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Chest Pain Evaluation, Risk Assessment for Acute
Coronary Syndrome & 2014 NSTEMI Guideline Update
Arie Szatkowski, MD FACCStern Cardiovascular FoundationBaptist Memorial Healthcare Corporation
Chest Pain FactsCV disease is #1 cause of death in the U.S.
9% of all ED visits are for Chest Pain, about 5.5 million to 6 million annually (ambulatory visits account for < 1%)
Etiology can be difficult to diagnose
NSTEMI affects > 625,000 annually (3/4 ACS)
A Chest Pain Case
A 65 year-old man with a past medical history significant for hypertension and dyslipidemia presents to clinic after 2 episodes of chest pain in past couple days. What do you want to know and do?
Clinical classification of chest pain
Typical angina (definite)1) Substernal chest discomfort with a characteristic
quality & duration that is 2) provoked by exertion or stress and 3) relieved by NTG or rest
Atypical angina (probable)Meets 2 of above characteristics
Noncardiac chest painMeets 1 or none of typical anginal characteristics
#1 Goal
EXCLUDE Coronary artery disease and other life-threatening conditions
So, what are those?
Acute Coronary Syndrome/Myocardial infarctionPulmonary embolusAortic dissectionTension PneumothoraxEsophageal Rupture
*All of these could lead to sudden death*
History
“PQRST”Provocative/palliative factorsQuality: character, duration, frequency, associated
sxsRadiationSeverityTiming
Risk factors: age, tobacco use, family history, DM/HTN/Lipids, cocaine; other- DVT/PE, Marfans/Pregnancy, ETOH, NSAIDS
PMHx: prior CV w/u & Rx, GI history
Provocation and Palliation
Postprandial? GI or cardiac disease
Exertion? Angina or esophageal pain
Cold, emotional stress, sexual intercourse can promote ischemic pain
Worse with swallowing? Esophageal origin
Body position, movement, deep breathing? Musculoskeletal origin
Antacids or food? Gastro-esophageal origin
Sublingual nitro? Esophageal or cardiac
“GI Cocktail” (viscous lidocaine and antacid)? GI or cardiac
Cessation of activity/rest? Ischemic origin
Sitting up and leaning forward? Pericarditis
Evaluation
Region or location:Radiation to neck, throat, lower jaw, teeth, upper extremity, or shoulder
Radiation to arms is useful and stronger predictor of acute MIBetween scapulae think aortic dissection
Larger areas of discomfort more likely ischemic etiology
Severity: not useful predictor for presence of CAD
Timing:Abrupt onset with greatest intensity in beginning: PTX, dissection, acute PEGradual with increasing onset over time: ischemic Crescendo pattern: esophageal diseaseLasts for seconds or constant over weeks ≠ ischemicCircadian rhythm (morning>afternoon) correlating with increase sympathetic tome- more likely myocardial ischemia
Associated SymptomsBelching, bad taste in mouth, dysphagia or odynophagia esophageal disease
Vomiting Transmural MI, GI problems
Diaphoresis MI> esophageal disease
Syncope dissection, PE, critical AS, ruptured AAA
Pre-syncope myocardial ischemia
Palpitations in setting of new A. Fib + chest pain PE
Fatigue can be presenting complaint of MI esp. in elderly
Any Exam Findings That Might Help Distinguish Cardiac From Non Cardiac Chest Pain?
General Appearance may suggest seriousness of symptoms.
Vital signs marked difference in blood pressure between arms suggests aortic dissection
Palpate the chest wall Hyperesthesia may be due to herpes zoster
Complete cardiac examination
pericardial rubsigns of acute AI or AS Ischemia may result in MI murmur, S4 or S3
Determine if breath sounds are symmetric and if wheezes, crackles or evidence of consolidation
Ancillary Studies
EKG“Normal” reduces probability chest pain is due to AMI, but does NOT exclude serious cardiac etiology (i.e. Unstable Angina) ST elevation, ST depression, or new Q waves- important predictor of Acute Coronary Syndrome (AMI or UA)“Nonspecific” ST and T wave changes is common- may or may not indicate heart disease
CXRUseful in acute setting to avoid missing dangerous diagnoses (e.g. PTX, Aortic dissection, Pneumo-mediastinum)
Relationship between cardiac troponin levels and risk of death in patients with ACS.
Used with permission from Antman EM, Tanasijevic MJ, Thompson B, et al.
Braunwald E et al. Circulation. 2000;102:1193-1209Copyright © American Heart Association, Inc. All rights reserved.
