triage of the ed patient complaining of chest pain david plaut snow, 2004
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TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN
David Plaut Snow, 2004
TRIAGE OF THE ED PATIENT COMPLAINING OF CHEST PAIN
AMI-DIAGNOSTIC ECG AMI-DIAGNOSTIC ECG
AMI-NON DIAGNOSTIC ECGAMI-NON DIAGNOSTIC ECG
QuestionableAdmissions
30%
QuestionableAdmissions
30%
~4% AMIND-ECG
~4% AMIND-ECG
NOAMI
NOAMI
100%
90%
5,000,000 PATIENTS ADMITTED 500,000 PATIENTS SENT HOME
0%
CAP TODAY 1:51, 1994
Unstableangina, stable
angina and other acute
coronary syndromes
30%
UnnecessaryAdmissions
30%
22.9 23
13.4
7.95
3.4 2.8 2.4 24.2
13.1
0
5
10
15
20
25
0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-12 >12
N = 74,365 pts.MEAN = 5.43hMEDIAN = 2.27h
(GISSI-3 STUDY POPULATION)
Time to PresentationP
ER
CE
NT
OF
PA
TIE
NT
S
ONSET TO PRESENTATION (HOURS)
Note: 50 % present within 4 Hours
Temporal Pattern of Cardiac Markers
Cardiac Marker Temporal Pattern
0
20
40
60
80
100
0 2 4 6 12 24 48 72 96
Time After Onset Post AMI (Hours)
Se
nsi
tivi
ty MYO
cTnI 2nd
CK/MB
Reference Range lie on a continuuuuum
TCK 0 ------------------------> 180
CK-MB 0 ------------------------> 5
Myo 0 ------------------------> 80
Age? Sex? Muscle mass? Genes?
cTn Reference Value.
Normal Value for cTnI
0.0
Case A
0.0342.02.51230 h
<0.06<80<2.5<5.0<200
cTnI MYO RIMB TCKTime
A 40 yr old male with CP for 2 hours. His ECG was non-diagnostic.
Case A
0.0312.02.51256
0.0332.02.71312
0.0272.02.31161
0.0342.02.51230 h
<0.06<80<2.5<5.0<200
cTnI MYO RIMB TCKTime
A 40 yr old male with CP for 2 hours. His ECG was non-diagnostic.
D’Costa et al. found a negative predictive value of 100% of Myo.at 2 hours. This was confirmed by Kircher and Montague.
Case B
A 76 yr old male with a history of IHD and mild CHF. Presents with severe chest pain which did not diminish with nitroglycerin.
Time MYO cTnI
<80 <0.06
0 h 66 <0.06
Case B
A 76 yr old male with a history of IHD and mild CHF. Presents with severe chest pain which did not diminish with nitroglycerin.
Time MYO cTnI
0 h 66 <0.06
3 147 0.47
As many as 34% AMI present with a “normal” cardiac profile.
Case B
A 76 yr old male with a history of IHD and mild CHF. Presents with severe chest pain which did not diminish with nitroglycerin.
Time MYO cTnI
0 h 66 <0.06
3 147 0.47
6 --- 1.30 As many as 34% AMI present with a “normal” cardiac profile.
Case C
21 43 1.6 4.0 24112
44 82 3.2 24 756 1
54 82 3.5 29 817 0 h
<0.06 <80<2.5<5.0<200
cTnIMYO RI MB TCKTime
A 48 yr old male complained of CP after working in his field all morning. After trying Maalox he presented to the ED the following morning.
Ladenson has found that cTnI remains detectable for as long as 15 days following an AMI.
Case D
0.02071.02.13126
0.02021.24.73192
0.02171.35.44110 h
<0.06<80<2.5<5.0<200
cTnI MYO RIMB TCKTime
A 64 yr old female with known chronic renal failure presents to the ED with “some pain in my chest.” Her EKG was non-diagnostic.
Final diagnosis: Renal failure
Case E
1.1 67---- 46 4
0.0 27---- 32 0 h
<0.06 <80<2.5<5.0<200
cTnIMyo RICK-MB TCKTime
A 83 yr old female with intermittent chest discomfort is admitted to the ED at Huntington Hospital in Pasadena, CA.
