
Datatype: Enum
Alias: Drug Reaction/
Substance Adverse
Event
Notes
Attribute Definition: In the instance of a quality measure, a substance adverse
event is an unexpected or dangerous reaction to a substance (e.g., food,
environmental agent). Serious adverse events are those that are fatal, lifethreatening, permanently/significantly disabling, those that require or prolong
hospitalization, and
those that lead to congenital anomaly or require intervention
to prevent permanent impairment or damage. A time/date
stamp is required as are notations indicating whether item is patient reported
and/or provider verified.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Medications
311. At Home Medications.
312. Aspirin in First 24 hours.
313. Clopidogrel in First 24 hours.
314. Prasugrel in First 24 hours.
315. Ticlopidine in First 24 hours.
316. Beta Blocker in First 24 hours.
317. ACE Inhibitor in First 24 hours.
318. Angiotensin Receptor Blocker in First 24 hours.
319. Statin in First 24 hours.
320. Non-Statin Lipid Lowering in First 24 hours.
321. Aldosterone Blocking Agent in First 24 hours.
322. Medication Timepoint.
323. Medications Held or Discontinued.
324. Blinded.
325. Contraindication.
326. Anticoagulant.
327. Cyclooxygenase 2 inhibitor.
328. P2Y12 inhibitor.
329. Beta blockers.
330. GP IIb/IIIa Inhibitor.
331. Lipid Lowering Statin Medications.
332. Non Statin Lipid Lowering Medications.
333. Prophylactic Antibiotics Within 1 hour or procedure start time.
334. Diuretic.
335. Direct Renin Inhibitor.
336. Alpha Blocker.
337. Steroid, systemic.
338. Nonsteroidal anti-inflammatory.
Medication Admin
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: A record of the substances administered to the patient in the context of the encounter.
Attributes
Attribute
Name:
ACEInhibitorFirst24H
rsIndicator
Datatype: Enum
Alias: ACE Inhibitor
administration within
First 24 hours
Name:
aldosteroneFirst24HrsI
ndicator
Datatype: Enum
Alias: Aldosterone
Blocking Agent
administration within
First 24 hours
Notes
Attribute Definition: Indicate if an ACE inhibitor was administered, regardless
of location of care (e.g., transferring facility or EMS). Target Value: Any
occurrence between first medical contact and 24 hrs after first medical contact.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if an aldosterone blocking agent was
administered, regardless of location of care (e.g., transferring facility or EMS).
Target Value: Any occurrence between first medical contact and 24 hours after
first medical contact.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate whether there is documentation of an order or
administration of an antibiotic. Note(s): 1. An order (written order, verbal order,
or standing order/protocol) for prophylactic antibiotics to be given within one
hour of procedure start time (two hours if receiving vancomycin or
fluoroquinolone). OR 2 Prophylactic antibiotic administered within one hour (if
fluoroquinolone or vancomycin, two hours) prior to procedure start time. In the
Alias: Prophylactic
event that the procedure is delayed, as long as the patient is redosed (if
Antibiotics Within 1
hour of procedure start clinically appropriate) the appropriate selection should be applied. Target
Value: Any occurrence between 2 hours prior to procedure and start of current
time
procedure.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1No -not given, medical reason documented
2No -not given, reason unspecified
3Yes
Attribute Definition: Indicate if an angiotensin receptor blocker was
Name:
ARBFirst24HrsIndicat administered, regardless of location of care (e.g., transferring facility or EMS).
Target Value: Any occurrence between first medical contact and 24 hrs after
or
Datatype: Enum
first medical contact.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Alias: Angiotensin
Enumerations:
Receptor Blocker
Selections: No, Yes
administration within
First 24 hours
Name:
antibiotics1HrPreProc
edureType
Datatype: Enum
Attribute
Notes
Name:
aspirinFirst24HrsIndic
ator
Datatype: Enum
Attribute Definition: Indicate if Aspirin was administered within First 24
Hours. Coding Instructions: Indicate if aspirin was administered in the first 24
hours before or after first medical contact, regardless of location of care (e.g.,
transferring facility or EMS). Target Value: Any occurrence between 24 hours
before first medical contact and 24 hours after first medical contact Indicator is
a selection of No/Yes values used in the enumerated, menu of choices or picklist.
