UNEXPLAINED INCREASE OF CARDIOVASCULAR DISEASES IN YOUNG ADULTS – GENETIC ASPECTS
Case Report Form (Cases)
Name of Institution:
Patient Name:
Select the Form Type
*
Healthy
Cases
A
Inclusion Criteria
B
Patient Identifier
C
Patient Registration
D
Interheart Risk
E
STAID Assessment
Form A - Inclusion Criteria and Enrollment Form of Cases
Patient eligibility and enrollment verification
A1
Heart disease as per the Inclusion criteria
*
Yes
No
A2
Consented for the study
*
Yes
No
A3
Patient enrolment criteria
*
Yes
No
A4
Both parents should be resident in Gujarat?
*
Yes
No
Father Address:
Mother Address:
A5
Age <45
*
Yes
No
A6
Angiography proven significant obstructive CAD (>50% stenosis in at least 1 major epicardial vessel)
*
Exclusion - Without Known CAD
A7
Anomalous coronary arteries
Yes
No
A8
Connective tissue disorders (Behçet disease, Takayasu arteritis, Kawasaki disease, Giant cell arteritis)
Yes
No
A9
Substance abuse (cocaine, marijuana etc.)
Yes
No
A10
Oral contraceptives
Yes
No
A11
Radiotherapy
Yes
No
A12
Active Infections (SARS-CoV-2, HIV, Chlamydia, Helicobacter pylori)
Yes
No
A13
Spontaneous dissection (Pregnancy, immune diseases, hyperhomocysteinemia etc.)
Yes
No
A14
Thrombophilia (hereditary or acquired)
Yes
No
Factor V Leiden, Factor II G20210A, MTHFR mutations, Hyper homocysteinemia, and Protein C, Protein S and Antithrombin III deficiency etc.
Enrolment Details
A15
Enrolment date
*
Form B - Patient Identifier Form
Patient demographic and contact information
B1
Hospital Identification Number (UHID/MRD/OP/IP NUMBER)
*
B2
Full Name of the Patient (BLOCK LETTER)
*
B3
Name of the Husband / Guardian
B4
Age (in completed years)
*
B5
Date of Birth
*
B6
Caste
Sub caste
B7
Gender
*
Male
Female
B8
Blood Group
Select blood group
A+
A-
B+
B-
AB+
AB-
O+
O-
other
B9
Address
*
B10
Patients mobile number (10 digit)
*
B11
Name of an alternate contact person
Alternate contact person's mobile number (10 digit)
B12
Occupation of patient
*
Professional
Semi-skilled labourer
Manual labourer
Home maker
Others
B13
Mention if any additional details
Form C - Patient Registration Form
Clinical profile, risk factors, and medical history
C1 - Clinical Profile
C1.1
Diagnosis
*
STEMI
NSTEMI
UA
CSA
C1.2
Age at diagnosis of CAD
*
C1.3
Presenting symptoms
*
Chest pain
Dyspnoea
Palpitations
Syncope
Others
C2 - Risk Factors and Past History
C2.1
Hypertension
Yes
No
Duration (years):
On medication:
Yes
No
C2.2
Diabetes Mellitus (DM)
Yes
No
Duration (years):
On medication:
Yes
No
C2.3
Dyslipidaemia
Dyslipidaemia is defined by abnormal lipid levels: total cholesterol ≥ 200 mg/dL, LDL-C ≥ 130 mg/dL, triglycerides ≥ 150 mg/dL, or HDL-C < 40 mg/dL in men and < 50 mg/dL in women.
Yes
No
Duration (years):
On medication:
Yes
No
C2.4
Angina or heart attack in a 1st degree relative < 60?
