Performance Improvement for Chest Pain

1
Performance Improvement for Chest Pain Heart
FailureUsing Bed Side Cardiac Markers

• S. Dadkhah MD.MBA.FACP.FACC
• Director Section of Cardiology Research
• Co-Director of Chest Pain Center
  Saint Francis Hospital, Evanston , IL
• Assistant Professor of Medicine
• University of Illinois

2
Disclosure

• Sanofi Synthelabo
• Bristol-Myers Squibb
• Aventis
• Novartis
• AstraZeneca
• GlaxoSmithKline
• Scios
• Biosite

3
8 Million Adults Visit Hospital Emergency
Departments Complaining of Chest Pain Annually

• 15-20 Experience AMI
• 600,000 Admitted/Discharged without CAD
• Diagnosing AMI costs the Nations
  HealthcareSystem about 10 Billion Annually

4
In the Emergency Department

• Approximately 5 of AMI Patients are Released
  Unintentionally
• 20 of Malpractice Claims are associated with the
  missed Diagnosis and Management of AMIs

5
Acute Coronary Syndromes Risk of Mortality
Cumulative 6-Month Mortality
25
(N 21,761)
20
15
Death (100/Pts/Month)
Acute MI Unstable Angina Stable Angina
10
5
0
0
1
2
3
4
5
6
Months After Hospital Admission
Theroux P et al. Circulation. 19989711951206.
6
Philosophy

• Remaining years of life are usually less
  important than the quality of remaining life.

7
Cardiac Milestones at Saint Francis Hospital

• First cardiac catheterization 1959
• First open heart surgery 1962
• First PTCA 1981
• First laser angioplasty 1987
• First accredited chest pain center in the state
  of Illinois 2003

8
Milestones in developing a Chest Pain Center

• 1991 established Chest Pain Committee
• 1992 developed chest pain pathways
• 1992 interventional call roster/ PCP preferred
  cardiologist List
• 1993 ED stress test after 4 hours observation
• 1994 Stress test by cardiology fellows or
  cardiologist
• 1997 qualitative bedside markers diagnose MI
• 1998 qualitative markers and ECG in the
  ambulance
• 1999 NSTEMI to cath lab from ED
• 2000 community outreach program
• 2002 rapid quantitative bedside markers/BNP
• 2002 stress test by third year Internal
  Medicine residents
• 2003 stress test by Emergency Physicians

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Chest Pain Center

• A Chest Pain Center in not a section of the
  Hospital that treats Acute Myocardial Infarction
• A Chest Pain Center is a process that starts
  from the time a patient activates EMS until that
  patient discharges from the hospital

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Chest Pain Committee Functions

• Collaboration between Emergency Medicine,
  Cardiology and laboratory
• Meets monthly
• Performs data collection and review
• Reviews Process Improvement initiatives
• Cost of Care and Reimbursement
• Education of Staff
• Recommendations to Administration

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Patient enters the CPC having ACS STEMI/NSTEMI
Laboratory turnaround time
Notification to cath lab staff of AMI
Delayed arrival to the CPC
Time from ECG to diagnosis
Time to ECG
Time from diagnosis to transportation to cath
lab
12
Patient enters the CPC having ACS
Delayed arrival Of cardiologist
D/C instruction
Delayed arrival of heart team
CCU LOS
Time to wire cross
Time from Admission to D/C
13
Critical PathwaysMyocardial Infarction - Track I
Possible Solutions

• Formation of Heart Center Code Team and the Code
  42
• Cardiology call roster
• PMD preferred cardiologist roster
• Rapid Blood Markers in the Emergency Department
  and in the Emergency Medical System (EMS)

14
WHO Criteria for AMI

• Definite AMI is Diagnosed in the Presence of
  Unequivocal ECG Changes and/or Unequivocal Enzyme
  Changes, History of Pain may be Typical or
  Atypical
• Definite AMI requires 2 of the 3 Criteria

Circulation 1979 59607-609
15
Within the clinical spectrum of acute chest pain
is a subset of patients in whom the quality,
duration, associated systems and precipitating
factors are not characteristic for cardiac
pain.These patients usually have a non-specific
pattern of chest discomfort, normal ECG and a
low likelihood of cardiac disease often are
classified as having atypical chest pain
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ECG and MI

• In a multi-center emergency department study,
  only 39 of 108 patients (36) with AMI had a
  diagnostic ECG.1

As many as 40 of individuals with
autopsy-proven AMIs have non-diagnostic ECGs
initially.2
1 Chest 19942 Annals of Emergency Medicine 1987
17
The Ideal Marker of Myocardial Injury/Ischemia

• Found in High Concentration within the Myocardium
• Not Found in other Tissues, even in Trace Amounts
  or under Pathological Conditions
• Released Rapidly and Completely after Ischemia
• Released in Direct Proportion to the Extent of
  Ischemia
• Persists in Plasma for Several Hours

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Characteristics
19
Myoglobin in the Early Evaluation of Chest Pain
89 Patients

• 13 of 25 patients (52) had positive myoglobins
  prior to an increase in CKMB or CK.One patient
  discharged home with positive myoglobin.