Enumerations:
Selections: No, Yes
Alias: Aspirin
administration within
First 24 hours
Name:
betaBlockerFirst24Hrs
Indicator
Datatype: Enum
Alias: Beta Blocker
administration within
First 24 hours
Name:
betaBlockersIndicator
Datatype: Enum
Alias: Administration
Name:
blindedIndicator
Datatype: Enum
Alias: Blinded
Name:
clopidogrelFirst24HrsI
ndicator
Datatype: Enum
Alias: Clopidogrel
administration within
First 24 hours
Attribute Definition: Indicate if a beta blocker was administered, regardless of
location of care (e.g., transferring facility or EMS). Target Value: Any
occurrence between first medical contact and 24 hours after first medical
contact.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if a beta blocker was administered.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if the medication was blinded.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if clopidogrel was administered, regardless of
location of care (e.g., transferring facility or EMS). Target Value: Any
occurrence between first medical contact and 24 hours after first medical
contact
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute
Name:
contraIndication
Datatype: Enum
Alias: Contraindication
Name:
GPIIbIIIaInhibitorIndi
cator
Datatype: Enum
Notes
Attribute Definition: Indicate if the medication was contraindicated.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if a GP IIb/IIIa inhibitor was administered.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: GP IIb/IIIa
Inhibitor administration
Name:
homeMedicationsIndic
ator
Datatype: Enum
Attribute Definition: Indicate if Medication was started at home.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: At Home
Medications
Name:
medicationConditions
MetIndicator
Datatype: Enum
Attribute Definition: Indicate if protocol conditions for the medications met.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Medication
Protocol Conditions Met
Name:
medicationsHeldDiscon
tinuedIndicator
Datatype: Enum
Attribute Definition: Medication held or discontinued.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Medication Held
or Discontinued.
Name:
medicationTimepointT
ype
Datatype: Enum
Attribute Definition: Indicate the planned time point for the medication.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
-First 24 hours of medical contact
Attribute
Alias: Medication
Timepoint
Notes
-Pre-procedure
-Post Procedure
Name:
nonStatinLipidLoweri
ngIndicator
Datatype: Enum
Attribute Definition: Indicate if a non-statin lipid lowering agent was taken.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Non Statin Lipid
Lowering Medications
administration status
Name:
nonStatinLipidLowFir
st24HrsIndicator
Datatype: Enum
Alias: Lowering agent
administration within
First 24 hours
Name:
prasugrelFirst24HrsIn
dicator
Datatype: Enum
Alias: Prasugrel
administration within
First 24 hours
Attribute Definition: Indicate if a non-statin lipid-lowering agent was
administered, regardless of location of care (e.g., transferring facility or EMS).
Target Value: Any occurrence between first medical contact and 24 hours after
first medical contact.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if Prasugrel was administered, regardless of
location of care (e.g., transferring facility or EMS). Target Value: Any
occurrence between first medical contact and 24 hours after first medical
contact. Indicator is a selection of No/Yes values used in the enumerated, menu
of choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if medication was administered prior to
procedure. Note: Timeframes of significance is different depending on
medication or other context – so each implementation should specify timeframe
for each medication of interest. (i.e. antibiotics w/in 3hrs of beginning of
procedure vs ASA or anticoagulant w/in 24hrs/48hrs or 7days of procedure.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Alias: Pre-Procedure
choices or pick-list.
Medication
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if a statin was administered, regardless of
Name:
statinFirst24HrsIndica location of care (e.g., transferring facility or EMS). Target Value: Any
occurrence between first medical contact and 24 hours after first medical
tor
Datatype: Enum
contact.
