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The Society of Thoracic Surgeons Frequently Asked Questions: Adult
Cardiac Surgery Database Version 2.52.1 August, 2006 How to use the interactive FAQ Document: 1. To
review all clinical questions in an individual section, click on the section
title below. |
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Section F:
seq# 750-870 |
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2.
To review an individual Seq# clinical question, click on the Seq# title
below. 1280 OpCAB
3090-3180 Section R. 3. CC/TM: Corrections/Clarifications to Training
Manual |
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NEW |
Date |
SeqNo |
FieldName |
Definition |
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750 |
MI |
Indicate whether the patient has a
history of an MI. For MI
occurrence prior to current hospitalization, one of the following is
necessary: 1. MI
documented in the medical record. OR 2. EKG
Documented Q wave. Q waves to be 0.03
seconds in width and/or > or = one third of the total QRS complex in two
or more contiguous leads. For MI
occurrence during current hospitalization, two of the following three
criteria are necessary: 1.
Ischemic symptoms in the presence or absence of chest discomfort. Ischemic symptoms may include: a)
chest, epigastric, arm, wrist or jaw discomfort with exertion or at rest; b)
unexplained nausea and vomiting; c)
persistent shortness of breath secondary to left ventricular failure; d)
unexplained weakness, dizziness, lightheadedness, diaphoresis or syncope. 2.
Enzyme level elevation. One of the
following four are necessary: a)
CK-MB: -Maximal
value of CK-MB > 2 x the upper limit of normal on one occasion during the
first hours after the index clinical event OR -Maximal
value of CK-MB, preferable CK-MB mass, > upper limit of normal on two
successive samples; b) CK
> 2x the upper limit of normal; c) LDH
subtype 1 > LDH subtype 2; d)
Maximal concentration of troponin T or I > the MI decision limit on at
least one occasion during the first 24 hours after the index clinical event. 3. Serial ECG (at least two) showing changes
from baseline or serially in ST-T. |
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760 |
MI-When |
Indicate the time period between the last documented myocardial
infarction and surgery. |
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8/04 |
The timing to the MI is in question. Is it the time from onset of
patient symptoms (if known) or is it documented time of ECG or cardiac
enzymes? |
As indicated in the definition:
Indicate the time period between the last documented myocardial
infarction and surgery. The key word
in this definition is "documented".
Please code the time based on when the last MI, prior to surgery, was
documented. |
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770 |
Congestive Heart Failure |
Indicate whether, within 2 weeks prior
to the initial surgical procedure, a physician has diagnosed that the patient is currently in
congestive
heart failure (CHF). CHF
can be diagnosed based on careful history and physical exam, or by one of the following criteria: 1. Paroxysmal nocturnal dyspnea (PND) 2.
Dyspnea on exertion (DOE) due to heart failure 3.
Chest X-Ray (CXR) showing pulmonary congestion 4.
Pedal edema or dyspnea and receiving diuretics or digoxin |
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780 |
Angina |
Indicate whether the patient has ever
had angina pectoris. |
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From version 2.41 |
6/03 |
Is
angina only captured if the patient had pain within 24 of surgical
intervention? |
No,
the intent of this field is to capture those patients that have a history of
angina prior to surgical intervention.
Essentially, if the patient ever
had angina, it should be captured here. |
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8/04 |
If the patient does not have chest pain but has an equivalent (arm
pain, diaphoresis, nausea -- things you have identified w/ MI) do we say
angina = yes. |
Yes, please use anginal equivalents. |
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9/04 |
We have had an unusual number of aortic dissections in the past couple
of weeks. All patients complain of
severe chest pain. Do we consider the
pain that these patients are experiencing angina? The surgeons feel that dissection patients
should be listed as having angina. |
Angina is caused by ischemia.
