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SHOCK TRIAL

HOSPITALIZATION SUMMARY I

Form 04

INSTRUCTIONS:  COMPLETE FOR ALL TRIAL AND REGISTRY PATIENTS

A.	IDENTIFICATION

A1.		Clinic Site Code and Patient I.D.
ID LABEL HERE
Sample Listing of Eight Patients

 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
A2.		Date of Initial Admission (may be satellite		___ ___ / ___ ___ / ___ ___
		hospital admission before transfer)							   MO		DAY	   YEAR
		(F4ADMITD is character and F4ADM_D is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
A3.		(Version 3 only) Time of Initial Admission				___ ___:___ ___ 
									   HRS      MINS

				(circle one):  				1.  AM       2.  PM       3.  24-hour clock


A4.		Date of Discharge					___ ___ / ___ ___ / ___ ___
		(DISCH_D is character and DISCHD is numeric)		MO		DAY	   YEAR
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

A5.		Vital Status at Hospital Discharge			1. Dead	2. Alive (Q.A6)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		A5.1	(Version 3 only) IF DEAD, Time of Death 	___ ___ : ___ ___
									   HRS      MINS

				(circle one):  				1.  AM       2.  PM       3.  24-hour clock


A6.		Date Form Completed					___ ___ / ___ ___ / ___ ___
		(COMP_D is character and COMPD is numeric)				MO		DAY	   YEAR
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
A7.		Person Completing Form								___________________________________
		[Omitted]																(NAME - PLEASE PRINT)

B.	PROCEDURES
B1.		Was Swan-Ganz catheterization done?				1.  No				2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
   If Swan-Ganz NOT DONE, please complete Q.B1.1 below and section B1.2i  through B1.2l.
     B1.1a.  Date vital signs/hemodynamics obtained		___ ___ / ___ ___/ ___ ___
		     (from time of shock diagnosis)							MO		DAY	  YEAR
		     (RCATH_D is character and RHCDTE is numeric)	
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  (Version 3 only) Time				___ ___ : ___ ___
									   HRS      MINS

				(circle one):  				1.  AM       2.  PM       3.  24-hour clock

	B1.2	Record values from the time of shock diagnosis.	
				a.	(Version 3 only) Mean right atrial pressure (or CVP)			___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.	(Version 3 only) Right ventricular systolic pressure				___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.	(Version 3 only) Right ventricular diastolic pressure			___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				d.	(Version 3 only) Pulmonary artery systolic blood pressure	___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				e.	(Version 3 only) Pulmonary artery diastolic blood pressure	___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			f1.	Mean pulmonary capillary wedge pressure  			___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				f2.	(Version 3 only) Was PAD entered above in the 
					absence of PCWP?										1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				g.	(Version 3 only) Cardiac Output 							___ ___ ___ l/min
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

				h1.	Cardiac Index												___ ___ ___ l/min/m2	
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				h2.	(Version 3 only) Was Fick Calculated CI entered above 
					in the absence of Thermodilution CI?						1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
i.	Systemic systolic blood pressure							___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
j.	Systemic diastolic blood pressure							___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗		
k.	Heart Rate													___ ___ ___ beats/min
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
l.   (Version 3 only) Arterial lactate (if performed)			___ ___ . ___       Not Done
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					(circle one):						1. mg/ml		2. Other_______
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B2.		Was coronary angiography performed
		during this hospitalization?									1. No (Q.B3)	2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B2.1	First coronary angiography/attempt

				a. Date attempted/performed						___ ___ / ___ ___ / ___ ___
			   (LHC1_D is character and									   MO		DAY	   YEAR
			    LHCDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

				b.  (Version 3 only) Time  						___ ___ : ___ ___  
																	   HRS		MINS

						(circle one):  								1.  AM     2.  PM     3.  24-hour clock

				c.  (Version 3 only) Was patient still in cardiogenic shock at 
				      the time of coronary angiography?						1. No 			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				d.  (Version 3 only) Left Ventricular Systolic Pressure			___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				e.  (Version 3 only) Left Ventricular Diastolic Pressure			___ ___ ___ mm Hg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B2.2	(Version 3 only) Second coronary angiography/attempt?	1. No (Q.B3)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a.  (Version 3 only) Date attempted/performed				___ ___ / ___ ___ / ___ ___
			     (LHC2_D is character and												   MO	     DAY       YEAR
			     LHC2DTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

				b.  (Version 3 only) Time  									___ ___ : ___ ___  
																	                      HRS	      MINS

