Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of...

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Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute Texas A&M College of Medicine

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Transcript of Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of...

Page 1: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Approach to The Low Risk Chest Pain

Patient

Approach to The Low Risk Chest Pain

Patient

John P Erwin, III, MD, FACC, FAHAAssociate Professor of Medicine

Scott and White Heart and Vascular Institute

Texas A&M College of Medicine

Page 2: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Background

• 8 million ED visits annually– At least three times that many presenting to

ambulatory clinics– Only a minority of these patients have a life-

threatening condition

• Failure to detect acute coronary syndrome (ACS) and inadvertent discharge of such patients from the ED may exceed 2%– Risk adjusted mortality ratio that is nearly 2-fold that

of patients hospitalized for ACS– Associated with substantial liability

Page 3: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Goals

• Accurate risk stratification

• Find the appropriate modality of evaluation for the circumstance

• Patient reassurance

• Appropriate utilization of resources

• Stay out of court!

Page 4: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Life isn't like a box of chocolates.

It's more like a jar of jalapenos.

What you do today, might burn your butt tomorrow.

Page 5: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

NON-CARDIAC DIAGNOSIS

Page 6: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Most Common Non-Cardiac Etiologies of Chest Pain

• Aortic Dissection• Pericarditis• Lung diseases (Don’t miss PTX and PE)• Musculo-skeletal (including cervical and

thoracic disc herniation)• Esophageal (even with normal manometry

studies)• Upper abdominal disease• Psycho-somatic• Functional

Page 7: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

See ACC/AHA Guidelines for Chronic Stable Angina

Page 8: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Criteria for Hospital Admission for Chronic Angina

• Worsening ("crescendo") angina attacks

• Sudden-onset angina at rest

• Angina lasting more than 15 minutes

Symptoms of unstable angina

Page 9: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

See ACC/AHA Guidelines for NSTEMI ACS

See ACC/AHA Guidelines for STEMI

Page 10: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

POSSIBLE ACS

Page 11: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

1.Immediate ECG

2. Observe

3. Study

Page 12: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Likelihood That Signs and Symptoms Represent an ACS

Secondary to CAD

Page 13: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Likelihood That Signs and Symptoms Represent an ACS

Secondary to CAD

Page 14: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Likelihood That Signs and Symptoms Represent an ACS

Secondary to CAD

Page 15: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

1.Immediate ECG

2. Observe

3. Study

Page 16: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

1.Immediate ECG

2. Observe

3. Study

Page 17: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

RISK SCORES

SIMPLE!!

IS THE TROPONIN ELEVATED (ecg

abnormal)?

Page 18: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

ED triage of patients with acute chest pain by means of rapid testing for cardiac

troponin I Protocol:• Chest pain less than 12 hours duration

and no STE or new LBBB on ECG• CKMB and TnI within 15 minutes of

evaluation and 4 hours later (or at least 6 hours from onset of chest pain)

Findings:• The overall event rate for patients with

negative troponin I = 0.3%.

NEJM. 337:1648-53. December 4, 1997.

Page 19: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Chest Pain Evaluation Units

Chest pain units manage patients at low risk for myocardial infarction:

1. As effectively as inpatient admission

2. At less cost. West J Med. 2000 December; 173(6): 403–407.

Page 20: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Chest Pain Evaluation Units

• Randomized controlled trial comparing patient satisfaction between those admitted to a chest pain observation unit and controls admitted for routine care – The chest pain unit scored higher than

inpatient management on all 7 satisfaction indices

– Attainment of a statistically significant difference in 4 of these scores.

Ann Emerg Med 1997;29: 109-115.

Page 21: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Exercise Stress Testing in Accelerated Diagnostic Protocols (ADP’s)

Page 22: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Rest Myocardial Pefusion Imaging

Page 23: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.
Page 24: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Stress Echo

Page 25: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Coronary Calcium ScoringIn patients presenting to the ED with undifferentiated

chest pain, a zero CAC score has been associated with:– a negative predictive value approaching 100%

for early adverse events – This prognostic value was maintained on follow-up

of 4 years. – High sensitivity, low positive predictive value

• often entails additional evaluation.

– Increasing CAC is associated with advancing age and male sex.

J Am Coll Cardiol. 2009;53:1642–1650.

Ann Emerg Med. 2010;56:220 –229.

Page 26: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Coronary CT Angiogram(CCTA)

• Provides anatomic rather than functional information regarding coronary patency and produces a noninvasive coronary angiogram.

• In a series of 103 patients presenting to the ED with chest pain, CTCA revealed:– Normal vessels or non-obstructive CAD

(negative predictive value 100%)– None of the patients discharged from the ED

had a major adverse cardiovascular event at 5 months.

Page 27: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Follow-up After Negative Evaluations

• Reconsider the possibility of non-cardiac chest pain etiologies

• In up to 40% of these patients, panic attack or somatoform disorders may be the causative factors

• False negatives are low, but re-take history and address CV risk factors

• Recidivism is high– Still may be a role for angiography (invasive vs CT)

Page 28: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

References

• See articles provided for your handouts

• Guidelines can all be found and downloaded at acc.org

Page 29: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

Conclusion

• Low risk chest pain is the most common category of chest pain syndromes that primary care providers encounter on a daily basis

• Develop a consistent algorithm of work-up founded upon a thorough H&P

• Good technology available to help us further risk stratify

• If negative work-up for CV cause , treat CV risk factors and address the non-cardiac etiologies of chest pain to help reduce recidivism

Page 30: Approach to The Low Risk Chest Pain Patient John P Erwin, III, MD, FACC, FAHA Associate Professor of Medicine Scott and White Heart and Vascular Institute.

An anxious heart weighs a man down,but a kind word cheers him up. --Proverbs 12:25


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