Name:
preprocedureMedicati
onIndicator
Datatype: Enum
Attribute
Alias: Statin
administration within
First 24 hours
Name: statinIndicator
Datatype: Enum
Alias: Lipid Lowering
Statin Medications
Name:
TiclipodineFirst24Hrs
Type
Datatype: Enum
Alias: Ticlopidine
administration within
First 24 hours
Notes
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if a statin was administered.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: Indicate if ticlopidine was administered, regardless of
location of care (e.g., transferring facility or EMS). Target Value: Any
occurrence between first medical contact and 24 hours after first medical
contact.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
No
Yes
Contraindicated
Blinded
Discharge
339. Vital Status.
342. CMS Discharge Disposition.
343. Dietary Counseling.
344. Exercise Counseling.
345. Smoking Counseling.
346. Cardiac Rehabilitation Referral.
347. Transfer for Procedure.
348. Transfer for Procedure Location.
Discharge Information
Type:
Package:
Alias:
Class
Cardiology CDE Library
Class Definition: Information that is either collected at the point the patient is discharged, or that is
directly related to the discharge process.
Attributes
Attribute
Name:
cardiacRehabilitationR
eferralType
Datatype: Enum
Alias: Cardiac
Rehabilitation Referral
Notes
Attribute Definition: Indicate if there was written documentation of a referral
for the patient (by the physician, nurse, or other personnel) to an outpatient
cardiac rehabilitation program, or a documented medical or patient-centered
reason why such a referral was not made. Note(s): The program may include a
traditional cardiac rehabilitation program based on face-to-face interactions and
training sessions or may include other options such as home-based approaches.
"Ineligible" may be selected for patients considered ineligible based on patientoriented barriers (patient refusal, for example), provider-oriented criteria
(patient deemed to have a high-risk condition or contraindication to exercise
such as dementia, homebound, long-term nursing home placement >60 days, for
example), or health care system barriers (financial barriers or lack of cardiac
rehabilitation programs near a patient's home, for example).
Supporting Definitions: Referral: A referral is defined as an official
communication between the health care provider and the patient to recommend
and carry out a referral order to an early outpatient Cardiac Rehabilitation
program. This includes the provision of all necessary information to the patient
that will allow the patient to enroll in an early outpatient CR program. This also
includes a communication between the health care provider or health care
system and the CR program that includes the patient's referral information for
the program. A hospital discharge summary or office note may potentially be
formatted to include the necessary patient information to communicate to the
Attribute
Notes
CR program [the patient's cardiovascular history, testing, and treatments, for
instance]. All communications must maintain appropriate confidentiality as
outlined by the 1996 Health Insurance Portability and Accountability Act
[HIPPA].)
Source: Thomas RJ, King M, Lui K, et al. "AACVPR/ACC/AHA 2007
Performance Measures on Cardiac Rehabilitation for Referral to and Delivery
of Cardiac Rehabilitation/Secondary Prevention Services." Journal of American
College of Cardiology. 2007: 50(14), pp 1400-1433
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
0 No
1 Yes
2 Ineligible
Attribute Definition: The place or setting to which the patient was discharged.
Name:
CMSDischargeDisposit This element is referenced in The Joint Commission AMI Core Measures,
AMI-1 through AMI-5. AMI-7, 7a, 8, 8a and AMI-9.
ionType
Datatype: Enum
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
Alias: CMS Discharge
1 Alive
Disposition
2 Deceased
Name:
dietaryCounselingIndic
ator
Datatype: Enum
Attribute Definition: Dietary Counseling.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Dietary
Counseling
Name:
exerciseCounselingIndi
cator
Datatype: Enum
Attribute Definition: Exercise Counseling.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Exercise
Counseling
Name:
smokingCounselingInd
icator
Datatype: Enum
Alias: Smoking
Attribute Definition: Indicate if there was documentation in the medical record
that smoking cessation advice or counseling was given during this admission.
. This element is referenced in The Joint Commission AMI Core Measures
AMI-4.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Attribute
Counseling
Notes
Enumerations:
Selections: No, Yes
Name:
transferPCIIndicator
Datatype: Enum
Attribute Definition: Indicate if the patient was transferred to another facility
for percutaneous coronary intervention (PCI).