The pain that these patients are experiencing is caused by ischemia
and truly cardiac in nature. The
dissection creates a disruption of flow to the coronaries/myocardium. Therefore, categorize the experienced pain
as angina. |
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790 |
Angina-Type |
Indicate the type of angina present
prior to this surgical intervention. Stable
= Angina that is controlled by oral and/or transcutaneous medication. Patients that are pain free with or without
medication but with a history of angina are captured here. Unstable
= Angina which necessitates the initiation, continuation or increase of
angina control therapies that may include: nitroglycerin drip, heparin drip,
or IABP placement. The type of angina
may include, but is not limited to: rest angina, new onset exertional angina
of at least New York Heart Association (NYHA) Class III in severity, recent
acceleration in pattern and increase of one NYHA class to at least NYHA Class
III, variant angina, non-Q wave myocardial infarction, or post-infarction
angina. |
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9/04 |
The STS has received
a number of clinical questions regarding seq# 790, Angina - Type. Upon closer inspection of the definition
and the language in the Training Manual, we agree the two contradict each
other. It is important to
note that there is no specific time frame stated in the version 2.52.1
definition for Angina - Type. The
specific time frame of 24 hours has been replaced with
prior to this
surgical intervention. This time
frame change was done intentionally, to allow, when necessary, the clinicians
assessment of the patients clinical presentation prior to the surgical
intervention to play a part in the coding of the Angina Type field. Clinical presentation including, but not
limited to, frequency and intensity of angina, last documented myocardial
infarction, stability or instability of therapies, vital signs, hemodynamic
parameters, skin temperature and color etc.
Clinical presentation
should not be a factor when coding the Angina Type field when the therapies
in question are oral and/or transcutaneous therapies. Proper coding of
Angina-Type is primarily based on whether the therapies to control the angina
frequency and/or intensity (excluding oral and/or transcutaneous therapies)
are stable (unadjusted) or unstable (adjusted) prior to the surgical
procedure. Clinical presentation of
the patient should be taken into consideration when anginal therapies have
been either initiated, continued or increased based on the intensity and/or
frequency of the patients angina prior to the surgical procedure. 1.
Current, version 2.52.1, Angina Type definition: Indicate the type
of angina present prior to this surgical intervention. Stable = Angina that is controlled by oral and/or transcutaneous
medication. Patients that are pain
free with or without
medication but with a history of angina are captured here. Unstable = Angina which necessitates the initiation, continuation
or increase of
angina control therapies that may include: nitroglycerin drip, heparin
drip, or IABP placement. The type of angina may include, but is not limited to:
rest angina, new onset
exertional angina of at least (NYHA) Class
III in severity, recent acceleration in pattern and increase of one NYHA class to
at least NYHA Class III, variant angina, non-Q wave myocardial infarction, or
post-infarction angina. 2.
Rewording the Angina Type definition with examples: Indicate
the type of angina present prior to this surgical intervention. Stable: A.
Patients with a history
of angina that are pain free with or without oral and/or transcutaneous
medication are captured here. B.
Angina which
necessitates the initiation, continuation or increase of oral and/or
transcutaneous medication is captured here.
C.
Patients with a history
of angina that are pain free with or without oral medication but due to poor
coronary anatomy (poor luminal blood flow) treatment therapies that may
include nitroglycerin drip, heparin drip etc. are prophylactically initiated. These patients are considered stable
because therapies were initiated for coronary anatomy reasons, not for
anginal reasons. D.
Angina which
necessitates the initiation and/or
continuation of angina control therapies that may include: nitroglycerin drip, heparin drip or IABP
placement. However, prior to surgical
procedure the patients angina pain is
controlled with these therapies and the therapies are NOT changed AT ALL (no
increase or decrease of the drips) prior to surgical procedure. Examples of stable angina:
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Patient has a past history of chest
pain. Angina has been well controlled
on current oral medications for one year.
Eight hours prior to surgical procedure patient experiences angina
that requires the initiation of nitroglycerin paste. After the initiation of
nitroglycerin paste, patient once again pain free. ·
Patient admitted 72 hours before
surgical procedure with angina. Relief
obtained with nitroglycerin drip. No
additional angina therapies were initialed.
Nitroglycerin was never increased and no attempts to reduce the
anginal control therapy were instituted.
Patient continued to remain pain free until surgery. ·
Patient was admitted 72 hours
before surgical procedure with angina.
Anginal control therapies (nitroglycerin and IABP) were instituted and
relief was obtained. 32 hours before
surgery all control therapies were discontinued. Patient then remains anginal free until
surgery. Unstable: Angina which necessitates the initiation, continuation and/or increase
of angina control therapies that may include: nitroglycerin drip, heparin
drip, or IABP placement. Prior to the
surgical procedure the patients angina pain requires
therapies to be changed (increase of drips and/or changing the ratio of the
IABP) in an attempt to eliminate anginal pain prior to the surgical
procedure. The
type of angina may include, but is not limited to: rest angina, new onset
exertional angina of at least New York Heart Association (NYHA) Class III in
severity, recent acceleration in pattern and increase of one NYHA class to at
least NYHA Class III, variant angina, non-Q wave myocardial infarction, or
post-infarction angina. Examples of unstable
angina: ·
Patient admitted 72 hours before
surgery with angina. Nitroglycerin and
IABP initiated. 48 hours before
surgery remained pain free, and attempts made to reduce NTG drip and/or
augmentation support of the IABP.
