This is the Cath PCI case scenario for April 2021. We will review appropriate use criteria. A 60-year-old female arrives at your facility for a Cath Lab visit. She has type 1 diabetes and has been experiencing typical angina for the past 6 months prior to this visit. She has no prior history of CAD. Her pre-procedure medications include Toprol XL 50 mg daily, Aspirin 81 mg daily, and an insulin pump. She had a stress echo performed one week prior, which was positive, with high risk of ischemia per physician documentation. Diagnostic coronary angiography reveals an 80% mid-LAD lesion, a 70% distal circumflex lesion, and an 80% dominant mid-RCA lesion. The physician discusses options with the patient, including PCI for multivessel disease versus CAVG. Her documented syntax score is 20. The patient opts for PCI, which is performed in the same Cath Lab visit. She receives PCI to the mid-LAD and mid-RCA. However, plans are to increase her medication therapy in lieu of treating the circumflex. Given the details of this scenario, what is the AUC evaluation or score for this PCI procedure? Would it be not classifiable, rarely appropriate with a score of 1 to 3, maybe appropriate with a score of 4 to 6, or appropriate with a score of 7 to 9? Here is your documentation and question for review. The answer is 4, appropriate with a score of 7. When we look at the 2017 AUC indications for coronary revascularization of stable ischemic heart disease, section 1 shows the AUC for SIHD without prior CAVG. This patient has 3-vessel disease, as demonstrated by disease greater than or equal to 70% in all 3 epicardial vessels, placing them in table 1.3, as well as a low disease complexity as documented by the syntax score of 20. She has ischemic symptoms of worsening angina and is on one anti-anginal, which is metoprolol succinate. Given the fact that she has diabetes and had high-risk findings on her stress echo performed one week prior, she meets indication number 19. Having all this information, we can see on the chart the AUC for performing PCI is appropriate with a score of 7. This patient will be included in the numerator of metric 34, PCI procedures that were evaluated as appropriate, PCI patients with stable ischemic heart disease. Determining AUC for a PCI procedure highlights the importance of complete and accurate documentation. Three crucial factors were involved in this specific PCI procedure to determine whether it was appropriate or not. Without complete documentation, the AUC score could have been lower or unclassifiable. The first factor is stress test. It is imperative to have sequence number 5200 stress test performed, coded yes, and to have all the supporting documentation, such as the type of test, the date in which it was performed, the results, and the risk or extent of ischemia. If there had not been a stress test documented or that stress test was performed greater than six months prior to the cath lab visit, this procedure is more likely to have been considered not classifiable by the AUC. The next factor is syntax score. Although syntax score is not crucial for certain patient populations, those with three vessel disease or disease in the left main coronary artery must have a syntax score calculated and documented to support performing the PCI procedure. Had the syntax score been coded unknown, the procedure would likely fall into metric 30, not classifiable. The final factor is pre-procedure medications, specifically anti-anginal medications, such as beta blockers, calcium channel blockers, long-acting nitrates, and or ranolazine. Ideally, a patient will be prescribed these medications within two weeks prior to the cath lab procedure. This supports medical therapy was initiated, and despite these medications, the patient continues to have symptoms. Thank you for viewing the Cath PCI Registry Monthly Case Scenario for April 2021.

Cath PCI case scenario

type 1 diabetes

angina

CAD

multivessel disease