Features Increasing Likelihood of AMI
Clinical Feature Likelihood Ratio (95% CI)
Pain in chest or left arm 2.7Chest pain radiation Right Shoulder 2.9 (1.4-6.0) Left arm 2.3 (1.7-3.1) Both left and right arm 7.1 (3.6-14.2)Chest pain most important symptom 2.0History of MI 1.5-3.0Nausea or vomiting 1.9 (1.7-2.3)Diaphoresis 2.0 (1.9-2.2)Third heart sound 3.2 (1.6-6.5)Hypotension (SBP<80) 3.1 (1.8-5.2)Pulmonary rales on exam 2.1 (1.4-3.1)
Features Decreasing Likelihood of AMI
Clinical Feature Likelihood Ratio (95% CI)Pleuritic chest pain 0.2 (0.2-0.3)
Chest pain sharp or stabbing 0.3 (0.2-0.5)
Positional chest pain 0.3 (0.2-0.4)
Chest pain reproduced with palpation
0.2-0.4
Panju, et al. JAMA 1998;280:14:1256-1263
ECG Findings Increasing Likelihood of AMI
Panju, et al. JAMA 1998;280:14:1256-1263
High Likelihood of ACS
Worsening frequency, intensity, duration, timing (e.g. nocturnal pain, rest pain) of prior anginaNew onset SOB, nausea, sweating, extreme fatigue in patient with known h/o CVDOnset of typical anginal symptoms in pt without h/o CVDNew murmur (or worsening of previously noted murmur), hypotension, diaphoresis, rales, pulmonary edemaTransient ST deviation (≥ 1mm) or TWI in multiple precordial leads
Pathophysiology of NSTE ACS
Supply-demand MismatchPlaque Disruption or RuptureThrombosisVasoconstrictionCyclical Flow
• Fever• Tachyarrhythmias• Malignant Hypertension• Thyrotoxicosis• Pheochromocytoma• Cocaine use• Amphetamine use• Critical Aortic Stenosis• Supravalvular Aortic Stenosis• Obstructive Cardiomyopathy• Aortovenous shunts• High Output States• Congestive Heart Failure
• Anemia• Hypoxemia• Polycythemia• Hypotension
Supply-Demand Mismatch
What’s New in the 2014 NSTEMI Guidelines?
Terminology change from unstable angina/NSTEMI to NSTEMI ACSApproach to patient remains unchangedIncrease focus on discharge instructions and transitionDiagnosis:
No benefit of CKMB (Class III)MI only if > 20% rise or fall of troponinPoint of care troponin not as specific
Special population: WomenClass III Early Invasive in Low Risk Women
Risk Stratification“Ischemia Guided Strategy” replaces “Initial Conservative
Management”Immediate Invasive < 2 hours if:
Refractory anginaCHF signs/symptomsNew or worsening MRHemodynamic instabilitySustained VT/VF
Early (within 24 hours)New ST segment depressionGRACE score > 140Temporal change in Troponin
Delayed InvasiveRenal insufficiencyLVEF < 40%TIMI > 2GRACE Risk 109-140
Medical TherapyACE inhibitors: Class I for NSTE ACS with LVEF < 40%Ticagrelor is Class IIa over Clopidogrel for NSTE ACS early initial anti-platelet therapyTicagrelor or Prasugrel over Clopidogrel prior to PCIDAPT remains 12 months for DES and BMSPain control post NSTE ACS discharge: careful assessment for need, first acetaminophen or tramadol, then small dose narcotics, then nonselective NSAIDS (naproxen)PPI for those receiving triple oral antithrombotic therapy or if NSAID used. The data that suggest increased harm are weak.
What About Clinical Tools/Risk Scores to Guide Decisions?
Risk Score
Year of Publication
Score Range Score Predicts C-Statistic of
Original Study
PURSUIT 2000 1 - 18 Risk of Death or death/MI at 30 days after admission
0.84 (death) and 0.67 (death/MI)
TIMI 2000 0 - 7
Risk of all cause mortality, MI, and severe recurrent ischemia requiring urgent revascularization within 14 days after admission
0.65
GRACE 2003 1 - 372Risk of hospital death and post-discharge death at 6 months
0.83
FRISC 2004 0 - 7 Treatment effect of early invasive strategies in ACS
0.77 (death) and 0.7 (death/MI)
HEART 2008 0 - 10Prediction of combined endpoint of MI, PCI, CABG or death within 6 weeks after presentation
0.90
What are some of the scoring methods currently used? (22294968)
PURSUIT: Does not include troponin assays as part of score and the majority of the score is dependent on patient age.