Case E
2.2 32---- 56 9
1.1 67---- 46 4
5.3 145 3.210.2 13416
0.0 27---- 32 0 h
<0.06 <80<2.5<5.0<200
cTnIMyo RICK-MB TCKTime
A 83 yr old female with intermittent chest discomfort is admitted to the ED at Huntington Hospital in Pasadena, CA.
Final diagnosis: AMI with extension
Case KS02
0.01650.2030 1431 2
0.02060.21311469 0 h
<0.06<80<2.5<5.0<200
cTnI MYO RIMB TCKTime
A 32 yr old male complains of chest pain. Admits todrinking 1 gallon alcohol per day.His ECG was non-diagnostic.
Discharge Dx: Subendocardial MI
Questions
Which marker(s)?
When?
A 6 hour protocol for chest pain evaluation
n = 292 (239 non-MI, 53 MI)
• Sensitivity: 97.2%, specificity: 93%
• The negative predictive value: 99.6%
• “The six hour rule-out protocol is… accurate and efficacious.”
Herren, BMJ 2001 Aug 18; 323:372
.
A 90 minute accelerated critical pathway for chest pain evaluation
• All AMI’s were diagnosed within 90 min.
• Negative predictive value: 100%
• Ninety percent of patients with negative cardiac markers and a negative ECG at 90 minutes were discharged home
Ng, S., Am J Cardiol 2001 Sept 15;88(6) 611-7
n = 1285
Evaluation of a 90 minute protocol
• Sensitivity: 96.9%
• Negative predictive value: 99.6%
• Addition of CK-MB did not improve the sensitivity or the NPV
• Addition of a 3 hour draw did not improve sensitivity or the NPV
McCord, Circulation.2001 Sept 25;104(13):1454-6
n= 817
Suggested ProtocolT0 Draw sample for cTn (and Myo?)
If cTn is diagnostic discontinue order If cTn is not diagnostic
Draw 2nd sample 2 - 3 hrs. later If cTn is diagnostic discontinue order If cTn is not diagnostic
Draw 3d sample 2 - 3 hrs. later
TRIAGE OF ED PATIENTS COMPLAINING OF CHEST PAIN
CAP TODAY 1:51, 1994
Unstableangina, stable
angina and other acute
coronary syndromes ~ 30%
Unstable angina is a time bomb …
A 68 yr old male with SOB, known chronic renal failure and acute renal insufficiency presents to the ED. His EKG was non-diagnostic.
Time cTnI
0 h 0.36
9 0.35
33 0.32Final diagnosis: Renal failure with CAD.Patient was discharged.
waiting to EXPLODE !
Time cTnI
0 0.46
2 0.69
6 2.90
Three weeks later patient returned with
severe chest pain and radiating left arm pain.
Serum cardiac troponin I values in unstable angina.
• 74 patients with chest pain at rest, electrocardiographic evidence of myocardial ischemia, and normal values of CK-MB
• Death or nonfatal myocardial infarction was more frequent in patients with elevated cTnI (27.7% vs 5.3%) than those with normal values.
Ottani F Am Heart J 1999 Feb;137(2):284-91
cTnI to Predict Risk of Mortality in ACS
0
1
2
3
4
5
6
7
8
42 d
ay M
ort
ality
(%
)
0 to < 0.4 0.4 to < 1.0 1.0 to < 2.0 2.0 to 5.0 5.0 to < 9.0 >=9.0
cTnI (ng/ ml)
Antman et al. NEJM 1996; 335:1342-9
TRIAGE OF ED PATIENTS COMPLAINING OF CHEST PAIN
CAP TODAY 1:51, 1994
Unstableangina, stable
angina and other acute
coronary syndromes ~ 30%
28
35% of CHDoOccurs 35% of CHDoOccurs in people with in people with TC <200 mg/dLTC <200 mg/dL
Adapted from Castelli. Adapted from Castelli. Atherosclerosis.Atherosclerosis. 1996;124(suppl):S1-S9. 1996;124(suppl):S1-S9.
150 200
No CHDNo CHD
Total Cholesterol (mg/dL)Total Cholesterol (mg/dL)
250 300
Framingham Heart Study—26-Year Follow-upFramingham Heart Study—26-Year Follow-up
CHDCHD
Total Cholesterol Distribution:CHD vs. Non-CHD Population
Questions:
Why add another test?
Why should it be hs-CRP?
30
•
Is there clinical evidence that hs-CRP, a marker of low grade vascular inflammation, predicts future coronary events?