						(circle one):  								1.  AM     2.  PM     3.  24-hour clock

IF YES TO B2 AND/OR B3, ATTACH A COPY OF THE ANGIOGRAM/ANGIOPLASTY REPORTS(S) FROM THE RECORD.  REMOVE PATIENT NAME AND HOSPITAL NUMBER.  AFFIX STUDY ID LABEL TO EACH REPORT.
B3.		Was PTCA attempted?									1. No (Q.B4)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B3.1	(Version 3 only) IF YES,
				a.  Number of lesions for which PTCA was attempted	______
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  Was PTCA of the infarct-related artery attempted?	1. No	2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.  Were all PTCA attempts for multiple												lesions in the same vessel? 								1. No  		2. Yes (Q.B3.2)

																3.  Only 1 lesion (Q.B3.2)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				d.  Was multi-vessel PTCA (same cath lab visit)			
					performed?								1. No 		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B3.2	First PTCA procedure/attempt		

				a. Date attempted/performed						___ ___ / ___ ___ / ___ ___
			   (PTCA1_D is character and									   MO		DAY	   YEAR
			    PTCADTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

				b. (Version 3 only) Time   ___ ___ : ___ ___ 		 (circle one):     
												HRS	MINS			1.  AM     2.  PM     3.  24-hour clock

		B3.3	Second PTCA procedure/attempt?				1. No (Q.B4)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a. Date attempted/performed						___ ___ / ___ ___ / ___ ___
			   (PTCA2_D is character and									   MO		DAY	   YEAR
			    PTCA2DTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b. (Version 3 only) Time   ___ ___ : ___ ___ 		 (circle one):     
												HRS	MINS			1.  AM     2.  PM     3.  24-hour clock

		B3.4	(Version 3 only) Third PTCA procedure/attempt?	1. No (Q.B4)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a. Date attempted/performed						___ ___ / ___ ___ / ___ ___
			   (PTCA3_D is character and									   MO		DAY	   YEAR
			    PTCA3DTE is numeric)

				 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b. Time   ___ ___ : ___ ___ 		 (circle one):     
							HRS        MINS		 1.  AM     2.  PM     3.  24-hour clock

B4.		Was CABG attempted?					1. No (Q.B5)2. Yes
    COMPLETE 
    FORM S1 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B4.1	a.	Date attempted/performed		___ ___ / ___ ___ / ___ ___
			     (CABG_D is character and						   MO		DAY	   YEAR
			      CABGDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.	(Version 3 only) Time of arrival in operating room 		___ ___ : ___ ___ 	
																				   HRS	     MINS	

	 							(circle one):  				   	1.  AM     2.  PM     3.  24-hour clock



B5.		Was an Intra-Aortic Balloon Pump inserted?					1. No (Q.B6)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B5.1  IF YES,  a.	Date inserted						___ ___ / ___ ___ / ___ ___
		         (BALLN_D is character and						   MO		DAY	   YEAR
		         IABPDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

						b.	Time inserted			___ ___:___ ___	
									  HRS	    MINS

							(circle one):						1.  AM     2.  PM     3.  24-hour clock

						c.	Date removed						___ ___ / ___ ___ / ___ ___
		         	 	      (RMVB_D is character and				   MO		DAY	   YEAR
		         		       RMVDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

						d.	Time removed			___ ___:___ ___	
																    HRS	 MINS

							(circle one):						1.  AM     2.  PM     3.  24-hour clock



				e.  (Version 3 only) Systolic blood pressure before IABP	___ ___ ___ mmHg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				f.  (Version 3 only) Diastolic blood pressure before IABP	___ ___ ___ mmHg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				g.  (Version 3 only) Blood pressure 10 to 30 minutes after IABP on 1:1
						Systolic (use augmented diastolic, if highest)		            ___ ___ ___ mmHg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
						Diastolic 								___ ___ ___ mmHg
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

			h.  (Version 3 only) Vasopressor support reduced after 
				IABP on 1:1?										1.  No			2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			i.  (Version 3 only) Systemic hypoperfusion reversed after 
				IABP on 1:1?										1.  No			2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			j.  (Version 3 only) Sheath used						1.  No			2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B6.		Was mechanical ventilation required?								1. No (Q.B7)	2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

