Elective Cardiac Catheterization Preauthorization

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PO Box 80 / Buffalo, New York 14240-0080

STAT Bulletin

June 15, 2009

Volume 7:Issue 17

________

To: All Cardiologists

Contracts Affected: All Lines of Business

Elective Cardiac Catheterization Preauthorization

There have been remarkable advancements in primary and secondary prevention for the medical

management of coronary artery disease. An evaluation into the use of interventional cardiac

procedures in our service area does not show a widespread adaptation of these advancements.

To ensure the highest quality treatment in a cost-effective manner, HealthNow New York is

implementing a preauthorization program to screen for the medical indications for elective

cardiac catheterization for procedures scheduled on or after July 15, 2009.

Licensed criteria from InterQual

®

(a McKesson company product) will be used for

preauthorization for the Current Procedural Terminology (CPT) codes listed below. InterQual's

criteria, based on a thorough and up-to-date review of medical literature, reflects current national

standards:

93510 93511 93514 93539 93545 93555 93556

While we recognize the additional work this may create for your office, we will work closely

with you to make the process as efficient as possible. Please familiarize yourself with the

InterQual criteria, which is available on our web site. Incorporating the latest standards of care

will help to achieve more favorable outcomes for your patients, our members.

To obtain prior authorization, please fax your request, along with an InterQual

®

Smart Sheet

™

(available on our secure provider web site), to our Use Management Department

at 1-716-887-7913 and include the following information:

• Member’s name, DOB (date of birth) and ID number

• Diagnosis code

• CPT code

• Date of service

• Facility name

• Requesting MD name

• Tax ID number

• Office phone number

• Office fax number

• Clinical documentation for medical necessity review

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ICD-9-CM:

37.22, 88.50, 88.55, 88.56, 88.57

CPT:

93510, 93511, 93514, 93539, 93545, 93555, 93556

INDICATIONS (choose one and see below)

100 Severe cardiac ischemia by stress test

200 Unstable angina

300 Postinfarction angina/ischemia

400 Post PCI

500 CAD evaluation prior to major surgery

600 Ventricular arrhythmia

700 New onset acute CHF by PE/CXR

800 Acute MI

♦

900 Newly discovered LV systolic dysfunction with EF ≤ 40%

1000 Canadian Class II angina/NYHA Class II CHF

1100 Valvular heart disease

1200 Congenital heart disease

1300 Constrictive pericarditis

Indication Not Listed (Provide clinical justification below)

Angiogram, Coronary (Left Heart Catheterization)

PATIENT:

Name

D.O.B.

ID#

GROUP#

CPT/ICD:

Code

Facility

Service Date

PROVIDER:

Name

ID#

Phone#

Signature

Date

100 Severe cardiac ischemia by stress test(2)(3)

200 Unstable angina (ONE)(4)(5)

210 Continued symptoms despite maximal medical Rx(6) 220 Troponin test positive(7)

230 New/worsening ST depression ≥ 1 mm 240 New/worsening CHF/MR(8)

250 Decreased LV function(9) 260 Hemodynamic instability 270 Sustained (> 30 secs) V tach 280 Prior revascularization (ONE)

281 PCI w/in prior 6 mos(10) 282 CABG(11)

290 Prior positive stress test(12)

InterQual® criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determination concerning the type or level of medical care provided, or proposed to be provided, to the patient.

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300 Postinfarction angina/ischemia (ONE)(13)(14) 310 During MI hospitalization (ONE)

