chest pain risk stratification

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Chest Pain Risk Stratification

Alex Beuning

WAPA Spring Conference, March 2020

ObjectivesAfter this lecture, participants will be better able to:

1) Discuss which patients with chest pain benefit from Acute Coronary Syndrome (ACS) risk stratification

2) Understand the term MACE (major adverse cardiac events) 3) Describe how to utilize risk stratification tools such as HEART pathway score

4) Utilize shared decision making to determine an evaluation and treatment plan in patients with chest pain

5) Understand how high sensitivity troponins change evaluation of chest pain

How big a problem is Chest Pain?

• 2nd most common chief complaint in Emergency Departments

• 7 million Annual ED visits in USA

• Cost ‐ $5 billion annually

• Januzzi J et al. Evaluating Chest Pain in the Emergency Department. JACC. Vol. 71, Feb 2018.

• McCaig, L, Burt, C. National Hospital Ambulatory Medical Care Survey: 2003 Emergency Department Summary. In: Advance Data from Vital and Health Statistics. Centers for disease control and prevention, Atlanta, GA 2005

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Why is chest pain a big deal in ED?

• Difficult to make diagnosis

• Large differential diagnosis

• Multiple organ systems cause chest pain

• Variable “atypical” presentations

• Non‐ED testing may be required (stress test, echo, etc)

• History is critical! And our time is limited…

• Risky chief complaint

• Both life threatening & benign conditions

• Patients with life threatening chest pain can look well and have normal vital signs

• Misses can be catastrophic

Chest Pain Differential Diagnosis

• Cardiac• ACS, CHF, valvular heart disease, pericarditis, myocarditis, endocarditis, pericardial effusion, aortic dissection, post cardiac surgery

• Pulmonary• Pneumonia, URI/bronchitis, PE, tracheitis, pulmonary malignancy, pleural effusion, pneumothorax

• Gastrointestinal• GERD, Esophageal spasm, Esophageal rupture (Boerhaave’ssyndrome), sliding hiatal hernia, pancreatitis, PUD, Biliary colic

• Musculoskeletal• Costochondritis, intercostal strain/spasm, rib contusion/fracture

• Psychiatric• Panic disorder

• Other• Herpes Zoster, referred pain, collagen vascular diseases, deep neck space infections, medication side effects

Chest pain – Life threats• Acute coronary syndrome (ACS)

• Aortic dissection

• Pulmonary embolism

• Pneumothorax

• Mediastinitis (Esophageal rupture, post‐op, deep tissue infections)

• Pericardial tamponade

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ED Chest Pain Visit Goals• Rule out the bad stuff! Who has risk for MI/death.

• Risk stratify the patient for ACS

• High, medium, low or very low risk

• Don’t forget to align your agenda with patient’s agenda

• Work excuse

• Pain control

• Anxiety about heart attack (even if very low risk)

• Shared decision making about evaluation and follow‐up plans

• Admit, OBS, outpatient follow‐up

Chest pain initial evaluation• Look at the patient, obtain history!

• Manage unstable patient/critical care/ABCs

• Get EMS/family report if possible

• Cardiac monitor, Oxygen, IV, ?crash cart

• EKG – EARLY (Goal < 10 min)

• Stat CXR

• Bedside ultrasound if indicated

• Labs – troponin, CBC, metabolic panel, ? lipase, ? liver enzymes, ? D‐dimer

Extended ED Chest Pain Evaluation

• Repeat cardiac enzymes (troponin)

• Repeat EKGs, cardiac monitoring

• Chest CT

• Observation

• In ED: low risk patients

• Hospital: Mod/high risk patients

• Echocardiogram

• Exercise stress testing (+/‐ nuclear cardiac imaging)

• Cardiac catheterization *

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Acute Coronary Syndrome (ACS)• ST‐Elevation Myocardial Infarction (STEMI)

• Non‐ST Elevation Myocardial Infarction (NSTEMI)

• Unstable Angina

• Stable Angina is NOT ACS

ACS Care Evaluation Milestones• 1960, early 1970s: Admit, monitor, aspirin

• 1969: CK introduced

• 1975: Thrombolytics become standard of care for STEMI

• 1988: Troponin T introduced

• 2000: NEJM: 2% of AMI patients discharged from ED!

