European League Against Rheumatism standardised reporting form for reporting ischaemic cardiovascular diseases, for risk factors and treatments
| Cardiovascular comorbidity | |||
|---|---|---|---|
| Report | |||
| Has the patient ever had a diagnosis of… | No | Yes | If yes, year of diagnosis |
| …ischaemic cardiovascular disease including myocardial infarction, pectoris angina or a stent | □ | □ | |
| …either stroke or transient ischaemic attack | □ | □ | |
| …heart failure | □ | □ | |
| …lower limb peripheral arterial disease | □ | □ | |
| Risk factors | |||
| Smoking status | □ Never □ Ever but cessation >1 year ago | □ Ever but cessation <1 year ago □ Ongoing | |
| Height (m) | Weight (kg), body mass index (kg/m2) | ||
| Diabetes | □ No □ Yes and treated □ Yes but not treated | Last year glycaemia was screened: □ Never done □ Don't know | |
| Hypertension | □ No □ Yes and treated □ Yes but not treated | Last year blood pressure was taken: □ Never done □ Don't know | |
| Hypercholesterolaemia | □ No □ Yes and treated □ Yes but not treated | Last year lipids were screened: □ Never done □ Don't know | |
| Renal insufficiency | □ No (GFR >60) □ Yes, moderate (GFR 30–60) □ Yes, severe (GFR <30) | Last year GFR was estimated: □ Never done □ Don't know | |
| Calculation of the global cardiovascular risk on the HEART-SCORE? | Year: □ Never done | Score (%) | |
| Treatments | No | Yes | |
| Antihypertensive therapy | □ | □ | |
| Antiplatelet therapy | □ | □ | |
| Diabetes insulin or non-insulin therapies | □ | □ | |
| Lipid-lowering agents (statins or not) | □ | □ | |
| Anticoagulants (including heparin and non-heparin) | □ | □ | |
GFR, glomerular filtration rate (mL/min).