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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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