Section: Diagnostic Information
Name: Clinical Status Change Date ID: 42
Definition: The date the patient's clinical status changed, requiring reprioritization.
Applicable to: All entries.
Valid Values: Must be a valid date (YYYY-MM-DD).
Instructions: Changes in clinical status are determined by a health care professional and will affect a patient’s wait. Changes in clinical status can be either an improvement or worsening of condition.
Section: Diagnostic Information
Name: Height ID: 63
Definition: The height of the patient in centimeters (cm).
Applicable to: All entries.
Valid Values: Description Code Definition
≥20 and ≤251 20 - 251 Must be a valid number.
Unknown U Documentation of the patient’s height is not available or is incomplete.
Instructions: If a measurement is not available, a documented estimate by a health care professional is acceptable.
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Name: Weight ID: 65
Definition: The weight of the patient in kilograms (kg).
Applicable to: All entries.
Valid Values: Description Code Definition
≥10 and ≤250 10 - 250 Must be a valid number.
Unknown U Documentation of the patient’s weight is not available or is incomplete.
Instructions: If a measurement is not available, a documented estimate by a health care professional is acceptable.
Section: Diagnostic Information
Name: History of Myocardial Infarction ID: 43
Definition: Documentation of myocardial infarction diagnosed and/or treated by a physician.
Applicable to: Coronary Angiogram | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Recent (≤30 days) R Myocardial infarction that occurred less than or equal to 30 days of referral is documented in the patient record.
History (>30 days) H Myocardial infarction that occurred greater than 30 days of referral is documented in the patient record.
No N No history of myocardial infarction is documented in the patient record.
Unknown U History of myocardial infarction documentation is not available or is incomplete.
Instructions: If both Recent (≤30 days) and History (>30 days) are applicable, select Recent (≤30 days).
CorHealth DCIS Data Dictionary
54 of 138 Section: Diagnostic Information
Name: Canadian Cardiovascular Society Classification ID: 44
Definition: Documented categorization of the severity of angina for stable coronary artery disease (CAD) patient.
Applicable to: Coronary Angiogram | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Scheduled Percutaneous Coronary Intervention | Staged Percutaneous Coronary Intervention
Valid Values: Description Code Definition
0 0 Asymptomatic
I 1 Ordinary physical activity such as walking or climbing stairs does not cause angina. Angina with strenuous, rapid, or prolonged exertion at work or recreation.
II 2 Slight limitation of ordinary activity like walking, climbing stairs, rapidly walking uphill, walking or stair climbing after meals, in cold, in wind, under emotional stress, or during the few hours after awakening. Walking more than two blocks on the level and climbing more than one flight of stairs at a normal pace and in normal conditions.
III 3 Marked limitation of ordinary physical activity. Walking one or two blocks on the level or climbing one flight of stairs in normal conditions and at a normal pace.
IV 4 Inability to carry out any physical activity without discomfort, angina syndrome may be present at rest.
Unknown U CCS class documentation is not available or is incomplete.
Instructions: For the value Unknown:
• If this value is submitted it will be treated as ACS Class Emergent for the purpose of prioritization.
For data quality purposes, if a value is indicated for this data element, Acute Coronary Syndrome Classification (Data Element ID: 45) cannot be entered and will be disabled.
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Name: Acute Coronary Syndrome Classification ID: 45
Definition: Documented categorization of risk for patients presenting with acute coronary syndrome (ACS).
Applicable to: Coronary Angiogram | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Scheduled Percutaneous Coronary Intervention | Staged Percutaneous Coronary Intervention
Valid Values: Description Code Definition
Low Risk L Low risk, see instructions.
Intermediate Risk I Intermediate risk, see instructions.
High Risk H High risk, see instructions.
Emergent E Emergent, classified as shock, PPCI, rescue PCI and facilitated PCI.
Unknown U ACS class documentation is not available or is incomplete.
