Dr.amsterdam_Low Risk ED Chest Pain Patients_SJMC Cardiovascular Symposium
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Transcript of Dr.amsterdam_Low Risk ED Chest Pain Patients_SJMC Cardiovascular Symposium
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Low Risk ED Chest Pain Patients: Is Computed Tomography Coronary
Angiography the Holy Grail?
Ezra A. Amsterdam UC Davis
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Conflicts
My only conflicts are inner conflicts and I decline to reveal them!
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Evaluation of Low Risk Patients Presenting to ED with Chest Pain
• Magnitude of the problem • Low and intermediate risk • “Confirmatory” tests • CPU and accelerated diagnostic protocols
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Magnitude of the Problem
• 8,000,000 ED visits/yr in the U.S. for chest pain • Minority of CP visits are for CVD
– Largest single cause: somatoform disorders
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Spectrum of Patients Presenting to ED with Chest Pain (8,000,000/yr)
STEMI <5% Reperfusion Non-STE ACS 20-30% Antiischemic Rx
Low Risk Chest Pain 65-75% Accelerated Dx Protocol (ADP)
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Inappropriate Discharges Missed ACS (2.3%, Pope, NEJM, 2000)
Medicolegal liability
Inappropriate Admissions Inefficient resource utilization Major expense to system
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Evaluation of Low Risk Patients Presenting to ED with Chest Pain
•Goal is to exclude ACS •Not to exclude CAD!
• We treat patients, not anatomy
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Evaluation of Low Risk Patients Presenting to ED with Chest Pain
• Magnitude of the problem • Low and intermediate risk • “Confirmatory” tests • CPU and accelerated diagnostic protocols
![Page 9: Dr.amsterdam_Low Risk ED Chest Pain Patients_SJMC Cardiovascular Symposium](https://reader034.fdocuments.in/reader034/viewer/2022042716/55a75d0f1a28ab97148b4671/html5/thumbnails/9.jpg)
Low Risk in Patients Presenting to the ED with Chest Pain
<5% Probability of ACS –History – Typical or atypical CP –Exam – Clinically stable –ECG – Normal (or unchanged) (Negative injury markers greatly risk) Intermediate risk: >65 yo, CAD, DM. CRI
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Low Risk Is Not No Risk “Confirmatory” test to further reduce risk
Nothing is 0%, Nothing is 100%
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Evaluation of Low Risk Patients
• Magnitude of the problem • Low and intermediate risk • Confirmatory tests • CPU and accelerated diagnostic protocols
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Multimarker
BMIPP
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“Confirmatory” Tests
• One size does not fit all
• Multiple approaches to the problem
• Test selection based on institutional expertise, resources, preference
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Scientific Statement of the American Heart Association
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“Confirmatory” Tests • Functional Neg. Predictive Value
– Treadmill Ex >99% – MPS(sestamibi, stress) >99% – Stress Echo ~95%
• Anatomic – CTCA >99% – (MRI)
• No Test? >99%
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Evaluation of Low Risk Patients
• Magnitude of the problem • Low and intermediate risk • Confirmatory tests • CPU and accelerated diagnostic protocols
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Chest Pain Unit
• Physical structure • “Virtual” Unit (UCDMC)
–Accelerated diagnostic protocol (ADP) • Serial ECGs • cardiac injury markers • LOS 2-6 hrs
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Accelerated Diagnostic Protocol
ED Clinically Stable
Negative ECG/Markers
CPU
Low Risk
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Accelerated Diagnostic Protocol
CPU Serial ECGs, Markers (1-2 sets)
To exclude ischemia/necrosis at rest
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Accelerated Diagnostic Protocol
CPU Serial ECGs, Markers (1-2 sets)
