Chest pain

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<ul><li> 1. The search for the verylow risk chest pain patient who goes home/who stays in? <ul><li>Stephen W. Smith, MD </li></ul></li></ul> <p> 2. Chest Pain No one factor can allow safe discharge </p> <ul><li>History of pain </li></ul> <ul><li>Demographics: age, sex </li></ul> <ul><li>Past Hx: CAD, risk factors </li></ul> <ul><li>ECG </li></ul> <ul><li>Initial Biomarkers (troponin) </li></ul> <ul><li>Rest Sestamibi </li></ul> <ul><li>Serial troponins </li></ul> <ul><li>Stress echo </li></ul> <ul><li>Stress sestamibi </li></ul> <ul><li>CT angio </li></ul> <ul><li>Angiography </li></ul> <p> 3. Endpoints for diagnosing ACS </p> <ul><li>Death </li></ul> <ul><li>MI</li></ul> <ul><li>Revascularization </li></ul> <ul><li><ul><li>Done for significant stenosis </li></ul></li></ul> <ul><li><ul><li>Stenosis can be present without ACS </li></ul></li></ul> <ul><li><ul><li>Injury biomarkers (e.g., Troponin) cannot detect stenosis </li></ul></li></ul> <p> 4. Case </p> <ul><li>40 yo with substernal chest pressure for 3 hours </li></ul> <ul><li>No radiation or associated symptoms </li></ul> <ul><li>Ongoing, not intermittent </li></ul> <ul><li>No cardiac history </li></ul> <ul><li>Cigarette smoker, no other risks </li></ul> <ul><li>ECG normal </li></ul> <ul><li>First trop &lt; .04 </li></ul> <p> 5. Lee Goldman Ann Int Med 2003; 139:987 </p> <ul><li>The sobering bottom line is that 2 decades of research has taught us that without compelling evidence for a noncardiac cause, there is no absolutely fail-safe way to exclude myocardial ischemia or infarction at the time of a patient's initial presentation. A short period of monitoring and measuring serial biomarker levels in a chest pain evaluation unit is an attractive approach for patients with an uncertain diagnosis.</li></ul> <p> 6. Life threatening causes of Chest Pain </p> <ul><li>Coronary syndrome </li></ul> <ul><li>Pulmonary Embolus </li></ul> <ul><li>Aortic dissection </li></ul> <ul><li>Pericarditis </li></ul> <ul><li>Pneumonia </li></ul> <ul><li>Pneumothorax </li></ul> <p> 7. Missed MI Pope JH et al.NEJM 2000; 342:1163-1170 </p> <ul><li>Prospective multicenter studyMay 1993-December 1993 </li></ul> <ul><li><ul><li>10,689 CP patients </li></ul></li></ul> <ul><li><ul><li>8% were proven to have AMI, 7% unstable angina.</li></ul></li></ul> <ul><li><ul><li>21% other cardiac etiologies, 55% noncardiac</li></ul></li></ul> <ul><li><ul><li>19 (2.1%) of 889 patients with AMI were discharged home ; </li></ul></li></ul> <ul><li><ul><li>17 of 19 ECGs no evidence of ischemia, and 2 normal. </li></ul></li></ul> <ul><li>22 of 966 (2.3%) with unstable angina were mistakenly discharged.In retrospect, none of the 22 patients ECGs showed evidence of ischemia and 2 were normal. </li></ul> <ul><li>Non-whites, women, chief complaint of dyspnea, and a normal ECGall correlated with mistaken discharge. </li></ul> <p> 8. Most recent data, with troponin Is the initial diagnostic impression of noncardiac chest pain adequate to exclude cardiac disease? MillerCD, Ann EM December 2004; 44(6):565-574 </p> <ul><li>17,000 patients with CP </li></ul> <ul><li>1992 thought to be noncardiac (75% d/ced to home) </li></ul> <ul><li>Physicians blinded to trop results, did not use them </li></ul> <ul><li>Of 1992, 71 (2.4%) had first trop &gt; 0.6 - 1.0 </li></ul> <ul><li>Troponin assay is critical.