<p> Central Okanagan QI Department</p><p>AMI DATA COLLECTION FORM</p><p>Patient Addressograph</p><p>DATE: ______Onset of Chest Pain (time):______</p><p>Arrival by:  Self/SO EHS  EHS(ALS) Transfer: Hospital/Facility/Home ______</p><p>Time of Arrival ______Time of Triage ______CTAS Level______</p><p>Time of Bed ______Time of ECG ______</p><p>Time Seen by Physician ______Time of Thrombolytic ______(where appropriate) For ST elevation MI patients only Thrombolysis within 30 minutes  yes  no  contraindicated For all heart attack patients Early measures Aspirin within 24 hours  yes  no  contraindicated ASA taken  prior to arrival at hospital  after arrival </p><p>Confirmation of AMI This patient had:  ST elevation on ECG  presumably new LBBB on ECG (see reverse for definitions)  elevated troponin level (>1.0 ug/L)</p><p>History of Tobacco Use in Past Year  yes  no (if no, go to next section)</p><p>During hospital stay did the patient receive: Pharmacological therapy Nicotine Replacement  yes  no  uncertain Dopamine Reuptake Inhibitor (Bupropion)  yes  no  uncertain</p><p>Non-pharmacological therapy Smoking Cessation Counseling  yes  no  uncertain Referral to Cardiac Rehab Program  yes  no  uncertain</p><p>Medications at discharge This patient has been prescribed the following medications (or counseled to continue this medication if taking pre-arrival) Aspirin  yes  no  contraindicated  uncertain</p><p>Sept 12, 2007 AMI DATA COLLECTION FORM</p><p>Central Okanagan QI Department</p><p>ACE inhibitor/ ARB  yes  no  contraindicated  uncertain Beta Blocker  yes  no  contraindicated  uncertain Statins  yes  no  contraindicated  uncertain (see reverse for assistance completing this section) TRANSFER OUT to/ EXPIRY (give Location) DATE:</p><p>MEDICATIONS GUIDE</p><p>Angiotensin Converting Enzyme Inhibitors (ACE-Inhibitors): Trade Name Benazepril Lotensin Cilazapril Inhibace Enalapril Vasotec Lisinopril Zestril Perindopril Coversyl Quinapril Accupril Ramipril Altace Trandolopril Mavik</p><p>Angiotensin Receptor Blockers (ARB): Trade Name Candesartan Atacand Eprosartan Teveten Irbesartan Avapro Losartan Cozaar Telmisartan Micardis Valsartan Diovan</p><p>Beta-Blockers:</p><p>Acebutolol (Monitan, Sectral, Rhotral) Metoprolol (Lopressor) Atenolol (Tenormin) Nadolol (Corgard) Betaxolol Oxprenolol Bisoprolol (Monocor) Pindolol Bucindolol Propranolol Carvedilol Sotalol Esmolol Timolol Labetalol</p><p>HMG Co-A Reductase Inhibitors (Statins): Trade Name Atorvastatin Lipitor Lovastatin Mevacol Pravastatin Prevachol Rosuvastatin Crestor Simvastatin Zocor</p><p>2 AMI DATA COLLECTION FORM</p><p>Central Okanagan QI Department</p><p>Bupropion Trade Names: Wellbutrin, Zyban</p><p>DEFINITIONS</p><p>ECG Findings (Confirmation of AMI) – ST elevation on 12 lead ECG greater than or equal to 1mm in 2 contiguous leads; or a presumably new LBBB</p><p>3</p>