Department of Emergency Medicine University of Pennsylvania Health System Emergency Department...

Department of Emergency MedicineDepartment of Emergency Medicine

University of Pennsylvania Health SystemUniversity of Pennsylvania Health System

Emergency Department Triage and Evaluation of the Patient

with Chest Pain

Judd E. Hollander, MDJudd E. Hollander, MDProfessor, Clinical Research DirectorProfessor, Clinical Research DirectorDepartment of Emergency MedicineDepartment of Emergency Medicine

University of PennsylvaniaUniversity of Pennsylvania

130,000,000 visits annually

8,000,000 chest pain

5,000,000suspected or actual cardiac

3,000,000likely noncardiac

sent home

40,000 MIs

ED VisitsED Visits

Goals of TriageGoals of Triage

Identify patients with AMIIdentify patients with AMI Identify patients with unstable anginaIdentify patients with unstable angina Identify patients at high risk of Identify patients at high risk of

cardiovascular complicationscardiovascular complications– resource utilization in hospitalresource utilization in hospital

• CCU vs. monitored vs. floor bedsCCU vs. monitored vs. floor beds

Identify patients safe for ED releaseIdentify patients safe for ED release– need for treatmentneed for treatment

Your Risk Tolerance…Your Risk Tolerance…

5%5% 2%2% 1%1%

Why Do More?Why Do More? The missed AMI rate is inversely proportional to The missed AMI rate is inversely proportional to

the admission rate for ED chest pain patientsthe admission rate for ED chest pain patients

Kontos MC & Jesse RL. Am J Cardiol 2000;85:32B-39B

OutlineOutline

Gut ImpressionGut Impression Clinical ParametersClinical Parameters ElectrocardiographyElectrocardiography Cardiac MarkersCardiac Markers Disposition with or without TelemetryDisposition with or without Telemetry Prior TestingPrior Testing Acute Cardiac ImagingAcute Cardiac Imaging

Initial Impression = “Noncardiac Pain”Initial Impression = “Noncardiac Pain”

itrACS itrACS 17,737 patients enrolled17,737 patients enrolled Conclusion: Even patients Conclusion: Even patients

thought to have noncardiac pain thought to have noncardiac pain can suffer adverse cardiac can suffer adverse cardiac events, especially if risk factors events, especially if risk factors are present are present

2.8% had adverse cardiac events (infarction, revascularization, or death) within 30 days

Miller CD, et al. Ann Emerg Med. 2004;44:565.

Patients with initial emergency impression of “noncardiac chest pain”

2,992

85



Clinical Parameters

Clinical ParametersClinical Parameters

Identifying low risk patients Identifying low risk patients Lee et al. 1985 Arch IM Lee et al. 1985 Arch IM

1985;145:65.1985;145:65.

596 ED patients596 ED patients MI USA Other


MIMI USAUSA Other Other

Lee et al. Arch IM 1985;145:65.

Clinical ParametersClinical Parameters MI USA OtherMI USA Other

Lee et al. Arch IM 1985;145:65.

Clinical Parameters: Risk FactorsClinical Parameters: Risk Factors

Risk factors do not affect likelihood of AMIRisk factors do not affect likelihood of AMI– 1700 patients1700 patients

• CholesterolCholesterol• HypertensionHypertension• Family historyFamily history

Slight increase in risk in men onlySlight increase in risk in men only– Diabetes mellitusDiabetes mellitus

• 2.4 (1.2 - 4.8)2.4 (1.2 - 4.8)

– Family historyFamily history• 2.1 (1.4 - 3.3)2.1 (1.4 - 3.3)

Jayes et al. J Clin Epidemiol 1992;45:621.


Han et al. Ann Emerg Med 2007;49:145.

CRF Burden and ACS (AUC=0.591)

CostochondritisCostochondritis

122 patients evaluated for ARA 122 patients evaluated for ARA definition of costochondritisdefinition of costochondritis– pain caused by pressure enough to blanch pain caused by pressure enough to blanch

skinskin– whether or not it precisely reproduced CCwhether or not it precisely reproduced CC

6% of patients had AMI6% of patients had AMI

Disla et al. Arch Intern Med. 1994;154:2466.