Angina returned and prior support was reinstituted. Patient remained pain free until surgery
with no other attempts to wean or reduce anginal support therapies. Code as Unstable because attempts were made
and failed and therapies needed to continue until surgery to maintain angina ·
Patient admitted within 24 hours of
time of surgery with angina. NTG and
Heparin drip initiated and relief was obtained. Patient remained anginal free until surgery
with continuation of therapy. Code as
Unstable because patient required implementation of control therapies within
the immediate hours preceding the surgical procedure. |
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810 |
Cardiogenic Shock |
Indicate whether the patient was, at
the time of procedure, in a clinical state of hypoperfusion according to
either of the following criteria: 1.
Systolic BP < 80 and/or Cardiac Index < 1.8 despite maximal treatment; 2. IV inotropes and/or IABP necessary to
maintain Systolic BP > 80 and/or CI > 1.8. |
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820 |
Cardiogenic Shock Type |
Indicate which of the following types of cardiogenic shock is present?
Select one: Refractory Shock: Systolic BP
< 80 and/or Cardiac Index < 1.8 despite maximal treatment Hemodynamic Instability: IV
inotropes and/or IABP necessary to maintain Systolic BP > 80 and CI >
1.8. |
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830 |
Resuscitation |
Indicate whether the patient required cardiopulmonary resuscitation
within one hour before the start of the operative procedure. |
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840 |
Arrhythmia |
Indicate whether there is a history of
preoperative arrhythmia (sustained ventricular tachycardia, ventricular
fibrillation, atrial fibrillation, atrial flutter, third degree heart block)
that has been clinically documented or treated with any of the following
treatment modalities: 1.
ablation therapy 2. AICD 3.
pacemaker 4.
pharmacological treatment 5.
electrocardioversion |
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From version 2.41 |
11/04 |
Pt has a history of A-fib and is
being treated with Amniodarone. If,
within two weeks of surgery, the patient does not have break through A-fib
would we still code yes to seq# 840? |
Yes. If the patient is being treated for an
arrhythmia but the patient does not experience the treated arrhythmia within
two weeks of surgery you would still code yes. Think of arrhythmias as you would
diabetes. Just because the patient is
being treated with insulin and thus has more normal blood sugars does not
mean that the patient no longer has the disease of diabetes. Rather the patient is successfully being
treated for diabetes. Similarly, if a
patient is being treated for an arrhythmia and does not have a breakthrough
arrhythmia within two weeks of surgery; you would still consider the patient
to have a history of the arrhythmia and thus would code yes. To define treated for an
arrhythmia: a patient is considered
being treated for an arrhythmia if they are on medication specifically to
treat an arrhythmia. Today, most
arrhythmias are treated with antiarrhythmics.
Coumadin would not be considered a treatment for A-fib. Rather, patients may be on Coumadin to
treat potential complications of the arrhythmia but not to treat the
arrhythmia. Patients may or may not be
on Digoxin to treat arrhythmias. In
the past Digoxin was used to treat A-fib, but patients can also be on Digoxin
to decrease the O2 demands on the heart, increase contractility etc. Therefore, do not assume that all patients
that are on Digoxin are being treated for A-fib. Amniodarone and other antiarrhythmic
medications are used to treat for A-fib and other arrhythmias. These antiarrhythmics should be recognized
as such as compared to Digoxin and anticoagulants. As an addendum: Patient with history of A-fib being
treated with Amniodarone, no A-fib two weeks prior to surgery -- in the
post-op period converts to A-fib. For
this patient do not capture seq# 2990, Complication A-fib, since the A-fib
would not be a new onset of A-fib. |
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850 |
Arrhythmia Type |
Indicate which arrhythmia is present within two weeks of the procedure;
choose one: -Sustained Ventricular Tachycardia or Ventricular Fibrillation
requiring cardioversion and/or IV amiodarone. -Third degree heart block. -Atrial fibrillation/flutter requiring Rx -None |
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4/05 |
If
the patient has |
Please
code Seq# 840 Arrhyth=No as it is the parent field to Seq# 850 ArrhyTyp.
