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Table 2 Description of data elements collection in abstraction tool

From: Field methods in medical record abstraction: assessing the properties of comparative effectiveness estimates

Demographic information

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Diagnosis at admission (STEMI, NSTEMI, unstable angina), arrival setting (home or facility, etc.), primary language

Presenting symptoms, initial vital signs and tests

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Presentation of chest pain, cognitive status

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Vitals at admission - pulse, systolic blood pressure, diastolic blood pressure, Respiration, temperature, weight and height

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Lab tests - LDL, HDL, HA1c, ALT, AST, Serum creatinine, cardiac troponin level, CK-MB, LVEF, ProBNP\BNP

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ECG findings (left/right ventricular hypertrophy, complete bundle branch block, heart block, AF, other arrhythmia) and Chest x-ray findings

Prior history – conditions, procedures, hospitalizations, and status immediately prior to AMI admission

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Cardiac conditions and procedures (prior AMI, angina, atrial fibrillation [AF], hypertension, and heart failure [HF]; prior PTCA, coronary artery bypass graft [CABG], stent, or pacemaker,)

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Non-cardiac condition (liver disease, diabetes, transient ischemic attack [TIA], stroke, chronic kidney disease [CKD], COPD, asthma, dyslipidemia, and tumor)

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Other history (past/current smoking, drug use, difficulty with activities of daily living and other indicators of mobility limitations and frailty, drug allergies)

Medication use - prior to admission and in-hospital

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Thrombolytic use, aspirin, clopidogrel/ticlopidine, beta blockers, ACE inhibitors, ARBs, statins, calcium channel blockers, loop diuretic, thiazide diuretics, aldosterone antagonists, digoxin, amiodarone, warfarin, heparin, and other lipid-lowing agents

In-hospital procedures or complications

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Procedures - coronary angiography and findings, coronary angioplasty, stent placement, echocardiography, and stress test

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Complications – HF, hypotension, cardiogenic shock, renal failure, major bleed, stroke, pneumonia, sepsis, and pulmonary embolism

In-hospital labs and test results, and results prior to discharge

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Lab tests (as above), ECG, chest x-ray, stress test, echocardiogram, blood pressure

Discharge instructions including prescribed medications.

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Cardiovascular-related discharge medications (as above) discharge disposition – to home, skilled nursing, home health, etc.