““Clear Cut Alt Diagnosis”Clear Cut Alt Diagnosis”

Of 1995 pts, 599 pts had an Alt DxOf 1995 pts, 599 pts had an Alt Dx Presence of an Alternative Diagnosis Presence of an Alternative Diagnosis

– Reduced the likelihood of 30 day death, MI, Reduced the likelihood of 30 day death, MI, revascularizationrevascularization

• 8.8 to 4.0%8.8 to 4.0%

• Risk ratio, 0.45 (95% confidence interval, 0.29-0.69)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., 2007:14:215


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

ElectrocardiogramsElectrocardiograms

Lee et al. 1985 Arch IM 1985;145:65.

ElectrocardiogramsElectrocardiograms Patients admitted to CCUPatients admitted to CCU Morbidity and mortality related to ECGMorbidity and mortality related to ECG

Slater et al. Am J Cardiol 1987;60:766.

ElectrocardiogramsElectrocardiograms Patients admitted to CCU (n=469)Patients admitted to CCU (n=469)

Brush et al. NEJM 1985;312:1137.

0

5

10

15

20

VF Sus VT NS VT Cond Dist

Neg ECG n=167

Pos ECG n=302

0

41 1

18

25

46

18

%

Late ElectrocardiogramsLate Electrocardiograms

Does the NPV of the ECG increase with time?Does the NPV of the ECG increase with time? Normal ECG over timeNormal ECG over time

Symptom durationSymptom duration NPVNPV

0-3 hrs0-3 hrs 93%93%

3-6 hrs3-6 hrs 93%93%

6-9 hrs6-9 hrs 93%93%

9-12 hrs9-12 hrs 94%94%

Singer et al. Annals EM 1997;29:575.



Combination of Clinical Combination of Clinical Parameters and Parameters and

ElectrocardiographyElectrocardiography

Chest Pain Study GroupChest Pain Study Group

Chest Pain Study Group RiskChest Pain Study Group Risk

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

Lee et al. NEJM 1991;324:1239.

Young Patients-Validated Young Patients-Validated Of 4492 visits for CP, 1023 visits were pts<40 yrs Of 4492 visits for CP, 1023 visits were pts<40 yrs If no cardiac risk factors and no prior cardiac history (n=436) If no cardiac risk factors and no prior cardiac history (n=436)

– 6 USA (1.4%) initial diagnosis6 USA (1.4%) initial diagnosis– 2 AMI (0.5%) during index visit 2 AMI (0.5%) during index visit – 30 days – no death, AMI, PCI or CABG (0.5%, 95% CI, 0-1.1%). 30 days – no death, AMI, PCI or CABG (0.5%, 95% CI, 0-1.1%).

Normal ECG and no prior cardiac history (n=593) Normal ECG and no prior cardiac history (n=593) – 6 USA (1%) initial diagnosis6 USA (1%) initial diagnosis– 1 AMI (0.17%) during index visit 1 AMI (0.17%) during index visit – no AMI, PCI or CV deaths during follow up (0%, 95% CI, 0-0.5%).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%)Risk of 30 day adverse events 0.3 (0-0.8%)

No prior history, no risks, normal ECG (n=299)No prior history, no risks, normal ECG (n=299)– 3 USA (1%), no AMI3 USA (1%), no AMI– No 30 day adverse events (0%; 0-1%)No 30 day adverse events (0%; 0-1%)

Add initial marker Add initial marker – Only 1 ACS, nothing else for any of the groups (0.14%; 0.1-0.2%)Only 1 ACS, nothing else for any of the groups (0.14%; 0.1-0.2%)

Marsan et al. AEM 2005;128:26.


Han et al. Ann Emerg Med 2007;49:145.

