low risk chest pain seminar - henryfordem.compe is usually normal in uncomplicated acs . may point...
TRANSCRIPT
LOW RISK CHEST PAIN SEMINAR
Emily McLaren, PGY 3 7 February 2013
What are the history and physical characteristics of
patients presenting to an ED with chest pain that is low risk
for ACS?
Objectives
What is the role of the H&P in identifying LRCPPTS?
What is the role of classic cardiac risk factors in risk stratification of ACS?
What clinical decision tools are available to aid in risk stratification of LRCPPTS?
What is low risk chest pain?
Typical chest pain Heberden 1768 A painful sensation in the breast accompanied
by a strangling sensation, anxiety, and occasional radiation of pain to the L arm
Associated with exertion, relieved with rest Atypical or low risk chest pain
Everything else?
Why do we care?
We miss about 2-5% of ACS Most CP admissions are for non-cardiac
chest pain
H+P, RF, and decision tools are available to aid in our decision making
Chest Pain History
JAMA 2005 Literature review of prospective and
retrospective observational studies and systematic reviews
Chest Pain Characteristics
Chest Pain Radiation
Typical CP: radiation to L neck, shoulder or arm
ACS To R arm, shoulder (PLR 4.7) To both arms (PLR 4.1) To L arm, shoulder (PLR 2.3)
Chest Pain Quality
Typical CP: pressure, ache
ACS Same as prior MI (PLR 1.8) Pressure (PLR 1.3)
ACS Sharp, stabbing (PLR 0.3)
Chest Pain Location
Typical CP: substernal, L chest Poorly studied Poor predictive value
Substernal CP Region of infarction (exception: inferior AMI)
ACS: Inframammary (PLR 0.8)
Area of Chest Pain
Typical CP: diffuse
ACS: < size of coin (PRL 0.6 with CI 0.3-1) Everts et al, 822 pts Non-AMI 11% vs AMI 7%
Chest Pain Severity
×
Time Course ACS: crescendo pattern Non-ACS: maximal intensity at onset
Duration Seconds – non-ACS 2-10 min – angina 10-30 min – unstable angina > 30 min – AMI vs non-ACS (GI) Recurrent, hrs-days – non-ACS
Palliative/Provocative Factors and Associated Symptoms
Palliative Factors
Nitro GI Cocktail Rest ×
Provocative Factors
ACS Exertion (PLR 2.4)
Equivocal Emotion Stress
Provocative Factors ACS
Pleuritic (PLR 0.2) Positional (PLR 0.3) Reproducible (PLR 0.3) Non-exertional (PLR 0.8)
Lee et al (1985) – 22% of pts with sharp pain dx with ACS (13% pleuritic, 7% reproducible)
Lee et al (1987) – 3 Ps + no hx of CAD, none dx with MI
Associated Symptoms
ACS Diaphoresis (PLR 2) Nausea/vomiting (PLR 1.9)
Disappears with multivariable testing
Conclusions
Conclusions
Individual elements are assoc with increased or decreased risk of ACS
No element of chest pain quality alone or in combination identify patients that can be safely discharged without further diagnostic testing
Limitations
Characteristics treated as independent, rather than interdependent variables
Quality is subjective Only addresses CP, not other anginal
equivalents
Physical Exam
HIGH LIKELIHOOD
INTERMEDIATE LIKELIHOOD
LOW LIKELIHOOD
• Pulmonary edema • New or worsening MR • S3 • Hypotension • Brady or tachycardia
• Extracardiac vascular disease (bruit)
Reproducible CP
PE is usually normal in uncomplicated ACS
May point to non-ACS Dx
Unequal pulses - dissection Murmurs - endocarditis Friction rub - pericarditis Fever, rhonchi - pneumonia Reproducible CP - MSK
Cardiac Risk Factors
Risk Factors
Age, Male Gender, HTN, HLP, DM, smoking, and family history
Framingham study: 2+ risk factors = higher lifetime risk of CAD
Jayes et al, 1992 1743 pts What to RF add to hx and EKG when
diagnosing ACS?
