Low Risk Chest Pain Strategies

Transcription

1 Low Risk Chest Pain Strategies Carol Lynn Clark MD MBA FACEP Associate Director of Research Department of Emergency Medicine Beaumont Health System Professor Oakland university William Beaumont School Of Medicine September, 2014 Disclosures Hospital research support from Biocryst, Cardiorentis, Genentech, Glaxo Smith Kline, Janssen, Nexbio, Novartis, Portola, Lundbeck, Pfizer, Radiometer Advisory boards for Astellas, Janssen, Pfizer, Society of Cardiovascular Patient Care Objectives Discuss the evaluation of chest pain in the Emergency Department and Observation Unit Discuss risk stratification of chest pain patients Discuss usefulness of Coronary CT Angiograms Coronary Artery Disease Estimated 620,000 New MIs each year Nearly 300,000 Recurrent MIs each year 150,000 Silent MIs each year 1 in 6 Deaths each year from CAD Chest Pain > 8,000,000 visits annually for chest pain 5% have ST Elevation MI (STEMI) 25% have NON ST Elevation MI(NSTEMI) 2% Missed MI RATE Those two percent: Have a 2 fold adjusted mortality rate over hospitalized MIs Highest pay out awarded for malpractice cases Are what we are looking for Needle in a haystack? 1

2 Chest Pain 10 % ED visits 25% of Hospitalizations 85% do not have final diagnosis of Acute Coronary Syndrome A lot of costs to find that needle! HELP? Chest Pain Evaluation Starts with a History and Physical Rule out other life threatening illness Assess for Pulmonary Embolus, Pneumonia, Dissection. Asthma/COPD, Pneumothorax, Trauma Ask the right questions Do a physical exam Assess their risk for cardiac disease/ events Hollander, History and Physical Non-cardiac Pain: 16.8 %, Still had MACE Costochondritis: 6 % MACE Alternative Dx: 4% MACE, still! So be careful! MACE= Major Adverse Cardiac Events TIMI Risk score 1 Point Each Age > 65 years old Greater Than3 Coronary Risk Factors Known CAD, > 50 % Stenosis Aspirin Use last 7 days Severe Angina last 24 hours, greater than 2 events or persistent ECG 0.05 mv on ECG Positive Cardiac Markers,(originally CPK- MB and Troponin) CAD Risk Factors TIMI Risk Score Family History Coronary Artery Disease Hypertension Hypercholesterolemia Diabetes Smoker Rate Percent TIMI Risk Rate of Death or MI at 14 Days percent 0 0/ TIMI Risk Score Problem is still a 2.9 % risk with 0/1 TIMI Risk Score! 2

3 TIMI RISK SCORE: Death or MI Within 14 days 0/1, 2.9 % risk 2, 2.9% Risk 3, 4.7 % Risk 4, 6.7 % Risk 5, 11.5 % Risk 6/7, 19.4 % Risk Those numbers may be old? With newer serial troponins? Than et al., ADAPT Trial 1,975 patients Used a 2 hour Accelerated Diagnostic Protocol Contemporary troponins TIMI score 0-1 MACE at 30 days ADAPT Trial: TIMI Score 0 Advanced Diagnostic Protocol (ADP) 0, 2 hour conventional troponins only plus ECG 1975 patients, 392 qualified for ADP TIMI Score =0 302 Had MACE in 30 days overall, 15.3 % If only TIMI score and ECG (no troponins) used, 3.2 % MACE at 30 days Than et al., ADAPT Trial 392 found to be low risk by: TIMI score 0 No new ischemic changes on ECG 0 and 2 hour negative Troponins Only 1 in ADP group within 30 days, TIMI 0, had MACE,.25%, ADAPT Trial: TIMI Score 0 Sensitivity of 99.7 % Negative Predictive Value, 99.7% Specificity of 23.4 % Positive Predictive Value 19.0 % Only 1 False Negative 3