• 2004: PCI within 90 min ‐ class IA recommendation

• 2010: AHA Guidelines: DO stress testing BEFORE DISCHARGE for “possible ACS”

• 2013: Crit Path Cardiology: Admission of low risk chest pain patients for stress testing is expensive and no benefit

• 2017: High sensitivity Troponin introduced in US

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ED ACS Rule-out Goals1) Diagnose & treat STEMI rapidly

2) Identify & treat alternate, non‐ACS, diagnoses

3) NSTEMI diagnosis

• Serial Troponins (0 & 2 – hours)

4) Risk stratify for ACS – MACE risk

• Heart pathway

Cardiac BiomarkersHow does Hs Trop compare?

Ideal Cardiac Biomarker

• High myocardial content

• Absence in non‐myocardial tissues

• Rapid release into blood after myocardial injury

• High sensitivity and specificity

• Rapid clearance from blood

• Detection by rapid, cost effective and simple assays

Biomed Rep. 2015 Nov; 3(6):743‐748.

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Troponin is “gold standard”• 1999: American College of Cardiology and Joint European Society of Cardiology Committee introduce cardiac troponin (cTn) as the gold standard for diagnosis of myocardial infarction.

Alpert JS, Thygesen K, Antman E, et al. Myocardial infarction redefined ‐ a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000;36:959–969. doi: 10.1016/S0735‐1097(00)00804‐4

High-Sensitivity Troponin

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Figure 2 ESC algorithm for diagnosis of acute myocardial infarction (AMI)with a 0/1-h approach and measurement of troponin using a high-sensitivity assay

Westermann, D. et al. (2017) High-sensitivity assays for troponin in patients with cardiac diseaseNat. Rev. Cardiol. doi:10.1038/nrcardio.2017.48

MORE ED RULE OUTS!LESS ED NSTEMIDIAGNOSES

LESS NEED FOR OBS CARE

Who needs OBS CARE for possible ACS?

• It’s NOT just based upon troponin value, but also based on patient risk

• 2 patients both have Negative ECG and no delta troponin:

• First is 65 yo M with typical exertional CP, family hx and DM

• Second is 31 yo F with atypical sharp CP in right chest and no other risk factors

• Which would you OBSERVE in hospital?

2010 AHA chest pain guideline

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Results of ED OBS: 2011-2013• Average age 44

• Females > Males 2 to 1

• MPI chosen over ETT 5 to 1

• False positive 10x > true positive

• Multiple cardiac cath procedures on false +

• Unnecessary procedural risk/cost/radiation

• Total cost of ED OBS stay often > $10,000

• Still had few ACS/MI misses…

• Can we avoid all risk?

HEART SCORE• 2008 Study – Netherlands

• HEART Score 0‐3: low risk of Major Adverse Cardiac Event

• MACE = Death, MI, Revascularization in 30 days

• Suggested practice adjustment:

• Inpatient/OBS for HEART score >3

• Outpatient for HEART Score 0‐3

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HEART PATHWAY• 2015 Study

• 282 ED patients

• HEART Pathway randomized vs ACC/AHA guideline

• Excludes patients with known CAD or Ischemic ECG

• HEART score, validated decision aid and serial troponins

• Troponins 4th generation, done at 0 and 3 hours

• NO MACE in 30 days for HEART Pathway “Early Discharge”

HEART PATHWAY

EPIC EMR HEART PATHWAY CALCULATOR

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HEART PATHWAY APP

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* Cath

HEART PATHWAY 1-YEAR F/U• 282 ED patients

• HEART Pathway randomized vs ACC/AHA guideline

• 1‐YEAR RESULTS:

