Welcome to Lesson 4 of this learning activity titled Understanding Metrics. The content in this lesson was developed by Denise Pond and Beth Denton. I'm Veronica Wilson and I will be narrating this lesson. The 2017 ACC AHA HRS Guideline for Management of Ventricular Arrhythmias and Prevention of Sudden Cardiac Death evaluates the current recommendations and identifies the class 1 recommendations which are beneficial, such as implanting an ICD in a patient with ischemic heart disease who is at less than 40 days post-MI and 90 days post-revascularization with an LVEF of less than or equal to 35% and a New York Heart Association of 2 or 3 despite guideline-directed medical therapy. The 2017 guideline also identifies class 2A recommendations which may be beneficial in the treatment of patients with arrhythmias to prevent sudden cardiac death. One example includes those patients with heart failure who are awaiting a heart transplant and discharge home. Additionally, the 2017 guideline identifies what is harmful or not recommended, which includes implanting an ICD in a patient with hypertrophic cardiomyopathy, or HCM, in the absence of risk factors for sudden cardiac death. Let's review how the Executive Summary Measures and Metrics Companion Guide highlights this information. We will use metric 25, which is based on the 2008 Device-Based Therapy Guideline, the 2012 Focused Update for Device-Based Therapy, and the 2017 Guideline for Management of Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. The numerator will include all initial ICD and CRTD implants that meet a class 1, 2A, or 2B guideline indication for a device. The denominator is the count of all patients who had an initial ICD or CRTD implanted, which is coded as procedure type sequence 7010, as an initial generator implant. The exclusion criteria remove any patient enrolled in a clinical trial for a generator or lead which has not been approved for use by the FDA. There are quite a few data elements involved in metric 25, and it is more easily evaluated when broken down. Most patients have their devices implanted for primary prevention, so let's start here. Does the patient have either ischemic cardiomyopathy with prior MI greater than 40 days, or a PCI or CABG greater than 3 months, or do they have non-ischemic cardiomyopathy? What is the NYHA class? Is it 2 or 3? What is the LVEF? Is it less than or equal to 35%, and has the patient been on guideline-driven medical therapy for more than 3 months, or were they unable to complete it? When looking at secondary prevention, is there documentation of a VT or VF arrest, spontaneous sustained unstable VT not due to a reversible cause, or does the patient have syncope, which the physician has deemed to be due to a ventricular arrhythmia? When neither of the first two scenarios apply, ask yourself, does the patient have a structural abnormality or a syndrome with risk of sudden death? Does the patient have any identified high-risk features? On this slide, we've listed just a few. A more complete listing can be found in your data dictionary on page 62. In our case scenario today, we will focus on a patient who had an ICD implanted for primary prevention. This 67-year-old female is admitted for an initial ICD implant on December 28, 2017. She has had multiple episodes of unexplained syncope that the clinician feels are due to ventricular arrhythmias. She has ischemic cardiomyopathy secondary to an MI in 2012. She has been on guideline-directed medical therapy for more than two years, and her current LVEF is 35% with an NYHA class of 1. Based on the documentation in the medical record, the abstractor codes a New York Heart Association of 1, an LVEF of 35%, ischemic cardiomyopathy, and guideline-directed medical therapy as yes, syncope as yes, and prior MI as yes, with the most recent date as January 26, 2012. Our question is, will this patient be included in the numerator for metric 25? Display this to drill down revealing the abstractor's coding. This patient falls out of the guideline indications for a device. Let's investigate further using our drill down and the companion guide. Looking at the companion guide located under Resources, Documents, page 23, we see that class 1 recommendation number 3 requires both syncope and clinically relevant arrhythmias induced. Our patient is missing clinically relevant arrhythmias induced. Let's look further. We see that the class 1 recommendation number 4 requires LVEF of less than or equal to 35% due to myocardial infarction more than 40 days ago and NYHA of 2 or 3. Our patient has an NYHA of 1. Let's look further. As we continue to look, we see that the class 1 recommendation number 6 requires LVEF of less than or equal to 30% due to myocardial infarction greater than 40 days ago and NYHA of 1. Our patient has LVEF of 35%. When the patient does not meet a guideline indication, please continue to review the patient's data in the appropriate use criteria metrics as the AUC does address gaps in the guidelines. Under Resources, you'll find a companion guide specific to each registry as well as information related to guideline or AUC documents pertinent to each metric. This concludes Lesson 4 of 4. Now, thank you for your participation.

ACC AHA HRS guideline

ventricular arrhythmias

ICDs

arrhythmias

patient data