IHE Cardiology Technical Framework Supplement Cardiac Imaging ...

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IHE Cardiology Technical Framework Supplement – Cardiac Imaging Report Content (CIRC)______________________________________________________________________________aortic or other major vascular surgery,peripheral vascular surgery, anticipatedprolonged surgical procedure associatedwith large fluid shifts and/or blood loss)● N/ANoncardiac surgery—patient activeconditions(Recommended if preoperative)Noncardiac surgery—patient risk factors(Recommended if preoperative)Medication ID—medications(Recommended)(Optional—TEE, TTE)For a patient scheduled to undergononcardiac surgery, does the patienthave any active cardiac conditions;defined as any of the following:● Unstable coronary syndrome● Decompensated heart failure (NYHAfunctional class IV, worsening or newheart failure)● Significant arrhythmias (e.g., highgradeAV block, ventricular arrhythmias,symptomatic bradycardia,supraventricular arrhythmias with anuncontrolled rate)● Severe valvular heart diseaseChoose 1 of the following:● Yes● NoFor a patient scheduled to undergononcardiac surgery, how many of thefollowing clinical risk factors are present:● Ischemic heart disease● Compensated or prior heart failure● Diabetes mellitus● Renal insufficiency● Cerebrovascular diseaseChoose 1 of the following:● 3 or more● 1 to 2● NoneIndicate which of the followingcategories of medications are routinelytaken by the patient. Choose allapplicable of the following:● ACE inhibitor/angiotensin receptorblocker● Aspirin, other antiplatelet agents● Calcium channel blockersMedications Section1.3.6.1.4.1.19376.1.5.3.1.3.19Parent Template CCD 3.9(2.16.840.1.113883.10.20.1.8)__________________________________________________________________________16Rev. 1.0 – 2011-04-22Copyright © 2011: IHE International, Inc.
IHE Cardiology Technical Framework Supplement – Cardiac Imaging Report Content (CIRC)______________________________________________________________________________● Beta-blockers● Erectile dysfunction medication● Nitrates● Warfarin● Antiarrhythmics● Digitalis● Metformin● Lipid-lowering medication (niacin,statins, fibrates, etc.)● Other antihypertensives● Aminophylline or theophylline● Dipyridamole● Inhaler● Diabetic medications● NoneMedications—normallyused but held prior totesting(Recommended)(Optional—TEE, TTE)History of reaction tocontrast agent(Recommended)Indicate if any medications normally usedby the patient that were notadministered per routine schedule priorto test:● ACE inhibitor/angiotensin receptorblocker● Aspirin, other antiplatelet agents● Calcium-channel blockers● Beta-blockers● Erectile dysfunction medication● Nitrates● Warfarin● Antiarrhythmics● Digitalis● Metformin● Lipid-lowering medication (niacin,statins, fibrates, etc.)● Other antihypertensives● Aminophylline or theophylline● Dipyrdiamole● Inhaler● Diabetic medications● NoneIf history of reaction to contrast agent,list all applicable:● Iodinated 426722004● Gadolinium 105879004● Echocardiography agent 409290009Allergies and Other AdverseReactions Section1.3.6.1.4.1.19376.1.5.3.1.3.13Parent Template CCD 3.8(2.16.840.1.113883.10.20.1.2)__________________________________________________________________________17Rev. 1.0 – 2011-04-22Copyright © 2011: IHE International, Inc.
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IHE Cardiology Technical Framework Supplement Cardiac Imaging ...

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