CRF Burden and ACS

.518

.602

.763

TIMI Risk ScoreTIMI Risk Score

TIMI Risk Score for UATIMI Risk Score for UA– Age > 65Age > 65– 3 or more CRF’s3 or more CRF’s– Known CAD > 50%Known CAD > 50%– ST segment changes on ECGST segment changes on ECG– 2 or more anginal events in past 24 hours2 or more anginal events in past 24 hours– ASA use within 7 days priorASA use within 7 days prior– Elevated cardiac markersElevated cardiac markers

TIMI Risk in the EDTIMI Risk in the ED

# of TIMI Risk FactorsChase, et al. Ann Emerg Med. 2006:48:252



High Sensitivity High Sensitivity Cardiac Cardiac MarkersMarkers

TnI-Ultra: 60d AMI/CV DeathTnI-Ultra: 60d AMI/CV Death

cTnIcTnI NN # Events# Events Rate, %Rate, % RRRR

<0.006<0.006 108 (29%)108 (29%) 22 1.91.9 --

0.006-0.040.006-0.04 174 (47%)174 (47%) 1111 6.46.4 3.33.3

>0.04-0.10>0.04-0.10 38 (10%)38 (10%) 99 24.124.1 13.013.0

>0.10>0.10 51 (14%)51 (14%) 2828 55.155.1 34.934.9

Apple et al. Clin Chem 2008;54:723

371 patients with symptoms suggestive of ACS

High Sensitivity TroponinHigh Sensitivity Troponin 718 patients with potential AMI; 123 had AMI718 patients with potential AMI; 123 had AMI

PresentationPresentation Sens = 84-95%Sens = 84-95% Spec = 80-84%Spec = 80-84%

Reichlin et al. NEJM 2009;361:858

High Sensitivity TroponinHigh Sensitivity Troponin 1818 patients with potential AMI; 413 had AMI1818 patients with potential AMI; 413 had AMI

PresentationPresentation Sens = 90%Sens = 90% Spec = 90%Spec = 90%

Within 3 hoursWithin 3 hours Sens = 100%Sens = 100%

Keller et al. NEJM 2009;361:868

hsTnI in UA: Protect TIMI 30hsTnI in UA: Protect TIMI 30

Wilson et al. Am Heart J 2009;158:386

100 potential ACS patients

65% admitted35% discharged

20092009

15% real85% bogus

100 potential ACS patients

65% admitted35% discharged

The FutureThe Future

15% real85% bogus

44

8

55 not sick (IM) 10 real (cards)35 discharged

90% Sens80% Spec

19 (trop FP) 9-10 real71 discharged



Stuck with Stuck with Admissions?Admissions?

Evidence Based Evidence Based Work AroundsWork Arounds

Observation Unit RationaleObservation Unit Rationale

Cannot identify a group of clinical and/or Cannot identify a group of clinical and/or ECG variables that identifies patients at such ECG variables that identifies patients at such low risk for AMI/complications that they can low risk for AMI/complications that they can be safely released from the EDbe safely released from the ED

No single test sufficiently excludes risk of No single test sufficiently excludes risk of AMI or complications AMI or complications

Attempts to shorten evaluationAttempts to shorten evaluation

Hollander et al – Prospective studyHollander et al – Prospective study– 460 CP pts with normal or nonspecific ECG’s460 CP pts with normal or nonspecific ECG’s

• 4 CV complications (1 VT/VF post op; 1 SVT in CHF pt; 2 4 CV complications (1 VT/VF post op; 1 SVT in CHF pt; 2 sinus pauses of 2.4 and 4 seconds without intervention)sinus pauses of 2.4 and 4 seconds without intervention)

Schull et al – Retrospective studySchull et al – Retrospective study– 8932 pts admitted to tele ward8932 pts admitted to tele ward

• 20 cardiac arrest20 cardiac arrest– 9 detected by monitor9 detected by monitor

• 3 survival to discharge3 survival to discharge– 1 definitely detected by monitor; 1 detected by neighbor when he 1 definitely detected by monitor; 1 detected by neighbor when he

fell to floor; 1 no record of when it began on monitor (?detected)fell to floor; 1 no record of when it began on monitor (?detected)

AJC 1997;110

AEM 2000;7:647

TelemetryTelemetry

Telemetry: HUP DataTelemetry: HUP Data

Total Patients(n=3686)

Floor110 (3%)

ICU/cath lab424 (12%)

Telemetry1748 (47%)

Home1383 (38%)

Goldman > 7591 (34%)

Goldman < 71157 (66%)

Markers negative1027 (89%)

Markers positive130 (11%)

Hollander et al. Annals EM 2004;43:71.