311 Angina/anginal equivalent

312 New/worsening ST elevation/depression ≥ 1 mm 313 Elevated troponin/cardiac enzymes

314 Cardiogenic shock 315 New/worsening CHF

316 Ventricular arrhythmia and nonischemic etiologies excluded(15) 317 By predischarge modified stress test (ONE)(16)

-1 Symptoms of angina/anginal equivalent -2 ST depression ≥ 1 mm

-3 Systolic BP decrease ≥ 10 mmHg during exercise -4 V tach

320 Positive stress test at 6 wks post MI(12) 330 Angina/anginal equivalent w/in 6 wks of MI

340 CHF at rest/with minimal exertion w/in 6 wks of MI(17)

400 Post PCI (ALL)(18)(19) 410 Sx/findings (ONE)

411 Unstable angina(4)(20)

412 Change in angina pattern and positive ETT(21)

413 Symptomatic ischemia in vascular distribution of prior procedure by nuclear test/ETT 420 PCI w/in prior 6 mos(22)

430 Repeat PCI planned in conjunction with angiogram(23)

500 CAD evaluation prior to major surgery (ONE)(24)(25) 510 Severe cardiac ischemia by stress test(3)

520 Mild/moderate cardiac ischemia by stress test (BOTH)(26) 521 Beta blocker Rx (ONE)(27)(28)

-1 Continued Sx/findings after Rx -2 Contraindicated/not tolerated(29) 522 Findings (ONE)

-1 EF ≤ 40% by TTE/TEE/RVG -2 NYHA Class III CHF(30) -3 Canadian Class III angina(31) 530 AS by TEE/TTE with AVA < 1.0 cm2(32) 600 Ventricular arrhythmia (ONE)

610 Cardiac arrest survivor w/o concomitant acute MI(33)(34)

620 Sustained (> 30 secs) V tach by ambulatory electrocardiography/ECG/ETT/EP testing(35) 630 Nonsustained (≤ 30 secs) V tach (BOTH)

631 Diagnosed by ambulatory electrocardiography/ECG/ETT/EP testing 632 CAD/SHD (ONE)

-1 Positive stress test(12)

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Patient Name

ID #

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-2 CAD by Hx(36)

-3 SHD by TTE/TEE (ONE)(37) A) EF ≤ 40% by TTE/TEE/RVG B) Valvular heart disease (ONE)(38)

1) AS

2) MS < 1.5 cm2 3) MR 3+/4+ 4) AR 3+/4+

C) Congenital heart disease (ONE) 1) VSD with shunt ≥ 1.5:1 2) ASD with shunt ≥ 1.5:1

700 New onset acute CHF by PE/CXR (ONE)(17)(39)(40)

710 Systolic dysfunction with EF ≤ 40% by TEE/TTE/RVG(41) 720 Diastolic dysfunction (BOTH)(42)

721 EF > 40% by TEE/TTE/RVG 722 LVH by ECG/TEE/TTE(43) 730 Valvular heart disease by TEE/TTE(44) 740 Positive stress test(12)

800 Acute MI

♦

(ONE)

810 Within 12 hrs of chest pain onset(45) 820 Cardiogenic shock(46)

830 Severe CHF/pulmonary edema(17)(8) 840 Hemodynamic instability

850 Ventricular arrhythmia(15) 860 Failed fibrinolysis (ONE)(47)

861 Continued/worsening symptoms(48) 862 Continued/worsening ECG findings 870 Mechanical complications (ONE)

871 Papillary muscle rupture (ONE)(49) -1 By TEE/TTE

-2 By right heart catheterization(50) 872 Postinfarction VSD (ONE)(51)

-1 By TEE/TTE

-2 By right heart catheterization(50)

900 Newly discovered LV systolic dysfunction with EF ≤ 40% (ALL) 910 Diagnosed by RVG/TEE/TTE

920 No valvular heart disease(44)

930 Positive stress test(12)

1000 Canadian Class II angina/NYHA Class II CHF (BOTH)(52)(53) 1010 Positive stress test(12)

(5)

1020 Unresponsive to maximally tolerated medical Rx(6)(54)

1100 Valvular heart disease (BOTH)(44)(55)

1110 Planned with right heart catheterization(56) 1120 Findings (ONE)

1121 Positive stress test(12) 1122 CAD by Hx(36)

1123 EF ≤ 40% by TEE/TTE/RVG 1124 Age ≥ 35(57)

1200 Congenital heart disease (BOTH)(58)

1210 Planned with right heart catheterization(59)(60)

1220 Findings (ONE)

1221 Positive stress test(12) 1222 CAD by Hx(36)

1300 Constrictive pericarditis (BOTH)(61)(62) 1310 Planned with right heart catheterization(63) 1320 Findings (ONE)

1321 CAD by Hx(36)

Notes

( 1) If there is no plan for revascularization were a lesion to be discovered, secondary medical review is required.

