Thank you for viewing the Chest Pain MI Registry July case scenario regarding metric 46, P2Y12 inhibitor at discharge. Our scenario involves a patient with a history of hypertension, CAD, with stents and hyperlipidemia who arrives in your emergency department with complaints of chest pain and diaphoresis. The patient's home medications include Prasugrel 10 mg daily, Lisinopril 20 mg daily, and Atavastatin 40 mg daily. The ECG intraponins are diagnostic for NSTEMI. The cardiologist on call is notified and the patient is taken to the cath lab. Diagnostic coronary angiography reveals a 70% non-dominant mid-LAD lesion and 60% instant restenosis in the distal RCA. The cardiologist opts to treat medically in lieu of PCI and proposes changing the patient's P2Y12 inhibitor from Prasugrel to Ticagrelor. However, the patient refuses. Upon discharge, documentation states the patient refused to change P2Y12 inhibitor, therefore will continue with same medications but increased dose of Atavastatin to 80 mg daily. Our question, how is sequence number 10205 discharge medications prescribed coded for Ticagrelor and Clopidogrel? Is it number one, no, no reason, number two, no medical reason, or number three, no patient reason? Please take a few moments to review the documentation and the question. And the answer is number three, no patient reason. These medications were not prescribed at discharge due to a reason documented related to the patient's preference. In this scenario, Prasugrel will be coded yes in sequence 10205. Now let's look at how this patient will be reflected in metric 46, P2Y12 inhibitor at discharge. This metric measures the percentage of patients hospitalized with AMI who are prescribed an appropriate P2Y12 inhibitor at discharge. This patient meets denominator criteria and that he had an instemi. However, looking at the numerator criteria, it appears the patient will not meet the numerator since he was treated medically but was not prescribed Clopidogrel or Ticagrelor at discharge. However, this scenario illustrates a denominator exception for metric 46, P2Y12 inhibitor at discharge, where the patient is medically treated and arrives on Prasugrel and is discharged on Prasugrel and has a medical or patient reason for not receiving Clopidogrel or Ticagrelor. Because there is a denominator exception, this patient will be removed from the eligible metric population. The logic for this exception comes from the Chest Pain MI Registry Steering Committee. On review of the performance measure off of which this metric was built, you will notice this exception does not exist. The Steering Committee supports the performance measure directive to treat medically treated enstemi patients with Clopidogrel or Ticagrelor and to treat the patient's current diagnosis versus continuing treatment based on the patient's history. However, they recognize that when patients are being treated with Prasugrel and are medically managed for their enstemi diagnosis, continuing Prasugrel may be in the patient's best interest to avoid unintended consequences from switching P2Y12 inhibitors. Thus, if Prasugrel is prescribed at discharge and the patient arrived on Prasugrel, they are removed from the metric denominator. Thank you for viewing the Chest Pain MI Registry's July 2021 case scenario.

Chest Pain MI Registry

NSTEMI

P2Y12 inhibitor

Prasugrel

Ticagrelor