Supraventricular Tachycardia is a different arrhythmia than ventricular
tachycardia. SVT is not currently captured under any arrhythmias listed in
Seq# 850. Will consider adding it in the next upgrade. The STS is currently
interested only in the specific arrhythmias listed in Seq# 850 ArrhyT because
of the significant risks posed to the patient. |
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From version 2.41 |
9/03 |
Regarding pre-op arrhythmia within 2 weeks of the procedure: Atrial
Fibrillation requiring treatment. Does this include a chronic A Fib in which
admission EKG strip shows the A Fib pattern and the patient is on Coumadin
and Cordarone at home or is this only meant to identify (in the case of a
chronic condition) a patient that has an uncontrolled A Fib in which a change
in medication was necessary in the two weeks before surgery? |
The intent is to capture a pre-op arrhythmia that is present within
two weeks of the procedure, whether chronic, new onset, stable,
unstable. In both of your examples, A
Fib is present within two weeks of procedure, thus would be coded as
"yes". |
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NEW! |
Preoperative Cardiac Status |
Third Degree Heart Block is
Complete Heart Block and should be coded as such. When the patient has a history of
arrhythmia for example Atrial Fibrillation greater that 2 weeks prior to
admission and is currently is sinus rhythm; Arrhythmia would be coded yes and
type would be none. Any change would
happen with changes in the data specifications. |
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870 |
Classification-NYHA |
Indicate the I = Patients with cardiac
disease but without resulting limitation of physical activity. Ordinary
physical activity does not cause undue fatigue, palpitation, dyspnea, or
anginal pain. II = Patients with cardiac disease
resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in
fatigue, palpitations, dyspnea, or anginal pain. III = Patients with cardiac
disease resulting in marked limitation of physical activity. They are
comfortable at rest. Less than
ordinary physical activity results in fatigue, palpitations, dyspnea, or
anginal pain. IV = Patients with cardiac
disease resulting in inability to carry on physical activity without
discomfort. Symptoms of cardiac
insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken,
discomfort is increased. |
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4/05 |
Patient is admitted with unstable
angina and chest pain at rest. I have been coding these types of
patients as a Class IV NYHA. However, most of these patients do
not have any symptoms of Heart Failure, just angina/chest pain.
Should I be coding them based on angina alone with no heart failure
symptoms? |
NYHA is for either CHF or angina or both. If your
patient just has angina code the patient's functional class as it is affected
by the angina only. Example: Minimal exertion such as walking and gardening results in
patient experiencing angina = Class III. One day, while gardening,
patient experiences chest pain that results in a trip to the hospital.
While in the ambulance the patient is experiencing pain at rest.
This pain at rest however, does not represent the overall functional class
that led to hospitalization. The minimal exertion such as walking and
gardening, Class III, represents the overall and highest functional class
that lead to hospitalization. The patient's activity initiated the
angina at rest, angina was not initially occurring at rest. |
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2/04 |
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Section G Preoperative
Medications |
Although the following text is not
included in each of the preoperative medication definitions, the following
does apply to each of the preoperative medications definitions in section
G, seq# 890-1040: Medications are time sensitive and
should reflect currently prescribed medications. Intent is to capture relevant current or
long-term pharmacological disease management as close to the surgical
procedure as possible. This does not include one time administration
of medications due to pathway guidelines or procedural preparation.
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2/04 |
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Section G Preoperative
Medications |
In regards for coding pre-operative medications: Patient is in the OR, anesthesia induction
in progress, no incision yet - is this still "prior to surgery or does
"surgery" begin when the patient rolls through the OR doors or when
induction starts? Basically, if the patient is receiving their first dose of a
medication in the OR, can we count this as pre-op medication? |
Pre-op", "intra-op" and "post-op" defined
according to the STS AC Database. Pre-op: time period prior to
the OR until the patient enters the OR Inta-op: from the time the
patient enter the OR until the patient exits the OR Post-op: from the time the
patient exits the OR until the patient leaves the hospital To answer your question, if a medication was given for the first time
while the patient was in the OR, (defined above as intra-op) do not code as
pre-op medication. |
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