( 2) _{These criteria address ischemia that is severe enough to warrant an angiogram, independent of clinical findings. A stress test with lesser} degrees of ischemia must be interpreted in light of the patient's entire clinical picture. For example, inadequate oxygen carrying capacity from anemia (e.g., hematocrit < 27) can cause ischemia without significant CAD. An angiogram is indicated only if severe ischemia is still provoked after the anemia is corrected.

( 3) Severe cardiac ischemia by stress test is defined by one of the following:

• ETT with horizontal ST segment depression ≥ 2 mm by ECG in two contiguous leads, chest pain within the first 3 minutes, systolic BP decrease of ≥ 10 mmHg within the first 3 minutes, or ventricular tachycardia (these changes may also be seen on nuclear stress or stress echo)

• Nuclear stress test, Persantine nuclear stress test, or dobutamine nuclear stress test with ≥ 2 reversible defects, or a single reversible defect consistent with a LAD lesion

• Nuclear stress test with lung uptake of thallium

• Stress echo or dobutamine echo with ≥ 2 areas of reduced or worsened wall contractility, left ventricle dilation during testing, decreasing EF during testing, or a single area of reduced wall contractility consistent with a LAD lesion

• Decreasing left ventricular function by exercise RVG

( 4) When provoked on minimal exertion or at rest, angina is deemed "unstable" (Canadian Class III/IV or preinfarction angina). Rapidly increasing frequency, duration, or severity of angina is also unstable and warrants investigation.

( 5) _{Unstable angina belongs in the category of cardiac conditions known as acute coronary syndrome (ACS). ACS refers to a group of clinical} symptoms associated with acute myocardial ischemia, ranging from unstable angina to acute MI (Becker, Clin Cardiol 2004; 27(3): 119−120; Braunwald et al., J Am Coll Cardiol 2002; 40(7): 1366−1374). Mechanisms for unstable angina include plaque rupture, thrombus embolization, or vasospasm. Management of unstable angina is aimed at aggressive medical therapy, noninvasive testing to determine risk stratification, and assessment of the necessity for cardiac catheterization and myocardial revascularization. In patients with high−risk features such as multiple

Angiogram, Coronary (Left Heart Catheterization)

Patient Name

ID #

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cardiac risk factors or more than 2 episodes of angina at rest within 24 hours, myocardial revascularization is associated with improved clinical outcomes (Anderson et al., J Am Coll Cardiol 2007; 50(7): e1−e157; Bhatt et al., JAMA 2004; 292(17): 2096−2104; Yeghiazarians et al., N Engl J Med 2000; 342(2): 101−114).

( 6) Medical treatment for angina is designed to lower myocardial oxygen demand (e.g., beta blockers, calcium channel blockers), increase coronary blood flow (e.g., nitrates, calcium channel blockers), and stabilize plaques (e.g., statins, antiplatelet agents). Antianginal drugs have

complementary mechanisms of action so are often used in combination.

( 7) According to the American College of Cardiology (ACC) and European Society of Cardiology (ESC), cardiac troponins are highly specific indicators of MI. Approximately 1/3 of patients with unstable angina are considered to have myocardial damage based on a positive troponin test (Antman, N Engl J Med 2002; 346(26): 2079−2082; Ferguson et al., Heart 2002; 88(4): 343−347).

( 8) Heart failure or pulmonary edema may present in a patient with an acute coronary occlusion causing decreased ventricular function and leading to acute pulmonary venous hypertension and intravascular fluid overload. The etiology of the heart failure should be determined and when indicated, coronary angiography and revascularization based on coronary anatomy should be performed to mitigate the high 30 day mortality rate associated with this complication (Antman et al., J Am Coll Cardiol 2004; 44(3): E1−E211).

( 9) For the purposes of these criteria, an EF of < 40% by noninvasive testing would place the patient in the high risk category to warrant coronary angiography (Braunwald et al., J Am Coll Cardiol 2002; 40(7): 1366−1374).

( 10) In−stent restenosis of the culprit vessel is frequently seen at 6 months and is caused by an increased production of cellular material within the stent. Earlier or abrupt stenosis is generally due to thrombosis.

