Objective evidence is coded where a patient has current symptoms of heart failure (typically breathlessness or fatigue), either at rest or during exercise and/or signs of pulmonary or peripheral congestion and objective evidence of cardiac dysfunction at rest. The diagnosis is derived from and substantiated by clinical documentation from testing according to current practices.
Collection methods:
For each Person—concurrent clinical condition (acute coronary syndrome), code NN, the data elements Person—clinical evidence status(chronic lung disease), code N; Person—clinical evidence status(heart failure), code N; Person—clinical evidence status(stroke), code N; Person—clinical evidence status(peripheral arterial disease), code N; Person—clinical evidence status(sleep apnoea syndrome), code N must also be recorded.
Comments:
The most widely available investigation for documenting left ventricular dysfunction is the transthoracic echocardiogram (TTE). Other modalities include:
transoesophageal echocardiography (TOE),
radionuclide ventriculography (RVG),
left ventriculogram (LVgram),
magnetic resonance imaging (MRI).
In the absence of any adjunctive laboratory tests, evidence of supportive clinical signs of ventricular dysfunction. These include:
