Emergency Department Triage and Evaluation of the Patient with Chest Pain

1
Emergency Department Triage and Evaluation of the
Patient with Chest Pain

• Judd E. Hollander, MD
• Professor, Clinical Research Director
• Department of Emergency Medicine
• University of Pennsylvania

2
ED Visits
130,000,000 visits annually
3,000,000likely noncardiac sent home
8,000,000 chest pain
5,000,000suspected or actual cardiac
40,000 MIs
3
Goals of Triage

• Identify patients with AMI
• Identify patients with unstable angina
• Identify patients at high risk of cardiovascular
  complications
• resource utilization in hospital
• CCU vs. monitored vs. floor beds
• Identify patients safe for ED release
• need for treatment

4
Your Risk Tolerance

• 5
• 2
• 1

5
Why Do More?

• The missed AMI rate is inversely proportional to
  the admission rate for ED chest pain patients

Kontos MC Jesse RL. Am J Cardiol
20008532B-39B
6
Outline

• Gut Impression
• Clinical Parameters
• Electrocardiography
• Cardiac Markers
• Disposition with or without Telemetry
• Prior Testing
• Acute Cardiac Imaging

7
Initial Impression Noncardiac Pain
Patients with initial emergency impression of
noncardiac chest pain

• itrACS
• 17,737 patients enrolled
• Conclusion Even patients thought to have
  noncardiac pain can suffer adverse cardiac
  events, especially if risk factors are present

2,992
2.8 had adverse cardiac events (infarction,
revascularization, or death) within 30 days
85
Miller CD, et al. Ann Emerg Med. 200444565.
8
Clinical Parameters
9
Clinical Parameters

• Identifying low risk patients Lee et al. 1985
  Arch IM 198514565.
• 596 ED patients

MI USA Other
10
Clinical Parameters

• MI USA Other

Lee et al. Arch IM 198514565.
11
Clinical Parameters

• MI USA Other

Lee et al. Arch IM 198514565.
12
Clinical Parameters Risk Factors

• Risk factors do not affect likelihood of AMI
• 1700 patients
• Cholesterol
• Hypertension
• Family history
• Slight increase in risk in men only
• Diabetes mellitus
• 2.4 (1.2 - 4.8)
• Family history
• 2.1 (1.4 - 3.3)

Jayes et al. J Clin Epidemiol 199245621.
13
Clinical Parameters Risk Factors
CRF Burden and ACS (AUC0.591)
Han et al. Ann Emerg Med 200749145.
14
Costochondritis

• 122 patients evaluated for ARA definition of
  costochondritis
• pain caused by pressure enough to blanch skin
• whether or not it precisely reproduced CC
• 6 of patients had AMI

Disla et al. Arch Intern Med. 19941542466.
15
Clear Cut Alt Diagnosis

• Of 1995 pts, 599 pts had an Alt Dx
• Presence of an Alternative Diagnosis
• Reduced the likelihood of 30 day death, MI,
  revascularization
• 8.8 to 4.0
• Risk ratio, 0.45 (95 confidence interval,
  0.29-0.69)

4 risk of 30 death, MI, revascularization is not
low enough to allow safe release from the ED
Hollander et al. Acad Emerg Med., 200714215
16
Clinical Parameters

• History and physical examination are not real
  helpful in identifying patients with AMI.

17
Electrocardiograms
Lee et al. 1985 Arch IM 198514565.
18
Electrocardiograms

• Patients admitted to CCU
• Morbidity and mortality related to ECG

Slater et al. Am J Cardiol 198760766.
19
Electrocardiograms

• Patients admitted to CCU (n469)

25

46
Neg ECG n167
Pos ECG n302
18
18
4
1
1
0
Brush et al. NEJM 19853121137.
20
Late Electrocardiograms

• Does the NPV of the ECG increase with time?
• Normal ECG over time
• Symptom duration NPV
• 0-3 hrs 93
• 3-6 hrs 93
• 6-9 hrs 93
• 9-12 hrs 94

Singer et al. Annals EM 199729575.
21
Combination of Clinical Parameters and
Electrocardiography
22
Chest Pain Study Group
23
Chest Pain Study Group Risk

• Heavily dependent on ECG
• No group of patients at less than 1 risk of AMI
• Cardiac risk factors not useful
• Defined high and low risk as 7 cut-off
• May be useful for triage
• No patients deemed safe for release from ED

