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Page 1
1. Outpatient / InpatientMark only one oval.
Outpatient
Inpatient (CTO surgery)
2. Date Example: 15 December 2012
3. 1. Medical Record
4. 2. Patient Name
5. 3. SexMark only one oval.
Male
Female
6. 4. Age
7. 5. Birthday Date Example: 15 December 2012
Page 2
8. 6. Diagnosis
9. 7. Height (cm)
10. 8. Weight (kg)
11. 9. Systole (mmHg)
12. 10. Diastol (mmHg)
Page 3
13. 11. Family History of Heart DiseaseMark only one oval.
Yes
No
14. 12. SmokingMark only one oval.
Yes
No
15. 13. Diabetes MellitusMark only one oval.
Yes
No
16. 14. HipertensiMark only one oval.
Ya
Tidak
17. 15. DislipidemiMark only one oval.
Yes
No
Page 4
18. 16. Creatinine
19. 17. Chronic Kidney DiseaseMark only one oval.
Ya
Tidak
20. 18. CHFMark only one oval per row.
Tidak 1 2 3 4
NYHA
21. 19. Prior Cerebrovascular AccidentMark only one oval.
Yes
No
22. 20. Prior Miocard InfarcMark only one oval.
Yes
No
Page 5
23. 21. Prior CABGMark only one oval.
Yes
No
Emergency
24. 22. Ejection Fraction (%)
25. 23. Unstable Angina PectorisMark only one oval.
Yes
No
26. 24. Coronary Artery DiseaseMark only one oval.
Yes
No
27. 25. Ischemic Vessel TreatedMark only one oval.
Yes
No
Page 6
28. 26. Average Vessel Treated
29. 27. CTO Vessel
30. 28. CTO Length
31. 29. Vessel Intervention
32. 30. Stent Deployed
Page 7
33. 31. No.of Stent
34. 32. DES
35. 33. IVUS
36. 34. Glycoprotein InhibitorMark only one oval.
None
Moderate
Mild
Severe
37. 35. Calcification
Page 8
38. 36. Ostial Location
39. 37. Procedure Time
40. 38. Fluoroscopy Time
41. 39. Fluoroscopy Dose
42. 40. Mace
Page 9
43. 41. Aortic Dissection
44. 42. Arrhytmia
45. 43. Delayed Tamponade
46. 44. Acute Vessel Oclusion
47. 45. Subacute Vessel Oclution
Page 10
48. 46. Distal Embolization
49. 47. Total Amount Contrast Used
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50. 48. Tortuosity
51. 49. In Stent Restenosis
52. 50. Lesion Length
Page 11
53. 51. ISR
54. 52. Side Branch
55. 53. PerforationMark only one oval.
Type I
Type II
56. 54. Cardiac Tamponade
57. 55. Cardiac Tamponade
Page 12
58. 56. Non Q Wave MI
59. 57. Q Wave MI
60. 58. Death
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