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
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
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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
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Goals
• Accurate risk stratification
• Find the appropriate modality of evaluation for the circumstance
• Patient reassurance
• Appropriate utilization of resources
• Stay out of court!
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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.
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NON-CARDIAC DIAGNOSIS
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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
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See ACC/AHA Guidelines for Chronic Stable Angina
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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
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See ACC/AHA Guidelines for NSTEMI ACS
See ACC/AHA Guidelines for STEMI
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POSSIBLE ACS
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1.Immediate ECG
2. Observe
3. Study
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Likelihood That Signs and Symptoms Represent an ACS
Secondary to CAD
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Likelihood That Signs and Symptoms Represent an ACS
Secondary to CAD
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Likelihood That Signs and Symptoms Represent an ACS
Secondary to CAD
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1.Immediate ECG
2. Observe
3. Study
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1.Immediate ECG
2. Observe
3. Study
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RISK SCORES
SIMPLE!!
IS THE TROPONIN ELEVATED (ecg
abnormal)?
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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.
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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.
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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.
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Exercise Stress Testing in Accelerated Diagnostic Protocols (ADP’s)
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Rest Myocardial Pefusion Imaging
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Stress Echo
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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.
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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.
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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)
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References
• See articles provided for your handouts
• Guidelines can all be found and downloaded at acc.org
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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
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An anxious heart weighs a man down,but a kind word cheers him up. --Proverbs 12:25