• HP: 9.9% MACE (0% low risk), 63% testing (stress/cath)

• Usual: 11.3% MACE, 71% testing (stress/cath)

HEART PATHWAY TRIAL RESULTS – Eau Claire, WI (2019)

719 patients

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ED Chest PAIN Shared Decision Making

• CHEST PAIN CHOICE TRIAL

• Give LOW RISK chest pain patient’s objective data about short term risk of ACS

• HEART SCORE 3 or 4

• Discuss this risk with them – using decision aid

• http://www.trialsjournal.com/content/pdf/1745‐6215‐11‐57.pdf

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Case 1• 72 yo male smoker presents with cough for 3 days productive of yellow sputum and fever today.

• Sharp, intermittent, central chest pain for past 2 days and mild dyspnea after coughing spells. No N/V or diaphoresis.

• PMH: ASHD, CABG, COPD, HTN, Ex‐smoker, unknown FHx

• Meds: ASA, Metoprolol, Isosorbide, Advair, Albuterol

• T 38.0, P 92, BP 162/90, RR 22, O2 Sat 91% 2L

EKG – Case 1

Case 1 - Evaluation• Exam: Normal

• Labs: Normal, except:

• Serial high‐sensitivity troponins: 28 and 32 ng/L (delta = 4)

• CXR‐ chronic changes of COPD, no acute infiltrates

• HEART score = 6 (2 for age, 1 for symptoms, 2 for risk factors, 1 for ECG)

• Admit or discharge?

• Cardiology consultation?

• Do you think ACS is cause of his chest pain?

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Case 1 Summary• Final Dx: COPD Exacerbation

• EKG: Left Bundle Branch Block, NOT STEMI

• Patient was admitted to medicine, MI ruled out, improved with steroids and nebulizer treatments, no acute cardiac issues identified

Case 2• 46 yo female with presents with chest “pressure” starting this morning while driving to work. Not exertional or pleuritic. She was worried she was having MI so drove to ED instead. She noted some SOB that is now improved but denies nausea or diaphoresis. Pain lasted for about 45 minutes and is now 1/10.

• PMH: HTN, Smoker, No family hx of early MI

• Meds: None

• T 36.8 C, P 94, BP 145/84, R 18, O2 Sat 99% RA

EKG – Case 2

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Case 2 - Evaluation• Exam normal

• Labs normal


• CXR‐ normal


Case 2 Summary• Final Dx: Chest pain, uncertain cause

• EKG: Normal ECG

• Patient was discharged home with follow‐up with PCP or Cardiology if unable to get in within a week.

• Exercise stress test was negative as outpatient.

Case 3• 45 yo female with System lupus erythematosus presents with intermittent central chest pressure for the past 2 hours now persistent in the past 30 minutes rated at 4/10 with some nausea and dyspnea but denies diaphoresis.

• Non‐smoker, no family hx of CAD

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EKG – Case 3

Case 3 - Evaluation• Exam normal

• Labs including D‐dimer is normal


• CXR‐ normal


Case 3 Continuation• Chest pain is worsening a bit, now rates it 7/10 and some mild dyspnea.

• What should you do next?

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EKG #2 (Case 3)

CASE 3 Summary• Final Dx: STEMI

• EKG #1: Normal

• EKG #2: STEMI

• Patient went directly to cath lab for angiogram within 25 minutes, Vfib arrest on cath lab table, defib successful, LAD blockage stented successfully, good outcome

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ED Chest Pain Summary• Chest pain is complicated. Don’t oversimplify.

• Chest pain is risky! Be appropriately anxious without paralysis.

• Understand ACS risk stratification

• Consider alternate life threats, not just ACS

• Build your EKG and CXR reading skills

• Know your system protocols and use your consultants/resources wisely

• Utilize shared decision making with patients and families and document this well

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chest pain risk stratification

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