56 100
83 100
Montaque, Colorado, American Journal of Chest
Physicians Oct 1995
20
Negative Predictive Value

• The negative predictive value if the serum
  Myoglobin did not double within 2 hours . . .
• . . . in patients who presented within 6 hours
  of the onset of their symptoms . . .
• . . . was 97.

Tucker, Annals of Emergency Medicine 1994
21
Myoglobin Cost Savings

• Cost of Single Myoglobin 20
• 25,000 Missed AMIs Discharged from the ED
  Annually(Atypical Presentations)
• Total Malpractice Loss for Missed AMI60
  Million (20 of ED Claims)
• Cost of Two Myoglobin Tests in ED for 25,0001
  million/year

Potential Cost Savings - 53 Million/year
Selective use in 250,000 Atypical
Presentations(1 of 10 AMIs) - Cost Savings of
44 Million/year
Brogan,Annals of Emergency Medicine Oct 1994
22
Troponin I

• Part of the Thin Filament Regulatory Complex that
  Confers Calcium Sensitivity to the ATPase
  Activity of the Striated Muscle Actin-Myosin
  Complex
• Identified as Three Isoforms expressed in a
  Muscle Fiber Type-Specific-Manner - Troponin
  I Fast - Troponin I Slow (both expressed
  exclusively in fast twitch and slow twitch
  skeletal fiber muscles, respectively) -
  Troponin I Cardiac with an extra 30 residues at
  the N-terminal (expressed
  exclusively in atrium and ventricle)

Clin. Chem. 1993
23
SERUM MARKERS POST AMI
24
Rapid Evaluation Of Chest Pain In The Emergency
Department
25
Chest Pain
Track I AMI
ST Elevation With Reciprocal Changes
CODE 42
Cath Lab
Thrombolytic
Surgery
PTCA
Admit to CCU
Medical TX
Angiography?
Stress Test?
Home in 5 Days
26
Chest Pain
Track III a Atypical CP
Non-diagnostic ECG without Exclusion Criteria
POC Myoglobin/CKMB/Troponin I on admission. POC
Myoglobin/CKMB/Troponin I at 2 4 hours
Cardiac Markers Positive
Cardiac Markers Negative
Admit TX per protocol
Exercise Stress Test in ED
Negative Test
Positive Test
Discharge home
Admit TX per PMD
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The 68th Scientific Sessions AHA 1995 California
Circulation Volume 92,No 8.1995
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Case 90

• ES - 61 Male physician for elective surgical
  repair of quadricep torn after a fall. In the
  holding area he became hypotensive after IV
  sedation. He had chest pain with increasing
  fatigue 3 days prior to that admission
• Risk Factors Hypertension, smoker
• Physical Exam Unremarkable
• ECG/Angiogram

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Case 90
ES
31
Case 90
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I

• Surgery cancelledemergency angiogram performed

32
Case 90
Dadkhah
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(NEW ERA)Now Evaluate Chest Pain with 12 Lead
Electrocardiograms and Rapid Assays for Early
Recognition of Myocardial Infarctions in the
Ambulance(IJEM volume1, N3 2005)
34
NEW ERA
Methods

• Multi-Centered Trial
• 5 Hospitals- 4 with Emergency PTCA
  Capabilities(St. Francis, Evanston, Holy
  Family, Rush North Shore) Glenbrook
• 5 Ambulance ServicesEvanston, Lincolnwood,
  Skokie, Wheeling, Glenview

• Performed prior to arrival in ED
• 12 Lead ECGs (Life-pack 11)
• Rapid CK-MB
• Rapid Myoglobin
• Rapid Troponin I performed

35
NEW ERA
Results

• 252 Patients enrolled
• 247 Patients had completed follow-up
• 44 (18) Patients diagnosed with AMI before being
  discharged from the hospital
• 7 Patients had negative ECG and Markers ED
  markers were negative but AMI occurred during
  course of hospitalization
• 37 (15) Patients positive for AMI in the ED

36
NEW ERA
Results

• 5 (2) Patients transferred to other institutions
  with diagnosis of AMI 2 out of the 5 patients
  with positive ECGs did not have markers
  performed in the ambulance
• 28 (11.3 ) Patients had either positive ECGs or
  Markers pre-hospital

