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Emergency Department Triage and Evaluation of the Patient with Chest Pain

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. ED Visits. 130,000,000 visits annually. 3,000,000 likely noncardiac sent home.

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Emergency Department Triage and Evaluation of the Patient with Chest Pain

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  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 2000;85:32B-39B

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

  7. itrACS 17,737 patients enrolled Conclusion: Even patients thought to have noncardiac pain can suffer adverse cardiac events, especially if risk factors are present Initial Impression = “Noncardiac Pain” Patients with initial emergency impression of “noncardiac chest pain” 2,992 2.8% had adverse cardiac events (infarction, revascularization, or death) within 30 days 85 Miller CD, et al. Ann Emerg Med. 2004;44:565.

  8. Clinical Parameters

  9. Clinical Parameters • Identifying low risk patients Lee et al. 1985 Arch IM 1985;145:65. • 596 ED patients MI USA Other

  10. Clinical Parameters MI USA Other Lee et al. Arch IM 1985;145:65.

  11. Clinical Parameters MI USA Other Lee et al. Arch IM 1985;145:65.

  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 1992;45:621.

  13. Clinical Parameters: Risk Factors CRF Burden and ACS (AUC=0.591) Han et al. Ann Emerg Med 2007;49:145.

  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. 1994;154:2466.

  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., 2007:14:215

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

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

  18. Electrocardiograms • Patients admitted to CCU • Morbidity and mortality related to ECG Slater et al. Am J Cardiol 1987;60:766.

  19. Electrocardiograms • Patients admitted to CCU (n=469) 25 % 46 Neg ECG n=167 Pos ECG n=302 18 18 4 1 1 0 Brush et al. NEJM 1985;312:1137.

  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 1997;29:575.

  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 1991;324:1239.

  24. Young Patients-Validated • Of 4492 visits for CP, 1023 visits were pts<40 yrs • If no cardiac risk factors and no prior cardiac history (n=436) • 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 (n=593) • 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 (n=299) • 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 2005;128:26.

  25. Clinical Parameters: Risk Factors .763 .602 .518 CRF Burden and ACS Han et al. Ann Emerg Med 2007;49:145.

  26. TIMI Risk Score • TIMI Risk Score for UA • Age > 65 • 3 or more CRF’s • Known CAD > 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. 2006:48:252

  28. High Sensitivity Cardiac Markers

  29. TnI-Ultra: 60d AMI/CV Death 371 patients with symptoms suggestive of ACS Apple et al. Clin Chem 2008;54:723

  30. High Sensitivity Troponin • 718 patients with potential AMI; 123 had AMI Presentation • Sens = 84-95% • Spec = 80-84% Reichlin et al. NEJM 2009;361:858

  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 2009;361:868

  32. hsTnI in UA: Protect TIMI 30 Wilson et al. Am Heart J 2009;158:386

  33. 2009 100 potential ACS patients 35% discharged 65% admitted 85% bogus 15% real

  34. 44 8 71 discharged 19 (trop FP) 9-10 real The Future 100 potential ACS patients 35% discharged 65% admitted 90% Sens 80% Spec 85% bogus 15% real 35 discharged 55 not sick (IM) 10 real (cards)

  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 AJC 1997;110 • Hollander et al – Prospective study • 460 CP pts with normal or nonspecific ECG’s • 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) AEM 2000;7:647

  38. ICU/cath lab 424 (12%) Telemetry 1748 (47%) Floor 110 (3%) Home 1383 (38%) Goldman < 7 1157 (66%) Goldman > 7 591 (34%) Markers positive 130 (11%) Markers negative 1027 (89%) Telemetry: HUP Data Total Patients (n=3686) Hollander et al. Annals EM 2004;43:71.

  39. 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 2004;43:71.

  40. Telemetry: HUP Outcomes Initial HospitalizationNo.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 2004;43:71.

  41. It’s Not My HeartI Had a Test Already

  42. 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 2007;25:39.

  43. 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 2007;25:39.

  44. 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 2005;11:1272

  45. 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

  46. Acute Cardiac Imaging (in the ED)

  47. 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

  48. 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 1997;29:116.

  49. 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 1997;29:116.

  50. ER Assessment of Sestamibi (ERASE) RCT of 2475 ED chest pain patients with normal or nondiagnostic ECGs Usual ED evaluation (n=1260) Usual evaluation & resting MPI (n= 1215) Primary outcome Appropriateness of initial triage decision Udelson JE et al. JAMA. 2002;288:2693

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