CorHealth DCIS Data Dictionary
56 of 138 Instructions: For the value Low Risk, if unstable angina or Non-ST elevation myocardial infarction
(NSTEMI), either:
1. Thrombolysis in myocardial infarction (TIMI) Risk Score 1 to 2; or 2. Any of the following:
a) No or minimum troponin rise (<1.0 ng/ml), b) No further chest pain,
c) Inducible ischemia ≥7 MET's workload, or d) Age <65 years.
For the value Low Risk, if ST elevation myocardial infarction (STEMI) not treated by primary PCI (PPCI), either:
1. TIMI risk score after STEMI of 0 to 3; or 2. Any of the following:
a) LVEF ≥40%,
b) Low risk on non-invasive assessment such as Duke treadmill score
≥5.
For the value Intermediate Risk, if unstable angina or NSTEMI, either:
1. TIMI Risk Score 3 to 4; or 2. Any of the following:
a) NSTEMI with small troponin rise (1 to 5 ng/ml), b) Worst ECG T wave inversion or flattening, c) Significant LV dysfunction (EF <40%), or d) Previous documented CAD, MI, CABG, or PCI.
For the value Intermediate Risk, if STEMI not treated by PPCI, either:
1. TIMI risk score after STEMI of 4 to 5; or 2. Any of the following:
a) Absence of high risk predictors, b) LVEF <40%,
c) High or intermediate risk on non-invasive assessment such as: Duke treadmill score <5, stress-induced large anterior or multiple perfusion defects.
For the value High Risk, if unstable angina or NSTEMI, either:
1. TIMI Risk Score 5 to 7; or 2. Any of the following:
a) Persistent or recurrent chest pain, b) Dynamic ECG changes with chest pain,
CorHealth DCIS Data Dictionary
57 of 138 c) CHF, hypotension, arrhythmias with C/P,
d) Moderate or high (>5 ng/ml) troponin rise, or e) Age >75 years.
For the value High Risk, if STEMI not treated by PPCI, either:
1. TIMI risk score after STEMI more than 5; or 2. Any of the following:
a) Failed reperfusion (recurrent chest pain, persistent ECG findings of infarction),
b) Mechanical complications (sudden heart failure, new murmur), c) Change in clinical status (shock).
For the value Unknown:
• If this value is submitted it will be treated as ACS Class Emergent for the purpose of prioritization.
For data quality purposes, if a value is indicated for this data element, Canadian
Cardiovascular Society Classification (Data Element ID: 44) cannot be entered and will be disabled.
CorHealth DCIS Data Dictionary
58 of 138 Section: Diagnostic Information
Name: Cardiogenic Shock ID: 46
Definition: Documentation that at the time of the procedure the patient is in a sustained (greater than 30 minutes) clinical state of hypoperfusion due to cardiac failure.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Coronary Angiogram |
Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Scheduled Percutaneous Coronary Intervention | Staged Percutaneous Coronary Intervention | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery
Valid Values: Description Code Definition
Yes Y Cardiogenic shock is documented in the patient record.
No N No cardiogenic shock is documented in the patient record.
Instructions: Cardiogenic shock is defined as a sustained (greater than 30 minutes) episode of hypoperfusion evidenced by systolic blood pressure < 90 mm Hg and/or, if available, cardiac index <2.2 L/min per square meter determined to be secondary to cardiac dysfunction and/or the requirement for parenteral inotropic or vasopressor agents or mechanical support (i.e., IABP, extracorporeal circulation, VADs) to maintain blood pressure and cardiac index above those specified levels.
Citation: STS Adult Cardiac Surgery Database Data Specifications Version 2.81
CorHealth DCIS Data Dictionary
59 of 138 Section: Diagnostic Information
Name: New York Heart Association Functional Classification ID: 47 Definition: The New York Heart Association (NYHA) Functional Classification is a risk stratification
tool used to classify the extent of heart failure.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Mitral Valve Clip | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery
Valid Values: Description Code Definition No Symptoms with
Ordinary Physical Activity
1 Patient has cardiac disease but without resulting limitations of ordinary physical activity. Ordinary physical activity (e.g., walking several blocks or climbing stairs) does not cause undue fatigue, palpitation, or dyspnea.
