TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN

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TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN
David Plaut Snow, 2004
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TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN
100
4 AMI ND-ECG
AMI-DIAGNOSTIC ECG
AMI-NON DIAGNOSTIC ECG
NO AMI
90
Questionable Admissions 30
Unstable angina, stable angina and other acute
coronary syndromes 30
Unnecessary Admissions 30
0
500,000 PATIENTS SENT HOME
5,000,000 PATIENTS ADMITTED
CAP TODAY 151, 1994
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Time to Presentation
PERCENT OF PATIENTS
ONSET TO PRESENTATION (HOURS)
Note 50 present within 4 Hours
(GISSI-3 STUDY POPULATION)
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Temporal Pattern of Cardiac Markers
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Reference Range lie on a continuuuuum
TCK 0 ------------------------gt 180 CK-MB
0 ------------------------gt 5 Myo 0
------------------------gt 80 Age? Sex? Muscle
mass? Genes?
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cTn Reference Value.

• Normal Value for cTnI
• 0.0

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Case A
A 40 yr old male with CP for 2 hours. His ECG
was non-diagnostic.


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Case A
A 40 yr old male with CP for 2 hours. His ECG
was non-diagnostic.

DCosta et al. found a negative predictive value
of 100 of Myo. at 2 hours. This was confirmed by
Kircher and Montague.

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Case B
A 76 yr old male with a history of IHD and mild
CHF. Presents with severe chest pain which did
not diminish with nitroglycerin.
cTnI
Time
MYO
lt0.06
lt80
lt0.06
66
0 h
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Case B

• A 76 yr old male with a history of IHD and mild
  CHF. Presents with severe chest pain which did
  not diminish with nitroglycerin.
• Time MYO cTnI
• 0 h 66 lt0.06
• 3 147 0.47
• As many as 34 AMI present with a normal
  cardiac profile.

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Case B

• A 76 yr old male with a history of IHD and mild
  CHF. Presents with severe chest pain which did
  not diminish with nitroglycerin.
• Time MYO cTnI
• 0 h 66 lt0.06
• 3 147 0.47
• 6 --- 1.30
• As many as 34 AMI present with a normal
  cardiac profile.

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Case C
A 48 yr old male complained of CP after working
in his field all morning. After trying Maalox
he presented to the ED the following morning.
Ladenson has found that cTnI remains detectable
for as long as 15 days following an AMI.
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Case D
A 64 yr old female with known chronic renal
failure presents to the ED with some pain in my
chest. Her EKG was non-diagnostic.
Final diagnosis Renal failure
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Case E
A 83 yr old female with intermittent chest
discomfort is admitted to the ED at Huntington
Hospital in Pasadena, CA.
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Case E
A 83 yr old female with intermittent chest
discomfort is admitted to the ED at Huntington
Hospital in Pasadena, CA.
Final diagnosis AMI with extension
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(No Transcript)
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Questions Which marker(s)? When?
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A 6 hour protocol for chest pain evaluation

• n 292 (239 non-MI, 53 MI)
• Sensitivity 97.2, specificity 93
• The negative predictive value 99.6
• The six hour rule-out protocol
• is accurate and efficacious.
• Herren, BMJ 2001 Aug 18 323372

  .
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A 90 minute accelerated critical pathway for
chest pain evaluation
n 1285

• All AMIs were diagnosed within 90 min.
• Negative predictive value 100
• Ninety percent of patients with negative cardiac
  markers and a negative ECG at 90 minutes were
  discharged home
• Ng, S., Am J Cardiol 2001 Sept 1588(6) 611-7

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Evaluation of a 90 minute protocol
n 817

• Sensitivity 96.9
• Negative predictive value 99.6
• Addition of CK-MB did not improve the
  sensitivity or the NPV
• Addition of a 3 hour draw did not improve
  sensitivity or the NPV
• McCord, Circulation.2001 Sept 25104(13)1454-6

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Suggested Protocol
T0 Draw sample for cTn (and Myo?) If cTn is
diagnostic discontinue order If cTn is
not diagnostic Draw 2nd sample 2 - 3 hrs. later
If cTn is diagnostic discontinue
order If cTn is not diagnostic Draw 3d
sample 2 - 3 hrs. later
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TRIAGE OF ED PATIENTS COMPLAINING OF CHEST PAIN
Unstable angina, stable angina and other acute
coronary syndromes 30
CAP TODAY 151, 1994
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Unstable angina is a time bomb
A 68 yr old male with SOB, known chronic renal
failure and acute renal insufficiency presents to
the ED. His EKG was non-diagnostic.
Time cTnI 0 h 0.36 9 0.35 33 0.32
Final diagnosis Renal failure with CAD. Patient
was discharged.
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waiting to EXPLODE !
Three weeks later patient returned with severe
chest pain and radiating left arm pain.
Time cTnI 0 0.46 2 0.69 6 2.90
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Serum cardiac troponin I values in unstable
angina.

