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0824 - Inclusion - Exclusion Criteria
0824 - Inclusion - Exclusion Criteria
0824 - Inclusion - Exclusion Criteria
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Video Transcription
Welcome to the Chest Pain MI Registry Case Scenario for August 2024, where we will focus on inclusion and exclusion criteria. A 32-year-old male experienced nausea, chest tightness, and shortness of breath shortly after snorting cocaine. His mother called 911. EMS arrived at the patient's side at 6.53 p.m. and transported the patient to the closest health care facility. Past medical history includes hypertension. An ECG was performed at 6.58 p.m. and met STEMI criteria. Upon arrival at the ED, the ED physician reviewed the EMS ECG confirming the EMS interpretation, noting typical ST elevation appearing mainly in the precordial leads. Two point-of-care troponin values were obtained. Both values were above the 99th percentile upper reference level. The on-call cardiologist was consulted, and a code heart was activated. The patient was transferred to the cardiac cath lab based on the ECG findings, the troponin values, and his symptoms. The angiogram revealed a narrowing in the mid-LAD, an intracoronary nitroglycerin was injected, and vasospasm was confirmed, and no coronary artery disease was identified. The interventionalist documents vasospasm in the cath lab report. At the conclusion of care, the STEMI clinical diagnosis remains. Our question, is this patient included in the chest pain MI registry? Number one, no, or number two, yes. Please take a few moments to review the documentation and the question before selecting your answer. The correct answer is number two, yes. This patient is included in the registry. Let us review the rationale as to why the correct answer is number two. At the conclusion of the episode of care, the clinical diagnosis of STEMI remained, and the inclusion and patient type definition were met. The patient is entered into the registry. The documentation of a non-thrombotic mechanism will not impact inclusion for the STEMI patient type. Now let's go over the evaluation steps to determine the inclusion of the patient with a clinical diagnosis of STEMI. First, let's go over the inclusion criteria. Patients greater than or equal to 18 years of age are included in the registry when a qualifying cardiac diagnosis is made on discharge. The registry has four qualifying cardiac classifications, identified as the following patient types, STEMI, NSTEMI, unstable angina, and low-risk chest pain. In this scenario, the inclusion criteria are met. This patient is 32 years old, meeting the minimum requirement of at least 18 years of age. At the conclusion of care, one of the four cardiac classifications remained on discharge, which was STEMI. Next, we'll explore if the patient type definition was met with specifics to assist with the process of determining whether a STEMI patient is entered into the registry. Step 1. Ask, is there a clinical diagnosis of STEMI that remains at the conclusion of care? If yes, proceed to Step 2. We know the inclusion criteria are met for the scenario. Let us proceed to Step 2. Step 2. Ask, what is the STEMI setting? Is it pre-admit or in-hospital? The line in the sand is admission orders. When the STEMI is identified prior to the admission order, pre-admit is selected in sequence 12447, STEMI type. In-hospital is selected when the STEMI is identified after admission orders for inpatient status are written. It is important to remember the only requirement for inclusion for in-hospital STEMI is the clinical diagnosis of STEMI. Pre-admit STEMIs must meet the patient type definition. In this scenario, the STEMI type is pre-admit. The STEMI was identified prior to admission orders. Let's proceed and review Step 3. Patient type definition next. Pre-admit STEMIs must have either revascularization, which includes PCI, thrombolytics, or CABG performed for the STEMI diagnosis, or the detection of a rise and or fall of cardiac troponin with at least one value above the 99th percentile upper reference limit and at least one of the following, either symptoms of acute myocardial ischemia, new or presumed new significant ST segment elevation consistent with acute myocardial infarction, development of pathological Q waves, imaging evidence of new loss of viable myocardium or new regional wall motion abnormality in a pattern consistent with an ischemic etiology, or identification of an intracoronary thrombus by angiography, including intracoronary imaging. The patient type definition is met. Let us proceed to Step 4. Step 4, ask, is there documentation of a non-thrombotic mechanism of injury associated with the MI, including coronary embolism, coronary vasospasm, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and or other? If yes, then make the appropriate selections and select all that apply in sequence 15-599, non-thrombotic mechanisms present. To clarify, the selection of other is selected only if coronary embolism, coronary vasospasm, spontaneous coronary artery dissection, or Takotsubo cardiomyopathy is not diagnosed as the mechanism of injury associated with the MI, and there is specific documentation in the medical record of type 2 MI or supply-demand mismatch. A STEMI patient type will not be excluded from the registry due to a non-thrombotic mechanism of injury associated with the MI. Thank you for viewing the chest pain MI registry case scenario for August 2024.
Video Summary
In the video transcript, a 32-year-old male with a history of hypertension experiences chest pain, nausea, and shortness of breath after using cocaine. He is diagnosed with STEMI and treated in the cardiac cath lab for vasospasm. Despite the non-thrombotic cause, he is included in the chest pain MI registry as he meets the criteria for STEMI. The process for determining inclusion involves confirming a clinical STEMI diagnosis, considering the setting of the STEMI, meeting patient type definitions including revascularization or troponin levels, and documenting any non-thrombotic mechanisms. The patient's case is used as an illustrative scenario for understanding the inclusion process in the registry.
Keywords
June 2024
75-year-old male
chest discomfort
heart score
coronary artery bypass graft surgery
STEMI diagnosis
chest pain
cocaine use
cardiac cath lab
registry inclusion process
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