37
NEW ERA, Phase II

• 203 Consecutive Patients
• 160 Patients had completed follow-up
• - 23 Ambulances
• - 7 Hospitals
• Findings
• 8.4 (17/203) Positive markers in the field vs.
  7.7 Positive markers in Phase I

38
Case 91

• BH - 75 WM Complaining of sharp, stuttering chest
  pain on and off for 12 hours was seen in his
  PMDs office. 911 was called and in the field
  12-Lead ECG and Rapid Cardiac Markers were
  performed
• Risk factors Hypertension, smoker
• Physical Exam Unremarkable
• Field ECG/Angiogram

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Case 91
40
Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
41
Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
42
Case 91
Dadkhah
43
Chest Pain Centers
Level I
Level II
Level III
EMS
44
Action Plan of the 4 Ds

• Door
• Data
• Decision
• Drug

45
SCPC Benefits

• The Heart Attack Act of 2005 was introduced by
  Senator Mike DeWein of Ohio ( on Judiciary
  Committee, Appropriations Committee, and others.)
  It was accompanied by a letter signed by Senators
  Arlen Specter, John McCain, Orin G. Hatch, Mary
  L. Landrieu, Mike DeWine and Sam Brownback. The
  act stipulates that in order to receive Medicare
  funds a facility that self designates as a Chest
  Pain Center must be accredited.

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The Triage System (POC)BEDSIDE SYSTEM

• Rapid, Whole Blood Testing
• 15 Minute Time to Result
• Hand Held, Portable System
• Markers Available
• Triage Cardiac Panel
• Troponin I
• Myoglobin
• CK-MB
• BNP
• D-Dimer
• Stored memory, printed results, Hospital
  Information System Interface

47
Abstract (SCPCP2004)
Critical Pathway in Cardiology V3,N3 Sept. 2004
48
Introduction

• Troponin I and Myoglobin are cardiac markers
  released from myocardium and are routinely used
  in the diagnosis of myocardial injury.They are
  released within hours of cardiac injury in the
  blood.
• We wanted to compare the levels of rapid bedside
  Troponin I and Myoglobin by TRIAGE assay with
  laboratory values by STRATUSDade.

49
Method

• 72 consecutive patients with chest pain or
  shortness of breath who come to the emergency
  department were enrolled in the study.
• Mean age was 68 (27 to 94)

50
Method

• 0.25 c.c. of blood was used for the analysis.
• Blood drawn was used for rapid bedside Troponin I
  and Myoglobin by TRIAGE assay.
• Same blood sample was sent to laboratory to be
  analyzed by STRATUSDade.

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Results

• Troponin I levels by rapid bedside TRIAGE assay
  and laboratory STRATUS Dade correlates when
  STRATUSDade cutoff at 1.0ng/ml and TRIAGE at
  0.4ng/ml with diagnostic agreement of 97.2.

52
Results
53
Results

• When Myoglobin levels by STRATUS Dade cutoff at
  82ng/ml and TRIAGE assay cutoff at170ng/ml and
  220ng/ml the diagnostic agreement was 77.8 and
  83.3 respectively

54
Results
55
Results
56
Conclusion

• Our results conclude that rapid bedside TRIAGE
  assay for Troponin I and Myoglobin in the
  emergency department can be done faster and are
  accurate

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Significant Clinical and Economic Burden of HF

• Persons with HF in US 5.0 million
• Overall prevalence 2.2
• Incidence 550,000/yr
• Mortality in 2001 52,828
• Cost 25.8 billion

AHA. Heart Disease and Stroke Statistics2004
Update
58
Outcomes in Patients Hospitalized With HF
Mortality
Hospital Readmissions
100
100
75
75
50
50
50
50
33
20
25
12
25
0
0
30 Days
6 Months
30 Days
12 Months
5 Years
Median LOS 6 days
N 38,702 Aghababian RV. Rev Cardiovasc Med.
20023(suppl 4)S3 Jong P et al. Arch Intern Med.
20021621689
59
Symptoms and signs in the diagnosis of heart
failure
Eur Heart J, Vol. 22, issue 17, September 2001
60
BNP vs. NYHA Classification

95th 43.1 673 1148 1956 3725 N 419 42 98 114 50
Wieczorek S, Wu A, et al..
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Early Initiation of Vasoactive Therapy Clinical
Outcomes
ADHERE National registry, gt250 US hospitals, N
46,559
Emerman C et al. Ann Emerg Med.
200342S36 Fonarow GC for ADHERE Scientific
Advisory Committee. Rev Cardiovasc Med.
20034(suppl 7)S21
62
Impact of ED vs In-patient Initiation of
IV Vasoactive Therapy on LOS
P?0.0001
LOS (days)
7.0
4.5
ED Initiation (n 4096)
In-patient Unit Initiation (n 3499)