Telemetry: HUP DataTelemetry: HUP Data

Sustained VT/VFSustained VT/VF Bradydysrrhythmias requiring treatmentBradydysrrhythmias requiring treatment

0% (95 CI, 0-0.3%)0% (95 CI, 0-0.3%)

Preventable CV DeathPreventable CV Death

0% (95 0% (95 CICI, 0-0.3%), 0-0.3%)


Telemetry: HUP OutcomesTelemetry: HUP Outcomes

Initial HospitalizationInitial Hospitalization No.No. PercentPercentMyocardial infarction Myocardial infarction 15 15 1.5% 1.5%Unstable anginaUnstable angina 121121 12%12%Percutaneous interventionPercutaneous intervention 11 11 1.1% 1.1%Stent PlacementStent Placement 10 10 1.0% 1.0%CABGCABG 4 4 0.4% 0.4%DeathDeath 2 2 0.2% 0.2%




It’s Not My HeartIt’s Not My HeartI Had a Test AlreadyI Had a Test Already

Stress Tests and ED DispositionStress Tests and ED Disposition

Disposition (% admitted)Disposition (% admitted)AbnormalAbnormal NormalNormal NoneNone

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

Per

cen

tP

erce

nt

92%92%

67%67%72%72%

Nerenberg et al. AmJEM 2007;25:39.Nerenberg et al. AmJEM 2007;25:39.

Stress Tests & 30-Day OutcomesStress Tests & 30-Day Outcomes

30-Day Adverse Cardiovascular Outcomes (%)30-Day Adverse Cardiovascular Outcomes (%)

AbnormalAbnormal NormalNormal NoneNone00

22

44

66

88

1010

1212

Per

cen

tP

erce

nt

10.1%10.1%

5.2%5.2%4.8%4.8%

Nerenberg et al. AmJEM 2007;25:39.Nerenberg et al. AmJEM 2007;25:39.

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

Maybe It Keeps Them Away?Maybe It Keeps Them Away?

Shaver et al. Acad EM 2005;11:1272Shaver et al. Acad EM 2005;11:1272

Better Than Stress Testing Better Than Stress Testing

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

deFillipi et al. JACC 2001deFillipi et al. JACC 2001



Acute Cardiac Acute Cardiac Imaging (in the ED)Imaging (in the ED)

EchocardiographyEchocardiography

Detects wall motion abnormalityDetects wall motion abnormality– sensitivity moderate highsensitivity moderate high

Cannot distinguish old from newCannot distinguish old from new– many “false positives”many “false positives”

May miss non-Q wave AMIMay miss non-Q wave AMI– usually small infarctsusually small infarcts

Never compared to physician judgment or Never compared to physician judgment or cardiac markers to assess incremental valuecardiac markers to assess incremental value

Sestamibi ImagingSestamibi Imaging

338 ED chest pain patients with normal scans338 ED chest pain patients with normal scans– None had a cardiac death during 1 year periodNone had a cardiac death during 1 year period

– None had an MINone had an MI

– 7 required coronary revascularization7 required coronary revascularization 100 abnormal scans100 abnormal scans

– 7 AMI7 AMI

– 30 revascularization within one year30 revascularization within one year

Tatum et al. Annals EM 1997;29:116.

Sestamibi ImagingSestamibi Imaging

Relative risks of abnormal scansRelative risks of abnormal scans– AMIAMI 50 (2.8-890)50 (2.8-890)– RevascularizationRevascularization14.5 (6-34)14.5 (6-34)– Death by 1 yearDeath by 1 year 30 (1.6-570)30 (1.6-570)

Sensitivity for AMISensitivity for AMI– 100% (64-100)100% (64-100)

SpecificitySpecificity– 78% (74-82)78% (74-82)

Tatum et al. Annals EM 1997;29:116.

