TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN

David Plaut Snow, 2004

TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN

AMI-DIAGNOSTIC ECG AMI-DIAGNOSTIC ECG

AMI-NON DIAGNOSTIC ECGAMI-NON DIAGNOSTIC ECG

QuestionableAdmissions

30%

QuestionableAdmissions

30%

~4% AMIND-ECG

~4% AMIND-ECG

NOAMI

NOAMI

100%

90%

5,000,000 PATIENTS ADMITTED 500,000 PATIENTS SENT HOME

0%

CAP TODAY 1:51, 1994

Unstableangina, stable

angina and other acute

coronary syndromes

30%

UnnecessaryAdmissions

30%

22.9 23

13.4

7.95

3.4 2.8 2.4 24.2

13.1

0

5

10

15

20

25

0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-12 >12

N = 74,365 pts.MEAN = 5.43hMEDIAN = 2.27h

(GISSI-3 STUDY POPULATION)

Time to PresentationP

ER

CE

NT

OF

PA

TIE

NT

S

ONSET TO PRESENTATION (HOURS)

Note: 50 % present within 4 Hours

Temporal Pattern of Cardiac Markers

Cardiac Marker Temporal Pattern

0

20

40

60

80

100

0 2 4 6 12 24 48 72 96

Time After Onset Post AMI (Hours)

Se

nsi

tivi

ty MYO

cTnI 2nd

CK/MB

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

0.0342.02.51230 h

<0.06<80<2.5<5.0<200

cTnI MYO RIMB TCKTime

A 40 yr old male with CP for 2 hours. His ECG was non-diagnostic.

Case A

0.0312.02.51256

0.0332.02.71312

0.0272.02.31161

0.0342.02.51230 h

<0.06<80<2.5<5.0<200

cTnI MYO RIMB TCKTime

A 40 yr old male with CP for 2 hours. His ECG was non-diagnostic.

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

0 h 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

0 h 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

0 h 66 <0.06

3 147 0.47

6 --- 1.30 As many as 34% AMI present with a “normal” cardiac profile.

Case C

21 43 1.6 4.0 24112

44 82 3.2 24 756 1

54 82 3.5 29 817 0 h

<0.06 <80<2.5<5.0<200

cTnIMYO RI MB TCKTime

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.

Ladenson has found that cTnI remains detectable for as long as 15 days following an AMI.

Case D

0.02071.02.13126

0.02021.24.73192

0.02171.35.44110 h

<0.06<80<2.5<5.0<200

cTnI MYO RIMB TCKTime

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.

Final diagnosis: Renal failure

Case E

1.1 67---- 46 4

0.0 27---- 32 0 h

<0.06 <80<2.5<5.0<200

cTnIMyo RICK-MB TCKTime

A 83 yr old female with intermittent chest discomfort is admitted to the ED at Huntington Hospital in Pasadena, CA.

Case E

2.2 32---- 56 9

1.1 67---- 46 4

5.3 145 3.210.2 13416

0.0 27---- 32 0 h

<0.06 <80<2.5<5.0<200

cTnIMyo RICK-MB TCKTime

A 83 yr old female with intermittent chest discomfort is admitted to the ED at Huntington Hospital in Pasadena, CA.

Final diagnosis: AMI with extension

Case KS02

0.01650.2030 1431 2

0.02060.21311469 0 h

<0.06<80<2.5<5.0<200

cTnI MYO RIMB TCKTime

A 32 yr old male complains of chest pain. Admits todrinking 1 gallon alcohol per day.His ECG was non-diagnostic.

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

• 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

n = 1285

Evaluation of a 90 minute protocol

• 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

n= 817

Suggested ProtocolT0 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

CAP TODAY 1:51, 1994

Unstableangina, stable

angina and other acute

coronary syndromes ~ 30%

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

0 h 0.36

9 0.35

33 0.32Final diagnosis: Renal failure with CAD.Patient was discharged.

waiting to EXPLODE !

Time cTnI

0 0.46

2 0.69

6 2.90

Three weeks later patient returned with

severe chest pain and radiating left arm pain.

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

0

1

2

3

4

5

6

7

8

42 d

ay M

ort

ality

(%

)

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

CAP TODAY 1:51, 1994

Unstableangina, stable

angina and other acute

coronary syndromes ~ 30%

28

35% of CHDoOccurs 35% of CHDoOccurs in people with in people with TC <200 mg/dLTC <200 mg/dL

Adapted from Castelli. Adapted from Castelli. Atherosclerosis.Atherosclerosis. 1996;124(suppl):S1-S9. 1996;124(suppl):S1-S9.

150 200

No CHDNo CHD

Total Cholesterol (mg/dL)Total Cholesterol (mg/dL)

250 300

Framingham Heart Study—26-Year Follow-upFramingham Heart Study—26-Year Follow-up

CHDCHD

Total Cholesterol Distribution:CHD vs. Non-CHD Population

Questions:

Why add another test?

Why should it be hs-CRP?

30

•

Is there clinical evidence that hs-CRP, a marker of low grade vascular inflammation, predicts future coronary events?

