Osama Jarkas. in Chest Pain Patients. STUDENT NAME: Osama Jarkas DATE: August 10 th, 2015

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1 STUDENT NAME: Osama Jarkas DATE: August 10 th, 2015 PROJECT TITLE: Analysis of ECG Exercise Stress Testing and Framingham Risk Score in Chest Pain Patients PRIMARY SUPERVISOR NAME: Dr. Edward Tan DEPARTMENT: Department of Emergency Medicine 1

2 Abstract Background In the Portage General Hospital (PGH) Emergency Department, chest pain accounts for one of the most common reasons of visitation. Most chest pains are of non-cardiac and non-organic etiologies. 4 Nonetheless, it is imperative to first rule out cardiac causes of chest pain. The vast majority of PGH patients who present to the emergency department with typical or atypical chest pain earn themselves an ECG exercise stress test (EST) within twenty-four hours to a week of admission. The Framingham Risk Score (FRS) is the recommended tool for predicting 10-year cardiovascular risk according to the American Heart Association (AHA). 1 The purpose of this study is to assess and compare the FRS of patients presenting with chest pain and their stress test results. It is also the purpose of this study to assess whether or not the approach to stress testing should be reevaluated by the emergency physicians and the hospital. Methods and Results A retrospective chart review of all patients who presented with chest pain to PGH emergency department during the period of June 1, August 1, 2015 was completed. A total of 55 patients were enrolled in the chart review. 11 were excluded because they did not meet the exclusion criteria for the study or the stress test. In total 44 patients (24 females and 20 males) participated in the chart review. All 44 patients had presented to the PGH emergency department. All patients participated and completed an ECG stress test reaching 85%- 100% of 2

3 their target heart rate. And all patients were then assessed using the FRS. According to the ECG stress tests 10 out of the 44 patients (22.7%) showed a positive ECG for myocardial ischemia. 5 out of 20 of the male population (25%) and 5 out of 24 of the female population (21%) had positive results for ischemia. It was found that 18.7% of low FRS patients had a positive stress test; 14.3 % of intermediate FRS patients had a positive stress test and 35.7 % of high-risk patients had a positive stress test. Conclusion It was expected that patients with the highest FRS would have the highest incidence of positive results on the ECG stress test. That being said, all high-risk patients regardless of the stress test result require further follow up and testing. The second highest percentage of positive patients was in the low risk category; these were all labeled as most likely false positives and not of cardiac etiologies. As such the true benefit of the stress test is found in intermediate FRS patients. Background In the Portage General Hospital (PGH) Emergency Department, chest 3

4 pain accounts for one of the most common reasons of visitation. Most chest pains are of non-cardiac and non-organic etiologies (not caused by cardiac, pulmonary, or gastrointestinal etiologies). 4 Nonetheless, it is imperative to first rule out cardiac causes of chest pain. In the PGH patients who present to the emergency department with typical or atypical chest pain earn themselves an ECG stress test within a twenty-four hours to a week of admission. It is critical to have a strong approach to the diagnosis and management of chest pain. Guidelines published by cardiovascular associations across North America recommend physicians to complete a detailed history, a thorough physical examination, and additional investigations and tests if the history and physical exam do not suffice. 4 The history should include all components of a traditional history with the addition of a focus on the description of the chest pain, the associated symptoms and the risk factors. The history is important in determining if this pain is typical or atypical; or if it is cardiac or non-cardiac. The physical exam is meant to support or disprove the history. The physical exam should include a thorough investigation to rule out cardiovascular, pulmonary, gastrointestinal, musculoskeletal, and psychogenic etiologies. Depending on the presentation of the patient and the history and physical exam, an ECG, chest radiograph, or stress test may be ordered. The ECG stress test is performed on all patients that present to the emergency department complaining of chest pain. According to the AHA, exercise stress tests utilize a treadmill or a bicycle to increase the cardiac effort while monitoring a patients ECG and blood pressure. 2 The stress test has many 4

