Peripheral arterial and other arterial thrombosis data elements
| Variable . | Level 1 (basic) . | Level 2 (intermediate) . | Level 3 (comprehensive) . |
|---|---|---|---|
| Date of acute arterial ischemic event | Date acute arterial ischemic event diagnosed: MM/DD/YYYY | Date acute arterial ischemic event diagnosed: MM/DD/YYYY | Date acute arterial ischemic event diagnosed: MM/DD/YYYY |
| Antithrombotic therapy at time of event | Antithrombotic therapy form | Antithrombotic therapy form | Antithrombotic therapy form |
| Type of event | Indicate type of arterial thrombotic event (select one): ☐ Peripheral arterial thromboembolism ☐ Abdominal arterial thromboembolism ☐ Microvascular thrombosis ☐ Other (specify): ________________________ | Indicate type of arterial thrombotic event (select one): ☐ Peripheral arterial thromboembolism ☐ Abdominal arterial thromboembolism ☐ Microvascular thrombosis ☐ Other (specify): ________________________ | Indicate type of arterial thrombotic event (select one): ☐ Peripheral arterial thromboembolism (select one) ☐ Atherosclerotic plaque ☐ Arterial embolism ☐ Other known cause (specify): _____________ ☐ Unknown ☐ Abdominal arterial thromboembolism (select one) ☐ Atherosclerotic plaque ☐ Arterial embolism ☐ Other known cause (specify): _____________ ☐ Unknown ☐ Microvascular thrombosis (select one) ☐ Diagnosed on biopsy ☐ Biopsy not done ☐ Unknown ☐ Other (specify): ________________________ |
| Cardiovascular risk factors | Select all that apply: ☐ Known cardiovascular disease (coronary artery disease, peripheral arterial disease, cerebrovascular disease) ☐ Hypertension ☐ Diabetes mellitus ☐ Current smoker ☐ Former smoker ☐ Hypercholesterolemia ☐ Obesity | ||
| Reperfusion treatment (vascular intervention) | Did the patient undergo reperfusion treatment of this arterial thrombotic event: ☐ No ☐ Yes (select all that apply): ☐ Angioplasty ☐ Stent ☐ Bypass ☐ Systemic thrombolytic therapy ☐ Catheter-directed thrombolytic therapy ☐ Embolectomy ☐ Other (specify): ____________ ☐ Unknown | Did the patient undergo reperfusion treatment of this arterial thrombotic event: ☐ No ☐ Yes (select all that apply): ☐ Angioplasty ☐ Stent ☐ Bypass ☐ Systemic thrombolytic therapy ☐ Catheter-directed thrombolytic therapy ☐ Embolectomy ☐ Other (specify): ____________ ☐ Unknown | |
| Limb amputation | Did the patient undergo limb amputation? ☐ No ☐ Yes ☐ Unknown | Did the patient undergo limb amputation? ☐ No ☐ Yes ☐ Unknown | |
| Antithrombotic treatment of thrombotic event | Antithrombotic therapy form |
| Variable . | Level 1 (basic) . | Level 2 (intermediate) . | Level 3 (comprehensive) . |
|---|---|---|---|
| Date of acute arterial ischemic event | Date acute arterial ischemic event diagnosed: MM/DD/YYYY | Date acute arterial ischemic event diagnosed: MM/DD/YYYY | Date acute arterial ischemic event diagnosed: MM/DD/YYYY |
| Antithrombotic therapy at time of event | Antithrombotic therapy form | Antithrombotic therapy form | Antithrombotic therapy form |
| Type of event | Indicate type of arterial thrombotic event (select one): ☐ Peripheral arterial thromboembolism ☐ Abdominal arterial thromboembolism ☐ Microvascular thrombosis ☐ Other (specify): ________________________ | Indicate type of arterial thrombotic event (select one): ☐ Peripheral arterial thromboembolism ☐ Abdominal arterial thromboembolism ☐ Microvascular thrombosis ☐ Other (specify): ________________________ | Indicate type of arterial thrombotic event (select one): ☐ Peripheral arterial thromboembolism (select one) ☐ Atherosclerotic plaque ☐ Arterial embolism ☐ Other known cause (specify): _____________ ☐ Unknown ☐ Abdominal arterial thromboembolism (select one) ☐ Atherosclerotic plaque ☐ Arterial embolism ☐ Other known cause (specify): _____________ ☐ Unknown ☐ Microvascular thrombosis (select one) ☐ Diagnosed on biopsy ☐ Biopsy not done ☐ Unknown ☐ Other (specify): ________________________ |
| Cardiovascular risk factors | Select all that apply: ☐ Known cardiovascular disease (coronary artery disease, peripheral arterial disease, cerebrovascular disease) ☐ Hypertension ☐ Diabetes mellitus ☐ Current smoker ☐ Former smoker ☐ Hypercholesterolemia ☐ Obesity | ||
| Reperfusion treatment (vascular intervention) | Did the patient undergo reperfusion treatment of this arterial thrombotic event: ☐ No ☐ Yes (select all that apply): ☐ Angioplasty ☐ Stent ☐ Bypass ☐ Systemic thrombolytic therapy ☐ Catheter-directed thrombolytic therapy ☐ Embolectomy ☐ Other (specify): ____________ ☐ Unknown | Did the patient undergo reperfusion treatment of this arterial thrombotic event: ☐ No ☐ Yes (select all that apply): ☐ Angioplasty ☐ Stent ☐ Bypass ☐ Systemic thrombolytic therapy ☐ Catheter-directed thrombolytic therapy ☐ Embolectomy ☐ Other (specify): ____________ ☐ Unknown | |
| Limb amputation | Did the patient undergo limb amputation? ☐ No ☐ Yes ☐ Unknown | Did the patient undergo limb amputation? ☐ No ☐ Yes ☐ Unknown | |
| Antithrombotic treatment of thrombotic event | Antithrombotic therapy form |