ER Assessment of Sestamibi ER Assessment of Sestamibi (ERASE)(ERASE)

RCT of 2475 ED chest pain patients with normal RCT of 2475 ED chest pain patients with normal or nondiagnostic ECGs or nondiagnostic ECGs – Usual ED evaluation (n=1260)Usual ED evaluation (n=1260)– Usual evaluation & resting MPI (n= 1215)Usual evaluation & resting MPI (n= 1215)

Primary outcomePrimary outcome– Appropriateness of initial triage decisionAppropriateness of initial triage decision

Udelson JE et al. JAMA. 2002;288:2693

Sensitivity for MI and acute Sensitivity for MI and acute ischemia were not ischemia were not significantly differentsignificantly different

Patients in the acute MPI arm Patients in the acute MPI arm had a significantly lower had a significantly lower hospitalization rate hospitalization rate

Costs reduced in the MPI arm Costs reduced in the MPI arm by an average of $70/patientby an average of $70/patient

97

83

42

96

81

52

0

25

50

75

100

MI ACS Admit

MPI

StandardNS

NS

P<.01

ERASE

Udelson JE et al. JAMA. 2002;288:2693

Coronary CTA AccuracyCoronary CTA Accuracy

StudyStudy ScannerScanner SensitivitySensitivity SpecificitySpecificity

Janne d’OtheeJanne d’Othee AllAll 95%95% 85%85%

Janne d’OtheeJanne d’Othee 64 slice64 slice 98%98% 91%91%

HeuschmidHeuschmid Dual sourceDual source 96%96% 87%87%

WeustnikWeustnik Dual sourceDual source 99%99% 87%87%

ScheffelScheffel Dual sourceDual source 96%96% 98%98%

Correlation with cardiac catheterization

Coronary CTA PrognosisCoronary CTA Prognosis

Hulton et al. JACC 2011:57:1237Hulton et al. JACC 2011:57:1237

Meta-analysisMeta-analysis 9592 patients9592 patients Median f/uMedian f/u

20 months20 months MACEMACE

Sensitivity = 99%Sensitivity = 99% LR - = 0.008LR - = 0.008

Hollander et al. Hollander et al. – 100% NPV for D/AMI/revasc in 525 patients at 30 100% NPV for D/AMI/revasc in 525 patients at 30

daysdays Hoffman et al. Hoffman et al.

– 100% NPV for ACS in 73 pts over 5 months100% NPV for ACS in 73 pts over 5 months Rubinshtein et al.Rubinshtein et al.

– 100% NPV for 35 pts over 15 months100% NPV for 35 pts over 15 months Pundziate et al. Pundziate et al.

– 100% NPV for 20 pts over 13 months100% NPV for 20 pts over 13 months

No / noncritical diseaseNo / noncritical disease

No / noncritical diseaseNo / noncritical disease

Goldstein et al. Goldstein et al. – 100% NPV for D/AMI/revasc in 67 patients at 30 100% NPV for D/AMI/revasc in 67 patients at 30

daysdays Hoffman et al. (ROMICAT) Hoffman et al. (ROMICAT)

– Any plaqueAny plaque• 100% NPV for ACS/events in 183 pts over 6 months100% NPV for ACS/events in 183 pts over 6 months

– Stenosis < 50%Stenosis < 50%• 98% NPV for ACS/events in 300 pts over 6 months98% NPV for ACS/events in 300 pts over 6 months

Largest cohort study Largest cohort study – 525 of 568 patients with negative CTA525 of 568 patients with negative CTA– 30 day follow-up 30 day follow-up

No cardiac deaths (95% CI, 0-0.8%)No cardiac deaths (95% CI, 0-0.8%) No AMI (95% CI, 0-0.8%)No AMI (95% CI, 0-0.8%) No revascularization (95% CI, 0-0.8%)No revascularization (95% CI, 0-0.8%)

CT Coronary AngiographyCT Coronary Angiography

Hollander et al Ann EM 2009;53:295.Hollander et al Ann EM 2009;53:295.

