Clinical Progress Notes: Updates from the 4th Universal Definition of Myocardial Infarction

From the patient perspective, documentation using STEMI and NSTEMI can mislead clinicians, given that this terminology does not specify the underlying cause (ie, plaque rupture or oxygen supply-demand mismatch), potentially leading to delayed initiation of appropriate therapy. Incorrect documentation, using STEMI/NSTEMI language or incorrectly labeling T2MI and NIMI, may lead patients to believe they have had a heart attack when they had myocardial injury instead. This may lead to unnecessary anxiety and change their interactions with the health system. These patients may be started on unnecessary therapies, have inaccurate preoperative evaluations, and be labeled with a preexisting condition for the rest of their lives.

Opportunities for Quality Improvement

Systems-based quality improvement can help to ensure that patients with NIMI and T2MI are labeled appropriately and receive the proper treatment. Clinical education is the cornerstone of such efforts. Hospital medicine practitioners looking for support in understanding this issue might first partner with cardiology colleagues who may already have training materials available. Billing and coding personnel stand to benefit from greater orientation to this topic considering the complexities and errors in the coding of MI. In an attempt to help nonclinical coding personnel, leaders in the American College of Cardiology have advocated for use of the term “non-MI troponin elevation” (nMITE)¹³ to describe NIMI patients. Finally, we see an important role for EHR-embedded decision support tools to facilitate appropriate documentation and management of patients with elevated troponin. A potential care pathway, for example, could be created in partnership between hospital medicine and cardiology providers to identify which patients would benefit from cardiologist consultation.

Understanding the definitions of T1MI, T2MI, and NIMI will help clinicians to better identify the appropriate clinical care and consultation strategy for patients with elevated cardiac troponin. There are relatively few published quality improvement initiatives to help guide clinicians through these nuanced distinctions, but there is great potential in such approaches to help clinicians provide the highest value care possible.

Disclosures

No authors have any conflict of interest, financial or otherwise, to declare regarding this study.

Funding

Dr. Levy receives funding from National Institutes of Health (NIH) T32 Training Grant 5T32-HL007822.