every ICU patient needs an EKG – not a troponin
Demand ischemia is commonly used to describe cardiac ischemia primarily due to cardiac supply/demand mismatch rather than coronary artery disease. In other words, the supply of blood flow to the heart is not limited but is inadequate to match the increased oxygen demands of an increased workload on the heart.
It is simply a supply-demand imbalance that happens at times when there is more demand for blood, such as when you are active, eating, excited, stressed or in the cold, and your body can’t keep up with the need for more blood. The supply problem can be caused by coronary artery disease.
Demand ischemia may clinically reflect a troponin elevation where myocardial tissue has not been injured or damaged from necrosis. Subsequently, question is, how is demand ischemia diagnosed? NSTEMI—even if characterized as mild or “early”—is classified as an acute MI, a more serious and complex diagnosis .
A: ICD-10-CM code I24. 8 would be used for demand ischemia where the patient did not have a current myocardial infarction (MI). This code also covers other forms of ischemic heart diseases.
Demand ischemia is another type of heart attack for which blockages in the arteries may not be present. It occurs when a patient's heart needs more oxygen than is available in the body's supply. It may occur in patients with infection, anemia, or tachyarrhythmias (abnormally fast heart rates).
Demand ischemia describes myocardial ischemia primarily due to cardiac supply/demand mismatch rather than CAD. In other words, the supply of blood flow to the heart is not limited but is inadequate to match the increased oxygen demands of an increased workload on the heart.
Demand ischemia should be reserved for when there is evidence of supply-demand mismatch causing ischemia without an elevated troponin above the 99th percentile. If the troponin is > 99th percentile the diagnosis is a Type 2 MI.
Type 2 MI is defined as "myocardial infarction secondary to ischaemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anaemia, arrhythmias, hypertension or hypotension."
A physician query is appropriate for the possibility of Type 2 MI when the diagnosis of demand ischemia is associated with elevated troponins above 99th percentile range. It may be necessary to verify what the 99th percentile reference range is for your hospital's lab.
For example, a physician recently documented that a patient had elevated troponin, likely a Type 2 MI/demand ischemia in the setting of a hypertensive emergency. In this case, demand ischemia would be a CC, and Type 2 MI would affect the DRG assignment, but it wouldn't add a CC/MCC.
Myocardial ischemia can lead to serious complications, including: Heart attack. If a coronary artery becomes completely blocked, the lack of blood and oxygen can lead to a heart attack that destroys part of the heart muscle. The damage can be serious and sometimes fatal.
ST segment elevation myocardial infarction (STEMI) non-ST segment elevation myocardial infarction (NSTEMI) coronary spasm, or unstable angina.
Type 1 MI is a primary coronary arterial event attributable to atherothrombotic plaque rupture or erosion. Type 2 MI occurs secondary to an acute imbalance in myocardial oxygen supply and demand without atherothrombosis.
Indeed, evidence suggests that sepsis may induce perturbations in regional coronary blood flow and microvascular failure leading to myocardial ischemia [12].
In pure demand ischemia, there is no stenosis in the coronary arteries, yet the volume of oxygen-containing blood is insufficient to meet the needs of the heart muscle. Conditions where the heart is working harder and/or faster such as infection, anemia, tachycardia, or overexertion may cause demand ischemia.
A: ICD-10-CM code I24.8 would be used for demand ischemia where the patient did not have a current myocardial infarction (MI). This code also covers other forms of ischemic heart diseases. ICD-10-CM code I21.A1 is reported for a current MI due to demand ischemia.
The EKG will therefore return to normal after ischemia resolves. The degree and/or duration of ischemia may proceed to actual infarction , which is a permanent death of some myocardium. This causes a recognizable pattern in EKGs acutely but also permanently thereafter.
A: I would code I24.8 (other forms of acute ischemic heart disease). Per the Alphabetic Index, reference Ischemia, demand, I24.8, and do not report the elevated troponin. The elevated troponins in the bloodstream indicate that there has been damage to the heart muscle and therefore can be an indicator of demand ischemia or a heart attack. However, if there is no mention of a myocardial infarction (MI), a query might be appropriate.
It’s an indicator, like how a runny nose may indicate a patient may have a cold but does not always mean a patient has a cold. Demand ischemia can occur without a myocardial infarction (MI), so if there is no mention of an MI, a query might be appropriate.
The condition is frequently confused with type 2 MIs, and clarification may be needed to code the diagnosis reflective of the condition. A type 2 MI is a myocardial infarction secondary to ischemic imbalance (myocardial demand exceeding supply). This is where a condition other than coronary artery disease results in the imbalance between myocardial oxygen supply and/or demand. While demand ischemia due to elevated troponin levels can fit in the definition of a type 2 MI, it should not be coded as a type 2 MI unless an MI is documented.
There is always an underlying condition or disease process that causes the Type 2 MI. Ischemia means insufficient blood perfusion, and prolonged ischemia leads to infarction, i.e., cell death. When cells die and break down, they release their contents, including troponin, a heart-muscle protein.
The reasons we should be documenting and coding conditions is for communicating with other clinicians, recognizing clinical significance and prognostication, and receiving appropriate compensation for utilization of resources. The implication that a Type 2 MI is different than a Type 1 MI and the new guidelines reflect this.
However, Type 2 MI does not have the same course, prognosis, or treatment as Type 1 MI. Once the underlying condition is brought under control, the Type 2 MI resolves. Healthcare providers were gun-shy about calling out Type 2 MIs initially because the inability to code and separate out the condition caused them to fall out of the AMI Core Measures. Most facilities bypassed this problem by using “not indicated due to Type 2 MI” as an exclusion in their order set.
A second Type 1 MI can either be reinfarction in the same anatomic distribution, as an extension of the first MI, or a patient can have another Type 1 MI in a different vessel , with a different area of the heart being affected. Treatment of myocardial infarction has always been informed by the desire to prevent death, reinfarction, ...