All CTA (n=568)

No stenosis or maximal stenosis < 50%

(n=508)

473 32 3

CathNone Stress

- +032

03- +

Ca>400, no contrast injection (n=6)

CTA with contrast injection (n=562)

Maximal stenosis 50-69%

(n=41)

18 21 5

CathNone Stress

- +516

10

- +50-69%

3*

3

Maximal stenosis >70%

(n=13)

5

CathStress

- +32

6

None

3

20

- +50-69%

4

1

5

RCT of CCTARCT of CCTA v MPI post CDU (n=197)v MPI post CDU (n=197)– Normal CCTA discharged home (75%)Normal CCTA discharged home (75%)– 9 with severe disease to catheterization9 with severe disease to catheterization– Intermediate disease to stress testIntermediate disease to stress test

CCTA reduced LOS (3.4 v 15.0 hours)CCTA reduced LOS (3.4 v 15.0 hours) CCTA reduced costs ($1586 v $1872)CCTA reduced costs ($1586 v $1872) Re-evaluation of chest pain (2% v 7%)Re-evaluation of chest pain (2% v 7%)

Goldstein et al JACC 2007;49:863-871Goldstein et al JACC 2007;49:863-871


Goldstein et al . JACC 2011;58:1414-22Goldstein et al . JACC 2011;58:1414-22

CT STATCT STAT

CCTA (n=361) MPI (n=338)

Time to Diagnosis 7.9 hrs 6.2 hrs

ED Cost $2137 $3458

Death within 6 months 0 0

AMI within 6 months 1 (0.3%) 5 (1.5%)

ED revisit, cardiac 2 (0.6%) 4 (1.3%)

Rehospitalization, cards 0 0

Normal test 82% 90%

MACE with nl test 2/268 (0.8%) 1/266 (0.4%)

Main Outcomes: EfficacyMain Outcomes: Efficacy

CTACTA

(N=98)(N=98)

Obs/CTAObs/CTA

(N=102)(N=102)

Obs/StressObs/Stress

(N=154)(N=154)

TeleTele

(N=289)(N=289)

Total Total Facility Facility Cost $Cost $

(IQR)(IQR)

1240 1240

(723-1943)(723-1943)

2318 2318

(2000-3041)(2000-3041)

4024 4024

(3322-4751)(3322-4751)

2913 2913

(1713-5592)(1713-5592)

LOS hours LOS hours (IQR)(IQR)

8.1 8.1

(5.9-13.7)(5.9-13.7)

20.9 20.9

(15.1-26.5)(15.1-26.5)

26.2 26.2

(21.3-32.1)(21.3-32.1)

30.2 30.2

(24.0-73.1)(24.0-73.1)

Testing$4154

Chang et al. AEM 2008;15:649.Chang et al. AEM 2008;15:649.

Main Outcomes: SafetyMain Outcomes: Safety

CTACTA

(N=98)(N=98)

Obs/CTAObs/CTA

(N=102)(N=102)

Obs/StressObs/Stress

(N=154)(N=154)

TeleTele

(N=289)(N=289)

% CAD% CAD5.1 5.1

(1.7-11.5)(1.7-11.5)

5.9 5.9

(2.2-12.4)(2.2-12.4)

5.8 5.8

(2.7-10.8)(2.7-10.8)

6.6 6.6

(4.0-10.1)(4.0-10.1)

% Death/MI% Death/MI0 0

(0-3.7)(0-3.7)

0 0

(0-3.6)(0-3.6)

0.7 0.7

(0.1-3.6)(0.1-3.6)

3.1 3.1

(1.4-5.8)(1.4-5.8)

% Rehosp% Rehosp00

(0.0-4.0)(0.0-4.0)

3.23.2

(0.7-9.0)(0.7-9.0)

2.32.3

(.06-12.0)(.06-12.0)

12.212.2

(8.5-16.7)(8.5-16.7)

Chang et al. AEM 2008;15:649.Chang et al. AEM 2008;15:649.

Fagan’s Nomogram for MACEFagan’s Nomogram for MACE

Hulton et al. JACC 2011:57:1237Hulton et al. JACC 2011:57:1237

CT Coronary AngiographyCT Coronary AngiographyVolume 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.


Thin-slab MIP (maximum intensity projection):

No stenosis in proximal LAD, circumflex and ramus medianus (RM) arteries.


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


Low density noncalcified plaque (arrow) causing >50% stenosis of the proximal right coronary artery.