</li></ul> <ul><li>Our trop today is a new generation high sensitivity troponin </li></ul> <ul><li><ul><li>(Dade Stratus CS cTNI) </li></ul></li></ul> <ul><li><ul><li>Very sensitive, but how much more? </li></ul></li></ul> <p> 9. Inverse relation between % with a "rule out MI evaluation" and the miss MI rate.Graff: Am J Cardiol, Volume 80(5):563-568, 9/1/1997 10. Use of chest pain centers vs. admission 4.5% MI miss rate 0.4% MI miss rate Graff: Am J Cardiol, Volume 80(5):563-568, 9/1/1997 $124 per patient cost savings 11. Risk factors for complications death, MI, CHF, shock, v fib, v tach </p> <ul><li>EKG: </li></ul> <ul><li><ul><li>ST elevation &gt; ST depression &gt; T wave inversion </li></ul></li></ul> <ul><li><ul><li>Normal has lower risk of complications, even if MI present </li></ul></li></ul> <ul><li>h/o recent MI </li></ul> <ul><li>Rales above the bases </li></ul> <ul><li>Pain</li></ul> <ul><li><ul><li>worse than previous angina </li></ul></li></ul> <ul><li><ul><li>Same as prior MI </li></ul></li></ul> <ul><li>BP &lt; 110 </li></ul> <ul><li>DM </li></ul> <ul><li>Active or recurrent pain </li></ul> <p>Brush JE et al.NEJM 312:1137-1141, 1985.Karlson BW et al.Eur Heart J 15:1558-65, 1994.Yusuf S et al.Eur heart J 5:690-96, 1984. 12. Patients with Acute MI sent home from the ED Multicenter Chest Pain Study Lee TH., et al.Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.Am J Cardiol 1987; 60:219-24. </p> <ul><li>2.5% of all patients sent home had MI's-- 26%of these died </li></ul> <ul><li>0.7% (n=9) of chest pain patients who were sent home died </li></ul> <ul><li><ul><li>Avg. EP 65 CP patients home per year </li></ul></li></ul> <ul><li>6 of 9 deaths were misread ECG's </li></ul> <ul><li>13 of 35 MI's sent home had evidence of acute ischemia </li></ul> <ul><li>5 of 35 were less than 42 years old </li></ul> <p> 13. 39 yo with atypical CP 14. Diagnostic ECG </p> <ul><li>New Q-waves </li></ul> <ul><li>ST-T abnormalitiesnot secondary to abnormal depolarization(i.e., abnormal QRS, e.g., LVH) </li></ul> <ul><li>ST depression&gt;/= 1 mm in2 consecutive leads(corresponds to a coronary distribution) </li></ul> <ul><li><ul><li>Not otherwise explained </li></ul></li></ul> <ul><li><ul><li>Changed from previous ECG </li></ul></li></ul> <ul><li>T-wave inversion&gt;/= 1 mm in2 consecutive leads </li></ul> <ul><li><ul><li>Not otherwise explained </li></ul></li></ul> <ul><li><ul><li>Changed from previous ECG </li></ul></li></ul> <ul><li><ul><li>In anatomic distribution </li></ul></li></ul> <p> 15. Normal ECG </p> <ul><li> Sinus rhythm with normal p-waves </li></ul> <ul><li> ST elevation/depression &lt; 0.5 mm relative to corresponding PR segments.