Jayes et al
Han et al, 2007 Retrospective analysis of 10,806 patients
with suspected ACS 8.1% met end point: ACS within 30 days
(PCI, biomarkers, death)
Conclusions
Conclusions Cardiac RF have limited value in diagnosing ACS in ED patients older than 40
Conclusions -LR 0 RF +LR 4+ RF
< 40 0.17 (0.04-0.66) 7.39 (3.09-17.67)
40-65 0.53 (0.4-0.71) 2.13 (1.66-2.73)
> 65 0.96 (0.74-1.23) 1.09 (0.64-1.62)
Limitations
RF given equal weight Verification bias
Clinical Decision Tools
Early Risk Scores
Pozen et al, 1980: created a ‘mathematical predictive instrument’ to decrease CCU admissions
Selker et al, 1998: ACI-TIPI Goldman et al, 1988: < 7% risk of AMI Limkakeng et al, 2001: < 4.9% risk of AMI
TIMI Risk Score
Developed to categorize risk of death or ischemic events in pts with NSTEMI or UA
Used as basis for MDM
Chase et al, 2006 First prospective observational cohort to
validate TIMI in ED pts 1458 pts
Chase et al, 2006
Chase et al, 2006
TIMI Score 0 = 1.7% event rate
Chase et al
Similar Studies
Pollack et al, 2006 3929 patients TIMI 0 = 2.1% risk
Conclusions
TIMI risk score does correlate with outcome Identified large group of pts that are low risk
for primary outcome at 30 days Cannot be used in isolation to determine
dispo
“Manchester” Modified TIMI
Body et al, 2009 Pts with positive troponin or EKG changes
may only have TIMI = 1 Prospective cohort 796 pts
Body et al
TIMI < 3 = sensitivity of 96%
Hess et al, 2010 Prospective observational study 1017 pts
Hess et al, 2010
Than et al, 2011 3582 pts in 14 EDs, 9 countries TIMI + biomarker panel at 0 and 2 hrs 2 hr TIMI 0 = 0.9% risk (9.8% of pts)
Than et al
Aldous et al, 2012 1000 from ASPECT Primary outcome in 36.2% Also included high sensitivity Troponin T 2 hr TIMI 0 = 0.8% risk (12.3% pts)
GRACE Global Registry of Acute Coronary Events Prospective multinational observational study
of hospitalized pts with ACS 8 variables
Looks at in-hospital and 6 month all-cause mortality
Age HR SBP Cr Killup score
ST segment depression
Elevated biomarkers
Cardiac arrest
Lyon et al, 2006 Retrospective cohort 1000 pts TIMI = GRACE
Lee et al 2011 TIMI vs GRACE vs PURSUIT Prospective cohort study 4723 pts
PURSUIT
Lee et al
TIMI = 0 in 39%
GRACE < 41 in 4.5%
Lee et al
Kline et al, 2005 Prospective database of 8 variables from
14,796 pts Attribute matching vs ACI-TIPI
Attributes matching
Kline et al
Mitchell et al, 2006 1114 pts Attributes matching vs. ACI-TIPI vs.
physician estimate
Mitchell et al
Sanchis Rule
Sanchis et al, 2005 646 pts Focuses on clinical history Excludes EKG changes and (+) troponin Primary end point at 1 year, secondary at 14
days
Chest Pain Score
Hospital Course and Results
322 had exercise ST: (-) 190, (+) 52 216 pts early D/C 430 pts hospitalized
227 cardiac cath 68 PCI 31 CABG
Primary end point: 1 yr (6.7%), 14 days (5.4%)
Calculated risk score
CP score > 10 1 point > 2 pain episodes in 24 hrs 1 point Age > 67 1 point IDDM 2 points Prior PCI 1 point
In pts with negative troponin and no EKG changes
Calculated Risk Score
Score 0 1 2 3 > 4
Event Rate 0% 3.1% 5.4% 17.6% 29.6%
Stress Results Event Rate
Negative Inconclusive Positive Not done
1.6% 3.9% 9.6% 10%
Score of 0 = 17.2% of pts
Limitations
Complicated CP score Subjective
Vancouver Rule
Christenson et al, 2006 Prospective cohort, 769 pts Screened 123 potential predictor variables Clinical decision tool that is 98.8% sensitive
and allows for D/C of VLRCP pts within 2-3 hrs (32.5%)
Other similar studies
Marsan et al (2005): age < 40, no CAD hx, normal EKG OR no CAD RF, normal initial biomarkers = ACS rate 0.14%, no CV events at 30 days
Collin et al (2011): no events for same patients at 1 year
Limitations
Outdated biomarkers Detroit ≠ Vancouver
Six et al, 2008 120 pts Clinical questions
Why do we admit to CCU? Predictors of 90 day events?
Six et al
0-3: 2.5% risk (32.5% of pts)
4-6: 20.3% risk
7-10: 72.7% risk
Six et al
Conclusion – can use HEART to determine early D/C vs. early intervention
Limitations Small study Use CP hx
PURSUIT vs TIMI vs GRACE vs FRISC vs HEART
Uses c-statistic to claim HEART superiority
Mahler et al, 2011 Prospective cohort 1070 CP Obs pts (TIMI < 2 and clinically low
risk) Outcome
HEART < 3: 0.6% events HEART < 3 + 4-6 hr troponin: 0 events
Fesmire et al, 2012 Retrospective study 2148 pts Weighted HEART + 3 S’s
Sex Serial troponin and EKG Decreased weight of RF, age and CAD hx Increased weight on chest pain hx
Fesmire et al
HEARTS3 < 2 = 0 events
(14% vs 8%)
Fesmire et al
Older troponin Retrospective study
Hess et al, 2012 Prospective observational cohort of 2,718
patients 12% met primary outcome (ACS,
revascularization, death) within 30 days Identified patients with zero risk for 30 day ACS
Conclusions
Developed a highly sensitive clinical decision tool to identify very low risk patients for ACS
Limitations
Does not include pts at risk for ACS with non-chest pain CC
Evaluation bias: not all patients underwent definitive testing
What is typical chest pain? Needs prospective multicenter validation
Aldous et al, 2012 Post hoc analysis of ASPECT trial Primary endpoint in 36.2%
Study Population
Results
Results
Conclusions
Several elements of CP hx and multiple decision tools available to aid in dx of ACS
Classic CAD risk factors less impt in acute setting
Ultimately unlikely to change our clinical practice
References 1. Swap and Nagurney. Value and Limitations of Chest Pain History in the Evaluation of Patient With Suspected Acute Coronary Syndrome.
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3. Sanchis et al. New risk score for patients with acute chest pain, non-ST- segment deviation, and normal troponin concentrations: a comparison with the TIMI risk score. J Am Coll Cardiology 2005;46:443-449.
4. Christenson et al. A clinical prediction rule for early discharge of patients with chest pain. Annals of Emergency Medicine. 2006;47:1-10.
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