Welcome, and thank you for joining this learning activity titled CVASC Registry Education to Sequence Numbers. This is a learning activity with focused education on the sequence numbers in the ICD portion of the CVASC registry. After participation in this learning activity, the learner should be able to identify, discuss, and explore the sequence numbered elements in the ICD portion of the registry. This presentation includes many elements at once and is provided as baseline education. In addition to this education, the user can search individual portions of this presentation by accessing individual videos using the search functionality provided. We thank you for choosing the American College of Cardiology's CVASC registry, and we'd like to welcome you to the team. If you have any questions after watching these educational resources, please let us know via the Contact Us feature on your registry homepage. Now, buckle in for some educational time as we navigate the sequences in the registry. Sequence 4170, Syndromes with Risk of Sudden Death Type, will populate when a history of syndromes of sudden death are captured. If the patient has a history of a syndrome with risk of sudden death, Sequence 4170 seeks to capture the type. The first selection we will review is Brugada syndrome. This is a polymorphic ventricular tachycardia that occurs in the absence of structural heart disease. It is associated with the baseline ACG pattern during sinus rhythm showing a right bundle branch block with ST elevation in leads V1 through V3. They can also be characterized by documentation of ECG patterns associated with Brugada syndrome, some of which may be unmasked when provoked with drugs. The most common genetic mutations identified for this syndrome are in a sodium channel gene. Therefore, sodium channel blocking agents may exacerbate the ECG features and clinical presentation. Brugada syndrome typically presents before the age of 50. CPVT is a highly malignant inheritable cardiac channelopathy in individuals without structural heart disease and QT prolongation on ECG. It is often thought of being a disease of childhood, setting itself in before the age of 21 with symptoms such as syncope or sudden cardiac arrest. However, there is an adult form that presents between the ages of 32 and 48. This syndrome is triggered by physical or emotional stress in patients who ECG is normal. Idiopathic or primary ventricular tachycardia or fibrillation occurs in patients without structural heart disease, metabolic abnormalities, or the prolonged QT syndrome. Long QT syndrome describes a group of inherited channelopathies that confer risks of polymorphic ventricular tachycardia and sudden cardiac death. A clinical diagnosis is required and is based on clinical presentation and ECG. Genetic testing is generally advised as certain variants are responsible for this syndrome. This cannot be determined by the abstractor based on a long QT on ECG. Short QT syndrome refers to the ECG manifestation of accelerated cardiac repolarization. Acquired disease, which is the most common cause, results from electrolyte disturbances or drugs in addition to hypercalcemia, hyperkalemia, and acidosis. Short QT syndrome manifests with digoxin, androgen use, increased fapal tone, and after ventricular fibrillation. Short QT syndrome is a ring, sporadic, or autosomal dominant disease that manifests with atrial and ventricular arrhythmias, sudden cardiac death, and shortened QT. Cardiac arrest occurs as the presenting symptom in up to 40% of the cases. Mutations in potassium and calcium channels have been identified as disease-causing. If the patient has an identified history of ventricular fibrillation not due to irreversible causes, then the registry wants to capture the date of this event. Sequence 14720, Ventricular Fibrillation Date, seeks to capture the most recent date of this event. If only the year is known, then the abstractor may code 01-01 and insert that year. If the specific year is not known, the year may be estimated based on timeframes found in the prior documentation. For example, if the patient had most recent ventricular fibrillation not due to reversible cause documented in a record from 2011, then the year 2011 can be utilized and coded as 01-01-2011. Sequence 4250, VT Date, Sequence 4275, VT Type, and Sequence 4255, Post-Cardiac Surgery Within 40 Hours, Sequence 4260, Bradycardia Dependent, Sequence 4265, Reversible Cause, and Sequence 4270, Hemodynamic Instability, will all populate when a history of ventricular tachycardia is captured. These child fields are coded according to the recent and most significant ventricular tachycardia event. The hierarchy from least to most severe is as follows, non-sustained ventricular tachycardia to monomorphic ventricular