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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
Hospital
Address
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
7 + 0 =