Protocol - Sudden Cardiac Arrest

To be completed by physician who signed the death certificate and/or the patients physician.

1. Are you familiar with the events surrounding the decedents death?

[ ] Yes

[ ] No

2. Did you witness the death?

[ ] Yes

[ ] No

If you answered No to both 1 and 2, skip to end. Otherwise, continue with item 3.

3a. Was there any pain in the chest, left arm or shoulder or jaw within 72 hours of death?

[ ] Yes

[ ] No

[ ] Uncertain

If No or Uncertain, skip to item 4.

3b. Did the pain include the chest?

[ ] Yes

[ ] No

[ ] Uncertain

3c. Did you think this pain was of a cardiac origin?

[ ] Yes

[ ] No

[ ] Uncertain

If No, specify what you think was the cause:

4. Was cardiopulmonary resuscitation (CPR) and/or cardioversion performed within 24 hours of death?

[ ] Yes

[ ] No

[ ] Uncertain

5. Please give time between onset of acute symptoms to death. (We are defining death as the point where spontaneous breathing ceased and the patient never recovered.)

[ ] More than three days

[ ] Two - three days

[ ] One day

[ ] At least 12 hours, but less than 24 hours

[ ] At least 4 hours, but less than 12 hours

[ ] At least 1 hour, but less than 4 hours

[ ] Less than 1 hour

[ ] Death instantaneous, no symptoms

[ ] Unknown

6. Would you classify the decedents cause of death as due to Coronary Heart Disease (CHD)?

[ ] Yes

[ ] No

[ ] Uncertain

To be abstracted from patients hospital medical records.

7. Location of death:

[ ] Out-of-Hospital

[ ] Emergency Room (not dead on arrival—DOA)

[ ] In Hospital

[ ] Nursing Home, Skilled Nursing Facility (SNF), or Extended Care Facility (ECF)

[ ] Other, specify:

8. Was the death witnessed?

[ ] Yes

[ ] No

[ ] Unknown

9. Multi-Ethnic Study of Atherosclerosis (MESA) classification of underlying cause of death (choose one):

[ ] Atherosclerotic coronary heart disease (complete questions 10, 11 and 12 only)

[ ] Stroke (skip to end)

[ ] Atherosclerotic disease other than coronary disease or stroke (specify): _______________________________ (complete question 12 only)

[ ] Other cardiovascular disease, not defined above (specify):_______________________________ (complete question 12 only)

[ ] Non-cardiovascular disease (specify):_______________________________ (skip to end)

[ ] Unknown because death certificate unavailable (skip to end)

10. Type of fatal coronary heart disease:

[ ] Definite fatal myocardial infarction (MI) (no known non-atherosclerotic cause and definite myocardial infarction within 4 weeks of death)

[ ] Definite fatal coronary heart disease (CHD) (no known non-atherosclerotic cause, and one or both of the following: chest pain within 72 hours of death or a history of chronic ischemic heart disease)

[ ] Possible fatal coronary heart disease (CHD) (no known non-atherosclerotic cause, and death certificate underlying cause: I20-25, I46, I51.6, R96 or R98-99)

11. Estimated time between onset of acute cardiac symptoms and death:

[ ] Less than five minutes

[ ] five minutes to one hour

[ ] one hour to 24 hours

[ ] More than 24 hours

[ ] Unknown

12. Mechanism of death in patients dying of cardiovascular causes (check all that apply):

[ ] Primary arrhythmic death

[ ] Secondary arrhythmic/mechanical death

[ ] Congestive heart failure (CHF)

[ ] Cardiac procedure such as coronary artery bypass graft (CABG) or angioplasty

[ ] Hemorrhage from thrombolytic therapy

[ ] Other (specify):_______________________________

[ ] Unknown or Uncertain