Transcript 280208

Complex Cardiac Diagnoses Often
Missed
Sandra M. Miller, MD
Independent Consultant
Palm Beach Gardens, FL
Objectives
• The participant will be able to:
– Indentify the types of acute coronary
syndromes
– Identify common complications of acute
myocardial infarction
– Identify clues in the medical record
– Identify evidence in the medical record
– Generate evidence-based query
Acute Coronary Syndrome
• What does it mean?
• To physicians and clinicians:
– 411.1, Unstable angina
– 410.7, Non-ST-segment elevation MI
(NSTEMI)
– 410.xx, ST-segment elevation MI (STEMI)
• To coders:
– 411.89, Other acute and subacute form of
ischemic heart disease
Definitions
• Unstable angina
– Rest angina usually > 20 minutes
– New-onset exertional angina
– Preexisting angina with increase in frequency,
duration, or with less than usual exertion
Definitions
• Non-ST-segment elevation MI
– Similar to unstable angina BUT may have
elevated cardiac enzymes, and/or EKG
changes:
• ST-segment depression
• T-wave inversions
• Other nonspecific ST-T wave changes
Definitions
• STEMI:
– Elevated cardiac enzymes
– ST-segment elevation on EKG
– New or presumed new left bundle branch
block (LBBB)
STEMI EKG
Actual patient EKG
Common Complications of
Myocardial Infarction
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Bradyarrhythmias
Bundle branch blocks
Ventricular tachycardia
Right ventricular infarct
Pericarditis
Cardiac Conduction System
Source: Wikipedia Commons - http://en.wikipedia.org/wiki/File:ConductionsystemoftheheartwithouttheHeart.png
Bradyarrhythmias
• Second-degree heart blocks
– Mobitz type I (Wenckebach)
• AV nodal block
• Progressive P-R prolongation prior to block of
atrioventricular impulse
• Frequently within first 24–48 hours of MI
• Usually seen with inferior wall MI
Mobitz I (Wenckebach)
Actual patient tracing
Bradyarrhythmias
• Mobitz type II
– Infranodal
– Conduction fails suddenly and unexpectedly
– No preceding P-R interval change
– Usually with anterior wall MI
– Can progress to complete heart block
– May need temporary pacemaker
Mobitz Type II
Note p-r interval remains constant with dropped ventricular beat
Actual patient tracing
Bradyarrhythmias
• Third degree
– Complete heart block
– Can be seen with anterior or inferior wall MI
– No P-wave associations
– Needs permanent pacemaker if anterior wall
– May resolve if inferior wall
Complete Heart Block
Note lack of relationship of p waves to ventricular contractions.
Actual patient tracing
Bundle Branch Blocks
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Associated with higher mortality
Bifascicular or trifascicular
Left or right
Associated with anterior wall MI within the first
24–48 hours
• Temporary pacemaker may be indicated if
bundle branch blocks are alternating between
left and right
Bundle Branch Blocks
Source: Wikipedia Commons - http://en.wikipedia.org/wiki/File:Right_bundle_branch_block_ECG_characteristics.png and
http://en.wikipedia.org/wiki/File:Left_bundle_branch_block_ECG_characteristics.png
Ventricular Tachycardia
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Can occur with any myocardial infarction
Most commonly with anterior wall
May be transient within the first 48 hours
Late VT may indicate ongoing ischemia
Most ventricular fibrillation occurs within the first
48 hours
Right Ventricular Infarct
• Inferior wall
• ST-segment elevation in V4, seen with rightsided lead placement
• Classic triad
– Increased jugular venous pressure
– Clear lungs
– Hypotension
Pericarditis
• Anterior or inferior wall MI
• 2–14 days after MI
• Diffuse ST-segment elevation and P-R
depression
• Pericardial friction rub in 85%*
• Dressler’s syndrome
– Occurs weeks to months after MI
– Consists of fever, malaise, serositis,
pulmonary infiltrates and pleural effusion in
addition to pericardial effusion
Pericarditis
Cardiogenic Shock
• Clinical presentation
– Hypotension
– Tachycardia
– Peripheral hypoperfusion
– Oliguria
– Encephalopathy
• Definition of shock
– Inadequate end-organ perfusion
Cardiogenic Shock
• Leading cause of death in patients hospitalized with
MI
• Typically associated with STEMI
• Left ventricular failure is the most frequent cause of
cardiogenic shock
• Factors associated with increased risk of CS with
acute MI
– Older age
– Female
– Prior MI
– Diabetes
– Anterior MI location
Cardiac Tamponade
• Occurs in 15% of acute pericarditis cases
• Occurs when pericardial fluid increases
intrapericardial pressures, and that exceeds
intracardiac pressures
• Results in compression of the cardiac chambers
– Limits diastolic filling
– Results in decreased:
• Stroke volume
• Cardiac output
• Systemic blood pressure and elevated venous
pressures
Cor Pulmonale
• Enlargement of the right ventricle secondary to
abnormalities of the lungs, thorax, pulmonary
ventilation, or circulation
• Can result in right heart failure
• EKG shows P pulmonale, RV hypertrophy, and
right axis deviation
• Common underlying causes:
– COPD
– Pulmonary embolism
– Pulmonary interstitial fibrosis
Cor Pulmonale
P pulmonale seen in leads II, III and aVF
(copy of actual patient EKG)
General Query Tips
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Review record for evidence
Identify key clinical information
Include specific information in query
Make the clinical case to support your question
Remember:
– Non-leading
– Nonthreatening
– Professional
Case Study
• 57-year-old male presented to the ED with chest
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pain radiating to the neck. His history is
significant for CAD, s/p DES to RCA, and
hypertension.
Vitals are stable.
EKG shows normal sinus rhythm, rate 86 and
nonspecific ST-T wave changes.
Initial troponin is elevated.
What are the questions you should be thinking
about?
Thought Process
• Detailed description of the characteristics of the
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chest pain
Changes in pattern or intensity
Prior EKG for comparison
Troponin trend
Treatment and response to treatment
Physician documents “acute coronary
syndrome, admit to telemetry”
What Could It Be?
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Stable angina
Unstable angina
NSTEMI
Noncardiac chest pain
• Look for the clues needed to develop the
question to the physician for clarification of the
diagnosis.
Questions?
In order to receive your continuing education certificate for
this program, you must complete the online evaluation which
can be found in the continuing education section at the front
of the workbook.