31

hs-CRP and Risk of Future MI in Apparently Healthy Men

PP<0.001<0.001

PP<0.001<0.001

PP=0.03=0.03

Quartile of hs-CRP (range, mg/dL)Quartile of hs-CRP (range, mg/dL)

P P Trend <0.001Trend <0.001

< 0.055< 0.055 0.056–0.1140.056–0.114 0.115–0.2100.115–0.210 0.2110.211

Rel

ativ

e R

isk

of

MI

Rel

ativ

e R

isk

of

MI

Ridker. N Engl J Med. 1997;336:973–979.

0

1

2

3

1 2 3 4

32

hs-CRP and Risk of Future Cardiovascular Events in Apparently Healthy Women

Quartile of hs-CRP (range, mg/dLQuartile of hs-CRP (range, mg/dL))

Rel

ativ

eR

elat

ive

Ris

kR

isk

Ridker. Circulation. 1998;98:731–733.

PP Trend <0.002 Trend <0.002

< 0.15< 0.15 0.15–0.370.15–0.37 0.37–0.730.37–0.73 > 0.73> 0.73

0

1

2

3

4

5

6

1 2 3 4

Any event

MI or stroke

33

0.0

1.0

2.0

3.0

4.0

5.0

High Medium Low Low

Medium

High

hs-CRP Adds to Predictive Value of TC:HDL Ratio in Determining Risk of First MI

TC:HDL RatioRidker. Circulation. 1998;97:2007–2011.

hs-C

RP

Rel

ativ

e R

isk

34

Is there clinical evidence that the effect of hs-CRP on cardiovascular risk can be modified by preventive therapies?

hs-CRP, Aspirin, and Risks of Future Myocardial Infarction

12

34

0

1

2

3

4

Placebo

Aspirin

Relative Risk Myocardial Infarction

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

ThromboembolismIncidence & 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 TraumaHepatic disease DICInfection PregnancyInflammation Age

Cancer DVTThrombolytic 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 recommendationsLevel 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-dimer2. 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-dimeror a negative qualitative d dimer (when not used with Wells system)

Wells et al. criteria

Suspected DVT 3.0Alternate Dx is less likely than PE 3.0Heart rate >100 1.5Immobilized or surgery in last 4 wk 1.5Previous DVT/PE 1.5Hemoptysis 1.0Malignancy (treated within is 6 mo.)1.0

Wells, PS et al. Thromb Haemost. 83: 416, 2000

Wells score and probabilities for PE

Score Probability0 - 2 3.6%3 - 6 20>6 67

Use of D dimer to rule out DVT/PE

Prevalence = 29%Sensitivity = 99.5NPV = 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.

Total = $38.1 billion(5.4% of total healthcare coats)

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

Hospitalization: The Predominant Contributor to CHF Costs

Transplants1%

$270 M

Hospitalization60%

$23.1 B

Outpatient Care39%

$14.7B(3.4 visits/year

/patient)

myocyte

pre proBNP (134 aa)

proBNP (108 aa) signal peptide (26 aa)

secretion

NT-proBNP (1-76) BNP (77-108)

Release of BNP from Cardiac Myocytes

Total <45 45 - 54 55 - 64 65 - 74 75 +

n 1411 56 472 455 308 120

mean 67.8 64.6 82.1 110.8 242.8SD 83.7 96.2 107.7 95.2 211.1median 41.4 39.6 57.7 83.4 191.195th % 167 174 208 318 717

proBNP: Expected Values for ‘Healthy’ Subjects

0

100

200

45- 45-54 55-64 65-74 75+

MaleFemale

Expected values are also gender-dependent (n = 2980)

proBNP: Expected Values for Healthy Subjects

Triage® BNP Test Package Insert

BNP vs. NYHA Classification

0

200

400

600

800

1000

1200

Normal Class I Class II Class III Class IV

Median

12.3 95.4 221.5 459.1 1006.3 (pg/mL)

Cumulative Survival Rates in CHF Patients With Left Ventricular Dysfunction Stratified on Median Plasma

BNP Concentration

Tsutamoto T. et al. Circulation 1997;96:509-516

0

20

40

60

80

100

0 10 20 30 40 50

BNP < 73 pg/ml

BNP > 73 pg/ml

Months

Cu

mu

lativ

e S

urvi

val (

%)

p < 0.001

Log BNP (pmol/l)

LV

EF

(%

)

0

20

40

60

80

100

0 1.0 2.0 3.0

Y = -0.7, p<0.001

Davis et al. Lancet 1994;343:440-4.

BNP vs. EF by Echocardiography

0

1

2

3

4

0 500 1000 1500 2000 2500

Distance (ft)

Lo

g B

NP

(p

g/m

L) r = 0.513

Wieczorek S, Wu AHB, et al. Unpublished data

BNP vs. Six-Minute Walk Study by Wu et.al.

BNP Concentration and the Degree of CHF Severity

BN

P C

on

cen

trati

on

(p

g/m

l)

186 ± 22

791 ± 165

2013 ± 266

n = 27n = 27 n = 34n = 34 n = 36n = 36

CHF SeverityCHF Severity

Mild Moderate Severe0

500

1000

1500

2000

2500

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, MDN Engl J Med 2002;347:158-159

THANK YOU!!

Davidplaut@yahoo.com

Case C

2.3 563 4

0.4 222 2

0.0 63 0 h

cTnI

<0.06

MYO

<80

Time

A 67 yr old male with a history of cardiac problems presentsto the ED with shortness of breath and pain in his left elbow.