Transcript No Slide Title

TRIAGE OF THE ED PATIENT
COMPLAINING OF CHEST PAIN
David Plaut
Snow, 2004
TRIAGE OF THE ED PATIENT
COMPLAINING OF CHEST PAIN
100%
~4% AMI
ND-ECG
AMI-DIAGNOSTIC ECG
AMI-NON DIAGNOSTIC ECG
90%
0%
Unstable
angina,
stable
angina and
other acute
coronary
syndromes
30%
Questionable Unnecessary
Admissions
Admissions
30%
30%
5,000,000 PATIENTS ADMITTED
CAP TODAY 1:51, 1994
NO
AMI
500,000 PATIENTS
SENT HOME
PERCENT OF PATIENTS
Time to Presentation
25
22.9
23
N = 74,365 pts.
MEAN = 5.43h
MEDIAN = 2.27h
20
13.4
15
10
13.1
7.9
5
5
4.2
3.4
2.8
2.4
2
5-6
6-7
7-8
8-9
0
0-1
1-2
2-3
3-4
4-5
9-12
>12
ONSET TO PRESENTATION (HOURS)
Note: 50 % present within 4 Hours
(GISSI-3 STUDY POPULATION)
Temporal Pattern of Cardiac
Markers
Cardiac Marker Temporal Pattern
Sensitivity
100
80
MYO
60
cTnI 2nd
40
CK/MB
20
0
0
2
4
6
12
24
48
72
Time After Onset Post AMI (Hours)
96
Reference Range lie on a continuuuuum
TCK
0 ------------------------> 180
CK-MB
0 ------------------------> 5
Myo
0 ------------------------> 80
Age? Sex? Muscle mass? Genes?
cTn Reference Value.
Normal Value for cTnI
0.0
Case A
A 40 yr old male with CP for 2 hours.
His ECG was non-diagnostic.
Time
0h
TCK
MB
RI
MYO
cTnI
<200
<5.0
<2.5
<80
<0.06
123
2.5
2.0
34
0.0
Case A
A 40 yr old male with CP for 2 hours.
His ECG was non-diagnostic.
Time
TCK
MB
RI
MYO
cTnI
<200
<5.0
<2.5
<80
<0.06
0h
123
2.5
2.0
34
0.0
1
116
2.3
2.0
27
0.0
2
131
2.7
2.0
33
0.0
6
125
2.5
2.0
31
0.0
D’Costa et al. found a negative predictive value of 100% of Myo.
at 2 hours. This was confirmed by Kircher and Montague.
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
0h
MYO
cTnI
<80
<0.06
66
<0.06
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
0h
66
<0.06
3
147
0.47
 As many as 34% AMI present with a “normal”
cardiac profile.
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
0h
66
<0.06
3
147
0.47
6
---
1.30
 As many as 34% AMI present with a “normal”
cardiac profile.
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.
Time
TCK
MB
RI
MYO
cTnI
<200
<5.0
<2.5
<80
<0.06
0h
817
29
3.5
82
54
1
756
24
3.2
82
44
12
241
4.0
1.6
43
21
Ladenson has found that cTnI remains
detectable for as long as 15 days following an AMI.
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.
Time
TCK
MB
RI
MYO
cTnI
<200
<5.0
<2.5
<80
<0.06
0h
411
5.4
1.3
217
0.0
2
319
4.7
1.2
202
0.0
6
312
2.1
1.0
207
0.0
Final diagnosis: Renal failure
Case E
A 83 yr old female with intermittent chest
discomfort is admitted to the ED at Huntington
Hospital in Pasadena, CA.
Time
0h
4
TCK CK-MB RI Myo cTnI
<200 <5.0 <2.5 <80 <0.06
32
--27
0.0
46
--67
1.1
Case E
A 83 yr old female with intermittent chest
discomfort is admitted to the ED at Huntington
Hospital in Pasadena, CA.
Time
0h
4
9
16
TCK CK-MB RI Myo cTnI
<200 <5.0 <2.5 <80 <0.06
32
--27
0.0
46
--67
1.1
56
--32
2.2
134
10.2
3.2 145
5.3
Final diagnosis: AMI with
extension
Case KS02
A 32 yr old male complains of chest pain. Admits to
drinking 1 gallon alcohol per day.