</li></ul> <ul><li> No LVH, abnormal Q-waves, or conduction abnormalities(QRS must be &lt; 100 ms) </li></ul> <ul><li> Size of T-waves is proportional to R-waves and T-wave axis is close to QRS axis </li></ul> <ul><li> Normal R-wave progression </li></ul> <p> 16. Nondiagnostic ECG </p> <ul><li>Old Q-waves </li></ul> <ul><li>ST-T abnormalities secondary to abnormal depolarization (i.e., abnormal QRS, e.g., LVH) </li></ul> <ul><li>Minor, non-dynamic ST or T-wave abnormalities, such as ST depression &lt; 1 mm and T-wave flattening or inversion &lt; 1 mm </li></ul> <ul><li><ul><li>not otherwise explained </li></ul></li></ul> <ul><li>May be changed from previous ECG, but is not specific for ischemia or infarction </li></ul> <p> 17. Sensitivity and specificity of ECG for MI as diagnosed by CK-MB Goldman L; Ann Int Med 2003; 139:987 18. Normal or Nondiagnostic ECG Karlson and Rouan combined data AMI as defined by CK-MB, MI rate will be higher in this age of troponin definition of MI </p> <ul><li>CP 11,805 </li></ul> <ul><li>AMI 1962 </li></ul> <ul><li>Diagnostic ECG 2979 (STEMI or UA/NSTEMI) </li></ul> <ul><li>nl ECG 3635 </li></ul> <ul><li>nl ECG &amp; AMI 125 ( 6.4% of AMI , 3.4% of nl ECG, 1.1% of all pts with CP) </li></ul> <ul><li>NS ECG 5191 </li></ul> <ul><li>NS ECG &amp; AMI 442 ( 23% of AMI , 9% of NS ECG,3.7% of all pts. with CP ) </li></ul> <ul><li>NlorNS ECG 8826</li></ul> <ul><li>NlorNS ECG &amp; AMI 567 ( 29% of all AMI , 6.4% of all nl or NSECG,4.8% of all pts with CP) </li></ul> <p> 19. Diagnostic vs. nondiagnostic (nonspecific) ECG MI Diagnosis by CK-MB (Trop) </p> <ul><li>Approx 45% (25%) of AMI has diagnostic STE </li></ul> <ul><li>Approx 26% (15%) of AMI has diagnostic ST depression or T-wave inversion </li></ul> <ul><li>Approx 23% (50%) of AMI is abnormal but nondiagnostic </li></ul> <ul><li><ul><li>8-15% some evidence of ischemia or infarction not known to be old </li></ul></li></ul> <ul><li>Approx 6% (10%) of AMI has normal ECG </li></ul> <ul><li>Normal with pain vs. without pain </li></ul> <ul><li><ul><li>Chase et al. Acad EM 13:1034, Oct 2006 </li></ul></li></ul> <p>Welch RD et al.JAMA Oct. 2001;286(16):1977-1984 20. Continuous 12-lead or ST segment monitoring </p> <ul><li>Non-diagnostic ECG may turn diagnostic </li></ul> <ul><li>Labor and equipment intensive </li></ul> <ul><li><ul><li>Routine use is for high risk patients </li></ul></li></ul> <ul><li>In high risk patients with ongoing symptoms </li></ul> <ul><li><ul><li>Increases sensitivity for STEMI from 46% to 62% (33%) of all MI as measured by CK-MB </li></ul></li></ul> <ul><li>Use serial EKGs every 15 minutes </li></ul> <p>Fesmire et al. Ann Emerg Med 1998; 31:3-11 21. Atypical Symptoms of MI Canto JG, Shlipak MG, Roger WJ, et al.Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.JAMA 2000;283:3223-3229. NRMI data . </p> <ul><li>33% of patients with MI (by CK-MB) present without chest pain </li></ul> <ul><li><ul><li>Both NSTEMI and STEMI </li></ul></li></ul> <ul><li>Other studies confirm this: </li></ul> <ul><li><ul><li>Of MI patients, 42% of those age &gt; 75 years and63%-75% of those age &gt; 85 years donotcomplain of chest pain (CP) </li></ul></li></ul> <ul><li><ul><li>Up to 30% of MI is silent </li></ul></li></ul> <p> 22. Characteristic No Chest Pain (33%) Chest Pain (67%) Mean age 74 years 67 years Received reperfusion 25% 74% Adjusted in-hospital mortality 23.3% 9.3% (OR: 2.17-2.26) Women 49% 38% Prior Heart Failure 26% 12% ST elevation on initial ECG 23% 47% LBBB on initial ECG 10% 5.4% Atypical Symptoms(continued--Canto et al.) 23. History Alternans </p> <ul><li>Kappa values for historical and physical