The International Convention Centre (ICC), Birmingham September 2017

Transcription

1 The International Convention Centre (ICC), Birmingham September 2017 Unstable Angina is a Medical Condition until proven Cardiology A Pro-Con Debate Dr Derek Connolly BSc (Hons) MB ChB (Edin) Phd (Cantab) FRCP Consultant Interventional Cardiologist Soon to be at the Midland Metropolitan Hospital

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3 Work on the build is continuing at a lightning pace in what will be one of the biggest emergency departments in Europe

4 WE PUT ACUTE MEDICINE FIRST

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9 CHD mortality rates by deprivation quintile, men, 1994 to 2008, Great Britain POOR RICH

10 Age standardised CVD death rates per 100,000 in Massive disparity Men Woman Total

11 Geographical disparity

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13 Explaining the fall in coronary heart disease deaths in England & Wales ,230 fewer deaths in Risk Factors worse +13% Obesity (increase) +3.5% Diabetes (increase) +4.8% Physical activity (less) +4.4% Risk Factors better -71% Smoking -41% Cholesterol -9% Population BP fall -9% Deprivation -3% Other factors -8% Treatments -42% AMI treatments -8% Secondary prevention -11% Heart failure -12% Angina:CABG & PTCA -4% Angina: Aspirin etc -5% Hypertension therapies -3% Unal, Critchley & Capewell Circulation (9) 1101

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18 Super Low LDL Article available at Slides available at

19 Types of CV Outcomes Endpoint Evolocumab (N=13,784) Placebo (N=13,780) 3-yr Kaplan-Meier rate HR (95% CI) CV death, MI, or stroke ( ) MI ( ) Stroke ( )

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22 F Eur Heart J. 2016;37(3): doi: /eurheartj/ehv320

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24 STE-ACS & STEMI acute chest pain persistent (>20 min) ST-segment elevation is termed ST-elevation ACS and generally reflects an acute total coronary occlusion. Most patients will ultimately develop an ST-elevation myocardial infarction (STEMI). The mainstay of treatment in these patients is immediate reperfusion by primary angioplasty or fibrinolytic therapy.

25 Primary Angioplasty

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27 Out of Hospital Cardiac Arrest Null score

28 Takotsubo syndrome Ken Kato et al. Heart 2017;103: Copyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

29 So should every presumed STEMI be treated by an Interventional Cardiologist?

30 Most ACS is NSTEMI

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33 Total number of doctors per capita

34 Top 20 specialties from the GMC Please note that doctors with more than one speciality will be counted within each speciality and therefore will have been counted more than once. Specialty Rank No. of doctors % of Specialist Register Anaesthetics 1 11, % General (internal) medicine 2 11, % Paediatrics 3 6, % General psychiatry 4 5, % Clinical radiology 5 5, % General surgery 6 5, % Obstetrics and gynaecology 7 4, % Trauma and orthopaedic surgery 8 4, % Ophthalmology 9 2, % Cardiology 10 2, % Histopathology 11 2, % Gastroenterology 12 2, % Respiratory medicine 13 2, % Haematology 14 1, % Emergency medicine 15 1, % Endocrinology and diabetes mellitus 16 1, % Child and adolescent psychiatry 17 1, % Old age psychiatry 18 1, % Urology 19 1, % Otolaryngology 20 1, % Total - 77, %

35 Can every hospital have PCI? Key points: Two cardiac dedicated catheter laboratories are the minimal requirement for a PCI service undertaking emergency cases. Minimum centre volume is 400 cases/year. Minimum of three interventional cardiologists per centre. PPCI centres should have at least two catheter laboratories and 24/7 provision of service for STEMI. PPCI centres should perform an absolute minimum of 100 STEMI/PPCI cases/year.

