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2.5.

Investigations/Procedures

1. ECG

o Performed

o Not performed

1a. Date of Examination

1b. Rhythm

o Atrial Flutter
o Atrioventricular Nodal Reentry Tachycardia
o Atrial Fibrillation

o Bradycardia

o Heart Block

o Multifocal Atrial Tachycardia


o Paroxysmal Supraventricular Tachycardia
o Sick Sinus Syndrome

o Sinus Rhythm
o Ventricular Fibrillation
o Ventricular Tachycardia

o Wolff Parkinson White Syndrome

o Others, describe

1c. Heart rate (beats/min)


1d. Axis

o Normal
o Left Deviation (LAD)

o Right Deviation (RAD)

1e. P wave (ms)

1f. PR interval (ms)

1g. QRS duration (ms)

1h. QT duration (ms)

1i. LBBB

o No

o Yes

1j. RBBB

o No

o Yes
1k. LVH

o No

o Yes

1l. RVH

o No

o Yes

1m. Pathological ST wave

o No
o Yes, describe

1n. Pathological Q wave

o No
o Yes

1o. LA Enlargement

o No

o Yes

1p. RA Enlargement

o No

o Yes

2. Chest X-Ray
o Performed

o Not performed

2a. Date of examination

2b. Normal ?

o No

o Yes

2c. Cardiac Enlargement

o No

o Yes

2d. Pulmonary Congestion

o No

o Yes

2e. Alveolar Oedema

o No

o Yes

2f. Others,

o No

o Yes, describe
3. Echocardiography (Echo-Doppler)

o Performed

o Not performed

3a. Date of Examination

3b. RA diameter

3c. RV diamater

3d. TAPSE

3e. TR Grading

3f. PAP systolic

3g. mPAP
3h. Tei Index RV

3i. Atrial Fibrillation

3j. Ejection Fraction (%)

3k.LVEDD (mm)

3l. LVH

o No

o Yes

3m. E/A ratio

3n. Deceleration time (ms)

3o. LA volume (ms)

3p. Restrictive/pseudonormal pattern

o No
o Yes

o Not evaluated

3q. Mitral Regurgitation Moderate-Severe

o No

o Yes

3r. Aortic Stenosis Moderate-Severe

o No

o Yes

3s. Aortic Regurgitation Moderate-Severe

o No

o Yes

4. 6-Minute Walking Test

o Performed
o Not performed

4a. Date of Examination

4b. Result
5. Ventilation/Perfusion Scintigraphy

o Performed

o Not performed

5a. Date of Examination

5b. Result

6. Pulmonary CT Scan

o Performed

o Not performed

6a. Date of Examination

6b. Result
7. Invasive Haemodynamic

o Performed

o Not performed

7a. Date of Examination

7b. Right Atrial Pressure

7c. Pulmonary Arterial Pressure

7d. Pulmonary Capillary Wedge Pressure

7e. Vasoreactivity Test/ Pulmonary Vasodilator Test

III. MEDICATION AND DOSES

3.1. Prior Medication

a. ACE Inhibitor (ACEI)


o No

o Ramipril
o Enalapril

o Perindopril

o Lisinopril

o Captopril

as. Dose (mg)

b. Angiotensin II Receptor Blockers (ARB)

o No
o Candesartan
o Losartan

bs. Dose (mg)

c. Beta Blockers

o No

o Carvedilol

o Bisoprolol
o Metoprolol

o Nebivolol

cs. Dose (mg)


d. Aldosterone Antagonists

o No
o Spironolactone

o Eplerenon

o Canrenon

ds. Dose (mg)

e. Diuretic Oral

o No
o Bendroflumethiazide
o Chlorthalidone
o Hydrochlorothiazide
o Furosemide
o Indapamide
o Torasemide

o Bumetadine

es. Dose (mg)

f. Diuretics Oral (2nd medication)

o No
o Bendroflumethiazide

o Chlorthalidone
o Hydrochlorothiazide

o Furosemide

o Indapamide

o Torasemide
o Bumetanide

fs. Dose (mg)

g. Other Cardiovascular Drugs

o No
o Digoxin

o Statins
o Antiplatelets

o Anticoagulants
o Amiodarone
o Ivabradine
o Nitrates

o Calcium Channel Blockers


o Antiarrhythmics

o Direct Renin Inhibitors

Non Cardiovascular Drugs


h. Antidiabetic Drugs : Insulin

o No

o Yes

i. Antidiabetic Drugs : Oral

o No

o Metformin

o Glitezones

o Incretins

o Sulfonylureas

j. Allopurinol

o No

o Yes

k. Non Steroidal Anti Inflamatory Drugs (NSAIDs)

o No

o Yes

l. Antidepressants

o No

o Yes

3.2. Current Medication

a. ACE Inhibitors (ACEI)


o No

o Ramipril
o Enalapril

o Perindopril

o Lisinopril

o Captopril

a1. If No,

o Contraindicated

o Not tolerated

o Other

a2. If Contraindicated,

o Bilateral Renal Stenosis

o Hyperkalemia

o Symptomatic Hypotension
o Severe Renal Dysfunction
o Other

a3. If Not tolerated,

o Cough

o Worsening Renal Function


o Symptomatic Hypotension
o Hyperkalemia

o Angioedema

o Other

a5. Reason for target dose not reached,

o Cough
o Worsening Renal Function
o Symptomatic Hypotension

o Hyperkalemia

o Angioedema

o Other

b. Angiotensin II Receptor Blockers (ARB)

