New Concepts for Diagnosis

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New Concepts for Diagnosis Management of
Chest Pain

• S. Dadkhah MD.MBA.FACP.FACC.FCCP
• Director Section of
  Cardiology Research Chest Pain Center
  Swedish
  Covenant Hospital
• Chicago, IL
• Assistant Professor of Medicine
• University of Illinois

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Disclosurespeakers Bureau

• Aventis Lovenox
• Sanofi-SynthelaboPlavix
• MillenniumIntegrillin
• GlaxoSmithKlineCoreg
• NovartisDiovan
• SCIOS Natrecor
• BiositeBNP

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Remaining years of life are usually less
important than the quality of remaining life.
4
8 Million Adults Visit Hospital Emergency
Departments Complaining of Chest Pain Annually

• 15-20 Experience AMI
• 600,000 Admitted/Discharged without CAD
• Diagnosing AMI costs the Nations
  HealthcareSystem about 10 Billion Annually

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In the Emergency Department

• Approximately 5 of AMI Patients are Released
  Unintentionally
• 20 of Malpractice Claims are associated with the
  missed Diagnosis and Management of AMIs

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Acute Coronary Syndromes Risk of Mortality
Cumulative 6-Month Mortality
25
(N 21,761)
20
15
Death (100/Pts/Month)
Acute MI Unstable Angina Stable Angina
10
5
0
0
1
2
3
4
5
6
Months After Hospital Admission
Theroux P et al. Circulation. 19989711951206.
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WHO Criteria for AMI

• Definite AMI is Diagnosed in the Presence of
  Unequivocal ECG Changes and/or Unequivocal Enzyme
  Changes, History of Pain may be Typical or
  Atypical
• Definite AMI requires 2 of the 3 Criteria

Circulation 1979 59607-609
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Within the clinical spectrum of acute chest pain
is a subset of patients in whom the quality,
duration, associated systems and precipitating
factors are not characteristic for cardiac
pain.These patients usually have a non-specific
pattern of chest discomfort, normal ECG and a
low likelihood of cardiac disease often are
classified as having atypical chest pain
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ECG and MI

• In a multi-center emergency department study,
  only 39 of 108 patients (36) with AMI had a
  diagnostic ECG.1

As many as 40 of individuals with
autopsy-proven AMIs have non-diagnostic ECGs
initially.2
1 Chest 19942 Annals of Emergency Medicine 1987
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The Ideal Marker of Myocardial Injury/Ischemia

• Found in High Concentration within the Myocardium
• Not Found in other Tissues, even in Trace Amounts
  or under Pathological Conditions
• Released Rapidly and Completely after Ischemia
• Released in Direct Proportion to the Extent of
  Ischemia
• Persists in Plasma for Several Hours

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Characteristics
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Myoglobin in the Early Evaluation of Chest Pain
89 Patients

• 13 of 25 patients (52) had positive myoglobins
  prior to an increase in CKMB or CK.One patient
  discharged home with positive myoglobin.

56 100
83 100
Montaque, Colorado, American Journal of Chest
Physicians Oct 1995
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Negative Predictive Value

• The negative predictive value if the serum
  Myoglobin did not double within 2 hours . . .
• . . . in patients who presented within 6 hours
  of the onset of their symptoms . . .
• . . . was 97.

Tucker, Annals of Emergency Medicine 1994
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Myoglobin Cost Savings

• Cost of Single Myoglobin 20
• 25,000 Missed AMIs Discharged from the ED
  Annually(Atypical Presentations)
• Total Malpractice Loss for Missed AMI60
  Million (20 of ED Claims)
• Cost of Two Myoglobin Tests in ED for 25,0001
  million/year

Potential Cost Savings - 53 Million/year
Selective use in 250,000 Atypical
Presentations(1 of 10 AMIs) - Cost Savings of
44 Million/year
Brogan,Annals of Emergency Medicine Oct 1994
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Troponin I

• Part of the Thin Filament Regulatory Complex that
  Confers Calcium Sensitivity to the ATPase
  Activity of the Striated Muscle Actin-Myosin
  Complex
• Identified as Three Isoforms expressed in a
  Muscle Fiber Type-Specific-Manner - Troponin
  I Fast - Troponin I Slow (both expressed
  exclusively in fast twitch and slow twitch
  skeletal fiber muscles, respectively) -
  Troponin I Cardiac with an extra 30 residues at
  the N-terminal (expressed
  exclusively in atrium and ventricle)

Clin. Chem. 1993
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SERUM MARKERS POST AMI
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Chest Pain Committee Functions

• Collaboration between Emergency Medicine,
  Cardiology and laboratory
• Meets monthly
• Performs data collection and review
• Reviews Process Improvement initiatives
• Cost of Care and Reimbursement
• Education of Staff
• Recommendations to Administration

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Rapid Evaluation Of Chest Pain In The Emergency
Department
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Patient enters the CPC having ACS STEMI/NSTEMI
Laboratory turnaround time
Notification to cath lab staff of AMI
Delayed arrival to the CPC
Time from ECG to diagnosis
Time to ECG
Time from diagnosis to transportation to cath
lab
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Patient enters the CPC having ACS
Delayed arrival Of cardiologist
D/C instruction
Delayed arrival of heart team
CCU LOS
Time to wire cross
Time from Admission to D/C
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Critical PathwaysMyocardial Infarction - Track I
Possible Solutions

• Formation of Heart Center Code Team and the Code
  42
• Cardiology call roster
• PC preferred cardiologist roster
• Rapid Blood Markers in the Emergency Department
  and in the Emergency Medical System (EMS)