• 74 patients with chest pain at rest,
  electrocardiographic evidence of myocardial
  ischemia, and normal values of CK-MB
• Death or nonfatal myocardial infarction was more
  frequent in patients with elevated cTnI (27.7 vs
  5.3) than those with normal values.

Ottani F Am Heart J 1999 Feb137(2)284-91
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cTnI to Predict Risk of Mortality in ACS
Antman et al. NEJM 1996 3351342-9
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TRIAGE OF ED PATIENTS COMPLAINING OF CHEST PAIN
Unstable angina, stable angina and other acute
coronary syndromes 30
CAP TODAY 151, 1994
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Total Cholesterol DistributionCHD vs. Non-CHD
Population
Framingham Heart Study26-Year Follow-up
No CHD
35 of CHDoOccurs in people with TC lt200 mg/dL
CHD
150
250
300
200
Total Cholesterol (mg/dL)
Adapted from Castelli. Atherosclerosis.
1996124(suppl)S1-S9.
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Questions Why add another test? Why should it
be hs-CRP?
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Is there clinical evidence that hs-CRP, a
marker of low grade vascular inflammation,
predicts future coronary events?
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hs-CRP and Risk of Future MI in Apparently
Healthy Men
P Trend lt0.001
Plt0.001
Plt0.001
P0.03
Relative Risk of MI
2
3
4
1
Quartile of hs-CRP (range, mg/dL)
Ridker. N Engl J Med. 1997336973979.
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hs-CRP and Risk of Future Cardiovascular Events
in Apparently Healthy Women
P Trend lt0.002
6
Any event
5
MI or stroke
4
Relative Risk
3
2
1
0
1
2
3
4
lt 0.15
0.150.37
0.370.73
gt 0.73
Quartile of hs-CRP (range, mg/dL)
Ridker. Circulation. 199898731733.
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hs-CRP Adds to Predictive Value of TCHDL Ratio
in Determining Risk of First MI
Relative Risk
hs-CRP
TCHDL Ratio
Ridker. Circulation. 19989720072011.
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• Is there clinical evidence that the effect of
  hs-CRP on cardiovascular risk can be
  modified by preventive therapies?

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hs-CRP, Aspirin, and Risks of Future Myocardial
Infarction
4
3
Relative Risk Myocardial Infarction
2
1
Placebo Aspirin
0
4
3
2
1
Quartile of C-Reactive Protein
Ridker PM, N Engl J Med 1997336973-9
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What are the recommended guidelines for the use
of hs-CRP assays?
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Guidelines for Use of hs-CRP the writing group
recommends against screening the entire adult
population for hs-CRP. it is reasonable to
measure hs-CRP as an adjunctto further assess
absolute risk for CAD primary prevention.
Circulation 107 (Jan) 499, 2003
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Relative Risk and Average hs-CRP
hs-CRP lt 1.0 mg/L Low 1.0 -- 3.0
Average gt3.01 High
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The Importance of the D-dimer Assay andIts Use
in the Clinical SettingDavid Plaut
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ThromboembolismIncidence Mortality

• DVT affects 2 million Americans per year
• Without treatment, PE mortality 30
• With treatment of heparin or TPA, mortality is
  lt2
• Only 15-25 of patients suspected of DVT/PE
  actually have DVT/PE.

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What is the role of D-Dimer Assays in PE
and DVT?
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Causes of Elevated D-dimer

• Atherosclerosis Trauma
• Hepatic disease DIC
• Infection Pregnancy
• Inflammation Age
• Cancer DVT
• Thrombolytic Rx PE

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What is the importance of a negative D-dimer
test?

