TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN by rct20360

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									 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
                         AMI-DIAGNOSTIC ECG             ND-ECG

                       AMI-NON DIAGNOSTIC ECG
    90%
             Unstable
              angina,
               stable                                     NO
                             Questionable Unnecessary     AMI
            angina and       Admissions   Admissions
            other acute         30%          30%
             coronary
            syndromes
                30%
      0%
                       5,000,000 PATIENTS ADMITTED   500,000 PATIENTS
                                                        SENT HOME
CAP TODAY 1:51, 1994
 PERCENT OF PATIENTS                     Time to Presentation


                       25   22.9   23                                            N = 74,365 pts.
                                                                                 MEAN = 5.43h
                       20                                                        MEDIAN = 2.27h

                       15                 13.4                                                  13.1

                       10                        7.9
                                                       5                                 4.2
                        5                                    3.4   2.8   2.4       2
                        0
                             0-1   1-2     2-3   3-4   4-5   5-6   6-7   7-8      8-9    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



              100
              80
Sensitivity




                                                                  MYO
              60
                                                                  cTnI 2nd
              40
                                                                  CK/MB
              20
               0
                    0   2     4    6   12   24    48    72   96
                        Time After Onset Post AMI (Hours)
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    TCK      MB        RI    MYO        cTnI
         <200      <5.0    <2.5    <80       <0.06
  0h       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             MYO             cTnI

                    <80            <0.06
     0h              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    TCK CK-MB RI Myo cTnI
            <200 <5.0 <2.5 <80 <0.06
      0h      32   --  --   27  0.0
      4       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    TCK CK-MB RI Myo cTnI
            <200 <5.0 <2.5 <80 <0.06
      0h      32   --  --   27  0.0
      4       46   --  --   67  1.1
      9       56   --  --   32  2.2
     16      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    TCK       MB          RI   MYO     cTnI
        <200      <5.0      <2.5   <80    <0.06
0h      1469        31      0.21   206      0.0
2       1431        30      0.20   165      0.0

Discharge Dx: Subendocardial MI
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

                       8

                       7
42 day Mortality (%)




                       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   5.0 to < 9.0   >=9.0

                                                         cTnI (ng/ml)
           Antman et al. NEJM 1996; 335:1342-9
          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
                                                                     P<0.001
             Relative Risk of MI




                                   2                   P=0.03



                                   1



                                   0
                                          1                2             3             4
                                       < 0.055       0.056–0.114 0.115–0.210         0.211
                                                 Quartile of hs-CRP (range, mg/dL)
Ridker. N Engl J Med. 1997;336:973–979.                                                        31
                           hs-CRP and Risk of Future Cardiovascular
                              Events in Apparently Healthy Women

                                          P Trend <0.002

                      6
                            Any event
                      5     MI or stroke
                      4
      Relative Risk




                      3

                      2

                      1
                      0
                            1              2            3         4
                          < 0.15        0.15–0.37   0.37–0.73   > 0.73
                             Quartile of hs-CRP (range, mg/dL)
                                                                         32
Ridker. Circulation. 1998;98:731–733.
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                                                                  High
                                                             Medium
 0.0
            High              Medium             Low   Low
                               TC:HDL Ratio
                                                                        33
       Ridker. Circulation. 1998;97:2007–2011.
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

                                                          4
                                                 3
       Aspirin              1
                                         2

                                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    Low

       1.0 -- 3.0    Average

      >3.01         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           Trauma
Hepatic disease           DIC
Infection                 Pregnancy
Inflammation              Age
Cancer                    DVT
Thrombolytic Rx           PE
           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                                     3.0
Alternate Dx is less likely than PE              3.0
Heart rate >100                                  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
Wells score and
probabilities for PE
Score          Probability
0 - 2                   3.6%
3 - 6                  20
>6                     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%                   ( 89 – 100)
NPV         = 97                    ( 92 – 100)

Specificity          = 54            ( 34 – 80)


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
                                                                    Outpatient Care
               Hospitalization                                            39%
                   60%                                                   $14.7B
                  $23.1 B                                           (3.4 visits/year
                                                                        /patient)




                                                                 Transplants
                                                                     1%
                                                                   $270 M
Total = $38.1 billion
(5.4% of total healthcare coats)

O’Connell JB et al. J Heart Lung Transplant. 1994;13:S107-S112
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


         Total   <45     45 - 54   55 - 64   65 - 74   75 +
n        1411    56        472       455      308      120
mean             67.8      64.6       82.1    110.8    242.8
SD                83.7     96.2      107.7    95.2     211.1
median            41.4     39.6       57.7    83.4     191.1
95th %           167       174       208      318       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       Class I   Class II Class III Class IV
                     12.3           95.4     221.5     459.1   1006.3   (pg/mL)

Triage® BNP Test Package Insert
     Cumulative Survival Rates in CHF Patients With Left
Ventricular Dysfunction Stratified on Median Plasma BNP
                                           Concentration
    Cumulative Survival (%)




                              100                         BNP < 73 pg/ml

                               80
                                                                           p < 0.001
                               60


                               40
                                                   BNP > 73 pg/ml

                               20

                               0
                                    0   10   20      30      40     50      Months
 Tsutamoto T. et al. Circulation 1997;96:509-516
 BNP vs. EF by Echocardiography

                  100

                   80
       LVEF (%)




                                                   Y = -0.7, p<0.001
                   60
                   40

                   20

                        0
                             0        1.0       2.0      3.0
                                            Log BNP (pmol/l)

Davis et al. Lancet 1994;343:440-4.
   BNP vs. Six-Minute Walk
   Study by Wu et.al.

                            4
                                                          r = 0.513
          Log BNP (pg/mL)




                            3

                            2

                            1

                            0
                                0   500   1000   1500     2000    2500
                                          Distance (ft)
Wieczorek S, Wu AHB, et al. Unpublished data
                               BNP Concentration and the
                                Degree of CHF Severity


                            2500                             2013 ± 266
BNP Concentration (pg/ml)




                            2000

                            1500
                                                791 ± 165
                            1000

                             500
                                   186 ± 22
                               0
                                     Mild       Moderate      Severe
                                    n = 27       n = 34       n = 36
                                              CHF Severity                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!!



   Davidplaut@yahoo.com
                      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                 cTnI
                     <80                 <0.06
     0h               63                  0.0

     2                222                  0.4

     4                 563                 2.3

								
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