Rapid Disposition of Chest Pain Patients February 2019

Transcription

1 UCSF High Risk Emergency Medicine Rapid Disposition of Chest Pain Patients February 2019 Corey M. Slovis, M.D. Vanderbilt University Medical Center Metro Nashville Fire Department Nashville International Airport Nashville, TN NY Times Sunday Jan 20, 2019 Missing AMI and ACS is usually the single biggest category for total malpractice claims payouts in Emergency Medicine Missed AMI Groups repetitively cited for missed ACS: The wrong age (< 45 or > 65-70) Atypical symptoms Less symptoms No prior angina/cashd hx WNL or Nonspecific ECG Female Minority Classic Ischemic Chest Pain Crushing Substernal Radiating to the left arm and/or jaw Associated with: Nausea Weakness Diaphoresis Lasting minutes Made better by rest, worse by exertion Relieved by Nitroglycerin Chest Pain Is The Hallmark Of AMI but May be absent May be fleeting May be different than substernal May be: Pleuritic, stabbing or even palpable 1

2 Medline and OVID searched sources reviewed JAMA 2005;294: Up to 11,000 patients per characteristic Objectively evaluates ability of clinicians to Rule-In or Rule-Out ACS Increased Likelihood of AMI (+LR) Decreased Likelihood of AMI (-LR) Radiation to R arm or shoulder 4.7 Pleuritic 0.2 Radiation to both arms or shoulder 4.1 Positional 0.3 Associated with exertion 2.4 Sharp 0.3 Radiation to L arm 2.3 Reproducible palpation 0.3 Diaphoresis 2.0 Inframammary 0.8 Nausea or vomiting 1.9 Not associated with exertion 0.8 Worse than prior angina or AMI 1.8 Described as pressure 1.3 JAMA 2005;294: No single element of the Chest Pain History is a powerful enough predictor of non-acs or non-ami to allow clinicians to make decisions according to it alone JAMA 2005;294: Atypical is Typical Grace Study The 8.4% Without Chest Pain Chest 2004;126: ,881 patients with ultimately suspected ACS 8.4% (1,783 pts.) had no chest pain, only atypical symptoms ¼ of patients without C.P. didn t have ACS initially suspected Mortality much higher if no C.P.: 13% vs. 4.3% (p < ) The Big 5 No CP AMIs Acute Onset of: Shortness of breath Diaphoresis GI sx: vague pain, N/V Acutely weaker, loss of energy Neuro sx; dizzy, pre-syncope, AMS 2

3 The Elderly are Different Age Chest Pain Atypical Presentations in the Elderly J AM Geriatr Soc 1986 Dyspnea 40% Syncope 14% AMS 7% Women are Different too Weakness 7% Giddiness 5% Stroke 4.5% Circulation 2018;137: How different is AMI in males vs females less than age 55? 2,009 women, 976 men with AMI Young defined as About 90% of M and F pts has chest sx: - pain, pressure, tightness, discomfort Women had more additional symptoms 50% more F than M had no CP Circulation 2018;137: Physicians much more likely to attribute AMI symptoms to another disease in women than men 53.4% F vs 36.7% M, p <

4 Women and AMI We need to be careful Be aware of our unconscious biases Atypical symptoms may be typical Acad Emerg Med 2018;25: Are women really treated differently for ACS if they are troponin positive? 7,272 pts from Vancouver, All pts troponin positive with ischemic CP 2,933 females: 4,339 males Evaluated % PCI, meds, mortality All had ctni > 99 th percentile Symptoms & Diagnosis in ED Troponin Positive Females More respiratory symptoms Acad Emerg Med 2018;25: (22.4% vs 14.8% F:M) Less classic chest pain symptoms (77.6% vs 85.2%) AMI less frequently diagnosed in ED (35.4% vs 52.5%) Less likely to be using evidence based meds: (ACE-I / ARB 0.32; BB 0.52, Statin 0.31) NY Times Sunday Feb 1, 2019 No one is too young for ACS Am J Cardiovasc Dis 2013;3:170-4 Up to 10% of all AMIs occur in patients under age 40 4

5 Reading the ECG for AMI Misreads are single biggest cause of missing AMI Must be as good as anyone in reading ECGs Must specifically look for all 5 AMI patterns Read 2-3 leads at a time! Beware NSSTW s Repeat ECGs!! Reading for AMI 3 at a Time, Not 12 2, 3, F Inferior V 1, V 2, V 3 V 4, V 5, V 6 Anteroseptal Anterolateral Always repeat 12-Lead ECG I, L Lateral AvR, V 1, V 2 Left Main, RV, Posterior ONE ECG BEGETS ANOTHER Repeat ECGs increase the likelihood of diagnosing an AMI by up to 16% in high risk patients Repeat an ECG before the patient leaves and/or if the patient re-develops CP or new symptoms 5

6 Atypical is Typical The Elderly and women are Different No one is too young for ACS Don t read all 12 ECG leads Repeat ECGs Circulation: Cardiovasc Qual Outcomes 2015;8: Pathway for early ED D/C Troponins at 0 and 3 hours Used HEART Score The HEART Score H History HEART Score History E A R T ECG Age Risk Factors Troponin Slightly suspicious 0 points Moderately suspicious 1 point Highly suspicious 2 points HEART Score ECG Circulation: Cardiovasc Qual Outcomes 2015;8: Normal 0 points Non specific 1 point Significant ST 2 points deviation 282 patients; 141 HEART Pathway HEART Pathway vs Regular Care 30 d follow-up Average age 53 yo Low-risk patients discharged 6