C2.5
CKD (Chronic Kidney Disease)
Yes
No
Select stage if yes
Stage 1
Stage 2
Stage 3
Stage 4
Stage 5
C2.6
eGFR
Medical History
C2.7
H/O Atrial fibrillation:
Yes
No
C2.8
H/O Migraines:
Yes
No
C2.9
H/O Rheumatoid arthritis:
Yes
No
C2.10
H/O SLE:
Yes
No
C2.11
H/O Severe mental illness:
Yes
No
C2.12
Regular use of steroid tablets:
Yes
No
C2.14
Erectile dysfunction:
Yes
No
C2.15
H/O COPD:
Yes
No
C2.16
H/O Hypothyroidism:
Yes
No
C2.17
H/O Obesity:
Yes
No
C2.13
Prior adverse drug reactions
Yes
No
Statin myopathy
Anticoagulant Bleeding
C2.18
H/O Covid-19 vaccine taken
Yes
No
Required hospitalization:
Yes
No
C2.19
Steroid use for covid-19
Yes
No
C2.20
Covid-19
Yes
No
C2.21
Covishield
Dose 1
Dose 2
Dose 3
C2.22
Covaxin
Dose 1
Dose 2
Dose 3
C3 - History of Addiction
C3.1
Smoking
No
Ex-smoker
Light (<10/day)
Moderate (10-19/day)
Heavy (20+/day)
C3.2
Duration of smoking (years)
C3.3
Tobacco
Yes
No
C3.4
Alcohol
Yes
No
C4 - Lifestyle Factors
C4.1
Daily hours of sitting
C4.2
Exercise
Yes
No
Exercise types:
Yoga
Walking
Gym
Cycling
Jogging
Daily/5 days a week:
Yes
No
C4.3
Inadequate Sleep (<7 hours)
Yes
No
C4.4
Night Job
Yes
No
C4.5
Food habits
Veg
Non-veg
Mix
C4.6
Cooking oil used
C4.7
Junk food consumption
Daily
Once in a week
Twice in a week
C4.8
List of Junk food
Fried food
Pasta and bread
Potato chips
C5 - Personality
C5.1
Type A
Competitive, ambitious, time-urgent, highly organized, impatient, aggressive under stress
Yes
No
C5.2
Type B
Relaxed, patient, flexible, less competitive, easy-going
Yes
No
C6 - Family H/O CAD
Relation
Yes/No
Heart Attack
Coronary angiography
Coronary angioplasty
CABG
Age at CAD
Father
Mother
Brother
Sister
Son
Daughter
C7 - Family H/O Of Risk Factors
Relation
Hypertension
Diabetes
Dyslipidaemia
CKD
Sudden cardiac death
Father
Mother
Brother
Sister
Son
Daughter
C8 - General Examination
C8.1
Pulse
C8.2
RR
C8.3
BP
C8.4
SpO2
C8.5
Height
C8.6
Weight
C8.7
BMI
C8.8
Waist Circumference
C9 - 2D-Echocardiography
Note: Full echocardiography parameters section would continue here...
C10 - Laboratory Investigation
Note: Full laboratory parameters section would continue here...
C11 - Lipid Profile
Note: Full lipid profile section would continue here...
C12 - Coronary Angiographic Findings
Note: Full angiography section would continue here...
Form D - For Interheart Risk Score
Assessment of cardiovascular risk factors
D1 - Medical History and Medications
D1.1
Diabetes
Yes
No
High Blood Pressure
Yes
No
D1.2
Have either or both of your biological parents had a heart attack
D2 - Tobacco
D2.1
Which best describes your history of tobacco use
Never
Former smoker (>12 months)
Current
D2.2
Over the past 12 months what has been your typical exposure to other people smoke
No
Yes
D3 - Stress
D3.1
How often have you felt stress in the past year
Never Experienced Stress
Some Period of Stress
Several periods of Stress
Permanent Stress
D3.2
During the past twelve months, was there ever a time when you felt sad, blue, or depressed for two weeks or more in a row
Yes
No
D4 - Diet
D4.1
Do you eat salty food or snacks one or more times a day
Yes
No
D4.2
Do you eat deep fried foods or snacks or fast foods 3 or more times a week
Yes
No
D4.3
Do you eat fruit one or more times daily
Yes
No
D4.4
Do you eat vegetables one or more times daily
Yes
No
D4.5
Do you eat meat and/or poultry 2 or more times daily
Yes
No
D5 - Physical Activity
D5.1
How active are you during your leisure time
Mainly sedentary
Mild exercise
Moderate exercise
Strenuous exercise
D6 - Physical Measurement
D6.1
Waist Circumference Measurement
D6.2
Hip Measurement
INTERHEART RISK SCORE
Low Risk (0-9)
Moderate Risk (10-15)
High Risk (16-48)
Form E - STAID Short Form Y-2
Psychological assessment questionnaire
Please rate each statement based on how you generally feel:
1
= Almost Never,
2
= Sometimes,
3
= Often,
4
= Almost Always
No.
Question
Almost Never (1)
Sometimes (2)
Often (3)
Almost Always (4)
E1.1
I feel nervous and restless
E1.2
I feel satisfied with myself
E1.3
I wish I could be as happy as others seem to be
E1.4
I feel like failure
E1.5
I worry too much over something that really doesn't matter
E1.6
I lack self confidence
E1.7
I feel secure
E1.8
I feel inadequate
E1.9
I am a steady person
E1.10
I get in a state of tension or turmoil as I think over my recent concerns and interest
Form Completion Details
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Signature:
Date:
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