o No

o Candesartan

o Losartan

o Valsartan

b1. If No,

o Contraindicated

o Not tolerated
o Other

b2. If Contraindicated,
o Bilateral Renal Stenosis

o Hyperkalemia
o Symptomatic Hypotension

o Severe Renal Dysfunction

o Other

b3. If Not tolerated,

o Worsening Renal Function


o Symptomatic Hypotension

o Hyperkalemia

o Angioedema

o Other

b4. If Yes, Dose (mg)

b5. Reason for target dose not reached,

o Worsening Renal Function

o Symptomatic Hypotension
o Hyperkalemia
o Angioedema

o Other
c. Beta Blockers

o No
o Carvedilol
o Bisoprolol

o Metoprolol

o Nebivolol

c1. If No,

o Contraindicated
o Not tolerated

o Other

c2. If Contraindicated,

o Asthma
o Bradyarrhytmia

o PAD

o Symptomatic Hypotension

o Other

c3. If Not tolerated,


o Brochospasm

o Worsening PAD
o Worsening Heart Failure (HF)

o Bradyarrhythmia

o Sexual dysfunction

o Symptomatic hypotension
o Other

c4. If Yes, Dose (mg)

c5. Reason for target dose not reached

o Brochospasm

o Worsening PAD
o Worsening Heart Failure (HF)

o Bradyarrhythmia
o Sexual dysfunction

o Symptomatic hypotension
o Other

d. Aldosterone Antagonists

o No
o Spironolactone
o Eplerenone

o Canrenone

d1. If No,

o Contraindicated
o Not tolerated

o Other

d2. If Contraindicated,

o Hyperkalemia
o Severe Renal Dysfunction

o Other

d3. If Not tolerated,

o Hyperkalemia
o Wosening Sexual Function

o Gynecomastia

o Other

d4. If Yes, Dose (mg)


d5. Reason for target dose not reached

o Hyperkalemia
o Wosening Sexual Function

o Gynecomastia

o Other

e. Diuretics Oral

o No
o Bendroflumethiazide

o Chlorthalidone
o Hydrochlorothiazide
o Furosemide

o Indapamide
o Torasemide

o Bumetanide

es. Dose (mg)

f. Diuretics Oral (2nd medication)

o No
o Bendroflumethiazide

o Chlorthalidone
o Hydrochlorothiazide
o Furosemide

o Indapamide
o Torasemide

o Bumetanide

fs. Dose (mg)

g. Other Cardiovascular Drugs

o No
o Digoxin

o Statins
o Antiplatelets
o Anticoagulants

o Amiodarone
o Ivabradine

o Nitrates
o Calcium Channel Blockers
o Antiarrhythmics

o Direct Renin Inhibitors

Non Cardiovascular Drugs

h. Antidiabetics drugs : Insulin

o No

o Yes
i. Antidiabetics drugs : Oral

o No
o Metformin

o Glitezones

o Incretins
o Sulfonylureas

j. Allopurinol

o No

o Yes

k. Non Steroidal Anti Inflamatory Drugs (NSAIDs)

o No

o Yes

l. Antidepressants

o No

o Yes

Current Medication

1. Calcium Channel Blockers

o No
o Diltiazem
o Nifedipine
o Other, describe

If Yes, describe.....

1a. Total Daily Dose (mg)

1a. Duration

1a. Route

If Yes, describe......

1b. Total Daily Dose (mg)

1b. Duration

1b. Route

If Yes, describe......

1c. Total Daily Dose (mg)


1c. Duration

1c. Route

2. Endothelin receptor antagonists

o No

o Ambrisentan
o Bosentan
o Sitaxentan

o Other, describe

If Yes, describe......

2a. Total Daily Dose (mg)

2a. Duration

2a. Route

If Yes, describe......
2b. Total Daily Dose (mg)

2b. Duration

2b. Route

If Yes, describe......

2c. Total Daily Dose (mg)

2c. Duration

2c. Route

If Yes, describe......

2d. Total Daily Dose (mg)

2d. Duration

2d. Route
3. Phospodiesterase type-5 inhibitors

o No
o Sildenafil

o Taladafil

o Other, describe

If Yes, describe......

3a. Total Daily Dose (mg)

3a. Duration

3a. Route

If Yes, describe......

3b. Total Daily Dose (mg)

3b. Duration
3b. Route

If Yes, describe......

3c. Total Daily Dose (mg)

3c. Duration

3c. Route

4. Prostanoids

o No

o Beraprost

o Epoprostenol
o Iloprost
o Treprostinil

o Other, describe

If Yes, describe......

4a. Total Daily Dose (mg)


4a. Duration

4a. Route

If Yes, describe......

4b. Total Daily Dose (mg)

4b. Duration

4b. Route

If Yes, describe......

4c. Total Daily Dose (mg)

4c. Duration

4c. Route

If Yes, describe......

4d. Total Daily Dose (mg)


4d. Duration

4d. Route

If Yes, describe......

4e. Total Daily Dose (mg)

4e. Duration

4e. Route

5. Other Drugs

o No

o Other 1, describe

o Other 2, describe

o Other 3, describe
If Yes, describe......

5a. Total Daily Dose (mg)

5b. Duration

5c. Route

If Yes, describe......

5b. Total Daily Dose (mg)

5b. Duration

5b. Route

If Yes, describe......

5c. Total Daily Dose (mg)


5c. Duration

5c. Route

IV. Doctors Identity/Patients Person in charge

1. Doctors name

2. Phone No/ Doctors Phone No

3. Date of Data Fulfillment

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