The EP Device Implant Registry case scenario for February 2024 will review Metric 26 device-based therapy guidelines and the appropriate use criteria. A 77-year-old male was admitted for loss of consciousness on January 29, 2024. The initial ECG revealed a heart rate of 41 with long QT intervals and first-degree heart block. He has a history of an MI with PCI to LAD on December 20, 2023. The current left ventricular ejection fraction is 20% with a New York Heart Association classification of 2 and persistent weakness associated with dizziness. Throughout the evening and night, the telemetry monitor reveals episodes of severe bradycardia alternating with non-sustained VT. The clinician documents, patient has been on guideline-directed medical therapy for his MI. However, given his syncopal episode, severe bradycardia, and episodes of non-sustained VT, it is recommended to implant a dual-chamber ICD for secondary prevention. Is this patient included in the numerator for Metric 26? Take a moment to select an answer from the available options. The correct answer is no. This patient does not meet the numerator criteria for Metric 26, Proportion of ICD Patients that Fulfill a Class I, Class IIa, or IIb Guideline Recommendation. To meet Metric 26, in addition to the syncopal episode, the device-based therapy guidelines also require an electrophysiology study where a clinically relevant arrhythmia is induced. An EPS was not performed prior to the implant of the dual-chamber ICD for secondary prevention. Thus, this patient scenario will not meet the numerator of Metric 26. Let us review how this scenario is evaluated in the appropriate use criteria document and metrics. First, let us look at the metric buckets or groups to assist us with our evaluation both within the metrics and within the 2013 appropriate use criteria for implantable cardioverter defibrillators and cardiac resynchronization therapy document. This patient had a dual-chamber ICD implanted for secondary prevention due to a syncopal episode, runs of non-sustained VT alternating with periods of severe bradycardia with no electrophysiology study performed. There are two buckets or groups of AUC metrics where this patient scenario will be evaluated. The first group is evaluating patients specific to dual-chamber ICD implants, Metric 109-112. The second is specific to secondary prevention metrics, 117-120. To recap, a 77-year-old male was admitted for loss of consciousness on January 29, 2024. The initial ECG revealed a heart rate of 41 with long QT intervals and first-degree heart block. He has a history of an MI with PCI to the LAD on December 20, 2023. The current left ventricular ejection fraction is 20% with an NYHA class of 2 and persistent weakness associated with dizziness. Throughout the evening and night, the telemetry monitor reveals episodes of severe bradycardia alternating with non-sustained VT. The clinician documented the patient has been on guideline-directed medical therapy for his MI. However, given his syncopal episode, severe bradycardia, and episodes of non-sustained VT, it is recommended to implant a dual-chamber ICD for secondary prevention. Read the question and possible answers. The correct answer is metric 118, appropriate. Let's look at the secondary AUC indication group and systematically determine how the indication was assigned. When reviewing scenarios independently, it is important to remember some scenarios are not able to be classified. When looking at Section 1 for secondary prevention for ICD procedures, Table 1.1, 1.2, 1.3, and 1.4 evaluate patients with CAD, however, this patient is greater than 40 days from their MI. Table 1.5 evaluates patients with no CAD, however, this patient does have CAD. Table 1.6 evaluates for genetic diseases and does not pertain to this patient. Table 1.7 evaluates an LVEF of greater than or equal to 50% with no structural diseases. However, this patient's LVEF is 20%. Table 1.8.3 evaluates patients with syncope with non-ischemic structural heart disease and does not apply to this patient. Table 1.9 evaluates spontaneous VT associated with structural heart disease, which does not pertain to this patient. The table for 1.8.1 evaluates patients with syncope without structural heart disease. Table 1.8.2 evaluates patients with syncope and CAD. Both tables, 1.8.1 and 1.8.2, may represent this scenario. Let's review them together. In the AUC indication in Table 1.8.1, Syncope in Patients Without Structural Heart Disease, it's determined that indication 36 and 37 require a normal ECG. Indications 38 through 40 require a left bundle branch block and indications 41 and 42 require a long Q syndrome. Indications 43 through 45 require Brugada syndrome. Indications 46 and 47 require catecholaminergic polymorphic VT. And all the indications within Table 1.8.1 do not apply to this patient scenario. So next, let us look at Table 1.8.2. Indications 48 through 52, 54, and 55 requires EP study. This patient did not have an EPS. Indication 53 is assigned to scenarios of patients with unexplained syncope with a non-acute prior MI, an LVEF of 35% or less, and an EPS is not performed. This patient is assigned an AUC rating of 9, which is appropriate, despite not meeting the device-based guidelines. It is important to review the AUC document, especially for patient scenarios that do not meet the device-based guidelines. The AUC indicators were derived from common applications and current clinical practice guidelines. This is recognition and representation of real-world scenarios where expert opinion is of value in addressing patient scenarios that are not represented in randomized clinical trials or not supported by lower levels of evidence. Thank you for viewing the EP Device Implant Registry's February 2024 case scenario. For more information, visit www.cdc.gov.

CRTD generator change

unsuccessful implantation

LV lead

metric 10

site performance

EP Device Implant Registry

heart attack

abnormal heart rhythms

dual-chamber ICD

appropriate use criteria