Lee et al. NEJM 19913241239.
24
Young Patients-Validated

• Of 4492 visits for CP, 1023 visits were ptslt40
  yrs
• If no cardiac risk factors and no prior cardiac
  history (n436)
• 6 USA (1.4) initial diagnosis
• 2 AMI (0.5) during index visit
• 30 days no death, AMI, PCI or CABG (0.5, 95
  CI, 0-1.1).
• Normal ECG and no prior cardiac history (n593)
• 6 USA (1) initial diagnosis
• 1 AMI (0.17) during index visit
• no AMI, PCI or CV deaths during follow up (0,
  95 CI, 0-0.5).
• Risk of 30 day adverse events 0.3 (0-0.8)
• No prior history, no risks, normal ECG (n299)
• 3 USA (1), no AMI
• No 30 day adverse events (0 0-1)
• Add initial marker
• Only 1 ACS, nothing else for any of the groups
  (0.14 0.1-0.2)

Marsan et al. AEM 200512826.
25
Clinical Parameters Risk Factors
.763
.602
.518
CRF Burden and ACS
Han et al. Ann Emerg Med 200749145.
26
TIMI Risk Score

• TIMI Risk Score for UA
• Age gt 65
• 3 or more CRFs
• Known CAD gt 50
• ST segment changes on ECG
• 2 or more anginal events in past 24 hours
• ASA use within 7 days prior
• Elevated cardiac markers

27
TIMI Risk in the ED
of TIMI Risk Factors
Chase, et al. Ann Emerg Med. 200648252
28
High Sensitivity Cardiac Markers
29
TnI-Ultra 60d AMI/CV Death
371 patients with symptoms suggestive of ACS
Apple et al. Clin Chem 200854723
30
High Sensitivity Troponin

• 718 patients with potential AMI 123 had AMI
• Presentation
• Sens 84-95
• Spec 80-84

Reichlin et al. NEJM 2009361858
31
High Sensitivity Troponin

• 1818 patients with potential AMI 413 had AMI
• Presentation
• Sens 90
• Spec 90
• Within 3 hours
• Sens 100

Keller et al. NEJM 2009361868
32
hsTnI in UA Protect TIMI 30
Wilson et al. Am Heart J 2009158386
33
2009
100 potential ACS patients
65 admitted
35 discharged
15 real
85 bogus
34
The Future
100 potential ACS patients
65 admitted
35 discharged
90 Sens 80 Spec
15 real
85 bogus
55 not sick (IM)
10 real (cards)
35 discharged
35
Stuck with Admissions?
Evidence Based Work Arounds
36
Observation Unit Rationale

• Cannot identify a group of clinical and/or ECG
  variables that identifies patients at such low
  risk for AMI/complications that they can be
  safely released from the ED
• No single test sufficiently excludes risk of AMI
  or complications
• Attempts to shorten evaluation

37
Telemetry

• Estrada et al Retrospective study
• Tele did not identify any VT/VF, asystole in 338
  patients remaining in telemetry bed.
• Estrada et al Prospective all comers to tele
• 19 of 2240 patients (0.8) were upgraded as a
  result of dysrrhythmias
• Only 0.3 of 1225 chest pain patients were
  transferred to CCU as a result of telemetry

Am J Cardiol 199474357
Am J Cardiol 199576960
38
Telemetry

• Hollander et al Prospective study
• 460 CP pts with normal or nonspecific ECGs
• 4 CV complications (1 VT/VF post op 1 SVT in CHF
  pt 2 sinus pauses of 2.4 and 4 seconds without
  intervention)
• Schull et al Retrospective study
• 8932 pts admitted to tele ward
• 20 cardiac arrest
• 9 detected by monitor
• 3 survival to discharge
• 1 definitely detected by monitor 1 detected by
  neighbor when he fell to floor 1 no record of
  when it began on monitor (?detected)

AJC 1997110
AEM 20007647
39
Telemetry HUP Data
Total Patients (n3686)
Hollander et al. Annals EM 20044371.
40
Telemetry HUP Data

• Sustained VT/VF
• Bradydysrrhythmias requiring treatment
• 0 (95 CI, 0-0.3)
• Preventable CV Death
• 0 (95 CI, 0-0.3)