36 PCI centres

37 The Department of Health View

38 MINAP Annual Public Report April 2013 March 2014.

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40 In the old days we only had Cardiologists and then

41 What types of Cardiologist are there? Adult congenital heart disease Cardiac imaging Electrophysiology and devices Heart failure Interventional cardiology

42 The Department of Health View

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44 Grace Score

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47 European Society of Cardiology (ESC) Congress 2017 ESC Rapid Rule-In, Rule-Out Algorithm for NSTEMI Safe, Accurate August 29, 2017 "ESC 0/1-hour algorithm using pooled data from two prospective studies: Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE) and Biomarkers in Acute Cardiovascular Care (BACC). They retrospectively identified 4350 patients in these trials who presented with symptoms suggesting an acute MI, excluding patients with STEMI, in 14 centers in six European countries. Of these, 743 patients (17%) were diagnosed with NSTEMI, based on central adjudication by two independent cardiologists. The patients had a mean age of 65, and 67% were male. Blood levels of hs-ctnt (Elecys assay, Roche Diagnostics) and hs-ctni (Architect i2000sr assay, Abbott Diagnostics) were determined from samples taken when the patients presented and then 1 hour later. As specified in the algorithm, based on their hs-ctnt and hs-ctni levels at time 0 and 1 hour, the patients were classified as "rule in," "rule out," or "observe" for NSTEMI. Using hs-ctnt values at time 0 and 1 hour, the 0/1-hour algorithm safely ruled out patients who did not have NSTEMI. The negative predictive value was 99.8%, and the sensitivity was 99.3%. Similarly, the algorithm accurately ruled in NSTEMI. The positive predictive value was 74.7%, and the specificity was 94.5%.

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52 NICE 2017

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54 Kaplan Meier survival curves indicating rates of survival in the transferred and non-transferred patients in the propensity score matched cohort. Isuru Ranasinghe et al. Heart 2015;101: Copyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

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56 Is there evidence that and invasive strategy is better than a conservative strategy in ACS?

57 July 2, 2008 Early Invasive vs Conservative Treatment Strategies in Women and Men With Unstable Angina and Non ST-Segment Elevation Myocardial Infarction A Meta-analysis Michelle O Donoghue, MD; William E. Boden, MD; Eugene Braunwald, MD; et alchristopher P. Cannon, MD; Tim C. Clayton, MSc; Robbert J. de Winter, MD, PhD; Keith A. A. Fox, MB, ChB; Bo Lagerqvist, MD, PhD; Peter A. McCullough, MD, MPH; Sabina A. Murphy, MPH; Rudolf Spacek, MD, PhD; Eva Swahn, MD, PhD; Lars Wallentin, MD, PhD; Fons Windhausen, MD; Marc S. Sabatine, MD, MPH JAMA. 2008;300(1): Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], ; 21.1% vs 25.0%) and in men was 0.73 (95% CI, ; 21.2% vs 26.3%) Conclusions In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk [biomarker positive] women for reducing the composite end point of death, MI, or rehospitalization with ACS..

58 ICTUS trial

59 Timing of invasive angiography not crucial Laurent Bonello et al. JCIN 2016;9: American College of Cardiology Foundation

60 August 2017 Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain Alexander T. Sandhu, et al JAMA Intern Med. 2017;177(8): privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia. aged 18 to 64 years with an average age of 44.4 years. A total of patients (57.9%) were women.

61 August 2017 Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, ) and revascularization (22.8 per 1000 patients tested; 95% CI, ) at 1 year no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, 1.4 to 17.0). Early testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.

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64 Proportion of patients with an event (%) Cumulative incidence, % Proportion of patients with an event (%) Cumulative incidence, % CTCA and Clinical Outcome 1.7 Years of Follow-up CHD Death and Non-Fatal MI CHD Death, Non-Fatal MI and Non-fatal Stroke 5 4 5% 4% HR 0.62 [ ], P= % 4% HR 0.64 [ ], P= % 2% 1% Standard Care CTCA strata 3 3% AllocatedTreatment=2 2 AllocatedTreatment=1 1 2% 1% Standard Care CTCA strata AllocatedTreatment=2 AllocatedTreatment=1 0 CTCA Standard Care 0% Time, days CTCA 0 Standard Care 0% Time, days Follow Up (years) Follow Up (years)

65 RAPID CTCA Trial INCLUSION CRITERIA Patient 18 years with symptoms mandating investigation for suspected or confirmed ACS with at least one of: ECG abnormalities e.g. ST segment depression >0.5 mm; History of ischaemic heart disease (where the clinician assessing patient confirms history based on patient history or available records); Troponin elevation above the 99 th centile of the normal reference range or increase in high sensitivity troponin meeting European Society of Cardiology criteria for rule-in or myocardial infarction (NB troponin assays will vary from site to site; local laboratory reference standards will be used).