• If D-Dimer is negative, then there
• are no clots being dissolved
• no DVT or PE
• The value lies in the ability of d-dimer assays
  to rule out the Dx of DVT and PE

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Clinical policy, College Emergency Physicians,
2003 Patient management recommendations Level A
(high clinical certainty) None specified
Ann. Emer. Med 41 257, 2003
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Clinical policy, College Emergency Physicians,
2003 Patient management recommendations Level B
(moderate) Low pretest probability of PE use the
following tests to exclude PE 1. A negative
quantitative d-dimer 2. A negative qualitative d
dimer if Wells score 2 or less.
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Clinical policy, College Emergency Physicians,
2003 Patient management recommendations Level C
(low) Low pretest prob. of PE use the following
tests to exclude PE A negative quantitative
d-dimer or a negative qualitative d dimer (when
not used with Wells system)
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Wells et al. criteria Suspected DVT
3.0 Alternate Dx is less likely than PE 3.0 Heart
rate gt100 1.5 Immobilized or
surgery in last 4 wk 1.5 Previous DVT/PE
1.5 Hemoptysis 1.0 Malignancy
(treated within is 6 mo.) 1.0 Wells, PS et al.
Thromb Haemost. 83 416, 2000
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Wells score and probabilities for
PE Score Probability 0 - 2 3.6 3 -
6 20 gt6 67
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Use of D dimer to rule out DVT/PE
Prevalence 29 Sensitivity 99.5 NPV
99 Specificity 41 n 671 Am. J. Resp.
Care 156 492, 1997
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Validity of D-dimer for DVT
(Venography)
Ten studies with 945 patients Sensitivity 97
( 89 100) NPV 97 ( 92
100) Specificity 54 ( 34
80) Brill-Edwards, P Thromb. Hemosta. 82
688, 1999
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Validity of D-dimer for PE (Various)
Ten studies with 1329 patients
Sensitivity 99 (93 100) NPV
99 (92 100) Specificity 28
( 10 50) Brill-Edwards, P Thromb. Hemosta.
82 688, 1999
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Hospitalization and Congestive Heart Failure

• Major public health problem worldwide
• Most frequent cause of hospitalization in
  patients older than 65 years
• Fourth leading cause of adult hospitalization in
  US
• DRG 127 (Congestive Heart Failure)
• Primary diagnosis 1,000,000
  hospitalizations/ yr
• Secondary diagnosis 2,000,000 hospitalizations/
  yr.

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Hospitalization The Predominant Contributor to
CHF Costs
Total 38.1 billion (5.4 of total healthcare
coats)
OConnell JB et al. J Heart Lung Transplant.
199413S107-S112
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Release of BNP from Cardiac Myocytes
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proBNP Expected Values for Healthy Subjects
Total lt45 45 - 54 55 - 64 65
- 74 75 n 1411 56 472
455 308 120 mean 67.8
64.6 82.1 110.8
242.8SD 83.7 96.2
107.7 95.2 211.1median 41.4
39.6 57.7 83.4 191.195th
167 174 208 318
717
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proBNP Expected Values for Healthy Subjects
Expected values are also gender-dependent (n
2980)
MaleFemale
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BNP vs. NYHA Classification

12.3 95.4 221.5 459.1
1006.3 (pg/mL)
Triage BNP Test Package Insert
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Cumulative Survival Rates in CHF Patients With
Left Ventricular Dysfunction Stratified on Median
Plasma BNP Concentration
Tsutamoto T. et al. Circulation 199796509-516
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BNP vs. EF by Echocardiography
Davis et al. Lancet 1994343440-4.
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BNP vs. Six-Minute Walk Study by Wu et.al.
Wieczorek S, Wu AHB, et al. Unpublished data
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BNP Concentration and the Degree of CHF Severity
2013 266
BNP Concentration (pg/ml)
791 165
186 22
Mild
Moderate
Severe
n 27
n 34
n 36
CHF Severity
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Ready for Prime Time?
Cardiologists and internists may now have a tool
with which to determine whether a patient has
congestive heart failure and to measure its
severity, much as physicians routinely measure
serum creatinine in patients with renal disease
and perform liver-function tests in patients
with hepatic disorders.
Kenneth L. Baughman, MD N Engl J Med
2002347158-159
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THANK YOU!!
Davidplaut_at_yahoo.com
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Case C
A 67 yr old male with a history of cardiac
problems presents to the ED with shortness of
breath and pain in his left elbow.