Symptoms with Ordinary Activity. Slight Limitations of Activity
2 Patient has cardiac disease resulting in slight limitation of ordinary physical activity. Patient is comfortable at rest. Ordinary physical activity such as walking more than two blocks or climbing more than one flight of stairs results in limiting symptoms (e.g., fatigue, palpitation, or dyspnea).
Symptoms with Less than Ordinary Activity. Marked Limitation of Activity
3 Patient has cardiac disease resulting in marked limitation of physical activity. Patient is comfortable at rest. Less than ordinary physical activity (e.g., walking one to two level blocks or climbing one flight of stairs) causes fatigue, palpitation, or dyspnea.
Symptoms with Any Physical Activity or Even at Rest
4 Patient has cardiac disease resulting in inability to perform any physical activity without discomfort.
Symptoms may be present even at rest or minimal exertion. If any physical activity is undertaken, discomfort is increased.
Not Applicable X NYHA functional classification is not applicable.
Unknown U NYHA functional classification documentation is not available or is incomplete.
Instructions: None
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60 of 138 Section: Diagnostic Information
Name: Rest Electrocardiogram Ischemic Changes ID: 48
Definition: The most recent documented type of electrocardiogram (ECG) ischemic changes acquired while the patient was at rest.
Applicable to: Coronary Angiogram
Valid Values: Description Code Definition
Persistent (Fixed) P Ischemic changes for a prolonged period of time.
Transient without Pain T Ischemic changes occurring without pain lasting for short period(s) of time.
Transient with Pain W Ischemic changes occurring with pain lasting for short period(s) of time.
Uninterpretable I Rest ECG ischemic changes are uninterpretable due to sustained resting ST segment depression, Left Bundle Branch Block, left ventricular hypertrophy (LVH), Digoxin therapy, paced ventricular rhythm, or Wolff-Parkinson-White (WPW) syndrome.
No N No rest ECG ischemic changes.
Unknown U Rest ECG ischemic changes documentation is not available or is incomplete.
Instructions: None
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61 of 138 Section: Diagnostic Information
Name: Exercise Electrocardiogram Risk ID: 49
Definition: The most recent documented risk category of the patient's probability for significant coronary artery disease (CAD) or events as determined while undergoing an
electrocardiogram (ECG) stress test.
Applicable to: Coronary Angiogram | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Low Risk L Results of exercise ECG test indicate low risk.
High Risk H Results of exercise ECG test indicate high risk.
Uninterpretable I Results of exercise ECG test cannot be interpreted for the determination of risk category.
Not Done N Exercise ECG test was not performed.
Unknown U Exercise ECG risk documentation is not available or is incomplete.
Instructions: None
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62 of 138 Section: Diagnostic Information
Name: Functional Imaging Risk ID: 50
Definition: The most recent documented risk category of the patient's probability for significant coronary artery disease (CAD) or events as determined while undergoing functional imaging testing.
Applicable to: Coronary Angiogram | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Low Risk L Results of functional imaging test indicate low risk.
High Risk H Results of functional imaging test indicate high risk.
Uninterpretable I Results of functional imaging test cannot be interpreted for the determination of risk category.
Not Done N Exercise ECG test was not performed.
Unknown U Functional imaging risk documentation is not available or is incomplete.
Instructions: None
CorHealth DCIS Data Dictionary
63 of 138 Section: Diagnostic Information
Name: Left Ventricular Ejection Fraction ID: 51
Definition: The most recent documented left ventricular ejection fraction (LVEF), represented as percentage.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Cardiac Resynchronization Therapy Implantable Cardioverter Defibrillator | Cardiac Resynchronization Therapy Pacemaker | Complex Ablation | Coronary Artery Bypass Graft and Valve
Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Dual Chamber Implantable Cardioverter Defibrillator | Mitral Valve Clip | Scheduled Percutaneous Coronary Intervention | Single Chamber Implantable Cardioverter Defibrillator | Staged Percutaneous Coronary Intervention | Standard Ablation | Valve
Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery Valid Values: 0 - 100
Instructions: If left ventricular ejection fraction is unknown, select Unknown in the Left Ventricular Ejection Fraction Grade data element.