5 advantages including low cost, ease of testing in many settings, low complications and the ability to be performed by accredited non-cardiologists. The risk of infarction or death during a stress test is 1 in The stress test is an incredibly useful diagnostic tool especially in low and intermediate risk patients with atypical chest pain. That ECG stress test is not the most sensitive or specific form of the stress test. The stress echocardiogram is of higher sensitivity and specificity. 5 False positives are common in low risk populations and false negatives are common in high-risk populations. This phenomenon will be further discussed in the discussion. The exercise stress test is considered abnormal if the patient experiences ischemic chest pain; if the ECG shows horizontal or down sloping of ST depression of 1 mm or greater; or if the ECG shows ST elevation of 1 mm or greater. 3 The use of the exercise stress test to risk stratify the cardiac risk of patients has a trend for almost six decades. 2 It is increasingly used in the PGH emergency department with all cases of chest pain. The effectiveness and statistics have never been studied previously. The purpose of this study is to assess and compare the FRS of patients presenting with chest pain and their stress test results. It is also the purpose of this study to assess whether or not the approach to stress testing should be reevaluated by the emergency physicians and the hospital. Methods and Results 5

6 A retrospective chart review of all patients who presented with chest pain to PGH emergency department during the period of June 1, August 1, 2015 was completed. A total of 55 patients were enrolled in the chart review. 11 were excluded because they did not meet the exclusion criteria for the study or the stress test. In total 44 patients (24 females and 20 males) participated in the chart review. Patients were excluded if they did not meet the exclusion criteria. Patients who did not have complete histories and physical exams charted and documented were excluded. Symptomatic patents who experienced any of the following were excluded as well: acute myocardial infarction (within two days), unstable angina, uncontrolled arrhythmias, severe valvular stenosis, symptomatic heart failure, acute endocarditis, acute myocarditis, acute pericarditis, acute pulmonary embolism, and acute non-cardiac disorders that maybe aggravated by exercise. All patients who presented with ECG abnormalities that would interfere with interpretation of the stress test were also excluded. 2 All 44 patients had presented to the PGH emergency department. All patients participated and completed an ECG stress test reaching 85%- 100% of their target heart rate. According to the AHA, the target heart rate is defined as 220 minus the patient s age. And all patients were then assessed using the FRS. The FRS estimates a patient s 10-year risk of developing cardiovascular disease. The FRS calculation involves taking into account a patients age, gender, total cholesterol, HDL, LDL, smoking history, blood pressure, whether the patient is being treated for high blood pressure and whether or not the patient is a diabetic. 6

7 1 According to the ECG stress tests 10 out of the 44 patients (22.7%) showed a positive ECG for myocardial ischemia. 5 out of 20 of the male population (25%) and 5 out of 24 of the female population (21%) had positive results for ischemia. It was observed that women were more likely to have atypical chest pains. Moreover, their FRS was generally significantly lower than men. Sixty percent of the positive female patients were not thought to be as true positives, because of their low FRS and their weak cardiac history. The majority of patients tested (16 out of 44) were of the low FRS category with scores below 10%. It was found that 18.7% of low FRS patients had a positive stress test. It must be noted that all the positive results were considered as borderline positive and most likely false positives. As such, further follow up was not recommended. These results were noted in the chart and copied to the family physician. The intermediate FRS category of patients (14 out of 44) had FRS, which ranged between 10 to 20%. 2 out of 14 patients (14.3%) with intermediate FRS had positive stress tests. These patients were scheduled for further follow-ups and were referred to a cardiologist. The final group of patients was of the high FRS category, patients with FRS of above 20%. Approximately, 35.7% of the high FRS population had positive stress tests. The attending physician scheduled all patients in the high-risk category for further testing and follow-up. Discussion This study was the first of its kind in the PGH. This retrospective study 7

