IMACS Users' Guide – Version 1.0 - The International Society for ...

IMACS Users’ Guide – Version 1.0
12/21/2012
Page 38 of 56
3 Month and 6 Month Follow-up
Mark whether the medications listed are used at the follow-up time period: Yes, No or
Other.
List of medications
Hydralazine
Calcium channel blockers
Nesiritide
Angiotensin receptor blocker drug
Amiodarone
ACE inhibitors
Beta-blockers
Aldosterone antagonist
Lovenox
Warfarin (coumadin)
Antiplatelet therapy drug – additionally, check all that apply.
If Other, specify is selected, type in the specification in the block
provided.
Nitric oxide
Phospodiesterase
Digoxin
Loop diuretics
MEDICAL CONDITION
NYHA Class: New York Heart Association Class for heart failure:
Class I: No limitation of physical activity; physical activity does not cause fatigue,
palpitation or shortness of breath.
Class II: Slight limitation of physical activity; comfortable at rest, but ordinary physical
activity results in fatigue, palpitations or shortness of breath.
Class III: Marked limitation of physical activity; comfortable at rest, but less than
ordinary activity causes fatigue, palpitation or shortness of breath.
Class IV: Unable to carry on minimal physical activity without discomfort; symptoms
may be present at rest.
Unknown
Has patient been rehospitalized since last follow-up?: Yes, No, or Unknown
If yes: 0 -1
2 – 3
4 or more