66 HeartFlow FFR CT Process A standard cardiac CT scan is performed and the data is uploaded to HeartFlow. HeartFlow Analysts use proprietary software to create a personalized, digital 3D model of the coronary arteries. Powerful computer algorithms solve millions of complex equations to assess the impact that blockages have on blood flow. Physicians interrogate the model and interpret the FFR CT results to assess, vessel-by-vessel, if sufficient blood is reaching the heart. 84

67 HeartFlow FFR CT Results Refer to product Instructions For Use for patient populations in which FFR CT has been clinically evaluated, relevant clinical data, and product warnings. 85

68 Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial. Heart Aug 27. Tomography of the HEART (SCOT-HEART) trial of 4146 participants with suspected angina randomised to CTCA. Patients were dichotomised into NICE guidelinedefined possible angina or non-anginal presentations. Primary (diagnostic) endpoint was diagnostic certainty of angina at 6 weeks and prognostic endpoint comprised fatal and non-fatal myocardial infarction (MI)..

69 Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial. In the possible angina cohort, CTCA did not change rates of invasive angiography (p=0.481) but markedly reduced rates of normal coronary angiography (HR 0.32 (0.19 to 0.52), p<0.001). In the non-anginal cohort, rates of invasive angiography increased (HR 1.82 (1.13 to 2.92), p=0.014) without reducing rates of normal coronary angiography (HR 0.78 (0.30 to 2.05), p=0.622).

70 Diagnostic and prognostic benefits of computed tomography coronary angiography using the 2016 National Institute for Health and Care Excellence guidance within a randomised trial. At 3.2 years of follow-up, fatal or non-fatal MI was reduced in patients with possible angina (3.2% to 1.9%%; HR 0.58 (0.34 to 0.99), p=0.045) but not in those with non-anginal symptoms (HR 0.65 (0.25 to 1.69), p=0.379).

71 Who should be referred to an Interventional Cardiologist? All STEMI All Higher / Intermediate Risk NSTEMI [lower risk NSTEMI?Rapid ACS] Most stable Bio Marker Negative Angina do not need referred as an inpatient Non cardiac sounding chest pain patients don t need CTCA and do not need investigation

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73 The International Convention Centre (ICC), Birmingham September 2017 Unstable Angina is a medical condition until proven cardiology : Against Adrian Large Interventional Cardiologist Debbie Jackson Cardiac Nurse Practitioner UHNM, Stoke-On-Trent.

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75 What do you mean by unstable angina?

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78 What do you mean by unstable angina?

79 What do you mean by unstable angina?

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81 Who should deal with this

82 to produce this?

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85 The test for unstable angina is talking and listening

86 Less useful

87 Less useful

88 The test for unstable angina

89 Like all tests

90 The ideal

91 Like all tests, its accuracy should be measured regularly?

92 Accuracy requires skill

93 Skill has to be acquired

94 Skill has to be acquired

95 Cardiac Assessment Nurse Team 24 hour service. Any patient with suspected cardiac presentation referred. Admitted to cardiology bed or discharged home with out patient investigations and/or follow up.

96 Chest pain assessment As a team we see a lot of suspected cardiac chest pain. Rapid Access chest Pain Clinics Emergency portals

97 Focus on unstable angina. We get a lot of referrals with suspected unstable angina/acs many are later discharged from ED with a non cardiac diagnosis. Almost everyone with chest pain gets a Troponin followed by a cardiology referral. (that s a debate for another day!) STEMI and NSTEMI relatively easy to identify. Unstable angina takes a bit more work to get right.

98 How to I identify unstable angina? I have been assessing chest pain for the past 5 years. We started out with some really good teaching sessions on chest pain assessment. Courses in health assessment and a cardiology specific masters programme. Mostly its comes down to practice and experience. Self audit is really useful what happened to the patient are you over or underdiagnosing?

99 Unstable angina Transient condition -important not to miss the diagnosis you can prevent a death or non fatal MI. Troponin and ECG often normal or near normal. The clues are all in the patient history. Take account of risk factors too.

100 My top tips. Take the time to get a full history of the chest pain.. If a patient has cardiac sounding pain at rest - when did it first start? (if you dig a bit deeper, there's almost always a period of stable anginal symptoms even if only for a few days, before the development of unstable symptoms) They wont tell you if you don t ask they are often focused on the one episode that brought them to hospital. If you think someone has stable angina ask specifically if they ever get it at rest (watching TV/in bed).

