Dear Committee Doctor,
kindly fill in the following data:
The sheet containing data about your centre:
AMI questionnaire: CRF Proposal (to be filled once)
السيد الدكتور عضو اللجنة
برجاء  ملأ البيانات التالية
الملف اللذى يحتوى على المعلومات الخاصة بالمركز التابع لسيادتكم
(‫يتم ملأه مرة واحدة فقط) AMI questionnaire: CRF Proposal

Application for pilot center Stent For Life Egypt

  Center Name (University/Hospital)
  Case Responsability of (Prof./Dr.)
  Operator (Prof./Dr.)
  Case Data entry by (Prof./Dr.)
1. Identification of the site
  Contact Physician
  Number of interventional cardiologists
2. Cath lab information
  Number of cath labs
  Number of IC
  Numer of cathlab nurses
  Number of cathlabs available (24/7)
3. Coronary interventional activity
  Number of coronary angiographies
  Number of total procedures/interventions
  Number of interventions just with balloon
  Number of thrombolysis
  Number of total stents used
4. Interventional Activity in AMI
  Number of total procedures/interventions Primary PCI    
    Rescue PCI     
    Facilitated PCI
  How many AMI patients undergo pPCI (%)
  Door-balloon time min (From Hospital door to Balloon)
  Number of aspirations
  Number of procedures just with balloon
  Number of procedures with stent
  # stents used # BMS
    # DES 
    # GW  
    # BDC
  # procedures without predilatation
  Security Question 6 + 1 =