4 ADAPT Trial: TIMI Score 0-1 Increased inclusion to 38.4 % Added an additional 9 false negatives Sensitivity 97.0%, Negative Predictive Value 98.8% Specificity of 44.8 % Positive Predictive Value 24.1 % So TIMI Risk 0, 0/1 So TIMI Risk 0 Probable Ok to do serial enzymes and Close Follow-up TIMI Risk 0/1 Maybe ok if you can get them to follow-up closely, Or at least can go to additional testing early At least talk numbers with the patient! TIMI Risk Score 2/3 2.9 % to 4.7% Risk, needs further testing Should undergo serial enzymes and some provocative testing Perfect patients for EDOU Soft 3s with cardiology consult Obvious ischemic ECG or positive markers or HARD 3s should be admitted to the hospital TIMI Score >3 High Risk patients Cardiac Step-down IV Nitrates Anticoagulation Aspirin, Clopidogrel Troponin Only marker you need now 99 th percentile cutoff Watch for change, delta troponins Only time to get a CPK-MB is if the cardiologist wants it Some help to follow reperfusion after procedure Troponin Any positive troponin has been shown to have increased mortality May be Myocardial Infarction, Myocarditis, Pulmonary Embolus Something is causing a leak Even in End stage Renal Disease it is a bad thing So if patient is having chest pain and an elevated troponin, admit the patient 4

5 Troponin May miss on first set of markers if chest pain is very early If no provocative test planned should do serial markers If provocative testing can do shorter, 0, 2 or 3 hour and then provocative test If no provocative testing planned, patients that are not cath eligible, should do longer rule out, 0,3,6 hours So in up to this point : The Ones you think Are, Aren't and the Ones You Think Aren t Are! So do the workup! So : Good history and physical Cardiac markers and ECG Repeat markers and ECGs Risk Stratify Do the workup Get provocative testing in all but the very low risk patients So if you do need a further test? When can a Coronary CT Angiogram (CCTA) help? Goldstein et al., CT STAT 699 Patients, 361 CCTA, 338 Stress MPI TIMI 0-4 LOS, 2.9 hours vs. 6.3 hours median Costs, $2,137 vs. $3,458 median MACE 30 days, no significant difference 64 slice to 320 slice, Standard MPI Goldstein et al, CT STAT 26 cases to cath, 76.9 % consistent with CCTA 2 Revisited ED One revisit with normal cath 1 with benign palpitations, no further workup CCTA group: 5.2% clinical events in 6 months, 14 revascularizations 5

6 Goldstein et al, CT STAT MPI group, 22 Cath, 54.5 % consistent with MPI 4 revisited ED 1 normal cath, 3 non cardiac chest pain MPI Group: 3.7 % clinical events 6 months, 8 revascularizations Goldstein et al., CT STAT NO clinical difference in early or late outcomes Similar cath numbers on index visit Similar AMI numbers Lower radiation in CCTA group, 11.5 msv verses 12.8 msv Goldstein et al, CT STAT More rapid diagnosis, 54 % time reduction to diagnosis Time reduction = Cost reduction Similar cost of studies themselves Zero mortality at 6 months both groups Hoffmann Et al., ROMICAT 11 Randomized to initial CCTA or Standard evaluation After CCTA could have anything at discretion of local physician years of age, BMI < 40 No other exclusions, i.e. contrast allergy etc. to CCTA Hoffmann Et al., ROMICAT 11 Low/ Intermediate Chest Pain 985 patients, 501 CCTA, 499 Standard Care Length of Stay Reduced by 7.6 hours Time to diagnosis decreased in CCTA group Discharged directly from ED, 47% CCTA vs. 12% Standard group Hoffmann Et al., ROMICAT 11 CCTA group more downstream testing Higher radiation exposure due to above Similar cumulative cost of care due to above Majority in standard group did not get MPI SPECT testing ( reason for lower radiation) Long term follow-up? 6