( 11) Ischemia can develop at any time after CABG and can be classified as early or late. Early ischemia, within 30 days of surgery, may be due to thrombosis in either the vein graft or the arterial conduit, technical inadequacy of an anastomosis, or incomplete revascularization. At

1 to 12 months, stenosis commonly occurs around the anastomosis site. Late ischemia, more than a year after CABG, can be caused from new stenosis in either the grafted or native vessels. More than 3 years post procedure the cause of the ischemia is generally progressive

atherosclerotic plaque (Smith et al., Circulation 2006; 113(7): e166−286).

( 12) A positive stress test includes findings of ischemia or prior infarct. For this criterion, the definition of a positive stress test is used primarily as an historical factor. The severity of the cardiac ischemia defines the necessity of specific diagnostic or therapeutic actions.

A positive stress test is defined by one of the following:

• ETT with horizontal ST segment depression ≥ 1 mm by ECG in two contiguous leads, chest pain or a systolic BP decrease of ≥ 10 mmHg during exercise, PVCs, or ventricular tachycardia (these changes may also be seen on nuclear stress or stress echo)

• Nuclear stress test, Persantine nuclear stress test, or dobutamine nuclear stress test with ≥ 1 reversible defect

• Stress echo or dobutamine echo with ≥ 1 area of reduced or worsened wall contractility, left ventricle dilation during testing, or decreasing EF during testing

( 13) Def: Angina pectoris is defined as discomfort in the chest or adjacent areas associated with myocardial ischemia. Symptoms of angina may vary from patient to patient and include sensations of pain, choking, pressure, squeezing, tightness, heaviness, or burning, classically involving the chest with radiation to the left arm. Isolated shoulder, back, neck, and jaw complaints can also be described.

( 14) Since as many as 1/3 of patients with acute MI do not have classic symptoms of chest pain, it is important to consider atypical angina (also known as an anginal equivalent) when evaluating a patient with risk factors or a history of CAD (Canto et al., JAMA 2000; 283(24): 3223−3229). While men typically present with chest pain and diaphoresis, women and the elderly often exhibit atypical symptoms such as dyspnea, jaw pain, and nausea with vomiting (Patel et al., Am Heart J 2004; 148(1): 27−33; Pfisterer et al., JAMA 2003; 289(9): 1117−1123; Canto et al.,

Am J Cardiol 2002; 90(3): 248−253).

( 15) Ventricular tachyarrhythmias, atrial arrhythmias, and bradyarrhythmias are commonly seen early after acute MI. A variety of mechanisms have been postulated as the cause of these electrical abnormalities. Electrolyte imbalance, adrenergic nervous system excitement, pH imbalance, and electrophysiological changes within the heart may be contributory. Currently, no single intervention has proven effective in decreasing the incidence of arrhythmia in patients with an acute MI but proactive management of life−threatening rhythms (e.g., polymorphic VT) can reduce myocardial ischemia and adrenergic stimulation. Therapies available to achieve this outcome include the use of beta blockers, an intra−aortic balloon pump, and emergency PCI or CABG (Antman et al., J Am Coll Cardiol 2004; 44(3): E1−E211).

( 16) _{Def: A modified ECG stress test is a specific stress test protocol, generally performed in the early post−MI period (during the admission) to} identify the high risk patients immediately post−MI who should proceed to coronary angiography.

( 17) _{Def: Congestive heart failure (CHF) is a clinical syndrome marked by passive congestion of the pulmonary (venous) vasculature. This results} from systolic or diastolic dysfunction. Left−sided heart failure is most common, causing dyspnea with or without exertion, paroxysmal nocturnal dyspnea, and orthopnea. Right−sided heart failure most commonly is a result of left ventricular failure, but may also occur secondary to chronic pulmonary disease. Findings associated with right heart failure include peripheral edema and hepatomegaly. Risk factors for CHF include CAD, HTN, cigarette smoking, LVH, valvular heart disease, and DM (Haider et al., Ann Intern Med 2003; 138(1): 10−16).

( 18) Def: Percutaneous coronary intervention (PCI) is the opening of a stenosed coronary vessel by means of balloon angioplasty, stent insertion, atherectomy, or combination thereof.