His ECG was non-diagnostic.
Time
0h
2
TCK
<200
1469
1431
MB
<5.0
31
30
RI
<2.5
0.21
0.20
Discharge Dx: Subendocardial MI
MYO
<80
206
165
cTnI
<0.06
0.0
0.0
Questions
Which marker(s)?
When?
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; 323:372
A 90 minute accelerated critical
pathway for chest pain evaluation
n = 1285
• All AMI’s 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 15;88(6) 611-7
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 25;104(13):1454-6
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
TRIAGE OF ED PATIENTS
COMPLAINING OF CHEST PAIN
Unstable
angina, stable
angina and
other acute
coronary
syndromes ~ 30%
CAP TODAY 1:51, 1994
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
0h
0.36
9
0.35
33
0.32
Final diagnosis: Renal failure with CAD.
Patient was discharged.
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
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 Feb;137(2):284-91
cTnI to Predict Risk of Mortality in ACS
42 day Mortality (%)
8
7
6
5
4
3
2
1
0
0 to < 0.4
0.4 to < 1.0
1.0 to < 2.0
2.0 to 5.0
cTnI (ng/ml)
Antman et al. NEJM 1996; 335:1342-9
5.0 to < 9.0
>=9.0
TRIAGE OF ED PATIENTS
COMPLAINING OF CHEST PAIN
Unstable
angina, stable
angina and
other acute
coronary
syndromes ~ 30%
CAP TODAY 1:51, 1994
Total Cholesterol Distribution:
CHD vs. Non-CHD Population
Framingham Heart Study—26-Year Follow-up
No CHD
35% of CHDoOccurs
in people with
TC <200 mg/dL
CHD
150
200
250
300
Total Cholesterol (mg/dL)
Adapted from Castelli. Atherosclerosis. 1996;124(suppl):S1-S9.
28
Questions:
Why add another test?
Why should it be hs-CRP?
Is there clinical evidence that
hs-CRP, a marker of low grade
vascular inflammation, predicts
future coronary events?
30
hs-CRP and Risk of Future MI
in Apparently Healthy Men
P Trend <0.001
P<0.001
3
Relative Risk of MI
P<0.001
2
P=0.03
1
0
1
< 0.055
2
3
0.056–0.114 0.115–0.210
Quartile of hs-CRP (range, mg/dL)
Ridker. N Engl J Med. 1997;336:973–979.
4
0.211
31
hs-CRP and Risk of Future Cardiovascular
Events in Apparently Healthy Women
P Trend <0.002
6
Any event
Relative Risk
5
MI or stroke
4
3
2
1
0
1
< 0.15
2
0.15–0.37
3
0.37–0.73
4
> 0.73
Quartile of hs-CRP (range, mg/dL)
Ridker. Circulation. 1998;98:731–733.
32
hs-CRP Adds to Predictive Value of TC:HDL Ratio in Determining Risk of
First MI
5.0
4.0
3.0
2.0
1.0
0.0
High
Medium
High
Medium
Low
Low
TC:HDL Ratio
Ridker. Circulation. 1998;97:2007–2011.
33
Is there clinical evidence
that the effect of hs-CRP
on cardiovascular risk can
be modified by preventive
therapies?
34
hs-CRP, Aspirin, and Risks of Future Myocardial Infarction
4
3
Relative Risk
Myocardial
2 Infarction
1
Placebo
0
Aspirin
2
1
3
4
Quartile of C-Reactive Protein
Ridker PM, N Engl J Med 1997;336:973-9
What are the recommended
guidelines for the use of hs-CRP
assays?
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 adjunct…to further assess absolute
risk for CAD primary prevention.”
Circulation 107 (Jan) 499, 2003
Relative Risk and
Average hs-CRP
hs-CRP < 1.0 mg/L
1.0 -- 3.0
>3.01
Low
Average
High
The Importance of the
D-dimer Assay and
Its Use in the Clinical Setting
David Plaut
Thromboembolism
Incidence & Mortality
• DVT affects 2 million Americans per year
• Without treatment, PE mortality ~ 30%
• With treatment of heparin or TPA,
mortality is <2%
• Only 15-25% of patients suspected of
DVT/PE actually have DVT/PE.