tachycardia to polymorphic ventricular tachycardia to monomorphic and polymorphic ventricular tachycardia. If the patient has a history of ventricular tachycardia, the first thing the registry wants to know is the most recent date of the most significant episode. If only the year is known, then the abstractor may code 01-01 and insert that known year. If the specific year is not known, the year may be estimated based on timeframes found in prior documentation. For example, if the patient had most recent ventricular tachycardia documented in a record from 2011, 2011 can be utilized and coded as 01-01-2011. When the patient has a history of ventricular tachycardia and a timeframe is unavailable and clarification with the clinician unobtainable, then please code the ventricular tachycardia as having occurred five years ago. Sequence 4275, ventricular tachycardia type, is coded according to the most recent and most significant ventricular tachycardia event. The hierarchy from least to most severe is as follows, non-sustained ventricular tachycardia to monomorphic ventricular tachycardia to polymorphic ventricular tachycardia to the most severe of monomorphic and polymorphic ventricular tachycardia. When there is documentation that doesn't neatly fit into one of the selections, the notes provide additional coding guidance. When sites find documentation the patient experienced ventricular tachycardia, that is enough to code non-sustained in sequence 4275. And when there is documentation of a sustained ventricular tachycardia or evidence ventricular tachycardia was treated appropriately with ATP or shock therapy or ventricular tachycardia arrest, but the type is unknown, that is enough to code monomorphic ventricular tachycardia. Sequence 4255, ventricular tachycardia occurred post-cardiac surgery, seeks to capture if the patient's most significant episode of ventricular tachycardia occurred within 48 hours of cardiac surgery. Sequence 4260, bradycardia-dependent ventricular tachycardia, seeks to capture if the patient's most significant episode of ventricular tachycardia was bradycardia-dependent. Sequence 4265, ventricular tachycardia reversible cause, seeks to capture if the patient's most seeks to capture if the patient's most significant episode of ventricular tachycardia was deemed to be a result of a reversible cause. The most common reversible causes of ventricular tachycardia can include acute ischemia and electrolyte imbalance. Others can be drug-induced. Sequence 4270, ventricular tachycardia with hemodynamic instability, seeks to capture if the patient's most significant episode of ventricular tachycardia caused the patient to experience hemodynamic instability, whether it was sustained or non-sustained. Hemodynamic instability can be described as periods of reduced, unstable, or abnormal blood pressure with near-syncope or episodes of syncope. It creates a state of hypoperfusion that does not support normal organ perfusion or function. Each cardiovascular ASC procedure pathway is assigned unique and specific procedure history data elements. The entire team, including ambulatory surgery center and office-based lab stakeholders, thoughtfully and concisely appointed these procedures to their respective pathway based on reporting needs and keeping in mind the need for lean data sets. So while the data dictionary lists all applicable procedures that could be used within the entire registry, constraints are applied in the back-end to allow certain procedures to appear in the specific pathway when using the data collection tool. Thus, the easiest means to know which procedures are captured for a specific pathway is taking a look at the data collection form. To code yes in sequence 15511, procedure history occurrence, there must be documentation the patient has undergone the indicated medical procedure. All pathways capture the date of the patient's most recent procedure that occurred prior to arrival at your facility. If the month or day of the most recent procedure is unknown, please code 0101 and insert that known year. But if the year is unknown, it may be estimated based on timeframes found in the medical record. For example, if the patient had the verbiage of most recent procedure, insert whatever the procedure may be, documented in a record from 2011, then the year, in this case 2011, can be used to support coding and 0101-2011 would be captured. The ICD pathway has additional child fields for certain procedure history data elements used to inform metrics and appropriate use criteria. We will review them here. If the patient underwent a coronary angiography procedure prior to the first procedure in this admission, sequence 4305 would be captured if it was performed after the patient's most recent cardiology procedure. If