Peacock WF et al. Ann Emerg Med. 20034292
63
Abstract (SCPCP2004)

• Utility of B-Type Natriuretic Peptide for the
  diagnosis of congestive heart failure in
  geriatric population in the emergency department
• Syed N.Ghani M.D, Shahriar Dadkhah M.D, Debbie
  Bishop R.N, Martin Fedko, Saint Francis Hospital,
  Evanston IL
• Introduction B-Type Natriuretic Peptide (BNP) is
  released from cardiac ventricles in response to
  increased wall tension. It is helpful in
  differentiating dyspnea due to congestive heart
  failure (CHF) and non-cardiac causes.
• Method 100 consecutive patients who came to
  emergency department of a community hospital with
  dyspnea in a two month period were enrolled in
  the study. 67 patients were with age 65 or older.
  Each patient had a rapid bedside assay of BNP by
  BIOSITE? at the time of arrival to the emergency
  department. Patient hospitalizations were
  reviewed and primary discharge diagnosis of
  pneumonia and heart failure were used as the
  basis for the analysis.
• Results Out of 67 patients who were 65 or older,
  43 patients had BNP ? 150 pg/ml. 40 patients had
  BNP ? 150 pg/ml and clinical and
  echocardiographic evidence of CHF. Three patients
  had BNP ? 150 pg/ml and no clinical but
  echocardiographic evidence of CHF. One patient
  had BNP ? 150 pg/ml with diagnosis of pneumonia
  and no clinical evidence of CHF.
• Conclusion Our results showed that rapid
  diagnosis of heart failure can be made in
  geriatric population by using the bedside marker
  BNP upon arrival to emergency department. We have
  found BNP levels of ? 150 pg/ml and above are
  highly consistent with discharge diagnosis of
  congestive heart failure.

Critical Pathway in Cardiology V3,N3 Sept. 2004
64
Method

• 100 consecutive patients who came to emergency
  department of a community hospital with dyspnea
  in a two month period were enrolled in the study.
  
• 67 patients were with age 65 or older.
• Each patient had a rapid bedside assay of BNP by
  BIOSITE? at the time of arrival to the emergency
  department.
• Patient hospitalizations were reviewed and
  primary discharge diagnosis of pneumonia and
  heart failure were used as the basis for the
  analysis.

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Results

• Mean BNP was 666 for diagnosis of CHF median BNP
  was 268.
• 79 of patients had 2D echo during their hospital
  stay.
• 60 of patients were diagnosed with CHF at time
  of discharge.
• 71 of patients had a BNP gt 150.
• 100 of patients with a diagnosis of CHF had a
  BNP gt 150.

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Results
Positive predictive value 93.02 Negative
predictive value 100
Sensitivity 100 Specificity 89
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August 29, 2005 1201 p.m. EDT  
 
 

• Dr. Shahriar Dadkhah, director of cardiology
  research at St. Francis Hospital in Evanston,
  Ill., said offering BNP testing in physician
  offices can save money. The test costs less than
  40 - much less than admission of a patient to
  the hospital for heart failure.
• "The test gives you an idea if you should
  increase treatment," Dadkhah said. If a patient
  has heart failure, the physician can prescribe
  medications such as diuretics to ease symptoms,
  and potentially keep the patient out of the
  hospital. "The No. 1 money loser for any hospital
  is admission for heart failure,"

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Average Length of Stay
2002 MedPar data
69
Average Per Patient Medicare Reimbursement
2002 MedPar data
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If you always dowhat youve always doneyoull
always getwhat you always got
71

• You are as good as
• the people you work for and
• the people you work with

72

• You are as good as
• Your Arteries

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• THE END

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Chest Pain Center Committee
Active members of Chest Pain Committee include
Ø      Chairman of Department of
Cardiology Ø      Chairman of Department of
Emergency Medicine Ø      Directors of Chest
Pain Center Ø       Director of Pharmacy Ø     
Director of laboratory Ø      Representative from
Performance Improvement
Ø      Chest Pain Center Coordinator Ø      VP of
Nursing/Operations Ø      Manager of Emergency
Department Ø      Manager of Heart Center Ø     
Data Collector for ACS
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Current Treatments for ADHF
Natriuretic Peptide
Diuretics
Vasodilators
Inotropes
Decrease Preload and Afterload Reduce Fluid
Volume
Decrease Preload and Afterload
Reduce Fluid Volume
Augment Contractility
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ASA on Arrival
Before implementation of pathways
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B-blocker on Arrival
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ACE
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Door To ECGMinute
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