What is the role of D-Dimer
Assays in PE and DVT?
Causes of Elevated D-dimer
Atherosclerosis
Hepatic disease
Infection
Inflammation
Trauma
DIC
Pregnancy
Age
Cancer
DVT
PE
Thrombolytic Rx
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
Clinical policy,
College Emergency Physicians, 2003
Patient management recommendations
Level A (high clinical certainty)
None specified
Ann. Emer. Med 41: 257, 2003
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.
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)
Wells et al. criteria
Suspected DVT
Alternate Dx is less likely than PE
Heart rate >100
Immobilized or surgery in last 4 wk
Previous DVT/PE
Hemoptysis
Malignancy (treated within is 6 mo.)
Wells, PS et al. Thromb Haemost. 83: 416, 2000
3.0
3.0
1.5
1.5
1.5
1.0
1.0
Wells score and
probabilities for PE
Score
0 - 2
3 - 6
>6
Probability
3.6%
20
67
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
Validity of D-dimer for DVT
(Venography)
Ten studies with 945 patients
Sensitivity = 97%
NPV
= 97
( 89 – 100)
( 92 – 100)
Specificity
( 34 – 80)
= 54
Brill-Edwards, P Thromb. Hemosta. 82: 688, 1999
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
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.


Hospitalization: The Predominant Contributor
to CHF Costs
Hospitalization
60%
$23.1 B
Total = $38.1 billion
(5.4% of total healthcare coats)
O’Connell JB et al. J Heart Lung Transplant. 1994;13:S107-S112
Outpatient Care
39%
$14.7B
(3.4 visits/year
/patient)
Transplants
1%
$270 M
Release of BNP from
Cardiac Myocytes
pre proBNP (134 aa)
proBNP (108 aa) signal peptide (26 aa)
myocyte
secretion
NT-proBNP (1-76)
BNP (77-108)
proBNP: Expected Values for
‘Healthy’ Subjects
n
mean
SD
median
95th %
Total
<45
45 - 54
1411
56
472
67.8
83.7
41.4
167
64.6
96.2
39.6
174
55 - 64
65 - 74
75 +
455
308
120
110.8
95.2
83.4
318
242.8
211.1
191.1
82.1
107.7
57.7
208
717
proBNP: Expected Values for Healthy
Subjects
Expected values are also gender-dependent (n = 2980)
200
Male
Female
100
0
45-
45-54
55-64
65-74
75+
BNP vs. NYHA Classification
1200
1000
800
600
Median
400
200
0
Normal
12.3
Triage® BNP Test Package Insert
Class I
95.4
Class II Class III Class IV
221.5
459.1
1006.3
(pg/mL)
Cumulative Survival (%)
Cumulative Survival Rates in CHF Patients With Left
Ventricular Dysfunction Stratified on Median Plasma BNP
Concentration
100
BNP < 73 pg/ml
80
p < 0.001
60
40
BNP > 73 pg/ml
20
0
0
10
20
Tsutamoto T. et al. Circulation 1997;96:509-516
30
40
50
Months
BNP vs. EF by Echocardiography
100
LVEF (%)
80
Y = -0.7, p<0.001
60
40
20
0
0
Davis et al. Lancet 1994;343:440-4.
1.0
2.0
3.0
Log BNP (pmol/l)
Log BNP (pg/mL)
BNP vs. Six-Minute Walk
Study by Wu et.al.
4
r = 0.513
3
2
1
0
0
500
1000
1500
Distance (ft)
Wieczorek S, Wu AHB, et al. Unpublished data
2000
2500
BNP Concentration (pg/ml)
BNP Concentration and the
Degree of CHF Severity
2013 ± 266
2500
2000
1500
791 ± 165
1000
500
0
186 ± 22
Mild
n = 27
Moderate
n = 34
CHF Severity
Severe
n = 36
61
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 2002;347:158-159
THANK YOU!!
[email protected]
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.
Time
MYO
<80
63
cTnI
<0.06
0.0
2
222
0.4
4
563
2.3
0h