( 19) Restenosis occurs in 30% to 40% of patients within 6 months after angioplasty, and in 20% to 30% of patients after stenting with bare metal stents. Restenosis of a stent is referred to as in−stent restenosis and has been difficult to treat, with a 60% restenosis rate (Sapirstein et al., N Engl J Med 2001; 344(4): 297−299). Intracoronary radiotherapy is a safe and effective treatment for in−stent restenosis, and significantly reduces the rate of recurrence (Waksman et al., Circulation 2003; 107(13): 1744−1749; Teirstein and Reilly, J Invasive Cardiol 2002; 14(3): 109−114.).

( 20) Canadian Class III/IV angina:

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precipitates symptoms.

IV. Inability to carry on any physical activity without discomfort. Anginal syndrome may be present at rest.

( 21) The change in angina pattern can be increased frequency or duration of symptoms, or the development of new symptoms.

( 22) Drug−eluting stents (DES) continue to show positive outcomes in controlled trials. TAXUS and SIRIUS trials both assessed single vessel lesions of intermediate length. Overall DES restenosis rates are ≤ 4.9% compared to bare metal stents (>15%). In the diabetic patient, the DES restenosis rate is ≤ 6.9% versus 15% to 20% in the bare metal stent (Holmes et al., Circulation 2004; 109(5): 634−640; Stone et al., Circulation 2004; 109(16): 1942−1947). Evidence is limited in the treatment of the complex patient (i.e., 2 or 3 vessel disease, bifurcation disease, left main lesions, long lesions). In the TAXUS VI trial, long complex coronary artery lesions were treated successfully and demonstrated a 53% reduction in subsequent revascularization procedures when compared to bare metal stents. In−stent stenosis (e.g., > 50%) was also lower by 72% in the TAXUS group. The study provides evidence that DES can be used safely and effectively in the treatment of long lesions in selected patients (Dawkins et al., Circulation 2005; 112(21): 3306−3313).

( 23) It has become increasingly common that a diagnostic coronary angiogram be followed immediately by PCI. Studies have not provided conclusive evidence that this is the best strategy for all patients. The current practice guidelines for PCI written by the American College of Cardiology, American Heart Association, and the Society for Cardiovascular Angiography and Interventions state that in selected patients with restenosis 6 to 12 months after the procedure, those with single vessel disease, patients having PCI for MI, or patients with unstable angina unresponsive to pharmacological therapy can be considered for the combined procedures. Patients who have diagnostic angiogram and PCI on separate days may have a better understanding of the risks, benefits, and options for treating their CAD (King et al., J Am Coll Cardiol 2008; 51 (2): 172−209; Smith et al., Circulation 2006; 113(7): e166−286).

( 24) _{Def: Major surgery is defined as a major vascular procedure (e.g., AAA repair, thoracic aneurysm repair, a proximal intra−abdominal procedure,} or a suprainguinal procedure), peripheral vascular surgery, thoracic surgery, lengthy abdominal surgery, or abdominal surgery with large fluid requirements.

( 25) Aggressive preoperative coronary evaluation is not indicated in a patient with stable CAD undergoing non−cardiac surgery (Eagle et al., Circulation 2002; 105(10): 1257−1267; Fleisher and Eagle, N Engl J Med 2001; 345(23): 1677−1682). However, these patients should be considered for pre−operative exercise or pharmacological stress testing to determine if myocardial ischemia is present or to evaluate the effectiveness of medical therapy (Eagle et al., Circulation 2002; 105(10): 1257−1267).

( 26) Mild to moderate cardiac ischemia by stress test is defined by one of the following:

• ETT with horizontal ST segment depression ≥ 1 mm by ECG in two contiguous leads, chest pain after the first 3 minutes during exercise, or systolic BP decrease of ≥ 10 mmHg after the first 3 minutes during exercise, (these changes may also be seen on nuclear stress or stress echo)

• Nuclear stress test, Persantine nuclear stress test, or dobutamine nuclear stress test with one reversible defect (not suggestive of an LAD lesion)

• Stress echo or dobutamine echo with one area of reduced or worsened wall contractility (not suggestive of an LAD lesion) ( 27) If the patient has only mild to moderate ischemia by stress test, treatment with a beta blocker (e.g., bisoprolol, metoprolol), initiated at least

several days prior to elective surgery, is indicated (unless contraindicated or not tolerated) (Eagle et al., Circulation 2002; 105(10): 1257−1267). If the patient remains symptomatic on beta blocker therapy, coronary angiogram is indicated.