Order of priority for sources:
1. Multiple-gated acquisition (MUGA) scan 2. Left Ventriculogram
3. Echo 4. Thallium
5. Estimate in operating room (direct vision)
For data quality purposes, if a value is indicated for this data element, Left Ventricular Ejection Fraction Grade (Data Element ID: 52) cannot be entered and will be disabled.
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Name: Left Ventricular Ejection Fraction Grade ID: 52
Definition: The most recent documented left ventricular ejection fraction (LVEF), represented as a grade.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Cardiac Resynchronization Therapy Implantable Cardioverter Defibrillator | Cardiac Resynchronization Therapy Pacemaker | Complex Ablation | Coronary Artery Bypass Graft and Valve
Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Dual Chamber Implantable Cardioverter Defibrillator | Mitral Valve Clip | Scheduled Percutaneous Coronary Intervention | Single Chamber Implantable Cardioverter Defibrillator | Staged Percutaneous Coronary Intervention | Standard Ablation | Valve
Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery Valid Values: Description Code Definition
≥50% 1 Grade 1
35%-49% 2 Grade 2
20%-34% 3 Grade 3
<20% 4 Grade 4
Unknown U LVEF documentation is not available or is incomplete.
Not Done N LVEF test was not performed.
Instructions: Order of priority for sources:
1. Multiple-gated acquisition (MUGA) scan 2. Left Ventriculogram
3. Echo 4. Thallium
5. Estimate in operating room (direct vision)
For data quality purposes, if a value is indicated for this data element, Left Ventricular Ejection Fraction (Data Element ID: 51) cannot be entered and will be disabled.
CorHealth DCIS Data Dictionary
65 of 138 Section: Diagnostic Information
Name: Serum Creatinine ID: 53
Definition: The most recent serum creatinine level obtained prior to procedure in micromoles per liter (μmol/L).
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Coronary Angiogram |
Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Mitral Valve Clip | Scheduled Percutaneous Coronary
Intervention | Staged Percutaneous Coronary Intervention | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery Valid Values: Description Code Definition
≥8 and ≤2652 8 - 2652 Must be a valid number.
Unknown U The most recent serum creatinine level is not available or is incomplete prior to procedure.
Instructions: None
Section: Diagnostic Information
Name: Dialysis ID: 55
Definition: Documentation that the patient is currently undergoing dialysis.
Applicable to: Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Yes Y Current dialysis is documented in the patient record.
No N No current dialysis is documented in the patient record.
Unknown U Current dialysis documentation is not available or is incomplete.
Instructions: Includes any form of peritoneal or hemodialysis patient is receiving prior to procedure.
Also, may include continuous Veno-Venous Hemofiltration (CVVH, CVVH-D), and Continuous Renal Replacement Therapy (CRRT) as dialysis.
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66 of 138 Section: Diagnostic Information
Name: Diabetes ID: 56
Definition: Documented history of diabetes diagnosed and/or treated by a regulated healthcare professional.
Applicable to: Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Yes Y History of diabetes is documented in the patient record.
No N No history of diabetes is documented in the patient record.
Unknown U History of diabetes documentation is not available or is incomplete.
Instructions: None
CorHealth DCIS Data Dictionary
67 of 138 Section: Diagnostic Information
Name: History of Tobacco Use ID: 57
Definition: Documented history of use of any form of tobacco (i.e., cigarettes, cigar, pipe, smokeless cans), or other tobacco products (chewing, orbs, strips, sticks, hookah, etc.).
