4 th Universal Definition of MI - PowerPoint Presentation

Slide1

4th Universal Definition of MICDI ImplicationsACDIS Radio – August 29, 2018

James S. Kennedy, MD, CCS, CDIP

President and Chief Medical Officer

CDIMD – Physician Champions

Smyrna, Tennessee

jkennedy@cdimd.com

– (615) 479-7021

Disclosures

This presentation is designed to provide accurate and authoritative information in regard to the subject matter covered. The information includes both reporting and interpretation of materials in various publications, as well as interpretation of policies of various organizations. This information is subject to individual interpretation and to changes over time.

VP-MA Health Solutions, dba CDIMD,

HCPro, ACDIS,

the individual speakers,

and all affiliated entities do not warrant that the written or oral opinions expressed in this lecture apply to every situation. Prior to implementing any of the suggestions discussed at this meeting, the attendee is advised to seek counsel from his or

her

compliance officer or their legal counsel.

CDIMD,

HCPro

, ACDIS, the individual speakers, and all affiliated entities support accurate coding of every clinical circumstance based upon physician documentation, recognize the role and responsibility of treating physicians to utilize language they deem appropriate to their circumstances, and support compliance to all local, state, and federal laws.

Learning Objectives

Discuss the new 4

th

Universal Definition of Acute Myocardial Infarction and its impact on CDI and coding practices

Advocate solutions that promote clinical validity and coding compliance

4th Universal Definition Now Available

http://www.tinyurl.com/2018UDMI

2018 4th UDMINew Concepts

Differentiation of myocardial infarction from myocardial injury.

Highlighting peri-procedural myocardial injury after cardiac and noncardiac procedures as discrete from myocardial infarction.

Consideration of electrical remodeling (cardiac memory) in assessing repolarization abnormalities with tachyarrhythmia, pacing, and rate-related conduction disturbances.

Use of cardiovascular magnetic resonance to define the etiology of myocardial injury.

Use of computed tomographic coronary angiography in suspected myocardial infarction.

2018 4th UDMIDefinition of Myocardial Injury

The term myocardial injury should be used when there is evidence of elevated cardiac troponin values (cTn) with at least one value above the 99

th

percentile upper reference limit (URL). The myocardial injury is considered acute if there is a rise and/or fall of cTn values.

What many physicians label as “troponin leak”, “

troponinemia

”

In some circumstances, “demand ischemia” without elaborating as to if it is a myocardial infarction or nonischemic myocardial necrosis is used

Myocardial Injury vs.Myocardial Infarction

Criteria for Type 1, 2, 3Acute Myocardial Infarction

The term acute myocardial infarction should be used when ALL THREE OF THE FOLLOWING APPLY:

Acute

myocardial injury (troponin must be elevated)

Detection of a

rise and/or fall

of cTn values with at least one value above the 99th percentile URL, AND

Clinical evidence of acute myocardial

ischaemia

withat

least one of the following:

Symptoms of myocardial

ischaemia

;

New

ischaemic

ECG changes;

Development of pathological Q waves;

Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an

ischaemic

aetiology

;

Identification of a coronary thrombus by angiography or autopsy

Criteria for Type 1Acute Myocardial Infarction

Acute myocardial injury +Symptoms of myocardial ischaemia;New ischaemic ECG changes;Development of pathological Q waves;Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology;Identification of a coronary thrombus by angiography or autopsy

Atherosclerotic plaque disruption with thrombosis

Criteria for Type 2Acute Myocardial Infarction

Acute myocardial injury +Symptoms of myocardial ischaemia;New ischaemic ECG changes;Development of pathological Q waves;Imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischaemic aetiology;Identification of a coronary thrombus by angiography or autopsy No evidence of type 1, 3, 4, or 5 mechanism

Type 2 MI Mechanisms

Reduced myocardial perfusion, e.g. Coronary artery spasm, microvascular dysfunction Coronary embolism Coronary artery dissection Sustained bradyarrhythmia Hypotension or shock Respiratory failure Severe anaemia

Increased myocardial oxygen demand, e.g. Sustained tachyarrhythmia Severe hypertension with or without left ventricular hypertrophy

Myocardial injury related to acute myocardial ischaemia because of oxygen supply/demand imbalance

NOTE:

Demand ischemia alone should have a normal troponin; not a “troponin leak”.

What Troponin Elevations are NOTAcute Myocardial Infraction

Cardiac conditions, e.g. Heart failure Myocarditis Cardiomyopathy (any type) Takotsubo syndrome Coronary revascularization procedure Cardiac procedure other than revascularization Catheter ablation Defibrillator shocks Cardiac contusion

Systemic conditions, e.g. Sepsis, infectious disease Chronic kidney disease Stroke, subarachnoid haemorrhage Pulmonary embolism, pulmonary hypertension Infiltrative diseases, e.g. amyloidosis, sarcoidosis Chemotherapeutic agents Critically ill patients Strenuous exercise

4

th

UDMI encourages the documentation of “acute myocardial injury”

ICD-10-CM Index ChallengesMyocardial Injury

INJURY- heart S26.90- - with hemopericardium S26.00- - - contusion S26.01- - - laceration (mild) S26.020- - - - moderate S26.021- - - - major S26.022- - - specified type NEC S26.09- - contusion S26.91- - laceration S26.92- - specified type NEC S26.99- - without hemopericardium S26.10- - - contusion S26.11- - - laceration S26.12- - - specified type NEC S26.19