8 was very limited in the number of participants and in the length of the study. That being said, in the years to come this study will be further continued and followed up on in PGH and across Manitoba. Several conclusions can be drawn from this study. In medicine, guidelines are important because they provide the latest evidence based research on different practices. At the same time it is crucial to understand the context and the appropriateness of practicing in different parts of the world. Not every patient presenting to the emergency department with chest pain necessarily needs or will benefit from an Exercise ECG stress test. According to this study, 35.7% of high FRS patients (FRS of 20% and above) showed positive findings on their exercise test. Regardless of the results of the stress test, these patients were at a high cardiac risk and were all referred to a cardiologist for further follow up. Did a positive or negative result on the stress test ultimately change the course of management for this high-risk population? As for the low FRS population (below 10% FRS), the stress tests showed that 18.7% of this population was positive. Were those positive results true positives? According to the attending physicians and the charts, these low risk patients were likely false positives. No management was recommended for them; however this group of patients was watched more carefully by their family physicians. Are exercise stress tests needed in all patients presenting to the emergency room with chest pain? Many low risk patients with atypical chest pain likely do not have cardiac pathology. Many high-risk patients may already be 8

9 seeing a cardiologist or may need to be referred to see a cardiologist as soon as possible. Medicine is about sound clinical reasoning and clinical judgment. Often, in Canada and the United States resources are not allocated appropriately. Tests and investigations are done simply for the sake of doing them. They may have very little value in the management of the patient. Every presenting patient should be approached differently. It is the few patients that physicians are truly uncertain about even after a comprehensive history and examination that should have further investigations completed. Often these puzzling patients present as the intermediate FRS patients and more rarely as the low FRS patients. It is these patients who would benefit most from an exercise stress test. It is also important to elaborate on the fact that a large percentage of the patient population in PGH and Manitoba as a whole are of Aboriginal demographics. These patients are often at an increasingly high Framingham risk from a young age. This population at a very staggering rate faces obesity, diabetes, inactivity, hyperlipidemia, smoking, alcohol abuse and positive family histories. It is almost uncommon, for these patients to present to the emergency department and not be high FRS patients. Resources and government agendas need to be directed towards changing this unfortunate reality. Prevention is the best treatment. Prevention must begin at primary and secondary levels. It is often too late in the diseases progression that these patients are stress tested and told that they have ischemic heart disease. The majority of high-risk patients featured in this study are of Aboriginal or First Nation descent. This is a critical target population. More resources and research should go into ways of improving the 9

10 general health of Canadians as well as the general health of Aboriginal people. In conclusion, it was expected that patients with the highest FRS would have the highest incidence of positive results on the ECG stress test. That being said, all high-risk patients regardless of the stress test result required further follow up and testing. The second highest percentage of positive patients was in the low risk category; these were all labeled as most likely false positives and not of cardiac etiologies. As such the true benefit of the stress test is found in intermediate FRS patients. Moreover, the highest incidence of ischemic heart disease was noted in the Aboriginal population. Future plans and research will be devoted to looking into the cardiovascular health of rural Canadians and Aboriginal people. Reference 1. American Heart Association. Exercise Standards for Testing and Training 2013 Update. Dallas, Texas: American Heart Association; American Heart Association. Heart Disease and Stroke Statistics 2004 Update. Dallas, Texas: American Heart Association; Carlisle R, Fitzpatrick KM, Oreskovich JM, Fredrick GT. Cardiac Stress Testing for Diagnosis of Coronary Artery Disease in Adults with Acute 10

11 Chest Pain. Hospital Physician. 2008; Meisel JL, Aronson MD, Park LP. Diagnostic approach to chest pain in adults. UpToDate. 2015; Mora S, Rita R, Sharrett R, Blumenthal R. Enhanced Risk Assessment in Asymptomatic Individuals With Exercise Testing and Framingham Risk Scores. Circulation. 2005; 112:

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