Severe RCA lesion


ACRINACRIN Randomized 2:1 to Coronary CTARandomized 2:1 to Coronary CTA Coronary CTA groupCoronary CTA group

Coronary CTA Coronary CTA Clinical bloods (c/w guidelines) at time 0 & 90-180 minutesClinical bloods (c/w guidelines) at time 0 & 90-180 minutes Banked bloods at T0, 90-180 and 6 hoursBanked bloods at T0, 90-180 and 6 hours Dispo per physiciansDispo per physicians

Traditional care groupTraditional care group Anything but coronary CTAAnything but coronary CTA Banked bloods at T0, 90-180 and 6 hoursBanked bloods at T0, 90-180 and 6 hours Dispo per physiciansDispo per physicians

Results March 26 at ACCResults March 26 at ACC ROMICAT 2 – March 27ROMICAT 2 – March 27



Putting It Together

TriageTriage

Clinical PresentationClinical Presentation ECGECG Past historyPast history

– CADCAD Available technologyAvailable technology Required medicationsRequired medications

– FibrinolyticsFibrinolytics– IV nitratesIV nitrates– HeparinHeparin

TriageTriage Risk stratificationRisk stratification

– TIMI Risk ScoreTIMI Risk Score– HEART ScoreHEART Score– GRACE or PURSUITGRACE or PURSUIT– Lee and Goldman algorithmLee and Goldman algorithm– Clinical impressionClinical impression

Adjunctive TestingAdjunctive Testing– MarkersMarkers– ImagingImaging

TriageTriage High risk patientsHigh risk patients

– ECG abnormalitiesECG abnormalities

– Heart failureHeart failure

– DysrrhythmiasDysrrhythmias

– Unstable vital signsUnstable vital signs

– Need for IV dripsNeed for IV drips

– Positive markers or MPI scans in the EDPositive markers or MPI scans in the ED

– Positive CCTA with good storyPositive CCTA with good story Admit to Cardiac Care UnitAdmit to Cardiac Care Unit

TriageTriage

Lowest risk patientsLowest risk patients– Young patientsYoung patients– Normal electrocardiogramsNormal electrocardiograms– Low risk storyLow risk story– TIMI Score <3TIMI Score <3– Normal markers and sestamibi scans, if doneNormal markers and sestamibi scans, if done

Triage to Triage to – Observation unitObservation unit– Nonmonitored bedsNonmonitored beds– Home if lowest possible riskHome if lowest possible risk

• Normal CCTA goes homeNormal CCTA goes home• individual and institutional cut-off for missesindividual and institutional cut-off for misses

TriageTriage

Intermediate Risk PatientsIntermediate Risk Patients– Equivocal storiesEquivocal stories– Abnormal but not diagnostic ECG’sAbnormal but not diagnostic ECG’s– TIMI Score > 3TIMI Score > 3– Markers normal or slightly elevatedMarkers normal or slightly elevated– Scans with old abnormalities (CAD)Scans with old abnormalities (CAD)

Most should be admitted to monitored bedsMost should be admitted to monitored beds

Unstable AnginaUnstable Angina

Distinguish real unstable angina from Distinguish real unstable angina from need to “rule out” AMIneed to “rule out” AMI

Single atypical episode of chest pain Single atypical episode of chest pain – ““rule out MI”rule out MI”– unstable angina?unstable angina?

SummarySummary

ACS versus anything else for dispo/triageACS versus anything else for dispo/triage CTA to allow dischargeCTA to allow discharge AMI is ANY elevation in markers above AMI is ANY elevation in markers above

normal normal STEMI or NSTEMI drive treatmentSTEMI or NSTEMI drive treatment

Words of wisdom? (without evidence)Words of wisdom? (without evidence)

Short cuts to “r/o MI”Short cuts to “r/o MI”– 90 minute to 3 hour “rule outs”90 minute to 3 hour “rule outs”

• Rising or delta cardiac markersRising or delta cardiac markers

Incidental abnormal ECG’sIncidental abnormal ECG’s– Always make referralAlways make referral– QTc intervalsQTc intervals

Admission diagnosis also should includeAdmission diagnosis also should include– ““rule out life threatening conditions”rule out life threatening conditions”

Stable anginaStable angina– Whatever it is – it is stable for outpt evaluationWhatever it is – it is stable for outpt evaluation

The ROS curseThe ROS curse

Department of Emergency Medicine University of Pennsylvania Health System Emergency Department...

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