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Chest Pain
Track I AMI
ST Elevation With Reciprocal Changes
CODE 42
Cath Lab
Thrombolytic
Surgery
PTCA
Admit to CCU
Medical TX
Angiography?
Stress Test?
Home in 5 Days
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Chest Pain
Track III a Atypical CP
Non-diagnostic ECG without Exclusion Criteria
Rapid Myoglobin/CKMB/Troponin I on
admission. Myoglobin and Troponin I at 2 hours,
Rapid Myoglobin/CKMB/Troponin I at 4 hours
Cardiac Markers Positive
Cardiac Markers Negative
Admit TX per protocol
Exercise Stress Test in ED
Negative Test
Positive Test
Discharge home
Admit TX per PMD
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The 68th Scientific Sessions AHA 1995 California
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1995-2005 7 years completed with 8282 enrolled
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Case 90

• ES - 61 Male physician for elective surgical
  repair of quadricep torn after a fall. In the
  holding area he became hypotensive after IV
  sedation. He had chest pain with increasing
  fatigue 3 days prior to that admission
• Risk Factors Hypertension, smoker
• Physical Exam Unremarkable
• ECG/Angiogram

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Case 90
ES
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Dadkhah
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Case 90
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I

• Surgery cancelledemergency angiogram performed

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Case 90
Dadkhah
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(NEW ERA)Now Evaluate Chest Pain with 12 Lead
Electrocardiograms and Rapid Assays for Early
Recognition of Myocardial Infarctions in the
Ambulance(IJEM volume1, N3 2005)
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NEW ERA
Methods

• Multi-Centered Trial
• 5 Hospitals- 4 with Emergency PTCA
  Capabilities(St. Francis, Evanston, Holy
  Family, Rush North Shore) Glenbrook
• 5 Ambulance ServicesEvanston, Lincolnwood,
  Skokie, Wheeling, Glenview

• Performed prior to arrival in ED
• 12 Lead ECGs (Life-pack 11)
• Rapid CK-MB
• Rapid Myoglobin
• Rapid Troponin I performed

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NEW ERA
Results

• 252 Patients enrolled
• 247 Patients had completed follow-up
• 44 (18) Patients diagnosed with AMI before being
  discharged from the hospital
• 7 Patients had negative ECG and Markers ED
  markers were negative but AMI occurred during
  course of hospitalization
• 37 (15) Patients positive for AMI in the ED

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NEW ERA
Results

• 5 (2) Patients transferred to other institutions
  with diagnosis of AMI 2 out of the 5 patients
  with positive ECGs did not have markers
  performed in the ambulance
• 28 (11.3 ) Patients had either positive ECGs or
  Markers pre-hospital

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NEW ERA, Phase II

• 203 Consecutive Patients
• 160 Patients had completed follow-up
• - 23 Ambulances
• - 7 Hospitals
• Findings
• 8.4 (17/203) Positive markers in the field vs.
  7.7 Positive markers in Phase I

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Case 91

• BH - 75 WM Complaining of sharp, stuttering chest
  pain on and off for 12 hours was seen in his
  PMDs office. 911 was called and in the field
  12-Lead ECG and Rapid Cardiac Markers were
  performed
• Risk factors Hypertension, smoker
• Physical Exam Unremarkable
• Field ECG/Angiogram

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Case 91
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Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
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Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
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Case 91
Dadkhah
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Chest Pain Centers
Level I
Level II
Level III
EMS
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Action Plan of the 4 Ds

• Door
• Data
• Decision
• Drug

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TIME-MCTimely Intervention in Myocardial
Emergency Multicenter studyThe study is based on
the hypothesis that reperfusion therapy will be
more rapidly initiated when the responsible
cardiologist has support for the reperfusion
therapy decision via immediate access to patient
data including a standard 12 lead ECG.
Duke
Welch Allyn
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Chest Pain Center

• A Chest Pain Center in not a section of the
  Hospital that treats Acute Myocardial Infarction
• A Chest Pain Center is a process that starts
  from the time a patient activates EMS/ED until
  that patient discharges from the hospital

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Accreditation

• Accreditation is a process that ensure
  hospitals use a common language, PATHWAYS, to
  accurately and rapidly diagnose and treat
  patients suffering from Acute Coronary
  Syndrome

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Facility Benefits

• Differentiates facility in market
• The Heart Attack Act of 2005 was introduced by
  Senator Mike DeWein of Ohio ( on Judiciary
  Committee, Appropriations Committee, and others.)
  It was accompanied by a letter signed by Senators
  Arlen Specter, John McCain, Orin G. Hatch, Mary
  L. Landrieu, Mike DeWine and Sam Brownback. The
  act stipulates that in order to receive Medicare
  funds a facility that self designates as a Chest
  Pain Center must be accredited.

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Facility Benefits

• With the move to Pay for Performance by Payers,
  CPC accreditation establishes the benchmarks for
  higher reimbursement rates.
• More efficient assessment ACS processes translate
  into more profitable PCI procedures being
  performed and fewer costly admissions.
• Helps reduce missed MIs, the number one payout
  for malpractice claims.
• Accreditation is a good theme to base for
  community marketing.

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Accreditation Numbers

• Projected by May 26 2006
• Accredited Facilities        298
• Under Review                  33

Facilities Accredited in 36 States IL 9 IN 9
WI 15
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You are as good as the people you work for
and the people you work with
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If you always dowhat youve always doneyoull
always getwhat you always got
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You are as good as Your Arteries
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THE END
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