the patient underwent a cardiac arrest procedure prior to the first cardiology procedure, sequence 4310 would be captured if it was performed after the patient's most recent cardiology procedure. If the patient underwent a cardiac arrest procedure prior to the first cardiology procedure, sequence 4310 would be captured if it was performed after the patient's most recent cardiology procedure. If the results of the most recent angiography indicate the patient is not a candidate for revascularization of their significant coronary artery disease, then non-revascularizable significant disease would be coded. If the results of the most recent angiography indicate there was less than 50% stenosis in the left main coronary artery and less than 70% stenosis in all other major coronary artery branches that were two millimeters in diameter or larger, then no significant disease would be coded. If the results of the most recent angiography indicated the patient had 50% or worse stenosis in the left main coronary artery and or 70% or worse stenosis in any major coronary artery two millimeters in size or more, then significant disease would be coded. If it is noted that the patient has significant disease on their most recent coronary angiogram, then sequence 4315 gives sites the opportunity to indicate if an attempt at revascularization was performed. The intent of this data element is to evaluate the status of the arteries and or bypass grafts at the time of the implant. If it is noted that the patient had revascularization performed, then sequence 4320 wants to identify the outcome. If the attempt at revascularization resulted in residual stenosis of less than 50% in all revascularizable diseased coronary arteries, then complete revascularization would be coded. If the attempt at revascularization reflects that not all revascularizable diseased coronary arteries resulted in less than 50% residual stenosis, then incomplete revascularization would be coded. If the patient is noted to have had a coronary artery bypass graft procedure, sequence 4530 pre-existing cardiomyopathy will populate. Sequence 4530 cardiomyopathy prior to CABG is seeking to identify if the patient had pre-existing cardiomyopathy prior to their procedure. The notes further clarify that if there is no documentation regarding a pre-existing cardiomyopathy to code no. But if the patient has documentation of a left ventricular ejection fraction of less than 40% as well as heart failure noted prior to the CABG, then you may code yes. If the patient has undergone a prior PCI procedure, then sequence 4510 pre-existing cardiomyopathy will populate. Sequence 4510 cardiomyopathy prior to PCI is seeking to capture if the patient had a pre-existing cardiomyopathy prior to their PCI procedure. The notes further clarify that if there is no documentation regarding a pre-existing cardiomyopathy, sites would code no. However, if the patient has documentation of a left ventricular ejection fraction of less than 40% as well as a diagnosis of heart failure prior to that PCI procedure, yes may be coded. Sequence 5000 electrophysiology study is indicating if the patient had an electrophysiology study any time prior to the procedure. If a patient has undergone a prior atrial or ventricular ablation, this would be coded as yes as it is understood an electrophysiology study occurred as this is an inherent part of an ablation procedure. If it has been noted the patient had a prior electrophysiology study, then sequence 5005 is capturing the most recent date one was performed. If the month or day of the electrophysiology study is unknown, please code 0101 and insert that known year. If the specific year is unknown in the current record, the year may be estimated based on timeframes found in prior documentation. So, for example, if the patient had most recent EP study documented in a record from 2011, the year 2011 would be utilized and 0101-2011 would be coded. However, if the most recent date when the electrophysiology study was performed is unknown, then sequence 5010 electrophysiology study date unknown would be selected instead. Sequence 5015 is indicating if clinically relevant ventricular arrhythmias were induced during the electrophysiology study. A clinically relevant ventricular arrhythmia induced during electrophysiology study most often represents sustained monomorphic ventricular tachycardia, but it may not be associated with represents sustained monomorphic ventricular tachycardia, but it can include other clinically relevant sustained ventricular tachyarrhythmias thought to contribute to syncope, aborted cardiac death, or other serious clinical presentations.

CVASC registry

sequencing numbers

cardiac conditions

arrhythmias

coronary angiography

electrophysiology studies