Hollander et al. Annals EM 20044371.
41
Telemetry HUP Outcomes

• Initial Hospitalization No. Percent
• Myocardial infarction 15 1.5
• Unstable angina 121 12
• Percutaneous intervention 11 1.1
• Stent Placement 10 1.0
• CABG 4 0.4
• Death 2 0.2

Hollander et al. Annals EM 20044371.
42
Its Not My HeartI Had a Test Already
43
Stress Tests and ED Disposition
92
100
72
90
67
80
70
60
Percent
50
40
30
20
10
0
Abnormal
Normal
None
Disposition ( admitted)
Nerenberg et al. AmJEM 20072539.
44
Stress Tests 30-Day Outcomes
10.1
12
10
8
5.2
4.8
Percent
6
4
2
0
Abnormal
Normal
None
30-Day Adverse Cardiovascular Outcomes ()
Nerenberg et al. AmJEM 20072539.
45
Maybe It Keeps Them Away?

• Shaver et al demonstrated that patients evaluated
  with stress testing were just as likely to
• Return to the ED (39 vs 40)
• Be admitted to the hospital (29 vs 32)
• Receive cardiac catheterization (12.5 vs 10.4)

Shaver et al. Acad EM 2005111272
46
Better Than Stress Testing

• deFillipi et al found that compared with patients
  who were evaluated with stress testing, patients
  evaluated with coronary angiography (CA) had
• Fewer repeat ED visits
• Fewer hospitalizations
• Higher satisfaction rates
• Better understanding of their disease

deFillipi et al. JACC 2001
47
Acute Cardiac Imaging (in the ED)
48
Echocardiography

• Detects wall motion abnormality
• sensitivity moderate high
• Cannot distinguish old from new
• many false positives
• May miss non-Q wave AMI
• usually small infarcts
• Never compared to physician judgment or cardiac
  markers to assess incremental value

49
Sestamibi Imaging

• 338 ED chest pain patients with normal scans
• None had a cardiac death during 1 year period
• None had an MI
• 7 required coronary revascularization
• 100 abnormal scans
• 7 AMI
• 30 revascularization within one year

Tatum et al. Annals EM 199729116.
50
Sestamibi Imaging

• Relative risks of abnormal scans
• AMI 50 (2.8-890)
• Revascularization 14.5 (6-34)
• Death by 1 year 30 (1.6-570)
• Sensitivity for AMI
• 100 (64-100)
• Specificity
• 78 (74-82)

Tatum et al. Annals EM 199729116.
51
ER Assessment of Sestamibi (ERASE)

• RCT of 2475 ED chest pain patients with normal or
  nondiagnostic ECGs
• Usual ED evaluation (n1260)
• Usual evaluation resting MPI (n 1215)
• Primary outcome
• Appropriateness of initial triage decision

Udelson JE et al. JAMA. 20022882693
52
ERASE
NS

• Sensitivity for MI and acute ischemia were not
  significantly different
• Patients in the acute MPI arm had a significantly
  lower hospitalization rate
• Costs reduced in the MPI arm by an average of
  70/patient

NS
Plt.01
Udelson JE et al. JAMA. 20022882693
53
Coronary CTA Accuracy
Correlation with cardiac catheterization
54
Coronary CTA Prognosis

• Meta-analysis
• 9592 patients
• Median f/u
• 20 months
• MACE
• Sensitivity 99
• LR - 0.008

Hulton et al. JACC 2011571237
55
No / noncritical disease

• Hollander et al.
• 100 NPV for D/AMI/revasc in 525 patients at 30
  days
• Hoffman et al.
• 100 NPV for ACS in 73 pts over 5 months
• Rubinshtein et al.
• 100 NPV for 35 pts over 15 months
• Pundziate et al.
• 100 NPV for 20 pts over 13 months

56
No / noncritical disease

• Goldstein et al.
• 100 NPV for D/AMI/revasc in 67 patients at 30
  days
• Hoffman et al. (ROMICAT)
• Any plaque
• 100 NPV for ACS/events in 183 pts over 6 months
• Stenosis lt 50
• 98 NPV for ACS/events in 300 pts over 6 months

57
CT Coronary Angiography

• Largest cohort study
• 525 of 568 patients with negative CTA
• 30 day follow-up
• No cardiac deaths (95 CI, 0-0.8)
• No AMI (95 CI, 0-0.8)
• No revascularization (95 CI, 0-0.8)

