Screenlink Calculator
ICD / CRT / LVAD
Screenlink Calculator
{{title}}
Wednesday 03/03/2021
Patient details
Name
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Address |
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Postcode |
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Tel. no |
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DOB |
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NHS no |
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Hospital no |
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Referring GP / Consultant / HF matron
Name |
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Address |
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Tel. no |
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Fax no |
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Patients GP (if not detailed above)
Name |
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Address |
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Tel. no |
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Fax no |
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Referral Date: PCT area: |
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ScreenLink Report
ETIOLOGY OF CARDIOMYOPATHY |
{{EtiOfCardi}} |
NYHA CLASS |
{{nyha-class}} |
ECHO AVAILABLE |
{{echoavailable}} |
LVEF % LAST ECHO |
{{lveflastecho}}% |
PRIOR MI |
{{priormi}} |
> 40 DAYS |
{{grater40days}} |
ARRHYTHMIAS HISTORY |
{{arrhythmiashistory}} |
PRIOR SUDDEN CARDIAC ARREST |
{{priorsuddencardiacarrest}} |
SYNCOPE |
{{syncope}} |
SURVIVAL EXPECTATION GREATER THAN 1 YEAR |
{{survivalMore1Year}} |
LEFT BUNDLE BRANCH BLOCK |
{{lbb}} |
QRS WIDTH |
{{qrswidth}} |
OPTIMAL MEDICAL THERAPY |
{{optimalmedicaltherapy}} |
ATRIAL RHYTHM |
{{atrialRhythm}} |
SEVERE SYMPTOMS DESPITE OMT > 2 MONTHS |
{{severe_symptoms_omt}} |
NUMBER OF REHOSPITALIZATIONS FOR HF IN 12 MONTHS ≥ 3 |
{{number_rehospitalizations}} |
DEPENDANCE ON INTRAVENOUS INOTROPIC THERAPY |
{{intravenous_inotropic_therapy}} |
PROGRESSIVE END-ORGAN DYSFUNCTION (WORSENING RENAL AND/OR HEPATIC FUNCTION) DUE TO REDUCED PERFUSION AND NOT TO INADEQUATE VENTRICULAR FILLING PRESSURE (PCWP ≥ 20 MMHG AND SBP ≤ 80-90 MMHG OR CI ≤ 2 L/MIN/M2) |
{{progressive_organ_dysfunction}} |
ABSENCE OF SEVERE RIGHT VENTRICULAR DYSFUNCTION TOGETHER WITH SEVERE TRICUSPID REGURGITATION |
{{severe_right_ventricular_dysfunction}} |
UPGRADE FROM CONVENTIONAL IPG OR ICD WITH HIGH PERCENTAGE OF VENTRICULAR PACING |
{{upgrade}} |
INDICATION FOR CONVENTIONAL PACING WITH HIGH DEGREE AV BLOCK |
{{conventionalPacing}} |
Guidelines results
SOURCE OF REFERRAL
(please tick one)
- ❏ Patient self presenting with symptoms
- ❏ Recent hospital admission
- ❏ Routine 'NYHA score CLASS' in chronic disease clinic
- ❏ Other (please specify) ..................................................................
BRIEF PRESENTING HISTORY:
(SOBAR, SOBOE, orthopnea, PND etc)
SELF ASSESSED NYHA SCORE: ❏ I ❏ II ❏ III ❏ IV
CLINICAL FINDINGS:
(Peripheral /pulmonary oedema, murmur etc)
BP:
................................................................................
MEDICATION:
(please tick if applicable)
- ❏ PMH
- ❏ IHD
Date of prev MI (if app.) .............................................................
- ❏ HBP
Date first diagnosed ..................................................................
- ❏ Atrial fibrillation
Date last known SR ....................................................................
- ❏ Known COAD/asthma
- ❏ PFT? ....................................................................................
Date ECG 1st reported broad QRS .......................................................
- ❏ Date LV dysfunction confirmed ...........................................................
- ❏ Hospital admission in last 12 month
Evaluated by ScreenLink Tool