( 28) A randomized controlled trial compared medical management and coronary artery revascularization prior to vascular surgery in patients at risk for CAD or with stable cardiac symptoms. Patients who received beta blockers had a significant reduction in perioperative ischemia and a lower mortality rate than those patients who were revascularized (McFalls et al., N Engl J Med 2004; 351(27): 2795−2804).

( 29) Beta blockers are generally well tolerated but can promote bronchospasm in patients with severe asthma and can adversely affect lipid profiles by decreasing HDL and increasing triglyceride levels. Diabetics often benefit from beta blockers, however these drugs can enhance glucose tolerance and blunt the normal adrenergic responses to hypoglycemia ("hypoglycemic unawareness"). Beta blockers can also exacerbate depression, impotence, and AV nodal block.

( 30) New York Heart Association Class III CHF:

III: Marked limitation of physical activity. Comfortable at rest. Less than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.

( 31) _{Canadian Class III angina:}

III. Marked limitation of ordinary physical activity. Walking one to two blocks on level ground or climbing more than one flight of stairs precipitates symptoms.

( 32) In patients with critical AS, AVR may be indicated prior to major surgery. The angiogram is performed to diagnose concomitant CAD. ( 33) Coronary angiogram is performed to identify CAD which may be responsible for the cardiac arrest. EP studies may be done in conjunction with

the CAD workup to identify potentially fatal arrhythmias.

( 34) _{The cardiac arrest survivor's functional status plays a role in determining which diagnostic tests or procedures should be performed after the} resuscitation. In the severely disabled patient (e.g., the patient in a vegetative state), medical therapy (e.g., amiodarone) may be more appropriate than revascularization or invasive testing and procedures. The determination of functional capabilities of the patient is ultimately a matter of clinical judgment.

( 35) POL: It is a matter of local medical policy whether to perform a stress test for sustained ventricular tachycardia. If the stress test shows no evidence of ischemia, a coronary angiogram is not indicated.

( 36) Patients are considered to have a history of CAD when they have had symptoms of angina or anginal equivalents, a previous MI, CABG, PCI, or positive stress test.

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Patient Name

ID #

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( 37) Def: Structural heart disease (SHD) is defined, in these criteria, as LVH, RVH, asymmetric septal hypertrophy, left ventricular systolic dysfunction, valvular heart disease (MR 3+/4+, MS, AR 3+/4+, AS, MVP), or congenital heart disease. Structural heart disease is most commonly documented by TTE or occasionally by TEE.

( 38) Valvular heart disease is not generally the primary cause of ventricular arrhythmias but is a relative contributor. Patients may have associated CAD, hormonal mediated rhythm disturbances, myocardial dysfunction, genetic predisposition, or poor LV function, which may be the primary cause of the arrhythmia. Coronary angiography as part of the diagnostic work−up provides valuable information about the presence or absence of obstructive CAD (Zipes et al., Circulation 2006; 114(10): e385−484).

( 39) _{One must be certain that there are no other contributing factors that may be causing CHF (e.g., anemia, fluid overload) which could be treated,} thus obviating the need for angiography.

( 40) Since CAD is thought to be a major cause of CHF in patients with impaired LVEF, coronary angiogram is indicated to determine the extent of the disease. When significant CAD is found to be the source of decreased LVEF, revascularization procedures can often improve LVEF. Both patients with anginal pain and those with risk factors for CAD should be evaluated by coronary angiography (Hunt et al., Circulation 2005; 112 (12): e154−235).

( 41) Left ventricular systolic dysfunction, defined by a LVEF of less than 40%, is the most common cause of CHF. Generally, a lower LVEF equates with a higher degree of systolic dysfunction and results in more clinically severe heart failure. Systolic dysfunction most commonly results from ischemic heart disease or cardiomyopathy (Branch et al., Clin Fam Pract 2001; 3(4): 883−911).