if negative
“Confirmatory” test
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Accelerated Diagnostic Protocol
CPU Serial ECGs, Markers (1-2 sets)
if negative
Confirmatory test
To exclude inducible ischemia or anatomic CAD
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Accelerated Diagnostic Protocol
CPU Serial ECGs, Markers (1-2 sets)
if negative
Confirmatory test
Discharge w/follow-up
Admit
if negative if positive
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UCDMC CPU • 17 years, >6,000 patients
– Elderly/young, M/F, +/- CAD, antianginal drugs, DM – TIMI risk score not applied in CPU patients
• ACC/AHA guidelines – ETT
• If ECG WNL and patient can exercise • 1/3 patients require a different test
• Preferred initial test at many centers - MPS, CTCA based on expertise, resources
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ADP in Low Risk Women Presenting with CP
• N = 371 • <50 yo, no DM/smoking, • ED ECG normal, clinically stable, neg. markers • ETT = 240, Stress imaging = 20, no confirmatory test = 111 • Negative CPU evaluation in all patients, all directly discharged
• 5 yr follow-up: 0 cardiac events • Conclusion: All CP patients do not require confirmatory testing
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No Confirmatory Test • If ECG, Troponin Negative: • UC Davis
– 40% of pts discharged without test, LOS <2 hr – NPV 100% at 1 year
• Than (Lancet, JACC) 2012 – No Test, LOS 2 hr
• TIMI score 0, ECG neg, hs-cTi neg at 0 and 2 hrs. – NPV >99% at 30 days
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TIMI Risk Score for UA/NSTEMI
4.7 8.3 13.2 19.9 26.240.9
01020304050
0/1 2 3 4 5 6/7
Number of Risk Factors
DI/M
I/Urg
Rev
asc
(%)
% Population 4.3 17.3 32.0 29.3 13.0 3.4
•Age ≥ 65 y•≥ 3 CAD Risk Factors•Prior Stenosis > 50%•ST deviation•≥ Anginal events ≤ 24 h•ASA in last 7 days•Elev Cardiac Markers
Antman et al JAMA 284: 835, 2000
• Age ≥65y •≥3CAD RFs •CAD •ST deviation •≥2 angina/24 h •ASA in last 7 d. •↑ Markers
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“Confirmatory” Tests • Functional Neg. Predictive Value
– Treadmill Ex >99% – MPS(sestamibi, stress) >99% – Stress Echo ~95%
• Anatomic –CTCA >99%
• No Test >99%
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Schlett et al, JACCi 2011;4:461
ROMICAT
ED ETT – 99% NPV Discharge in <6 hr. Cost $1200 (UCDMC)
38% of patients did not qualify for CTCA
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CTA in the ED • 12 studies (2005-2012) • N = 5865 pts, 30-81 y.o. • NPV 96-100% (ED and >1 yr)
• PPV 13-87% • LOS 7-21 hrs • Radiation 5-18 mSv
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Radiation • 10-20 mSv exposure = 1 new Ca for
every 500-1000 scans • US National Research Council on
ionizing radiation (2005)
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Revascularization after CTA for Low Risk ED CP Patients (Positive Predictive Value 13-87%)
Std Care (%) CTA (%) Goldstein 1.0 5.0 CT-STAT 2.4 3.6 Litt 1.3 2.7 ROMICAT-II 4.2 6.4
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CTA in ED – Exclusions CTA ETT
CAD- h/o MI, PCI or CABG YES NO CKD YES NO COPD YES NO Allergy to contrast/ shellfish YES NO > 6 hrs since presentation to ED YES NO BMI ≥39 kg/m2 YES NO Metformin therapy YES NO Contraindication to β-blocker YES NO
Pregnancy YES NO Inability to hold breath YES NO
HR >90 bpm** YES NO
CT imaging within past 48 hours YES NO Normal CTA/cor angiography in previous year YES NO Cocaine use within past 48 hours YES NO Radiographic abnormalities YES NO
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Exclusions 12%
Standard of Care?
50% 52% 46%
CTA in ED
(More than half of studies do not include % exclusions)
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CTA for Chest Pain Patients in the ED
The gold standard OR…
The Midas touch?
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Summary • Low/interm risk - ID on presentation
• Goal – Exclude ACS (not exclude CAD)
• Evaluation - ADP, Confirmatory test
• All patients do not require confirmatory test
• CTCA – Selected patients only!