Transcript Chest Pain Evaluation and Risk Assessment

Arie Szatkowski, MD FACC
Stern Cardiovascular Foundation
Baptist Memorial Healthcare Corporation
CV disease is #1 cause of death in the U.S.
9% of all ED visits are for Chest Pain, about 5.5 million to 6 million
annually (ambulatory visits account for < 1%)
Etiology can be difficult to diagnose
NSTEMI affects > 625,000 annually (3/4 ACS)
A Chest Pain Case
A 65 year-old man with a past
medical history significant for
hypertension and dyslipidemia
presents to clinic after 2
episodes of chest pain in past
couple days. What do you
want to know and do?
Typical angina (definite)
1) Substernal chest discomfort with a characteristic
quality & duration that is 2) provoked by exertion
or stress and 3) relieved by NTG or rest
Atypical angina (probable)
Meets 2 of above characteristics
Noncardiac chest pain
Meets 1 or none of typical anginal characteristics
EXCLUDE Coronary artery disease and
other life-threatening conditions
Acute Coronary Syndrome/Myocardial
infarction
Pulmonary embolus
Aortic dissection
Tension Pneumothorax
Esophageal Rupture
*All of these could lead to sudden death*
“PQRST”
Provocative/palliative factors
Quality: character, duration, frequency, associated
sxs
Radiation
Severity
Timing
Risk factors: age, tobacco use, family history,
DM/HTN/Lipids, cocaine; other- DVT/PE,
Marfans/Pregnancy, ETOH, NSAIDS
PMHx: prior CV w/u & Rx, GI history
Postprandial? GI or cardiac disease
Exertion? Angina or esophageal
pain
Antacids or food? Gastroesophageal origin
Sublingual nitro? Esophageal or
cardiac
Cold, emotional stress, sexual
intercourse can promote ischemic
pain
“GI Cocktail” (viscous lidocaine
and antacid)? GI or cardiac
Worse with swallowing?
Esophageal origin
Cessation of activity/rest?
Ischemic origin
Body position, movement, deep
breathing? Musculoskeletal origin
Sitting up and leaning forward?
Pericarditis
Region or location:
Radiation to neck, throat, lower jaw, teeth, upper extremity, or
shoulder
Radiation to arms is useful and stronger predictor of acute MI
Between scapulae think aortic dissection
Larger areas of discomfort more likely ischemic etiology
Severity: not useful predictor for presence of CAD
Timing:
Abrupt onset with greatest intensity in beginning: PTX, dissection,
acute PE
Gradual with increasing onset over time: ischemic
Crescendo pattern: esophageal disease
Lasts for seconds or constant over weeks ≠ ischemic
Circadian rhythm (morning>afternoon) correlating with increase
sympathetic tome- more likely myocardial ischemia
Belching, bad taste in mouth, dysphagia or odynophagia 
esophageal disease
Vomiting Transmural MI, GI problems
Diaphoresis MI> esophageal disease
Syncope dissection, PE, critical AS, ruptured AAA
Pre-syncope myocardial ischemia
Palpitations in setting of new A. Fib + chest pain PE
Fatigue can be presenting complaint of MI esp. in elderly
General Appearance
may suggest seriousness of
symptoms.
Vital signs
marked difference in blood
pressure between arms
suggests aortic dissection
Palpate the chest wall
Hyperesthesia may be due to
herpes zoster
Complete cardiac
examination
pericardial rub
signs of acute AI or AS
Ischemia may result in MI
murmur, S4 or S3
Determine if breath sounds
are symmetric and if
wheezes, crackles or
evidence of consolidation
EKG
“Normal” reduces probability chest pain is due to AMI,
but does NOT exclude serious cardiac etiology (i.e.
Unstable Angina)
ST elevation, ST depression, or new Q waves- important
predictor of Acute Coronary Syndrome (AMI or UA)
“Nonspecific” ST and T wave changes is common- may or
may not indicate heart disease
CXR
Useful in acute setting to avoid missing dangerous
diagnoses (e.g. PTX, Aortic dissection, Pneumomediastinum)
Relationship between cardiac troponin levels
and risk of death in patients with ACS.