( 42) It is estimated that up to 20% to 60% of patients with the clinical diagnosis of CHF have diastolic dysfunction. This disorder is often suspected in older female patients with left ventricular hypertrophy and normal systolic function. In diastolic dysfunction, increased ventricular stiffness causes impairment of ventricular filling during diastole. Cardiac output is preserved at the expense of elevated ventricular filling pressures, but

pulmonary congestion and symptoms of CHF ensue. Diastolic dysfunction most commonly results from ischemic heart disease, atrial fibrillation, DM, or HTN. In patients too ill to undergo stress testing, coronary angiogram may be needed to rule out ischemically related disease (Hunt et al., Circulation 2005; 112(12): e154−235; Torosoff and Philbin, Postgrad Med 2003; 113(3): 51−58). Diastolic dysfunction may also be manifested as abnormal left ventricular distensibility or compliance when TTE or myocardial doppler studies are done.

( 43) Echocardiography along with Doppler flow studies provide the best diagnostic information about heart failure. Most patients will demonstrate LVH by this method but some patients with heart failure and near normal LVEF will have a normal study. These patients, by virtue of their symptoms should be aggressively treated (Hunt et al., Circulation 2005; 112(12): e154−235).

( 44) Valvular heart disease includes: AR 3+/4+, MR 3+/4+, AS, and MS.

( 45) The angiogram should be done in a setting where PCI can be performed if indicated. Although intervention for acute MI performed within 6 hours is recommended, treatment can be beneficial if performed within 12 hours with ST elevation (O'Neill and Dixon, J Am Coll Cardiol 2004; 43(5): 875−890).

( 46) _{Cardiogenic shock is caused by extensive and severe compromise of the left or right ventricle and is commonly seen in ST elevation MI, LBBB,} or when there is rupture of the ventricular septum. A randomized controlled trial compared patients with an acute MI complicated by cardiogenic shock undergoing early PCI or CABG to patients treated with medical therapy or fibrinolysis. The PCI/CABG group had lower mortality rates at 6 months and 1 year. Initial mortality rates at 30 days were not significantly different between the medically treated group and the invasively treated group (Hochman et al., N Engl J Med 1999; 341(9): 625−634). Long−term analysis of this study 6 years after randomization revealed that the PCI/CABG group maintained a consistent survival benefit (Hochman et al., JAMA 2006; 295(21): 2511−2515).

( 47) _{Determining when fibrinolysis has failed to re−establish blood flow in a coronary artery remains a challenge. Response to fibrinolysis is variable} and patients with continued, worsening, or new findings of ischemia (e.g., chest pain, unresolved ST segment elevation, cardiogenic shock, CHF, arrhythmias) should have coronary angiography and rescue PCI promptly performed (King et al., J Am Coll Cardiol 2008; 51(2): 172−209; Smith et al., Circulation 2006; 113(7): e166−286).

( 48) A reliable, noninvasive method of determining the success of fibrinolysis has not been discovered. When the patient's clinical status fails to improve 90 minutes after administration of the lytic agent, the patient should be evaluated for rescue PCI. Biomarkers such as creatine kinase MB fraction, troponin, and myoglobin are under investigation to evaluate their usefulness in objectively determining the success of fibrinolytic treatment (Gershlick et al., N Engl J Med 2005; 353(26): 2758−2768; Goldman and Eisenberg, Ann Intern Med 2000; 132(7): 556−565). ( 49) Papillary muscle rupture secondary to an acute MI can lead to severe mitral valve regurgitation. Emergency mitral valve replacement or when

feasible, papillary muscle reconstruction and mitral valvuloplasty is the treatment of choice for those who develop cardiogenic shock, pulmonary edema, and MR. Angiography prior to surgery identifies the infarct related artery. The CABG and the valve repair or replacement are done together in one operation (Van de Werf et al., Eur Heart J 2003; 24(1): 28−66).

( 50) This refers to a right heart catheterization performed urgently in an ICU or CCU setting.