101 My top tips Look out for rapidly increasing episodes of angina/ crescendo symptoms/ excessive GTN use. Episodes may last longer than in stable angina GTN will help. It goes when I take my spray, but then it comes back ADMIT these patients! They are at high risk of imminent MI.

102 Unstable angina is not Prolonged episodes of continuous chest pain with normal Troponin - even when multiple coronary risk factors. If cardiac pain is constant for more than 45 mins, the bloods will be abnormal. Ask about their normal angina is it stable, has it worsened recently?... If not.. You need to look for another cause of the symptoms.

103 So, who should do it?

104 So, who should do it?

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109 as long as they ve acquired the skill.

110 Suggestion for how to decide Clinical directors / leads of relevant specialties get together. Decide on service lead(s). Choose / design your system Stick to it Invest in it Audit its performance Continually improve it as a team

111 One last thought / opinion

112 One last thought / opinion

113 One last thought / opinion

114 One last thought / opinion

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116 The International Convention Centre (ICC), Birmingham September 2017 Unstable Angina is a medical condition until proven cardiology : Against Adrian Large Interventional Cardiologist Debbie Jackson Cardiac Nurse Practitioner UHNM, Stoke-On-Trent.

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118 What do you mean by unstable angina?

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121 What do you mean by unstable angina?

122 What do you mean by unstable angina?

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124 Who should deal with this

125 to produce this?

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128 The test for unstable angina is talking and listening

129 Less useful

130 Less useful

131 The test for unstable angina

132 Like all tests

133 The ideal

134 Like all tests, its accuracy should be measured regularly?

135 Accuracy requires skill

136 Skill has to be acquired

137 Skill has to be acquired

138 Cardiac Assessment Nurse Team 24 hour service. Any patient with suspected cardiac presentation referred. Admitted to cardiology bed or discharged home with out patient investigations and/or follow up.

139 Chest pain assessment As a team we see a lot of suspected cardiac chest pain. Rapid Access chest Pain Clinics Emergency portals

140 Focus on unstable angina. We get a lot of referrals with suspected unstable angina/acs many are later discharged from ED with a non cardiac diagnosis. Almost everyone with chest pain gets a Troponin followed by a cardiology referral. (that s a debate for another day!) STEMI and NSTEMI relatively easy to identify. Unstable angina takes a bit more work to get right.

141 How to I identify unstable angina? I have been assessing chest pain for the past 5 years. We started out with some really good teaching sessions on chest pain assessment. Courses in health assessment and a cardiology specific masters programme. Mostly its comes down to practice and experience. Self audit is really useful what happened to the patient are you over or underdiagnosing?

142 Unstable angina Transient condition -important not to miss the diagnosis you can prevent a death or non fatal MI. Troponin and ECG often normal or near normal. The clues are all in the patient history. Take account of risk factors too.

143 My top tips. Take the time to get a full history of the chest pain.. If a patient has cardiac sounding pain at rest - when did it first start? (if you dig a bit deeper, there's almost always a period of stable anginal symptoms even if only for a few days, before the development of unstable symptoms) They wont tell you if you don t ask they are often focused on the one episode that brought them to hospital. If you think someone has stable angina ask specifically if they ever get it at rest (watching TV/in bed).

144 My top tips Look out for rapidly increasing episodes of angina/ crescendo symptoms/ excessive GTN use. Episodes may last longer than in stable angina GTN will help. It goes when I take my spray, but then it comes back ADMIT these patients! They are at high risk of imminent MI.

145 Unstable angina is not Prolonged episodes of continuous chest pain with normal Troponin - even when multiple coronary risk factors. If cardiac pain is constant for more than 45 mins, the bloods will be abnormal. Ask about their normal angina is it stable, has it worsened recently?... If not.. You need to look for another cause of the symptoms.

146 So, who should do it?

147 So, who should do it?

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152 as long as they ve acquired the skill.

153 Suggestion for how to decide Clinical directors / leads of relevant specialties get together. Decide on service lead(s). Choose / design your system Stick to it Invest in it Audit its performance Continually improve it as a team

154 One last thought / opinion

155 One last thought / opinion

156 One last thought / opinion

157 One last thought / opinion

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