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Heart Conscious Making Sense of Elevated Troponins

Jill O’Brien, MD Medical Director Case Management Physician Advisor to CDI/Coding The Miriam Hospital. Heart Conscious Making Sense of Elevated Troponins. Clarifying Principles. Clear Definition for Type 2 MI Expanded Rationale for Elevated T roponins without MI

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Heart Conscious Making Sense of Elevated Troponins

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  1. Jill O’Brien, MD Medical Director Case Management Physician Advisor to CDI/Coding The Miriam Hospital Heart Conscious Making Sense of Elevated Troponins

  2. Clarifying Principles • Clear Definition for Type 2 MI • Expanded Rationale for Elevated Troponins without MI • Acknowledgement that often several processes are occurring in tandem resulting in elevated troponin • What’s Missing? • Demand Ischemia

  3. MI versus Myocardial Injury Troponin Elevation reflects an injury to myocytes but does not indicate the underlying pathophysiological mechanism.

  4. MI versus Myocardial Injury • “Although myocardial injury is a prerequisite for the diagnosis of MI, it is also an entity in itself” • “To establish the diagnosis of MI, criteria in addition to abnormal biomarkers are required.” • “Clinicians must distinguish whether patients have suffered a non-ischemic myocardial injury or one of the MI subtypes” • “If there is no evidence to support the presence of myocardial ischemia, a diagnosis of myocardial injury should be made”

  5. Cellular Factors Leading to Release of Troponin Mechanical Stretch Normal Cell Turnover Apoptosis (organized cell death do to other factors) Increased cell permeability Formation and release of membranous blebs Myocyte necrosis

  6. Causes of Elevated Troponin in CHF • Type 1 MI • Coronary thrombosis leading to cardiac dysfunction, reduced cardiac output and thus heart failure symptoms • Type 2 MI • During heart failure exacerbation: Increased transmural pressure, small-vessel coronary obstruction, endothelial dysfunction, anemia, hypotension • Myocardial Injury with cellular death • During heart failure exacerbation: Wall stretch, direct cellular toxicity related to inflammation

  7. Causes of Elevated Troponin in Critical Illness • Type 1 MI • Plaque disruption leading to thrombosis in a coronary artery • Type 2 MI • Increased myocardial oxygen demand • Myocardial Injury with cellular death • Endotoxin release resulting in local cell death and reduced cardiac function

  8. Potential Clinical Scenario: Increased heart rate for “demand reason” with ischemic changes on EKG but NO troponin elevation This term in confusing Troponin elevation from ischemia indicates myocardial injury and if there is a rise/fall of troponins with evidence of ischemia this denotes a “Myocardial Infarction” When to use “Demand Ischemia”

  9. Who’s seen this? “I’m a bit concerned that we are labeling the population of RI as having varying degrees of cardiac ischemia which will affect everyone’s ability to be insured both medically and for life. I find these definitions flawed and their use disabling to our population on paper.” 4th Universal Definitions Helps the Cause: Myocardial Injury without Ischemia But there’s no ICD-10 Code… YET

  10. Bridging the Gap Assumptions about clinicians: • Most have not read the 4th Universal Definition for MI • Demand Ischemia, as a term, has been explained in a variety of ways that do not always make sense to providers clinically • Feel it necessary to write something when they see a positive troponin to avoid “the Query” • Are feeling uncomfortable with the frequency they are diagnosing a type 2 MI but recognize that the abnormal troponin signifies an increase risk to their patients in the short and long term

  11. Bridging the Gap Coding/CDI side: • Terms like: elevated troponin, troponinemiaor combinations of terminology are non-specific and can signify different pathophysiology • End Coder/ICD 10 limitations for “non-ischemic myocardial injury” Elevated troponin can’t be coded Myocardial injury  implies trauma

  12. Bridging the Gap GOAL: • Offer definitions to match clinical reasoning • Include definitions on all queries • Honestly present the lack of a “codable” diagnosis for “myocardial injury without ischemia” • Lobby to AHIMA/ACDIS to address ICD-10 short-comings

  13. Feeling StagnantUnderstanding Acuity of VTEs

  14. New Clot Time frame for acute episode not agreed upon in literature Abrupt onset leg swelling, redness, pain Usually brought on by venous stasis, hypercoagulability and/or endovascular insult Treat with anticoagulation for 3-6months Old clot that has not resolved despite appropriate management with blood thinners Clot scars vessel and causes complications due to venous stasis Patients can have chronic swelling, skin changes, ulcerations, recurrent infections Management can include: surgical repair, stenting, TEDS, anticoagulation DVT ACUTE CHRONIC

  15. Distended Vein Partially Compressible Vein Thrombus visualized – hypoechoic (black) No Collaterals Small, irregular vein Non-compressible Thrombus is well adherent and hyperechoic (bright) Collaterals present Ultrasound Diagnosis - DVT ACUTE CHRONIC

  16. New Clot Symptoms of Chest Pain, Shortness of Breath Patients can have hypoxia, tachycardia, hypotension Diagnosed by CTA Treatment with anticoagulation for 3-6months Severe cases may require thrombolytics, EKOS, or embolectomy Old clot that has not resolved despite appropriate management with blood thinners Patients develop complications from Pulmonary Hypertension Diagnosis can be by CTA but usually by V/Q scan; echo shows pulmonary hypertension Management is with anticoagulation and possibly sildenafil Pulmonary Embolism ACUTE CHRONIC

  17. Coding Clinic Guidance ICD-9-CM Coding Clinic, Fourth Quarter 2009 Pages: 85-87 Effective with discharges: October 1, 2009

  18. “History Of” Coding Clinic (1stQ, 2011) • Patient has had a DVT/PE in past • Does not have complications of a “Chronic DVT/PE” • May or May Not be receiving anticoagulation

  19. These diagnoses do not follow a continuum: Rather: Take Home Points “History of” Acute Chronic

  20. Bridging the Gap Assumptions about Clinicians: • We have no idea what time frame to utilize to define an acute clot • Chronic clots act very differently than acute clots and management can be very different or look very similar • We may not always write “history of” when creating our problem list, even though that is what we mean. For instance: DVT – cont Coumadin, trend INR

  21. Bridging the Gap Coding/CDI Side: • Acuity is necessary for precise coding • Treatment for all 3 types of clot can be the exact same which is challenging • End Coder Limitations: Unspecified DVT/PE  Acute DVT/PE

  22. Bridging the Gap • Consider Phase of Management when asking if a clot is acute • “Acute phase of Management” • Utilize imaging findings to help clarify clot type • Anticoagulation in a patient with “history of” is for prevention of new clot not treatment of an existing clot

  23. Happy Valentine’s Day

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