Hollander et al Ann EM 200953295.
58
All CTA (n568)
Cagt400, no contrast injection (n6)
CTA with contrast injection (n562)
No stenosis or maximal stenosis lt 50
(n508)
Maximal stenosis 50-69 (n41)
Maximal stenosis gt70
(n13)
5
3
18
21
5
5
6
473
32
3
1
3
-
-

-


0
32
5
16
3
2



50-69
50-69
3
0
3
1
0
4
2
0
59
CT Coronary Angiography

• RCT of CCTA v MPI post CDU (n197)
• Normal CCTA discharged home (75)
• 9 with severe disease to catheterization
• Intermediate disease to stress test
• CCTA reduced LOS (3.4 v 15.0 hours)
• CCTA reduced costs (1586 v 1872)
• Re-evaluation of chest pain (2 v 7)

Goldstein et al JACC 200749863-871
60
CT STAT
Goldstein et al . JACC 2011581414-22
61
Main Outcomes Efficacy
Testing 4154
Chang et al. AEM 200815649.
62
Main Outcomes Safety
Chang et al. AEM 200815649.
63
Fagans Nomogram for MACE
Hulton et al. JACC 2011571237
64
CT Coronary Angiography
Volume rendered (VR) LAO view Normal LAD and
diagonal branches VR images provide an overview
of the coronary arteries but can not be used on
their own to exclude stenosis.
65
CT Coronary Angiography
Thin-slab MIP (maximum intensity projection) No
stenosis in proximal LAD, circumflex and ramus
medianus (RM) arteries.
66
CT Coronary Angiography
L Main Calcified plaque with 50 stenosis of the
left main LAD Mixed calcified and noncalcified
plaque resulting in 70 stenosis Diagonal mild
stenosis LCx Patent
67
CT Coronary Angiography
Low density noncalcified plaque (arrow) causing
gt50 stenosis of the proximal right coronary
artery.
68
CT Coronary Angiography
Severe RCA lesion
69
ACRIN

• Randomized 21 to Coronary CTA
• Coronary CTA group
• Coronary CTA
• Clinical bloods (c/w guidelines) at time 0
  90-180 minutes
• Banked bloods at T0, 90-180 and 6 hours
• Dispo per physicians
• Traditional care group
• Anything but coronary CTA
• Banked bloods at T0, 90-180 and 6 hours
• Dispo per physicians
• Results March 26 at ACC
• ROMICAT 2 March 27

70
Putting It Together
71
Triage

• Clinical Presentation
• ECG
• Past history
• CAD
• Available technology
• Required medications
• Fibrinolytics
• IV nitrates
• Heparin

72
Triage

• Risk stratification
• TIMI Risk Score
• HEART Score
• GRACE or PURSUIT
• Lee and Goldman algorithm
• Clinical impression
• Adjunctive Testing
• Markers
• Imaging

73
Triage

• High risk patients
• ECG abnormalities
• Heart failure
• Dysrrhythmias
• Unstable vital signs
• Need for IV drips
• Positive markers or MPI scans in the ED
• Positive CCTA with good story
• Admit to Cardiac Care Unit

74
Triage

• Lowest risk patients
• Young patients
• Normal electrocardiograms
• Low risk story
• TIMI Score lt3
• Normal markers and sestamibi scans, if done
• Triage to
• Observation unit
• Nonmonitored beds
• Home if lowest possible risk
• Normal CCTA goes home
• individual and institutional cut-off for misses

75
Triage

• Intermediate Risk Patients
• Equivocal stories
• Abnormal but not diagnostic ECGs
• TIMI Score gt 3
• Markers normal or slightly elevated
• Scans with old abnormalities (CAD)
• Most should be admitted to monitored beds

76
Unstable Angina

• Distinguish real unstable angina from need to
  rule out AMI
• Single atypical episode of chest pain
• rule out MI
• unstable angina?

77
Summary

• ACS versus anything else for dispo/triage
• CTA to allow discharge
• AMI is ANY elevation in markers above normal
• STEMI or NSTEMI drive treatment

78
Words of wisdom? (without evidence)

• Short cuts to r/o MI
• 90 minute to 3 hour rule outs
• Rising or delta cardiac markers
• Incidental abnormal ECGs
• Always make referral
• QTc intervals
• Admission diagnosis also should include
• rule out life threatening conditions
• Stable angina
• Whatever it is it is stable for outpt
  evaluation
• The ROS curse