		B6.1	IF YES,
		a.  Number of days ventilated		___ ___ days
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  (Version 3 only) Date ventilation initiated	___ ___ / ___ ___ / ___ ___  
		         	     (VENT_DAT is character and								   MO		DAY	   YEAR
		                  VENTDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.  (Version 3 only) Time ventilation initiated		___ ___ : ___ ___ 
																   		HRS		MINS

	 							(circle one):  				   	1.  AM     2.  PM     3.  24-hour clock

B7.		(Version 3 only) Were any circulatory assist devices (other than IABP)
		placed during this hospitalization? (Answer СNoТ if device used only 
		during cardiac surgery)								1. No (Q.B8)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
	B.7.1	(Version 3 only) Name of device		__________________________________________________

 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B8.		(Version 3 only) Was mitral valve surgery performed?	1. No 2. Yes
    COMPLETE
    FORMS S1 and S3 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B9.	(Version 3 only) Was ventricular septal rupture repair surgery 
		performed?1. No 2. Yes
     COMPLETE
     FORM S1 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B10.	(Version 3 only) Did the patient receive an RBC or 
	whole blood transfusion during this hospitalization?				1. No (Q.B11)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		B10.1 	(Version 3 only) IF YES, Number of units				___ ___
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B11.	a.	(Version 3 only) Left Ventricular Ejection Fraction	  ___ ___ %   -9.  Not Available (Q.B12)
			(closest to time of shock diagnosis)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.	(Version 3 only) Value obtained by				1.  Echo		2.  LVgram		3. RVG
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.	(Version 3 only) Date value obtained			___ ___ / ___ ___ / ___ ___  
		      (LVEC_DT is character and								   MO		DAY	   YEAR
		      LVEFDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
B12.	(Version 3 only) Was there any evidence in the record that any of the 
		following occurred during hospitalization?

		a.	(Version 3 only) Pulmonary edema on examination				1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.	(Version 3 only) Pulmonary edema on chest X-ray				1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.	(Version 3 only) Bilateral rales present > half-way up			1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		d.	(Version 3 only) Bilateral rales present < half-way up			1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C.	HISTORY AND MEDICATIONS
		C1.		How was the index MI diagnosed? (answer all items)
				a.  Chest pain or equivalent ischemic symptom				1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  > 2 ECG leads with ST elevation 									1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.  New Q waves in > 2 leads 											1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				d.  Acute posterior MI, e.g. posterior
					ST elevation (anterior ST depression)
					and/or posterior Q waves 											1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				e.  New LBBB															1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C2.		Location of the index MI  (answer all items)
				a.	Anterior   (V1 - V4)									1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.	Inferior   (II, III, AVF)									1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.	Posterior   (V1-V3 - tall RТs and/or ST ()		1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				d.	Lateral   (I, AVL)										1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				e.	Apical   (V5,6)											1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
NOTE:  For trial patients, save copies of initial MI EKG and 2 subsequent EKGs that 
               demonstrate evolving MI in study file, as well as EKG at the time of shock onset
               if different time from that of initial MI EKG.  AFFIX SHOCK TRIAL EKG
               LABELS and SEND COPIES OF THESE EKGs to DATA COORD. CENTER
C3.		For the index MI, were:		(circle one):					1.	Enzymes CPK/MB not done (Q.C4)
																		2.	Less than 3 values available 
																		3.	At least 3 values available
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
	C3.1  IF DONE, complete a - c.  Highest value may be obtained from different samples.  

				a1.	Highest Total CPK 				 ___ ___ ___ ___ ___
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a2.	Upper limit of lab normal value 	 ___ ___ ___	1.  Units	2.  ng/ml	3.  Other _______
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b1.	Highest MB (out of total CPK) 	 ___ ___.___	1.  % 		2.  index
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b2.	Upper limit of lab normal value 	 ___ ___ ___	1.  Units	2.  ng/ml	3.  Other _______
																					4.  %		5.  index
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c1.	Highest MB 	 					 ___ ___ ___	1.  Units	2.  ng/ml	

																					3.  (g/L	4.  Other _______
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c2.	(Version 3 only) Upper limit of lab normal value 	___ ___. ___ 	
																							1.  Units	2.  ng/ml	