examination vary widely for different signs and symptoms </li></ul> <ul><li><ul><li>&lt; .40 = poor, .40-.60 = fair </li></ul></li></ul> <ul><li>Pleuritic, positional, and sharp chest pain have poor interphysician reliability (K=0.27 to 0.44). </li></ul> <ul><li>S3 gallop, 0.14 to 0.37 </li></ul> <ul><li>rales, 0.12 to 0.31 </li></ul> <ul><li>neck vein distention, 0.31 to 0.51 </li></ul> <ul><li>hepatomegaly, 0.00 to 0.16 </li></ul> <ul><li>dependent edema, 0.27 to 0.64 </li></ul> <ul><li><ul><li>Hickan DH, Sox HC, Sox CH.Systematic bias in recording the history in patients with chest pain. J Chronic Dis.1985;38:91-100. </li></ul></li></ul> <ul><li><ul><li>Gadsboll N, et al. Symptoms and signs of heart failure in patients with myocardial infarction: reproducibility and relationship to chest x-ray, radionuclide ventriculography and right heart catheterization.Eur Heart J.1989;10:1017-1028. </li></ul></li></ul> <p> 24. Risk of MI with Chest Pain Lee TH, et al. Acute chest pain in the emergency room.Identification and examination of low-risk patients. Arch Int Med 1985; 145:65-69 </p> <ul><li>increased with history of known angina </li></ul> <ul><li>increased when identical to previous MI </li></ul> <ul><li><ul><li>Deceptive </li></ul></li></ul> <ul><li>"burning," "indigestion," (23% with MI) and "numbness" orinability to characterize the pain(23% with MI) are as likely to be MI as "pressure," "tightness", "crushing (24% with MI)</li></ul> <ul><li>5% prob. if pain was"sharp" or "stabbing" </li></ul> <p> 25. Chest Pain characteristics and MI Lee TH, et al. Acute chest pain in the emergency room.Identification and examination of low-risk patients. Arch Int Med 1985; 145:65-69 </p> <ul><li>% with ACS if pain is pleuritic, positional, or reproducible : </li></ul> <ul><li><ul><li>13% (n = 96) if painpartlypleuritic or positional </li></ul></li></ul> <ul><li><ul><li>0% (n = 36): fullypleuritic or positional </li></ul></li></ul> <ul><li><ul><li>24% (n=158) if pain ispartly reproduced on exam </li></ul></li></ul> <ul><li><ul><li>7% (n = 124) iffullyreproduced </li></ul></li></ul> <ul><li><ul><li>greater with radiation to left arm, shoulder or neck </li></ul></li></ul> <ul><li><ul><li>less with radiation to back, abdomen, or legs </li></ul></li></ul> <ul><li>Probability of MI </li></ul> <ul><li><ul><li>greater with duration &gt; 60 minutes </li></ul></li></ul> <p> 26. Positive Likelihood Ratios for MI Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction?JAMA 1998 Oct 14;280(14):1256-63. </p> <ul><li><ul><li>new ST-segment elevation 11.2 (LR range, 5.7-53.9); </li></ul></li></ul> <ul><li><ul><li>New ST depression, T wave inversion </li></ul></li></ul> <ul><li><ul><li>new Q wave 7.0(LR range, 5.3-24.8); </li></ul></li></ul> <ul><li><ul><li>new conduction defect 6.3 (LR range 2.5-15.7) </li></ul></li></ul> <ul><li><ul><li>chest painradiating to both the left and right armsimultaneously7.1(3.6-14.2) </li></ul></li></ul> <ul><li><ul><li>radiation to left (2.3) or right arm (2.9) </li></ul></li></ul> <ul><li><ul><li>presence of a third heart sound 3.2 (LR, 3.2); </li></ul></li></ul> <ul><li><ul><li>hypotension 3.1 (LR, 1.8-5.2). </li></ul></li></ul> <ul><li><ul><li>crackles 2.1 (1.4-3.1) </li></ul></li></ul> <ul><li><ul><li>diaphoresis 2.0 (1.9-2.2) </li></ul></li></ul> <p> 27. Negative Likelihood Ratios for MI Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. Is this patient having a myocardial infarction?JAMA 1998 Oct 14;280(14):1256-63 . </p> <ul><li>a normal ECG result(LR, 0.2) </li></ul> <ul><li>pleuritic chest pain(LR, 0.2) </li></ul> <ul><li>sharp or stabbing chest pain(LR, 0.3) </li></ul> <ul><li>positional chest pain(LR, 0.3) </li></ul> <ul><li>chest pain reproduced by palpation(LR, 0.3) </li></ul> <ul><li>Not associated with exertion (LR, 0.8) </li></ul> <ul><li>Infra-mammary location (LR, 0.8) </li></ul> <ul><li><ul><li>These calculations did not distinguish between partial or full reproducibility </li></ul></li></ul> <p> 28. Right arm involvement: Berger JP, et al.Right arm involvement and pain extension can help to differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain.Int Med 1990 March; 227(3):165-72 Everts B. et al., Localization of pain in suspected acute myocardial infarction in relation to final diagnosis.Heart and Lung 1996; 25:430-7. </p> <ul><li>Berger: Most important in this study waswide radiationthat included the right arm:of 51 patients with R arm involvement, 48 had coronary disease and 41 had MI. </li></ul> <ul><li>Everts: pain in both right and left arms was the only distinguishing characteristic oflocalizationthat differed between those with and without MI </li></ul> <p> 29. Low risk Features , summary (ECG must be normal or nonspecific) </p> <ul><li>Right side only </li></ul> <ul><li>Pain primarily in middle or lower abdomen</li></ul> <ul><li>Pain lasts seconds only </li></ul> <ul><li>While the patient has this pain, it improves with exertion </li></ul> <ul><li><ul><li>(e.g. goes away if I play basketball) </li></ul></li></ul> <ul><li>clear non-ischemic cause for pain is found </li></ul> <ul><li><ul><li>Chest wall trauma or chest x-ray abnormality</li></ul></li></ul> <ul><li><ul><li>GI etiology is NEVER a clear alternative Dx </li></ul></li></ul> <ul><li>Palpation reproduces pain exactly on multiple exams </li></ul> <ul><li>Pain is pleuritic </li></ul> <ul><li>Pain is brought on by changes in position or movement </li></ul> <ul><li>Pain is localized to a fingertip </li></ul> <ul><li>Sharp (stabbing) pain </li></ul> <p> 30. Typical Symptoms (higherprobabilitythat cardiac ischemia is the etiology) </p> <ul><li>1. Same as symptoms of previous proven cardiac ischemia </li></ul> <ul><li>2. Substernal or left-sided, poorly localized discomfort, with or without radiation </li></ul> <ul><li><ul><li> Indigestion </li></ul></li></ul> <ul><li><ul><li> Pressure </li></ul></li></ul> <ul><li><ul><li> Burning </li></ul></li></ul> <ul><li><ul><li> Tightness </li></ul></li></ul> <ul><li><ul><li> Crushing </li></ul></li></ul> <ul><li><ul><li> Nondescript discomfort </li></ul></li></ul> <ul><li>3. Brief, sudden, unexplained dyspnea </li></ul> <ul><li>Other typical features </li></ul> <ul><li>1. During episode of pain, is worsened by exertion and improved by rest </li></ul> <ul><li>2. Radiation to leftorright or especiallybotharms or shoulders </li></ul> <p> 31. Significant Risk Factors </p> <ul><li>Anyoneof: </li></ul> <ul><li>Age &gt; 50 (male), &gt; 55 (female) </li></ul> <ul><li>&gt;/= 2 risk factors (other than diabetes) </li></ul> <ul><li><ul><li>Smoking (RR 1.5, CI = 1.0-2.4) </li></ul></li></ul> <ul><li><ul><li>Hypertension (NS) </li></ul></li></ul> <ul><li><ul><li>Hyperlipidemia (NS) </li></ul></li></ul> <ul><li><ul><li><ul><li>high cholesterol (total, LDL-cholesterol [LDL-C]), low high-density lipoprotein (HDL), and high triglyceride levels </li></ul></li></ul></li></ul> <ul><li><ul><li>Family history (RR = 2.1, 1.4-3.3) </li></ul></li></ul> <ul><li>Diabetes mellitus (RR = 2.4, 1.2-4.8) </li></ul> <p>Jayes RL, J Clin Epidem 45:621, 1992 32. Pitfalls in diagnosis of ischemia </p> <ul><li>Pts. often interpret "sharp" to mean severe </li></ul> <ul><li>Therapeutic trials may be very misleading</li></ul> <ul><li><ul><li>Nitroglycerin no different from placebo </li></ul></li></ul> <ul><li><ul><li><ul><li>Henrickson, CA. Chest Pain relief by Nitroglycerin Does Not Predict Active Coronary Artery Disease. Ann Int Med 139(12):979-986, Dec. 16, 2003 </li></ul></li></ul></li></ul> <ul><li><ul><li>Antacids may improve up to 25% of MI pain </li></ul></li></ul> <ul><li>Up to 33% of pts. with ACS have some chest wall tenderness, (24% partly, 7% fully reproducible) </li></ul> <ul><li><ul><li>Lee TH, Arch Int Med 145:65-69, 1985. </li></ul></li></ul> <ul><li>Fully v. partly pleuritic or positional pain </li></ul> <p> 33. Pitfalls (contd) </p> <ul><li>Unchanged ECG, even normal ECG</li></ul> <ul><li><ul><li>with an atypical history , a normal ECG is rarely an MI, but not so rarely unstable angina </li></ul></li></ul> <ul><li>Clinical presentation particularly variable in theelderly </li></ul> <ul><li><ul><li>40-50% fail to c/o chest pain </li></ul></li></ul> <ul><li><ul><li>Bayer AJ et al. J Am Soc Geriatr 34:263-266 </li></ul></li></ul> <ul><li>Common atypical symptoms-- shortness of breath, abdominal pain, dizziness, arm/shoulder/jaw pain </li></ul> <ul><li>Pain thatpersistsin ED orrecursin ED </li></ul> <ul><li><ul><li>associated with 3.8 x the risk of complications (Fesmire FM. Wears RL. Am J Em Med 1989 July; 7(4):372-377) </li></ul></li></ul> <p> 34. Previous negative stress testing Nerenberg, Smith, Engineer </p> <ul><li>Imaging, sestamibi or echo </li></ul> <ul><li><ul><li>85% sensitive for significant stenosis </li></ul></li></ul> <ul><li>Non-imaging (ECG) stress tests </li></ul> <ul><li><ul><li>70% sensitive </li></ul></li></ul> <ul><li>They only look for fixed stenosis </li></ul> <ul><li>5% incidence of MI within 3 years of negative stress imaging test </li></ul> <ul><li>Nevertheless: it has some (unknown) negative LR (= 0.5?) </li></ul> <p> 35. Previous normal angiogram </p> <ul><li>"Normal" was formerly used for coronaries with small nonobstructive (e.g. 50% (70%) may be flow-limiting and correlates with stable angina </li></ul> <ul><li>Totally normal means no luminal narrowing </li></ul> <ul><li><ul><li>Does not rule out extraluminal atheroma which can ulcerate </li></ul></li></ul> <ul><li><ul><li>Diagnosis byIVUS(intravascular ultrasound), maybe CT/MRI </li></ul></li></ul> <ul><li>If patient presents for same pain which led to the angiogram </li></ul> <ul><li><ul><li>Then a "negative" angiogram is very helpful (high negative LR).</li></ul></li></ul> <ul