7 Hoffman et al., ROMICAT 11 8% overall Acute Coronary Syndrome More MACE in SOC group,.4% vs. 1.2%, but not powered to evaluate, More Invasive Procedures in CCTA group: 11% vs. 7% index, 12% vs. 8% through 28 day follow-up Curry et al., Triage Coronary CT 529 patients CCTA in patients with low risk of ACS, TIMI 2, Normal ECG normal troponins, pain less than 20 minutes Decreased LOS, 14 vs hours 88.4 % discharged from ED: neg. 317, mild disease 151 2% MACE in discharged patients One mild, days total occlusion CURY et al., Triage Coronary CT 4.7% (25) had moderate stenosis and 68 % (17) underwent further testing 9 underwent MPI, all negative Mod. CCTA, 7 direct to cath, 6 >50%, 5 PCI 0 MACE Don t really know difference? Why who went where? CURY et al., Triage Coronary CT 6.8% (36) had > 70% stenosis on CCTA 9 underwent MPI, 7 positive, 6 to cath 23 directly to cath, 21 positive > 70% Of the 36 >70%, 27 cath, PCI 17, MACE % MACE in > 70 % stenosis patients 47% PCI in > 70 % stenosis Again don t know who and why for PCI? CURY et al., Triage Coronary CT 3.2 % (17) of 529 low risk patient got PCI TIMI 0-2 So not sure who was a 0, a 1 or a 2? Who were the 6.8 %? Not sure of breakdown of who had what in the PCI group? No mention of bypass grafting? So what we know? Negative CCTAs appear very good in all studies Moderate CCTAs should likely have functional action test added at least Severe should probably go to cath 7

8 What we know? Maybe more invasive procedures in CCTA patients, good or bad Good if saves future damage, bad if just doing more with no better long term outcomes? Decreases LOS in ED, important in crowding If negative less radiation Radiation, 1-3 msv Coronary CT Angiogram (CCTA) Currently about 1-3 Millisieverts of radiation Radiation dose increases with BMI and Heart Rate Do not need calcium scoring So CCTA Radiation is less than 25 % of MPI Stress Test Radiation Coronary CT Angiogram (CCTA) Stress Importance of Beta-blockade to lower heart rate The higher the BMI the more important it is to slow the heart rate MPI Stress test around Millisieverts radiation Beta- Blocker For CCTA The excitement of feeling the input of dye increases the heart rate Diagnostic quality is dependent on beta-blockade Dose should be checked by hand grip for adequate blockade before going to CCTA Hand squeeze for 30 seconds, use heart rate Lopressor Dosing Pre CCTA Heart Rate >65 Heart Rate Heart Rate <55 BP>90 BP>90 Or BP<90 Give lopressor 100mg Give lopressor 50mg No premed Evaluated by 30 second hand grip order for one hour prior to testing 8

9 Beta Blocker for CCTA Contraindications COPD/ asthma requiring daily inhalers or steroids within 3 months PVCs or Atrial Fibrillation History of Heart block/ pacemaker Other CCTA Contraindications Iodine allergy- needs 13 hour prep if necessary scan Patients taking Viagra like meds, discussion of nitrates Severe aortic stenosis Other CCTA Contraindications Renal Disease Pregnancy Decompensated heart failure Active unstable coronary symptoms Who to not use CCTA in? Avoid BMI > 38 or very truncal obese, barrel chest Avoid in high heart rate Avoid in elderly, cut off Patients not amendable to intervention if positive Avoid in previous CAD, PCI/ Stented patients So if you have availability of a CCTA use it in your Low Risk Population We use it preferentially if not contraindicated Unless it is a young woman with very low risk then we use a Stress echo as the preferred test Young women Reason no radiation Can use exercise stress test alone if very low pretest probability Coronary CT Angiograms Need 20 gauge AC IV Need BUN, CR; beta HCG if appropriate Remember sufficient IV fluids/ renal protection as with any contrast CT We use cardiologists as readers for our CCTAs 9

10 CCTA Keys to success Must be able to slow heart rate Must hydrate patient Treat anxiety if necessary Use in younger (< 70 y.o.) Low to intermediate risk patients with no other contraindications Coronary CT Angiograms A negative CCTA is as good as a negative cath! A negative CCTA goes home! If you have a negative CCTA don t do further testing on revisit if labs, ECG remain normal GI? Or other referral Coronary CT Angiograms Saves time Minimal radiation Shortens ED length of stay and overall length of stay If used wisely saves costs! I don t have heart Disease! Thank you, Any Questions? 10