Used with permission from Antman EM, Tanasijevic MJ, Thompson B, et al.
Braunwald E et al. Circulation. 2000;102:1193-1209
Copyright © American Heart Association, Inc. All rights reserved.
Clinical Feature
Likelihood Ratio (95% CI)
Pain in chest or left arm
2.7
Chest pain radiation
Right Shoulder
2.9 (1.4-6.0)
Left arm
2.3 (1.7-3.1)
Both left and right arm
7.1 (3.6-14.2)
Chest pain most important symptom
2.0
History of MI
1.5-3.0
Nausea or vomiting
1.9 (1.7-2.3)
Diaphoresis
2.0 (1.9-2.2)
Third heart sound
3.2 (1.6-6.5)
Hypotension (SBP<80)
3.1 (1.8-5.2)
Pulmonary rales on exam
2.1 (1.4-3.1)
Clinical Feature
Likelihood Ratio (95% CI)
Pleuritic chest pain
0.2 (0.2-0.3)
Chest pain sharp or stabbing
0.3 (0.2-0.5)
Positional chest pain
0.3 (0.2-0.4)
Chest pain reproduced with
palpation
0.2-0.4
Panju, et al. JAMA 1998;280:14:1256-1263
Panju, et al. JAMA 1998;280:14:1256-1263
Worsening frequency, intensity, duration, timing
(e.g. nocturnal pain, rest pain) of prior angina
New onset SOB, nausea, sweating, extreme fatigue
in patient with known h/o CVD
Onset of typical anginal symptoms in pt without h/o
CVD
New murmur (or worsening of previously noted
murmur), hypotension, diaphoresis, rales,
pulmonary edema
Transient ST deviation (≥ 1mm) or TWI in multiple
precordial leads
Supply-demand Mismatch
Plaque Disruption or Rupture
Thrombosis
Vasoconstriction
Cyclical Flow
• Fever
• Tachyarrhythmias
• Malignant Hypertension
• Thyrotoxicosis
• Pheochromocytoma
• Cocaine use
• Amphetamine use
• Critical Aortic Stenosis
• Supravalvular Aortic Stenosis
• Obstructive Cardiomyopathy
• Aortovenous shunts
• High Output States
• Congestive Heart Failure
• Anemia
• Hypoxemia
• Polycythemia
• Hypotension
Terminology change from unstable
angina/NSTEMI to NSTEMI ACS
Approach to patient remains unchanged
Increase focus on discharge instructions and
transition
Diagnosis:
No benefit of CKMB (Class III)
MI only if > 20% rise or fall of troponin
Point of care troponin not as specific
Special population: Women
Class III Early Invasive in Low Risk Women
“Ischemia Guided Strategy” replaces “Initial Conservative
Management”
Immediate Invasive < 2 hours if:
Refractory angina
CHF signs/symptoms
New or worsening MR
Hemodynamic instability
Sustained VT/VF
Early (within 24 hours)
New ST segment depression
GRACE score > 140
Temporal change in Troponin
Delayed Invasive
Renal insufficiency
LVEF < 40%
TIMI > 2
GRACE Risk 109-140
ACE inhibitors: Class I for NSTE ACS with LVEF < 40%
Ticagrelor is Class IIa over Clopidogrel for NSTE ACS
early initial anti-platelet therapy
Ticagrelor or Prasugrel over Clopidogrel prior to PCI
DAPT remains 12 months for DES and BMS
Pain control post NSTE ACS discharge: careful
assessment for need, first acetaminophen or
tramadol, then small dose narcotics, then
nonselective NSAIDS (naproxen)
PPI for those receiving triple oral antithrombotic
therapy or if NSAID used. The data that suggest
increased harm are weak.
