Tuesday, October 31, 2017

New Classification of Ischemic Heart Disease( IHD)

The  definitions of disease have been updated about once every five years, so a revision this year would be timely. Presumably, new definitions will separate out at least some MINOCA.
What is the origin of these new terms: myocardial infarction with non-obstructive coronary arteries (MINOCA) and ischemia and no obstructive coronary artery disease (INOCA)?
It has been common for cardiologists to describe patients with chest pain and abnormal stress tests, but mild or no CAD on catheterization, as “false positives.” However, studies have long shown that such patients have a worse prognosis than patients with normal stress tests. In recognition of this fact, these patients have now been designated as “INOCA.”
 MINOCA patients have been particularly common with the advent of sensitive troponin testing. For the most part, cardiologists have done reasonably well in identifying the causes of the troponin elevations, though many cases have remained troubling, and some have still been written off as false positives. The term itself was coined in 2013.
It often applies to type 2 MI. What are the causes of MINOCA and INOCA? Generally speaking, INOCA is associated with conventional cardiac risk factors such as hypertension, hyperlipidemia, and obesity. It is much more common in women. Underlying mechanisms may involve decreased coronary flow reserve and elevated platelet reactivity. Coronary intravascular ultrasound can reveal more extensive atherosclerosis than is appreciated on angiography, due to positive remodeling. This may indicate a diffuse inflammatory state in the vessels.

 MINOCA encompasses a heterogeneous group of issues, including: Plaque rupture without severe obstruction, but with resultant vasospasm, microscopic thromboembolism, or thrombosis with spontaneous thrombolysis. Technically a type 1 MI Vasospasm without plaque rupture Thromboembolism due to thrombophilic state Coronary dissection, if not visible on angiography Takotsubo (stress) cardiomyopathy Type 2 MI with other primary diagnosis (e.g. sepsis, hypertensive crisis, arrhythmia, severe valvular disease) Pulmonary embolism and myocarditis can cause this picture, but are not considered to produce myocardial infarction. In this context, what do coders and clinical documentation integrity specialists need to know about MINOCA and INOCA – and when? These diagnoses only come into consideration after cardiac catheterization (and perhaps infrequently after coronary CT) since they require objective evidence of non-obstructive CAD. Thus, catheterizations that do not result in percutaneous intervention or CABG should be scrutinized.

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