Cath coding on ABIM

[bulldog]

If you get an left coronary injection shown,
1) LM normal
2) LAD has some luminal irregularities proximally
3) OM had a myocardial bridge

Do you code:

1) Insignificant stenosis in LM
2) Insignificant stenosis in LAD
3) Myocardial bridge Cx

or

1) Only myocardial bridge in Cx

I'm not sure when you mark "insignificant stenosis" vs leaving it blank if it is not the primary problem.

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[punk]

I had the same question. I have been told to code "insignificant stenosis" for sake of completion.

 

[bulldog]

If you look on the sample cases, http://www.abim.org/pdf/cert-related/cvd_sample_cases.pdf, they code insignificant lesions for the RCA and Cx when the LAD had significant lesion. However, they left how LM. Maybe it's because they didn't visualize left main well? i.e. if the injection had a better view of LM, you should have also coded LM insigificant lesion.

Second question, do you know why LVH and repol abnormality isn't code on the sample ECG? Lead I is > 14 mm

 

[JACO22]

If you look on the sample cases, http://www.abim.org/pdf/cert-related/cvd_sample_cases.pdf, they code insignificant lesions for the RCA and Cx when the LAD had significant lesion. However, they left how LM. Maybe it's because they didn't visualize left main well? i.e. if the injection had a better view of LM, you should have also coded LM insigificant lesion.

Second question, do you know why LVH and repol abnormality isn't code on the sample ECG? Lead I is > 14 mm

To answer your question about the LVH/repol abnormality, I feel that they didn't bother coding LVH because it wasn't the main point of the question, the WPW was. During fellowship, we had a cardiologist, who was very familiar with the EKG coding on the board exam, present several EKGs everyday and have fellow try to code them in the board format. Have taught us several general rules to follow for EKG coding(which I think applies to echo and cath coding). There is usually one primary diagnosis for each EKG(eg WPW, anterior MI, etc). You should of course get the rhythm and the main diagnosis to get most of the points for the questions. Adding minute things like left atrial enlargement, nonspecific T wave abnormality, etc, may get you minimal extra points or no additional points. However, if you overcode and mark something that is contradictory to the primary diagnosis, you will get that entire question wrong.

Btw, I'm not familiar with voltage criteria that uses lead I alone for diagnosing LVH. Using R in lead I requires adding S from lead III. Maybe you're thinking of the aVL criteria for LVH?

 

[JACO22]

If you get an left coronary injection shown,
1) LM normal
2) LAD has some luminal irregularities proximally
3) OM had a myocardial bridge

Do you code:

1) Insignificant stenosis in LM
2) Insignificant stenosis in LAD
3) Myocardial bridge Cx

or

1) Only myocardial bridge in Cx

I'm not sure when you mark "insignificant stenosis" vs leaving it blank if it is not the primary problem.

I would code myocardial bridge and insignificant stenosis in the LAD. From the ABIM sample, it seems that they want you to code insignificant stenoses in the main epicardial vessels. I wouldn't code a "normal" LM as insignificant stenosis(which is on the coding sheet as a fixed stenosis).

 

[punk]

If you look on the sample cases, http://www.abim.org/pdf/cert-related/cvd_sample_cases.pdf, they code insignificant lesions for the RCA and Cx when the LAD had significant lesion. However, they left how LM. Maybe it's because they didn't visualize left main well? i.e. if the injection had a better view of LM, you should have also coded LM insigificant lesion.

Second question, do you know why LVH and repol abnormality isn't code on the sample ECG? Lead I is > 14 mm

In general, you should not code LVH in a patient who has a WPW.

 

[bulldog]

On the coding sheet, there is:

1) junctional escape complexes
2) junctional rhythm/tachycardia

What's the difference between the two? It seems from looking at some of the OKeefe ECG's, junctional escape complexes are coded when there are p-waves/heart block present.

Junctional rhythm/tachycardia are coded if it is afib, or if there are no p-waves presents and the rhythm is regular.

 

[bulldog]

To answer your question about the LVH/repol abnormality, I feel that they didn't bother coding LVH because it wasn't the main point of the question, the WPW was. During fellowship, we had a cardiologist, who was very familiar with the EKG coding on the board exam, present several EKGs everyday and have fellow try to code them in the board format. Have taught us several general rules to follow for EKG coding(which I think applies to echo and cath coding). There is usually one primary diagnosis for each EKG(eg WPW, anterior MI, etc). You should of course get the rhythm and the main diagnosis to get most of the points for the questions. Adding minute things like left atrial enlargement, nonspecific T wave abnormality, etc, may get you minimal extra points or no additional points. However, if you overcode and mark something that is contradictory to the primary diagnosis, you will get that entire question wrong.

Btw, I'm not familiar with voltage criteria that uses lead I alone for diagnosing LVH. Using R in lead I requires adding S from lead III. Maybe you're thinking of the aVL criteria for LVH?

Page 540 of OKeefe. R wave in lead I >= 14. Punk points out that you should not code LVH which makes sense.

 

[JACO22]

Page 540 of OKeefe. R wave in lead I >= 14...

I see that now. I looked to try to find out where O'Keefe got it from and the 2009 AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the Electrocardiogram credits Gubner(1943) for a voltage in lead I greater than 1.5mV.