Risk
Score
Year of
Publication
Score
Range
Score Predicts
C-Statistic of
Original Study
PURSUIT
2000
1 - 18
Risk of Death or death/MI at 0.84 (death) and
30 days after admission
0.67 (death/MI)
Risk of all cause mortality, MI,
and severe recurrent
ischemia requiring urgent
0.65
revascularization within 14
days after admission
Risk of hospital death and
post-discharge death at 6
0.83
months
TIMI
2000
0-7
GRACE
2003
1 - 372
FRISC
2004
0-7
Treatment effect of early
invasive strategies in ACS
0 - 10
Prediction of combined
endpoint of MI, PCI, CABG or
0.90
death within 6 weeks after
presentation
HEART
2008
0.77 (death) and
0.7 (death/MI)
PURSUIT: Does not include troponin assays as part of score and
the majority of the score is dependent on patient age.
TIMI: Simple to use, but has a poor predictive power (i.e. cstatistic 0.65)
GRACE: Very complex to use and a large portion of the score is
dependent on the patient age. Also patients not divided into
different risk groups
FRISC: Like TIMI, is simple to use but has a poor predictive
power (i.e. c-statistic 0.70)
Proposed Policy
Patients can be divided into three distinct groups. A score of 0-3 indicates a
risk of 1.6% for reaching a MACE, and therefore supports a policy of early
discharge.
In case of a HEART score of 4-6 points, with a risk of MACE of 13%,
immediate discharge is not an option. These patients should be admitted for
clinical observation and subjected to non-invasive investigations such as
repeated troponin or advanced ischemia detection. A HEART score ≥ 7 points,
with a risk of 50% for a MACE, calls for early aggressive treatments possibly
including invasive strategies without preceding non-invasive testing.
HEART Score
Risk of MACE
Proposed Policy
0-3
1,6%
Discharge
4-6
13%
X-ECG
7 - 10
50%
CAG
• What they did:
• 2,440 unselected, chest pain patients from 10 hospitals
• Applied TIMI, GRACE, and HEART Scores
• Primary endpoint:
• Occurrence of major adverse cardiac events (MACE) at 6 weeks
• MACE = AMI, PCI, CABG, and death
• Results of Validation Study (Different than original study shown
above):
• Low HEART Score (0 -3) = 1.7% MACE Rate
• Intermediate HEART Score (4 – 6) = 16.6% MACE Rate
• High HEART Score (7 – 10) = 50.1% MACE Rate
• C-statistic of HEART Score (0.83) > TIMI (0.75) > GRACE (0.70)
Total # of LRCP Pts
40
35
30
25
20
15
10
5
0
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
2014 Total Referrals
for Low Risk Chest Pain by ED MD
(Blinded)
60
49
50
47
44
40
30
22
20
20
17
17
14
14
10
10
10
3
2
2
1
1
F
G
1
2
2
N
O
2
3
1
0
A
B
C
D
E
H
I
J
K
L
M
P
Q
R
S
T
U
V
% of Pts with Stress Tests Scheduled in <72 hrs
120%
100%
91%
80%
95%
100%
100%
100%
100%
97%
92%
84%
83%
85%
97%
83%
60%
40%
20%
0%
Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
% of Pts No Show/Cancel
70%
63%
60%
54%
50%
50%
47%
43%
43%
40%
38%
38%
30%
29%
37%
35%
29%
20%
10%
8%
0%
Dec-13
Jan-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
% of Readmissions < 30 days
6%
5%
5%
1 pt
4%
3%
2%
1%
0%
0%
Dec-13
0%
Jan-14
0%
Feb-14
0%
Mar-14
0%
Apr-14
0%
May-14
Jun-14
0%
0%
0%
0%
0%
Jul-14
Aug-14
Sep-14
Oct-14
Nov-14
Utilization in ED
If not ACS then doesn’t need risk stratification.
Appropriate risk stratifying test
Patient follow up
Weekends
Cost assessment (pending)
Outcomes assessment (pending)
Focus on the life threatening causes first
Know the indicators for immediate invasive
therapy
Use Risk Tools but Clinical judgment prevails
Know the right test for the situation