New concepts for the Management of Chest Pain in the Prehospital

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New concepts for the Management of Chest Pain in
the Pre-hospital

• Shahriar Dadkhah, MD, MBA, FACP, FACC,FCCP
• Assistant Clinical Professor, University of
  Illinois
• Interventional Cardiologist
• Director, Chest Pain Center SFH SCH
• Medical Director Section of Cardiology Research
  SFH SCH
• Member Board of Trustee Society of Chest Pain

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Disclosurespeakers Bureau

• Aventis Lovenox
• Sanofi-SynthelaboPlavix
• MillenniumIntegrillin
• GlaxoSmithKlineCoreg
• NovartisDiovan
• SCIOS Natrecor
• BiositeBNP

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Time Myocardium
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Remaining years of life are usually less
important than the quality of remaining life.
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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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1995-2005 7 years completed with 8282 enrolled
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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
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Delayed arrival to the CPC
Who interprets the ECG?
Field ECG
ECG transmission ?
Time from ECG to diagnosis
Time to ECG
Time from diagnosis to transportation to cath
lab
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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
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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

• 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

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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
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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
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Dadkhah
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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

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Chest Pain Centers
Level I
Level II
Level III
EMS
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Action Plan of the 4 Ds

• Door
• Data
• Decision
• Drug

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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)
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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

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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

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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
• One patient went to Cath lab 11 minutes from ED
  arrival

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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
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Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
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Case 91
Rapid Myoglobin
Rapid CKMB
Rapid Troponin I
Myoglobin
Troponin I
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Case 91
Dadkhah
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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

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Case PA

• 60 year-old W male Complaining of sub-sternal
  pain which described as a pressure on his chest.
  911 was called and 12-Lead ECG and Rapid Cardiac
  Markers were performed in the field.
• Risk factors sex, age
• Physical Exam Unremarkable.

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PA-12 lead field ECG
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12 lead field ECG 840ED to PTCA 66 minutes
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Case SW

• 39 yr-old nonsmoker WM complaining of chest
  tightness and pain with radiation to his
  arms.911 was called and 12-Lead ECG and Rapid
  Cardiac Markers were performed in the field.
  PMH AMI and Angioplasty 5 years agoPhysical
  Exam normal VS, unremarkable

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SW-12 lead field ECG

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• 12 lead field ECG 942
• ED To PTCA 43 minutes
• Cath outcome 100 LAD

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Case LI

• A 85 year-old w female complaining of chest pain
  describing as pressure on her chest which radiate
  to her left arm.
• 911 was called and 12-Lead ECG and Rapid Cardiac
  Markers were performed in the field.
• Risk factor HTN
• Physical Exam Unremarkable

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LI-12 lead field ECG
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• 12 lead field ECG 1013
• ED to PTCA 140 minutes
• Cath outcome 100 LAD

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ECG transmission directly to a physicians
cellular phone/PDA through a wireless modem has
only recently become an option.The recent study
(Time-North East) results show a reduction in
time to reperfusion for acute MI patients by 66
minutes (116 to 50)

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TIME-MCTimely Intervention in Myocardial
Emergency Multicenter studyThe study is based on
the hypothesis that reperfusion therapy will be
more rapidly initiated when the responsible
cardiologist has support for the reperfusion
therapy decision via immediate access to patient
data including a standard 12 lead ECG.
Duke
Welch Allyn
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You are as good as the people you work for
and the people you work with
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If you always dowhat youve always doneyoull
always getwhat you always got
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You are as good as Your Arteries
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THE END
www.dadkhamd.com
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