CARDIOVASCULAR JOURNAL OF AFRICA • Volume 25, No 4, July/August 2014
AFRICA
183
Pan-African SCD task force survey
Country*:
State:
Ethnicity*:
Completed by*:
Date*:
Identity*:
Sex*:
❏
M
❏
F
Date of birth*:
Age*:
EPIDEMIOLOGY OF SCD AND INITIAL CLINICAL PRESENTATION – Criteria for Eligibility
• Natural death due to cardiac causes, heralded by abrupt loss of conciousness within 1 hour of the onset of acute symptoms
• Pre-existing heart disease may have been known to be present, but the time and mode of death are unexpected
❏
In-hospital SCD
❏
Out-of-hospital SCD
❍
Home
❍
Work
❍
Public place
❍
Others, precise: ______________________
❏
Unwitnessed SCD
❏
Witnessed SCD
❍
Family
❍
Friends
❍
Colleagues
❍
Others, precise: ______________________
Resuscitation
attempts
❍
No
❍
Yes
❏
Defibrillation
❏
VT
❏
VF
❏
Bradycardia/asystole/pulseless electrical activity
❏
Others __________________________________________
Documented ECG
❍
No
❍
Yes
Activity at the time
of SCD
❍
Sleeping
❍
Resting
❍
Physical activity
❍
Sport activity
❍
Others, precise: __________________________________________
Hour of occurrence
❍
Night time
❍
Day time
❏
Hour (if available)
Time interval between
cardiac arrest and
first CPR (if available)
__________ (min)
❏
Survive
❍
Yes
❍
No
Post-resuscitation
syndrome
❍
Cardiac death
❍
Neurological death
❍
Motor and/or cognitive deficits
PREVIOUS HISTORY OF STRUCTURAL CARDIAC DISEASE
❍
No
❍
Yes, precise ______________________ LV ejection fraction:
NYHA classification:
Previous cardiac
evaluation
❏
Ambulatory
❍
Yes
❍
No
❏
In-hospital
❍
Yes
❍
No
MEDICAL HISTORY
CARDIOLOGIC
❍
Yes
❍
No
❏
HF
❏
Congenital
❏
Family history of
SCD
❏
RAA
❏
Coronary artery
diseases
❏
Idiopathic dilated
cardiomyopathy
❏
Hypertrophic
cardiomyopathy
❏
Other
cardiomyopathy
❏
Pacemaker or ICD
❏
Hypertension
NEUROLOGICAL
❍
Yes
❍
No
❏
Cor pulmonary
❏
Epilepsy
❏
Cerebro-vascular
disease
❏
Other, precise
_____________________________________
OTHERS
❍
Yes
❍
No
❏
Diabetes
❏
Alcoholism
❏
Smoking
❏
Other addiction
❏
Depression/anxiety
disorders
❏
HIV/AIDS
❏
Other, precise ______________________________________________________________
TROPICAL DISEASES
❍
No
❍
Yes, precise
_____________________________________
❏
Other, precise
_____________________________________