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Scheduled Percutaneous Coronary Intervention | Staged Percutaneous Coronary Intervention | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery
Valid Values: Description Code Definition
Never N No history of any form of tobacco use is documented in the patient record.
Current C Present use of any form of tobacco less than or equal to 30 days of referral date.
Former F History of any form of tobacco use greater than 30 days of referral date.
Unknown U History of tobacco use documentation is not available or is incomplete.
Instructions: Electronic cigarettes (vaping) and cannabis are not considered tobacco products.
CorHealth DCIS Data Dictionary
68 of 138 Section: Diagnostic Information
Name: Cerebral Vascular Disease ID: 58
Definition: Documented history of cerebral vascular disease (CVD) including any history of stroke, transient ischemic attack (TIA), previous cervical or cerebral artery revascularization or any known ≥50% stenosis of any major extracranial or intracranial vessels to the brain.
Applicable to: Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Yes Y History of CVD is documented in the patient record.
No N No history of CVD is documented in the patient record.
Unknown U History of CVD documentation is not available or is incomplete.
Instructions: Citation: STS Adult Cardiac Surgery Database Data Specifications Version 2.81
Section: Diagnostic Information
Name: Chronic Obstructive Pulmonary Disease ID: 59
Definition: Documented history of chronic obstructive pulmonary disease (COPD) diagnosed and/or treated by a regulated healthcare professional.
Applicable to: Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery
Valid Values: Description Code Definition
Yes Y History of COPD is documented in the patient record.
No N No history of COPD is documented in the patient record.
Unknown U History of COPD documentation is not available or is incomplete.
Instructions: None
CorHealth DCIS Data Dictionary
69 of 138 Section: Diagnostic Information
Name: History of Coronary Artery Bypass Graft Surgery ID: 60
Definition: Documented previous coronary artery bypass graft (CABG) surgery.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Coronary Angiogram |
Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Scheduled Percutaneous Coronary Intervention | Staged Percutaneous Coronary Intervention | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery
Valid Values: Description Code Definition
Yes Y History of previous CABG surgery is documented in the patient record.
No N No history of previous CABG surgery is documented in the patient record.
Unknown U History of CABG surgery documentation is not available or is incomplete.
Instructions: None
CorHealth DCIS Data Dictionary
70 of 138 Section: Diagnostic Information
Name: Endocarditis ID: 61
Definition: Documented infection of the endocardium.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Coronary Artery Bypass Graft and Valve Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery
Valid Values: Description Code Definition
Treated T No antibiotic medication (other than prophylactic medication) is being given at the time of surgery.
Active A Currently being treated with antibiotic medications.
No N No history of endocarditis is documented in the patient record.
Unknown U History of endocarditis documentation is not available or is incomplete.
Instructions: For the value Active:
• This includes patients who are diagnosed in the operating room but began treatment post-operatively.
CorHealth DCIS Data Dictionary
71 of 138 Section: Diagnostic Information
Name: History of Congestive Heart Failure ID: 62
Definition: Documented history of congestive heart failure (CHF) diagnosed and/or treated by a regulated healthcare professional.
Applicable to: Aortic Surgery | Atrial Septal Defect Closure Surgery | Cardiac Resynchronization Therapy Implantable Cardioverter Defibrillator | Cardiac Resynchronization Therapy Pacemaker | Coronary Angiogram | Coronary Artery Bypass Graft and Valve
Repair/Replacement Surgery | Coronary Artery Bypass Graft Surgery | Dual Chamber Implantable Cardioverter Defibrillator | Scheduled Percutaneous Coronary Intervention
| Single Chamber Implantable Cardioverter Defibrillator | Staged Percutaneous Coronary Intervention | Transcatheter Aortic Valve Implantation | Valve Repair/Replacement Surgery | Ventricular Septal Defect Closure Surgery Valid Values: Description Code Definition
Yes Y History of CHF is documented in the patient record.
No N No history of CHF is documented in the patient record.
No N No history of CHF is documented in the patient record.