Title: Most recent data, with troponin Is the initial diagnostic impression of noncardiac chest pain adequa
1(No Transcript)
2(No Transcript)
3Most recent data, with troponinIs the initial
diagnostic impression of noncardiac chest pain
adequate to exclude cardiac disease? Miller CD,
Ann EM December 2004 44(6)565-574
- 17,000 patients with CP
- 1992 thought to be noncardiac (75 d/ced to
home) - Physicians blinded to trop results, did not use
them - Of 1992, 71 (2.4) had first trop 0.6 - 1.0
- Troponin assay is critical.
- Our trop today is a new generation high
sensitivity troponin - (Dade Stratus CS cTNI)
- Very sensitive, but how much more?
4Inverse relation between with a "rule out MI
evaluation" and the miss MI rate.
Graff Am J Cardiol, Volume 80(5)563-568,
9/1/1997
539 yo with atypical CP
6Risk of MI with Chest PainLee TH, et al. Acute
chest pain in the emergency room. Identification
and examination of low-risk patients. Arch Int
Med 1985 14565-69
- increased with history of known angina
- increased when identical to previous MI
- Deceptive
- "burning," "indigestion," (23 with MI) and
"numbness" or inability to characterize the pain
(23 with MI) are as likely to be MI as
"pressure," "tightness", "crushing (24 with MI)
- 5 prob. if pain was "sharp" or "stabbing"
7Chest Pain characteristics and MILee TH, et al.
Acute chest pain in the emergency room.
Identification and examination of low-risk
patients. Arch Int Med 1985 14565-69
- with ACS if pain is pleuritic, positional, or
reproducible - 13 (n 96) if pain partly pleuritic or
positional - 0 (n 36) fully pleuritic or positional
- 24 (n158) if pain is partly reproduced on exam
- 7 (n 124) if fully reproduced
- greater with radiation to left arm, shoulder or
neck - less with radiation to back, abdomen, or legs
- Probability of MI
- greater with duration 60 minutes
8Positive Likelihood Ratios for MIPanju AA,
Hemmelgarn BR, Guyatt GH, Simel DL. Is this
patient having a myocardial infarction? JAMA
1998 Oct 14280(14)1256-63.
- new ST-segment elevation 11.2 (LR range,
5.7-53.9) - New ST depression, T wave inversion
- new Q wave 7.0 (LR range, 5.3-24.8)
- new conduction defect 6.3 (LR range 2.5-15.7)
- chest pain radiating to both the left and right
arm simultaneously 7.1 (3.6-14.2) - radiation to left (2.3) or right arm (2.9)
- presence of a third heart sound 3.2 (LR, 3.2)
- hypotension 3.1 (LR, 1.8-5.2).
- crackles 2.1 (1.4-3.1)
- diaphoresis 2.0 (1.9-2.2)
9Negative Likelihood Ratios for MIPanju AA,
Hemmelgarn BR, Guyatt GH, Simel DL. Is this
patient having a myocardial infarction? JAMA
1998 Oct 14280(14)1256-63.
- a normal ECG result (LR, 0.2)
- pleuritic chest pain (LR, 0.2)
- sharp or stabbing chest pain (LR, 0.3)
- positional chest pain (LR, 0.3)
- chest pain reproduced by palpation (LR, 0.3)
- Not associated with exertion (LR, 0.8)
- Infra-mammary location (LR, 0.8)
- These calculations did not distinguish between
partial or full reproducibility
10Low risk Features, summary (ECG must be normal
or nonspecific)
- Right side only
- Pain primarily in middle or lower abdomen
- Pain lasts seconds only
- While the patient has this pain, it improves with
exertion - (e.g. goes away if I play basketball)
- clear non-ischemic cause for pain is found
- Chest wall trauma or chest x-ray abnormality
- GI etiology is NEVER a clear alternative Dx
- Palpation reproduces pain exactly on multiple
exams - Pain is pleuritic
- Pain is brought on by changes in position or
movement - Pain is localized to a fingertip
- Sharp (stabbing) pain
11Pitfalls in diagnosis of ischemia
- Pts. often interpret "sharp" to mean severe
- Therapeutic trials may be very misleading
- Nitroglycerin no different from placebo
- Henrickson, CA. Chest Pain relief by
Nitroglycerin Does Not Predict Active Coronary
Artery Disease. Ann Int Med 139(12)979-986,
Dec. 16, 2003 - Antacids may improve up to 25 of MI pain
- Up to 33 of pts. with ACS have some chest wall
tenderness, (24 partly, 7 fully reproducible) - Lee TH, Arch Int Med 14565-69, 1985.
- Fully v. partly pleuritic or positional pain
12Pitfalls (contd)
- Unchanged ECG, even normal ECG
- with an atypical history, a normal ECG is rarely
an MI, but not so rarely unstable angina - Clinical presentation particularly variable in
the elderly - 40-50 fail to c/o chest pain
- Bayer AJ et al. J Am Soc Geriatr 34263-266
- Common atypical symptoms--shortness of breath,
abdominal pain, dizziness, arm/shoulder/jaw pain
- Pain that persists in ED or recurs in ED
- associated with 3.8 x the risk of complications
(Fesmire FM. Wears RL. Am J Em Med 1989 July
7(4)372-377)