31
hs-CRP and Risk of Future MI in Apparently Healthy Men
PP<0.001<0.001
PP<0.001<0.001
PP=0.03=0.03
Quartile of hs-CRP (range, mg/dL)Quartile of hs-CRP (range, mg/dL)
P P Trend <0.001Trend <0.001
< 0.055< 0.055 0.056–0.1140.056–0.114 0.115–0.2100.115–0.210 0.2110.211
Rel
ativ
e R
isk
of
MI
Rel
ativ
e R
isk
of
MI
Ridker. N Engl J Med. 1997;336:973–979.
0
1
2
3
1 2 3 4
32
hs-CRP and Risk of Future Cardiovascular Events in Apparently Healthy Women
Quartile of hs-CRP (range, mg/dLQuartile of hs-CRP (range, mg/dL))
Rel
ativ
eR
elat
ive
Ris
kR
isk
Ridker. Circulation. 1998;98:731–733.
PP Trend <0.002 Trend <0.002
< 0.15< 0.15 0.15–0.370.15–0.37 0.37–0.730.37–0.73 > 0.73> 0.73
0
1
2
3
4
5
6
1 2 3 4
Any event
MI or stroke
33
0.0
1.0
2.0
3.0
4.0
5.0
High Medium Low Low
Medium
High
hs-CRP Adds to Predictive Value of TC:HDL Ratio in Determining Risk of First MI
TC:HDL RatioRidker. Circulation. 1998;97:2007–2011.
hs-C
RP
Rel
ativ
e R
isk
34
Is there clinical evidence that the effect of hs-CRP on cardiovascular risk can be modified by preventive therapies?
hs-CRP, Aspirin, and Risks of Future Myocardial Infarction
12
34
0
1
2
3
4
Placebo
Aspirin
Relative Risk Myocardial Infarction
Quartile of C-Reactive Protein
Ridker PM, N Engl J Med 1997;336:973-9
What are the recommended guidelines for the use of hs-CRP assays?
Guidelines for Use of hs-CRP
the writing group “recommends against screening the entire adult population for hs-CRP….”“it is reasonable to measure hs-CRP as an adjunct…to further assess absolute risk for CAD primary prevention.”
Circulation 107 (Jan) 499, 2003
Relative Risk and Average hs-CRP
hs-CRP < 1.0 mg/L Low
1.0 -- 3.0 Average
>3.01 High
The Importance of the D-dimer Assay and
Its Use in the Clinical Setting
David Plaut
ThromboembolismIncidence & Mortality
• DVT affects 2 million Americans per year
• Without treatment, PE mortality ~ 30%
• With treatment of heparin or TPA, mortality is <2%
• Only 15-25% of patients suspected of DVT/PE actually have DVT/PE.
What is the role of D-Dimer Assays in PE and DVT?
Causes of Elevated D-dimer
Atherosclerosis TraumaHepatic disease DICInfection PregnancyInflammation Age
Cancer DVTThrombolytic Rx PE
What is the importance of a negative D-dimer test?
If D-Dimer is negative, then there
are no clots being dissolved
= no DVT or PE
The value lies in the ability of d-dimer assays to rule out the Dx of DVT and PE
Clinical policy, College Emergency Physicians, 2003
Patient management recommendationsLevel A (high clinical certainty) None specified
Ann. Emer. Med 41: 257, 2003
Clinical policy, College Emergency Physicians, 2003
Patient management recommendations
Level B (moderate)Low pretest probability of PE use the following tests to exclude PE:
1. A negative quantitative d-dimer2. A negative qualitative d dimer
if Wells score 2 or less.