ICD-10-CM Index classifies “myocardial injury” only as traumatic in nature

Code Title Suggested by IndexConflicting with Clinical Diagnoses

(If the index is confusing), A basic rule of coding is that further research is done if the title of the code suggested by the index clearly does not identify the condition correctly. Coding Clinic, Second Quarter 1991 Page: 20 Coding Clinic, Third Quarter 2004 Page: 5 to 6 Coding Clinic, First Quarter 2013 Pages: 13-14

Possible options:

Consider myocardial injury as integral to the linked heart disease (e.g. myocarditis, Takotsubo cardiomyopathy, heart trauma)

I52, Other heart disorders in diseases classified elsewhere, if the linked underlying cause is not cardiac in nature (cannot be PDx)

I51.89 Other ill-defined heart diseases if no cause is given

Myocardial Injury w/o M. InfarctionCoding Clinic, 1st Quarter, 1992, pp 9-10

Question: - The physician has documented acute myocardial injury as a diagnosis. There is no evidence of myocardial infarction, based on cardiac enzymes, and no electrocardiogram changes noted other than acute myocardial injury. Should this be coded to 410.90-410.92, Acute myocardial infarction, unspecified site?Answer: No, assign code 411.89, Other acute and subacute forms of ischemic heart disease. The Alphabetical Index is silent under acute myocardial injury and the entry under acute heart injury implies only trauma (external injury) to the heart, codes 861.00-861.13. It is inappropriate to extrapolate "acute myocardial injury" to infarction; in fact, the term acute myocardial injury is most commonly synonymous with acute myocardial ischemia. Here, the index does differentiate between acute myocardial ischemia with and without infarction and should be followed in this situation.

DR. KENNEDY BELIEVES THAT THIS ADVICE IS INVALID, ESPECIALLY WITH 4

TH

UDMI

Type 4 and 5 MIs

Percutaneous coronary intervention (PCI) related MI is termed type 4a MI.

Coronary artery bypass grafting (CABG) related MI is termed type 5 MI.

Other types of 4 MI include

Type 4b MI stent thrombosis

Type 4c MI restenosis

Criteria for 4b and 4c use type 1 MI criteria

Criteria for Type 4a and Type 5 MI is on next slide

Type 4A and Type 5 MI Criteria

Coronary procedure-related MI ≤ 48 hours after the index procedure is arbitrarily defined by an elevation of cTn values > 5 times for type 4a MI and > 10 times for type 5 MI of the 99th percentile URL in patients with normal baseline values.

Patients with elevated pre-procedural cTn values, in whom the pre-procedural cTn level are stable (≤ 20% variation) or falling, must meet the criteria for a > 5 or > 10 fold increase and manifest a change from the baseline value of > 20%.

In addition with at least one of the following:

New

ischaemic

ECG changes (this criterion is related to type 4a MI only);

Development of new pathological Q waves;

Imaging evidence of loss of viable myocardium that is presumed to be new and in a pattern consistent with an

ischaemic

aetiology

;

Angiographic findings consistent with a procedural flow-limiting complication such as coronary dissection, occlusion of a major epicardial artery or graft, side-branch occlusion-thrombus, disruption of collateral flow or distal embolization.

Isolated development of new pathological Q waves meets the type 4a MI or type 5 MI criteria with either revascularization procedure if cTn values are elevated and rising but less than the pre-specified thresholds for PCI and CABG.

Post-mortem demonstration of a procedure-related thrombus meets the type 4a MI criteria or type 4b MI criteria if associated with a stent.

Other Updated Concepts

Type 1 myocardial infarction: Emphasis on the causal relationship of plaque disruption with coronary

athero

-thrombosis; new Figure 3.

Type 2 myocardial infarction:

Settings with oxygen demand and supply imbalance unrelated to acute coronary

athero

-thrombosis; new Figures 4 and 5.

Relevance of presence or absence of coronary artery disease to prognosis and therapy.

Differentiation of myocardial injury from type 2 myocardial infarction; new Figure 6.

Type 3 myocardial infarction: Clarify why type 3 myocardial infarction is a useful category to differentiate from sudden cardiac death.

Types 4–5 myocardial infarction: Emphasis on distinction between procedure-related myocardial injury and procedure-related myocardial infarction.

Other Updated Concepts

Cardiac troponin: Analytical issues for cardiac troponins; new Figure 7.

Emphasis on the benefits of high-sensitivity cardiac troponin assays.

Considerations relevant to the use of rapid rule-out and rule-in protocols for myocardial injury and myocardial infarction.

Issues related to specific diagnostic change (’delta’) criteria for the use of cardiac troponins to detect or exclude acute myocardial injury.

Consideration of new non-rate-related right bundle branch block with specific repolarization patterns.

ST-segment elevation in lead

aVR

with specific repolarization patterns, as a STEMI equivalent.

ECG detection of myocardial

ischaemia

in patients with an implantable cardiac defibrillator or a pacemaker.

Enhanced role of imaging including cardiac magnetic resonance imaging for the diagnosis of myocardial infarction; new Figure 8.

New Sections

Takotsubo syndrome.

MINOCA (and INOCA)

Myocardial infarction w/non-obstructive coronary arteries (<50% stenosis)

Ischemia w/non-obstructive coronary arteries

Chronic kidney disease (including ESRD).

Atrial fibrillation.

Regulatory perspective on myocardial infarction.

Silent or unrecognized myocardial infarction.

Thank you. Questions?

James S. Kennedy MD

(615) 479-7021

jkennedy@cdimd.com