																							3.  (g/L	4.  Other _______
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
   				c3.	(Version 3 only) Date of highest MB units or highest 
					 CPK if MB units not available				___ ___ / ___ ___ / ___ ___   
		         	      (MB_DATE is character and								   MO		DAY	   YEAR
		                  MBDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c4.	(Version 3 only) Time of highest MB units or highest 
						CPK if MB units not available				 ___ ___:___ ___	
																							    HRS	  MINS

										(circle one):				1.  AM     2.  PM     3.  24-hour clock
						

		C3.2  (Version 3 only) If all CPK's and MB are negative, is LDH >
			   1.5 X upper limit and LD1 > LD2 fraction?				1. No 		2. Yes		-1. Not Applicable

 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C4. 	Thrombolytic Therapy Status 
			a.	Eligible for thrombolytic therapy?					1. No    		2. Yes
				(see definition of УeligibleФ)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			b.	Was thrombolytic therapy administered?				1. No (Q.C5)	2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
	C4.1	Complete a - g  for administration of IV thrombolytic therapy 				(NOT given in the cath lab in association with the PTCA procedure), 			for MI causing shock 

					a.	Date started							___ ___ / ___ ___ / ___ ___
		         	            (THERA_D is character and					   MO		DAY	   YEAR
		                         LYTICDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

					b.	Time started				___ ___:___ ___	
									  HRS	    MINS

								(circle one):					1.  AM	2.  PM		3.  24-hour clock
					c.	TPA, front-loaded regimen				1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					d.	TPA, 3-hour regimen						1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					e.	Streptokinase								1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					f.	APSAC									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					g.	rPA										1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					h.	TNK TPA									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					i.	Other Thrombolytic						1. No				2. Yes
						_____________________________
						(specify)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C5.		(Version 3 only) Were any of the following medications mentioned in the record as being taken 
		during this hospitalization?
		a.	IV Inotropic 
				a1.  Dobutamine									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a2.  Milrinone or Amrinone						1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a3.  Digoxin										1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.	Vasopressors
				b1.  Dopamine										1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b2.  Norepinephrine								1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b3.  Epinephrine									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b4.  Other											1. No (Q.C6)		2. Yes
					(Specify)_____________________________
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗C6.		(Version 3 only) Was chest pain present at the time of:

			a.  Shock onset?					1.  No (Q.C6b)	2.  Yes 	3.  Sedated/Unknown (Q.C6b)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				a.1  IF YES, was chest pain associated with/present at:

					a.  Suspected ischemia (without	 infarction)			1.  No				2.  Yes 
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
					b.  Suspected infarction							1.  No				2.  Yes 
	 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		b.  Time of Randomization?						1.  No							 2.  Yes
															3.  Sedated	/Unknown		-1.  Not Randomized
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		c.  Time of PTCA or CABG?						1.  No							 2.  Yes
															3.  Sedated	/Unknown		-1.  No PTCA or CABG
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C7.		(Version 3 only) Was ST elevation present at the time
		of shock onset?											1.  No (Q.C8)		2.  Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C7.1  IF YES, specify location:
				a.	Anterior   												1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.	Inferior   												1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c.	Posterior   												1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				d.	Lateral  												1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				e.	Apical  												1. No			2. Yes		9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