7 Simplicity of the HEART Score It is safe to discharge patients if their HEART Score is 3 or less ( 3) Patients with HEART Scores above 3 ( 4) should undergo stress testing and/or admission Acad Emerg Med 2018;epub June How does the HEART pathway perform in a randomized trial-over a 1 year study? 282 patients, single center trial ACC/AHA std care vs HEART pathway 1 year MACE and downstream testing Used 0 and 3 hour troponins 0-3 pts: DC d, follow up with PCP HEART Performance 1 Year Results Acad Emerg Med 2018;epub June 66/141 patients had negative 0-3 hour troponin and a HEAR score of 0-3 None of these discharged patients had a major adverse cardiac event (MACE) by 1 year NPV % 100%; Sensitivity for MACE: 100% But only 8% reduction in 1 year for cardiac testing HEART Score and Pathway Take Homes First 1 year study of HEAR No longer HEART Beware positive Trop A subjective objective test Am J Emerg Med 2017;35:704-9 Is Low Risk by HEART and other scoring systems really low risk? 434 pts from 7 EDs Average age 57 (49-64) Used HEART, TIMI, GRACE, EDACS Compared HEART 3 vs 2 Am J Emerg Med 2017;35:704-9 HEART 3 has a miss rate of 3.6% HEART 2 had a miss rate of 0 7

8 Annals of Emerg Med 2018;72:668-9 Annals of Emerg Med 2018;72:668-9 Can you depend on a HEART Score to provide safe discharge of CP pts who are not ACS? Meta-analysis 9 studies, 11,217 pts Compare HS 3 vs HS 2 HEART Score Sensitivity Annals of Emerg Med 2018;72:668-9 Acad Emerg Med 2019 in press ( ) Meta-analysis 20 studies, 44,202 pts ( ) Up to 4.1% of CP patients could have a Major Adverse Outcome with scores < 4 including up to a 2.5% 30 d AMI miss Acad Emerg Med 2019 in press Acad Emerg Med 2019 in press How well do we agree on a HEART Score? Only a 68% agreement on HS 3 or less History 52% ECG 46% Risk Factors 67% Before we accept HEART as the winner of the chest pain decision rule derby, we would like to see it compared to other rules and most especially the judgement of experienced clinicians 8

9 New High Sensitivity Troponins High Sensitivity Troponins are changing the 0 and 3 hour standard AHA-ACC recommended troponin recommendations Acad Emerg Med 2018;25: Can a single initial high sensitivity Troponin allow early ED discharge when combined with a risk score? 2,258 low risk CP patients Pooled data from 4 Australian/NZ studies Used hs Troponin T and hs Troponin I EDACS: ED Assessment of Chest Pain Score 30 day MACE results Acad Emerg Med 2018;25: Detectable Troponin = implicit risk = be careful This study says you will miss 1.5% of ACS with only a single troponin it s the same as most studies before high sensitivity Troponin were available Circ 2018;138:00-00 Can a multi-step 0, 1 and 3 hour protocol deal with the indeterminate patients when using high-sensitivity Troponin (hstrop) 536 pts, Parkland Hospital, HS and Trop T Uses delta changes Above 52 ng/l = AMI, < 6 ng/l 3 hrs = R/O < 3 ng at 1 hr = R/O < 7 ng from baseline at 3 hrs = R/O Circ 2018;138:00-00 Annals Emerg Med 2018;72: Is a 0 and 30 minute R/O possible? Protocol provided 100% Sensitivity for AMI 100% Negative predictive values for R/O Used a fifth generation HS Trop T (ctnt) 569 pts from Henry Ford Hospital < 6 ng/l on ED entry < 8 ng/l on entry + < 3 ng rise at 30 min 100% rule-out in 28% and 41% of pts 9

10 JAMA Cardiol 2018 online Oct 17 Novel point of care I STAT Tnl-Nx provides same results as traditional HS troponin testing in 15 minutes Take Homes on High Sensitivity Troponins Undetectable at 0-1 or 0-3 rules out AMI Delta testing excludes evolving AMI Early AMI presenters need values over time Using the 99 th percentile may not be optimal Beware detectable Troponin At the current time there is no universally accepted high sensitivity Troponin protocol and objective scoring system that is proven to be optimal All important decisions are made on incomplete information. Yet we are responsible for every decision we make. Sheldon Kopp 1972 Acad Emerg Med 2018;25: Does shared decision making lead to decreased testing without increased risk to patients and/or physicians? 834 CP patients evaluated 45 days s/p ED Multicenter trial, 5 EDs across USA All eligible for Stress or MD CT All kept health care diaries Compared usual care to shared decision making Acad Emerg Med 2018;25: Key Findings Shared decision making patients had 25.8% less advanced testing than routine care over 45 days without any worsening of outcomes or increased number of adverse conditions 10

11 So Enough Already What Should You Do: Do a very careful history What to do in 5 steps or less Use HEART but diaphoresis &/or radiation to R arm or shoulder, Abn ECG = high risk Do 2 Troponins, check for Delta rises Be more careful in HS = 3 Always involve the patient and family 11