The April case scenario for the EPDI registry will review metric 26 and appropriate use criteria. A 55-year-old male is admitted for an EPS and possible dual-chamber implant after several presyncopal episodes. He has a history of first-degree AV block and symptomatic beta-blocker-induced sinus bradycardia. The EP study elicited monomorphic VT. Therefore, a dual chamber was implanted for secondary prevention. Is this patient included in the numerator for metric number 26? Please take a few moments to review the documentation and select the best possible answer. The correct answer is no. This patient does not meet the numerator for metric 26, proportion of ICD patients that fulfill a class 1, 2A, or 2B guideline recommendation. To meet metric 26, a syncopal episode is required in addition to the clinically relevant ventricular arrhythmia induced. This patient did have several presyncopal episodes, however, never experienced a loss of consciousness. Syncope is defined as an abrupt, transient, complete loss of consciousness associated with inability to maintain postural tone with rapid and spontaneous recovery. Let us review how this scenario is evaluated in the appropriate use criteria document and metrics. Let us review the bucket or group of AUC metrics where this patient's scenario will be evaluated. We know that this patient had a dual chamber ICD implanted for secondary prevention and marked sinus bradycardia induced by beta-blocker therapy. There are three groups of AUC metrics that will evaluate the patient. The first group is metrics 101 through 104, which will evaluate the patient regardless of device type and will display the patient based on evaluation of the specific buckets of device type and device indication. When the patient is classified into one of the four groups or buckets of AUC metrics, it will be displayed in metrics 102 through 104. Likewise, if the patient is not classifiable for any of the four groups of AUC metrics, then the patient will be displayed in 101, proportion of all procedures not classifiable for AUC. The second evaluates patients specific to dual chamber implants, metrics 109 through 112. The third is specific to secondary prevention for metrics 117 through 120. First, let's look at the secondary prevention group of AUC metrics. To recap, a 55-year-old male is admitted for an EPS and possible dual chamber implant after several presyncable episodes. He has a history of first degree AV block and symptomatic beta-blocker induced sinus bradycardia. The EP study elicited monomorphic VT, therefore, a dual chamber was implanted for secondary prevention. Our question number two is, how is this patient classified for secondary prevention in metrics 117 through 120? Number one, not classifiable, 117. Number two, classified, appropriate, 118. Number three, classified, maybe appropriate, 119. Or number four, classified, rarely appropriate, 120. Please take a few moments to review the documentation and select the best answer. The answer is not classifiable for secondary prevention in the AUC document and metrics. Let us review the AUC document for further understanding. When looking at section 1 for secondary prevention for ICD procedures, tables 1.1, 1.2, 1.3, and 1.4 evaluate patients with CAD, which does not pertain to this patient. Although table 1.5 evaluates patients with no CAD, this patient did not have spontaneous VT or VF. Table 1.6 evaluates for genetic diseases and does not pertain to this patient. Table 1.7 evaluates structural heart disease and genetic causes of VT, and this patient has neither. Tables for 1.8 evaluate patients with syncope, and this patient had presyncopal episodes only. Table 1.9 evaluates spontaneous VT associated with structural heart disease, which does not pertain to this patient. This patient is not classifiable for any secondary indications in the AUC documents. Let us review indications that are specific to dual chamber ICD implants. To recap, a 55-year-old male is admitted for an EPS and possible dual chamber implant after several presyncopal episodes. He has a history of first-degree AV block and symptomatic beta blocker-induced sinus bradycardia. The EP study elicited monomorphic VT. Therefore, a dual chamber was implanted for secondary prevention. How is this patient classified for a dual chamber ICD in metrics 109 through 112? Is it number one, not classifiable, 109? Number two, classified appropriate, 110? Number three, classified maybe appropriate, 111? Or number four, classified rarely appropriate, 112? Please take a few moments to review the documentation and select the best answer. The answer is classified as appropriate in the AUC document in metrics. Let us review the AUC document for further understanding. Section 5 is specific to dual chamber ICDs. Table 5.1 evaluates patients based on conduction system abnormalities. Indication 169 is assigned to patient scenarios of symptomatic sinus node dysfunction caused by sinus pauses, chronotropic incompetence, or marked sinus bradycardia that results from drug therapy required to treat other conditions. To review the scenario, the patient was admitted for an EPS and possible dual chamber implant after several presyncable episodes. His history includes first-degree AV block and symptomatic beta blocker-induced sinus bradycardia. The EP study elicited monomorphic VT. Therefore, a dual chamber was implanted for secondary prevention. This patient meets indication 169 criteria and is assigned an appropriate use score of 9 appropriate. Although this patient did not meet a device-based therapy guideline metric recommendation, the patient did meet an AUC recommendation. It is important to review the AUC metrics as another opportunity to evaluate real-world practices that bridge the gaps in the guidelines. Thank you for viewing the EP Device Implant Registry's April 2023 case scenario.

dual-chamber implant

patient evaluation

presyncopal episodes

monomorphic VT

appropriate use criteria (AUC)