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Selections: No, Yes
Alias: Transfer for PCI
Name:
transferProcedureLoca
tionType
Datatype: Enum
Alias: Transfer for
Procedure Location
Attribute Definition: Indicate the location where the procedure is being
performed. Note(s): Code the appropriate selection for surgeries performed at
your facility or transferred for planned CABG surgery at another facility.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Enumerations:
1 At your facility
2 Transferred to other facility
Name: vitalStatusType Attribute Definition: Indicate whether the patient was alive or deceased at
Datatype: Enum
discharge.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: Vital Status
Enumerations:
1 Alive
2 Deceased
340. Comfort Measures.
341. CMS Comfort Measures Timing.
Comfort Measures
Type:
Package:
Alias:
Class
Cardiology CDE Library
Comfort Measures
Class Definition: Comfort measures are commonly referred to as palliative care in the medical
community and comfort care by the general public. Palliative care includes attention to the psychological
and spiritual needs of the patient and support for the dying patient and the patient's family. Usual
interventions are not received because a medical decision was made to limit care to comfort measures
only.
Attributes
Attribute
Name:
comfortMeasureReceiv
edIndicator
Datatype: Enum
Notes
Attribute Definition: Indicate if there was physician/nurse
practitioner/physician assistant documentation that the patient was receiving
comfort measures. Comfort Measures are not equivalent to the following: Do
Not Resuscitate (DNR), living will, no code, no heroic measures.
Indicator is a selection of No/Yes values used in the enumerated, menu of
Alias: Comfort Measures choices or pick-list.
Enumerations:
Selections: No, Yes
Attribute Definition: When is the earliest physician/APN/PA documentation
Name:
comfortMeasuresTimi of comfort measures only? Note(s):
This element is referenced in The Joint Commission AMI Core Measures, AMIngType
Datatype: Enum
1 through AMI-9.
Type is a collection of values used in the enumerated, menu of choices or picklist.
Alias: CMS Comfort
Enumerations:
Measures Timing
1 Day 0 or 1 The earliest day the physician/APN/PA documented comfort
measures only was the day of arrival (Day 0) or day after arrival (Day 1).
2 Day 2 or after The earliest day the physician/APN/PA documented comfort
measures only was two or more days after arrival day (Day 2+).
3 Timing unclear There is physician/APN/PA documentation of comfort
measures only during this hospital stay, but whether the earliest documentation
of comfort measures only was on day 0 or 1 OR after day 1 is unclear.
4 Not Documented/UTD There is no physician/APN/PA documentation of
comfort measures only, or unable to determine from medical record
documentation if there is physician/APN/PA documentation of comfort
measures only during this hospital stay.
Supporting Definitions: (none)
Outcomes
349. Death.
350. Date of death.
351. Cause of death.
352. Cardiac death.
353. Death During Procedure.
Death
Type:
Package:
Alias:
Class
Cardiology CDE Library
Death
Class Definition: C0011065 Cessation of life (irreversible, permanent cessation of all vital bodily
functions).
Attributes
Attribute
Name: deathIndicator
Datatype: Enum
Notes
Attribute Definition: Death includes all deaths regardless of etiology.
Indicator is a selection of No/Yes values used in the enumerated, menu of
choices or pick-list.
Enumerations:
Alias: Death
Selections: No, Yes
Attribute Definition: Select the PRIMARY cause of death, i.e. the first
Name:
primaryCauseOfDeath significant abnormal event which ultimately led to death.
Type is a collection of values used in the enumerated, menu of choices or pickType
Datatype: Enum
list.
Enumerations:
Cardiac
Alias: Cause of Death
Neurologic
Renal
Vascular
Infection
Valvular
Pulmonary
Unknown
Gastrointestinal
Hepatobiliary
Pancreatic
Infection (includes sepsis)
Non-infectious (e.g., systemic inflammatory response syndrome (SIRS))
Hemorrhage that is neither cardiovascular bleeding nor a stroke
Attribute
Notes
Non-CV procedure or surgery
Accidental (e.g., physical accidents or drug overdoses) or trauma
Suicide
Prescription Drug Error
Neurological Process that is not a stroke or hemorrhage
Malignancy
Other non-CV
Acute Myocardial Infarction
Sudden cardiac death
Congestive Heart Failure
Stroke
Cardiovascular Procedures
Cardiovascular Hemorrhage
Other Cardiovascular causes