Protocol - Sudden Cardiac Arrest

To be completed by physician who signed the death certificate and/or the patient's physician.

1. Are you familiar with the events surrounding the decedent's 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 decedent's cause of death as due to Coronary Heart Disease (CHD)?

[] Yes

[] No

[] Uncertain

To be abstracted from patient's 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