		C7.2	Was this ST elevation with a 
				recurrent MI during hospitalization?				1.  No				2.  Yes  
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C8.		(Version 3 only) Were there recurrent ischemic events (without
		 re-MI) between the first MI associated with initial admission and 
             shock onset?							1.  No (Q.C9)		2.  Yes 	
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗																			
		C8.1  IF YES,
				a.  Number of Episodes								________
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  Did ischemic episodes cause hypotension?		1.  No				2.  Yes  
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C9.		(Version 3 only) Was there one or more re-MI's 
		between the first MI associated with 
		initial admission and shock onset?							1.  No (Q.C10)	2.  Yes 	
						 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗													
		C9.1  IF YES,
				a.  Number of re-MI's									________
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.  Did re-MI cause hypotension?						1.  No				2.  Yes  
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C10.	(Version 3 only) Was there a recent MI and/or rest ischemic 
		symptoms within 1 week prior to initial hospital admission? 	1.  No (Q.C11)	2.  Yes    
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
		C10.1  IF YES, Was this event associated with:
				a.	Suspected MI									1.  No				2.  Yes  
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				b.	Suspected Ischemia							1.  No				2.  Yes  
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C11.	(Version 3 only) Initial BUN  								 ____ ____ ____ .  ____ ____ mg/dl
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C12.	(Version 3 only) Initial Creatinine  							____ ____ . ____ mg/dl
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C13.	(Version 3 only) Initial Hematocrit							____ ____ . ____ ____ %
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C14.	(Version 3 only) Height		___ ___ ___ .___ ___		
						(circle one):	1. inches	2.  cm		-9.  Ht. not available
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C15.	(Version 3 only) Weight		___ ___ ___ .___ ___		
						(circle one): 	1.  lbs 		2.   kg		-9.  Wt. not available
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
C16.	Was there evidence in the record of any 
		of the following before this hospitalization? 	
			a.	Prior myocardial infarction 			1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			b.	Hypertension 							1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			c.	Diabetes								1. No (Q.C16d)	2. Yes			-9. Unknown (Q.C16d)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
				c1.  (Version 3 only) On oral hypoglycemics or insulin
					  therapy prior to hospitalization?		1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			d.	Congestive heart failure 				1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			e.	Renal insufficiency 					1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			f.	Prior CABG 							1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			g.	Prior PTCA 							1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			h.	Cigarette Smoking 					1. No				2. Yes			-9. Unknown
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
	i.	(Version 3 only) Elevated Lipids 	1. No 							2. Yes				-9. Unknown 
	 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
	j.	(Version 3 only) Peripheral Vascular Disease	1. No 			2. Yes				-9. Unknown 
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			k.	Other life-shortening, non-cardiac disease	1. No (Q.D1)		2. Yes		-9. Unknown

	_____________________________________________________________
				(specify)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
Sample Listing of Eight Patients
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

D.	(Version 3 only) DISCHARGE DIAGNOSES
D1.		Were there discharge diagnoses other than 
		acute MI or cardiogenic shock for this patient?			1. No (END)		2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

		D1.1	IF YES, list all other discharge diagnoses and 
				corresponding ICD-9 codes, if available.

				a1.  Discharge Diagnosis (specify)	________________________________________
				a2.  ICD-9 Code						___ ___ ___.___ ___			-9.  Not Available
				b1.  Discharge Diagnosis (specify)	________________________________________
				b2.  ICD-9 Code						___ ___ ___.___ ___			-9.  Not Available
				c1.  Discharge Diagnosis (specify)	________________________________________
				c2.  ICD-9 Code						___ ___ ___.___ ___			-9.  Not Available
				d1.  Discharge Diagnosis (specify)	________________________________________
				d2.  ICD-9 Code						___ ___ ___.___ ___			-9.  Not Available
				e1.  Discharge Diagnosis (specify)	________________________________________
				e2.  ICD-9 Code						___ ___ ___.___ ___			-9.  Not Available

Sample Listing of Eight Patients
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
Version 1 questions not appearing on Version 2.1:


B3.1.c.	Was the target vessel in the second
      	PTCA the same one as for the first
		PTCA?											1. No			2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗



	C4.2	Complete a-f for IV thrombolytic therapy
			NOT associated with the PTCA procedure
			(second administration)

			a.	Date started									___ ___ / ___ ___ / ___ ___
		         	(THERB_D is character and							   MO		DAY	   YEAR
		            THERBDTE is numeric)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			b.	Time started					_____:_____	
									HRS.	MINS.
										(circle one)			1. a.m.	2. p.m.		3. 24 hour clock

			c.	TPA, front-loaded regimen?					1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			d.	TPA, 3-hour regimen?						1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			e.	Streptokinase?									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			f.	APSAC?										1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			g.	Other Thrombolytic?							1. No				2. Yes
					_____________________________
					(Specify)
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
	C4.3	In the Cath Lab was thrombolytic therapy administered:
			(answer both a and b)

			a.	Before PTCA attempted?						1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			b.	After PTCA attempted?						1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			c.	Intracoronary, not in association
				with PTCA?									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗

C6.		Were any of the following medications recorded as being administered between onset of 				the index (presenting) myocardial infarction and onset of cardiogenic shock?

			a.	Beta blockers									1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗
			b.	Calcium channel blockers				      	1. No				2. Yes
 MERGEFIELD TABLE лTABLE╗ NEXT лNext Record╗








 Patient ID Number   ___ ___ - ___ ___ ___ ___ - ___

SHOCK TRIAL - Form 04 - Version 3.0 Date 9/23/96 - Page PAGE13

SHOCK TRIAL - Form 04 - Version 3.0 Date 9/23/96 - Page PAGE1




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