( 51) Acute MI can be complicated by a VSD. Surgery is the treatment of choice for this complication since mortality is high in untreated patients. Patients are generally stabilized by the use of an intra−aortic balloon pump and have coronary angiography to determine the need for CABG. Repair of the cardiac defect and the CABG are then performed as tandem procedures (Van de Werf et al., Eur Heart J 2003; 24(1): 28−66). ( 52) _{Canadian Class II angina:}

New York Heart Association Class II CHF:

II. Slight limitation of ordinary activity. Walking or climbing stairs rapidly, walking uphill, walking or stair climbing after meals, in cold, or wind, or when under emotional stress, or only during the few hours after awakening. Walking more than two blocks on level ground and climbing more than one flight of stairs at a normal pace and in normal conditions.

II. Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain.

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( 53) Patients identified as being at risk for future cardiac events by noninvasive testing should be evaluated by coronary angiography. Results of coronary angiography and subsequent revascularization when indicated can improve long−term survival in patients with stable disease but unresponsive to medical therapy (Gibbons et al., Circulation 2002; 106(14): 1883−1892)

( 54) Medical therapy in patients with CHF should include beta blockers, ACE inhibitors, and spironolactone. Beta blocker therapy (e.g., carvedilol) and ACE inhibitors have been shown to reduce mortality and morbidity (Hunt, J Am Coll Cardiol 2005; 46(6): e1−82; Sackner−Bernstein, Am J Cardiol 2004; 93(9A): 69B−73B; Krum et al., JAMA 2003; 289(6): 712−718). Patients who are intolerant of ACE inhibitors may benefit from angiotensin II receptor antagonists. The Valsartan Heart Failure Trial (Val−HeFT) investigated the use of valsartan (an angiotensin II receptor antagonist) in heart failure patients and demonstrated a decrease in morbidity and mortality (Maggioni et al., J Am Coll Cardiol 2002; 40(8): 1414−1421). Digoxin therapy, in low serum concentration levels, reduced hospitalizations in patients with worsening heart failure but had no effect on overall mortality (Rathore et al., JAMA 2003; 289(7): 871−878).

( 55) In general, coronary angiography is performed in advance of a valvular repair or replacement along with a diagnostic hemodynamic catheterization when the echocardiography results are incongruent with the clinical findings. In addition, patients at risk for CAD should have their coronary anatomy evaluated to determine if coronary revascularization may be done concomitantly with the valve surgery (Bonow et al., Circulation 2006; 114(5): e84−231).

( 56) A coronary angiogram (which includes a left ventriculogram) is an adjunctive study to a right heart catheterization for valvular heart disease. This is generally performed as part of a preoperative evaluation prior to valve repair. The right heart catheterization must be approved by the "Cardiac Catheterization, Right Heart with Coronary Angiogram" criteria subset.

( 57) Patients ≥ 35 are at risk for CAD and should have a coronary angiogram in addition to a right heart catheterization. Patients < 35 are considered to be at low risk for the purposes of these criteria.

( 58) Congenital heart disease in adults is, most commonly, ASD, VSD, or pulmonic stenosis. These criteria do not cover complex congenital heart disease.

( 59) A coronary angiogram (which includes a left ventriculogram) is an adjunctive study to a right heart catheterization for congenital heart disease. This is generally performed as part of a preoperative evaluation prior to congenital heart disease repair. The right heart catheterization must be approved by the "Cardiac Catheterization, Right Heart with Coronary Angiogram" criteria subset.

( 60) A right heart catheterization is performed to define the shunt size of the ASD or VSD, and to measure the gradient across the pulmonic valve in patients with pulmonic stenosis.

( 61) _{Def: Constrictive pericarditis results when a thick, fibrotic pericardium restricts diastolic filling. Potential causes of constrictive pericarditis include} infectious diseases, trauma, metastases, and connective tissue disorders.

( 62) Cardiac catheterization is the "gold standard" for diagnosing constrictive pericarditis (Gibbons et al., Circulation 2002; 106(14): 1883−1892). ( 63) _{A coronary angiogram (which includes a left ventriculogram) is an adjunctive study to a right heart catheterization. The right heart catheterization}

must be approved by the "Cardiac Catheterization, Right Heart with Coronary Angiogram" criteria subset.