Clinical policy, College Emergency Physicians, 2003
Patient management recommendations
Level C (low) Low pretest prob. of PE use the following tests to exclude PE:A negative quantitative d-dimeror a negative qualitative d dimer (when not used with Wells system)
Wells et al. criteria
Suspected DVT 3.0Alternate Dx is less likely than PE 3.0Heart rate >100 1.5Immobilized or surgery in last 4 wk 1.5Previous DVT/PE 1.5Hemoptysis 1.0Malignancy (treated within is 6 mo.)1.0
Wells, PS et al. Thromb Haemost. 83: 416, 2000
Wells score and probabilities for PE
Score Probability0 - 2 3.6%3 - 6 20>6 67
Use of D dimer to rule out DVT/PE
Prevalence = 29%Sensitivity = 99.5NPV = 99
Specificity = 41
n= 671
Am. J. Resp. Care 156: 492, 1997
Validity of D-dimer for DVT (Venography)
Ten studies with 945 patients
Sensitivity = 97% ( 89 – 100)NPV = 97 ( 92 – 100)
Specificity = 54 ( 34 – 80)
Brill-Edwards, P Thromb. Hemosta. 82: 688, 1999
Validity of D-dimer for PE (Various)
Ten studies with 1329 patients
Sensitivity = 99% (93 – 100)NPV = 99 (92 – 100)
Specificity = 28 ( 10 – 50)
Brill-Edwards, P Thromb. Hemosta. 82: 688, 1999
Hospitalization and Congestive Heart Failure
Major public health problem worldwide Most frequent cause of hospitalization in
patients older than 65 years Fourth leading cause of adult hospitalization in
US DRG 127 (Congestive Heart Failure):
Primary diagnosis 1,000,000 hospitalizations/ yr
Secondary diagnosis 2,000,000 hospitalizations/ yr.
Total = $38.1 billion(5.4% of total healthcare coats)
O’Connell JB et al. J Heart Lung Transplant. 1994;13:S107-S112
Hospitalization: The Predominant Contributor to CHF Costs
Transplants1%
$270 M
Hospitalization60%
$23.1 B
Outpatient Care39%
$14.7B(3.4 visits/year
/patient)
myocyte
pre proBNP (134 aa)
proBNP (108 aa) signal peptide (26 aa)
secretion
NT-proBNP (1-76) BNP (77-108)
Release of BNP from Cardiac Myocytes
Total <45 45 - 54 55 - 64 65 - 74 75 +
n 1411 56 472 455 308 120
mean 67.8 64.6 82.1 110.8 242.8SD 83.7 96.2 107.7 95.2 211.1median 41.4 39.6 57.7 83.4 191.195th % 167 174 208 318 717
proBNP: Expected Values for ‘Healthy’ Subjects
0
100
200
45- 45-54 55-64 65-74 75+
MaleFemale
Expected values are also gender-dependent (n = 2980)
proBNP: Expected Values for Healthy Subjects
Triage® BNP Test Package Insert
BNP vs. NYHA Classification
0
200
400
600
800
1000
1200
Normal Class I Class II Class III Class IV
Median
12.3 95.4 221.5 459.1 1006.3 (pg/mL)
Cumulative Survival Rates in CHF Patients With Left Ventricular Dysfunction Stratified on Median Plasma
BNP Concentration
Tsutamoto T. et al. Circulation 1997;96:509-516
0
20
40
60
80
100
0 10 20 30 40 50
BNP < 73 pg/ml
BNP > 73 pg/ml
Months
Cu
mu
lativ
e S
urvi
val (
%)
p < 0.001
Log BNP (pmol/l)
LV
EF
(%
)
0
20
40
60
80
100
0 1.0 2.0 3.0
Y = -0.7, p<0.001
Davis et al. Lancet 1994;343:440-4.
BNP vs. EF by Echocardiography
0
1
2
3
4
0 500 1000 1500 2000 2500
Distance (ft)
Lo
g B
NP
(p
g/m
L) r = 0.513
Wieczorek S, Wu AHB, et al. Unpublished data
BNP vs. Six-Minute Walk Study by Wu et.al.
BNP Concentration and the Degree of CHF Severity
BN
P C
on
cen
trati
on
(p
g/m
l)
186 ± 22
791 ± 165
2013 ± 266
n = 27n = 27 n = 34n = 34 n = 36n = 36
CHF SeverityCHF Severity
Mild Moderate Severe0
500
1000
1500
2000
2500
61
Ready for Prime Time?
“Cardiologists and internists may now have a tool with which to determine whether a patient has congestive heart failure and to measure its severity, much as physicians routinely measure serum creatinine in patients with renal disease and perform liver-function tests in patients with hepatic disorders.”
Kenneth L. Baughman, MDN Engl J Med 2002;347:158-159
Case C
2.3 563 4
0.4 222 2
0.0 63 0 h
cTnI
<0.06
MYO
<80
Time
A 67 yr old male with a history of cardiac problems presentsto the ED with shortness of breath and pain in his left elbow.