TIMI: Simple to use, but has a poor predictive power (i.e. c-statistic 0.65)
GRACE: Very complex to use and a large portion of the score is dependent on the patient age. Also patients not divided into different risk groups
FRISC: Like TIMI, is simple to use but has a poor predictive power (i.e. c-statistic 0.70)
What is the Applicability of Each Score to Clinical Practice in the ED?
HEART Score Risk of MACE Proposed Policy
0 - 3 1,6% Discharge
4 - 6 13% X-ECG
7 - 10 50% CAG
Proposed Policy
Patients can be divided into three distinct groups. A score of 0-3 indicates a risk of 1.6% for reaching a MACE, and therefore supports a policy of early discharge.
In case of a HEART score of 4-6 points, with a risk of MACE of 13%, immediate discharge is not an option. These patients should be admitted for clinical observation and subjected to non-invasive investigations such as repeated troponin or advanced ischemia detection. A HEART score ≥ 7 points, with a risk of 50% for a MACE, calls for early aggressive treatments possibly including invasive strategies without preceding non-invasive testing.
• What they did:• 2,440 unselected, chest pain patients from 10 hospitals• Applied TIMI, GRACE, and HEART Scores
• Primary endpoint:• Occurrence of major adverse cardiac events (MACE) at 6
weeks• MACE = AMI, PCI, CABG, and death
• Results of Validation Study (Different than original study shown above):• Low HEART Score (0 -3) = 1.7% MACE Rate• Intermediate HEART Score (4 – 6) = 16.6% MACE Rate• High HEART Score (7 – 10) = 50.1% MACE Rate• C-statistic of HEART Score (0.83) > TIMI (0.75) > GRACE
(0.70)
Has the HEART Score Been Validated Against TIMI and GRACE Scores (Validation Study)?
Dec-13
Dec-13
Dec-13
Dec-13Jan
-14Jan
-14Jan
-14
Feb-14
Feb-14
Feb-14
Mar-14
Mar-14
Mar-14
Mar-14
Apr-14
Apr-14
Apr-14
May-14
May-14
May-14
May-14
Jun-14
Jun-14
Jun-14Jul-1
4Jul-1
4Jul-1
4
Aug-14
Aug-14
Aug-14
Aug-14
Sep-14
Sep-14
Sep-14
Oct-14
Oct-14
Oct-14
Oct-14
Nov-14
Nov-14
Nov-14
0
5
10
15
20
25
30
35
40
Total # of LRCP Pts
A B C D E F G H I J K L M N O P Q R S T U V0
10
20
30
40
50
60
3
47
2
17
21 1
2022
1
10
49
14
2 2
17
14
23
44
10
1
2014 Total Referrals for Low Risk Chest Pain by ED MD
(Blinded)
Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-140%
20%
40%
60%
80%
100%
120%
91%95%
100%
84%92%
83%
100% 100% 100%
85% 97%
97%
83%
% of Pts with Stress Tests Scheduled in <72 hrs
0%
10%
20%
30%
40%
50%
60%
70%
38%
63%
47%
43%
54%
50%
29%
43%
29%
38% 37%35%
8%
% of Pts No Show/Cancel
Dec-13
Dec-13
Dec-13Jan
-14Jan
-14Jan
-14
Feb-14
Feb-14
Feb-14
Mar-14
Mar-14
Mar-14
Mar-14
Apr-14
Apr-14
Apr-14
May-14
May-14
May-14
Jun-14
Jun-14
Jun-14
Jun-14Jul-1
4Jul-1
4Jul-1
4
Aug-14
Aug-14
Aug-14
Aug-14
Sep-14
Sep-14
Sep-14
Oct-14
Oct-14
Oct-14
Nov-14
Nov-14
Nov-14
Nov-14
0%
1%
2%
3%
4%
5%
6%
0% 0% 0% 0% 0% 0%
5%
0% 0% 0% 0% 0%
% of Readmissions < 30 days
1 pt
Chest Pain Protocol Obstacles and Lessons
Utilization in EDIf not ACS then doesn’t need risk stratification.Appropriate risk stratifying test Patient follow upWeekendsCost assessment (pending)Outcomes assessment (pending)
Take Home/Summary
Focus on the life threatening causes firstKnow the indicators for immediate invasive therapyUse Risk Tools but Clinical judgment prevailsKnow the right test for the situation
