Introduction to Risk Stratification

Transcription

1 Introduction to Risk Stratification Tim Fendler, MD, MSc Heart Failure/Transplant Fellow St. Luke s Mid America Heart Institute 1

2 Disclosures: No financial relationships to disclose. A 74 year-old male presents with chest pain... 3 days of new-onset, intermittent, substernal, non-radiating, pressure-like chest discomfort, 6/10 in severity 4 distinct episodes Bedtime x2 nights > improved with baby aspirin and a hot shower While driving > associated dyspnea > spontaneous resolution In ED > improved with full-dose aspirin Both similar to and different from GERD symptoms 2

3 Audience Poll: Based on this presentation, what is the likelihood of significant coronary artery disease? How likely is it that these symptoms are due to ischemia? Very Low Low Intermediate High 3

4 How likely is it that these symptoms are due to ischemia? Typical angina (definite) 1) Substernal chest discomfort with a characteristic quality & duration 2) Provoked by exertion or emotional stress & 3) Relieved by rest or nitroglycerin Atypical angina (probable) meets 2 of the above criteria Non-cardiac chest pain meets 1 or none of the above criteria How likely is it that these symptoms are due to ischemia? Low Risk + Diabetes, Hyperlipidemia & Smoking = Intermediate Risk 4

5 A 74 year-old male presents with chest pain... PMHx: HTN (no meds), HLD (no meds), GERD (no meds), BPH PSHx: Appendectomy (childhood) Meds: ASA 81, Vitamin D, Flaxseed, Flomax SHx: never-smoker, occasional social EtOH FHx: Brother w/ 59 (smoker) RoS: No weight changes, fevers, PND/orthopnea, swelling, palpitations, weakness, or GI symptoms. A 74 year-old male presents with chest pain... VS: BP 156/98 HR 77 Temp 36.3 RR 18 SaO2 95% RA PE: no notable findings Cardiac: Regular rate & rhythm, no murmurs or gallops. Non-displaced PMI. Normal peripheral pulses. No JVD or edema. Pertinent Labs: Creatinine 0.9 Glucose 105 HbA1c 5.8 TC 164 HDL 34 LDL 93 Troponin: 0.01 > 0.03 > 0.03 Electrocardiogram: Normal Sinus Rhythm, no Q waves, ST-T flattening 5

6 Audience Poll: Based on this presentation, what is the risk of a major adverse cardiac event in the near future? Assessing Risk Low Intermediate High Amsterdam et al AHA/ACC NSTE-ACS Guidelines 6

7 Assessing Risk Sometimes patients don t follow the rules... The patient was admitted to the hospital Patient reported recurrent chest pain later that night Tightness, radiating to the back, worse lying down Maybe like GERD... Maybe not... On-call physician asked to come evaluate the patient... 7

8 How good is a first impression? Every story has an ending Patient in duress, diaphoretic, uncomfortable in any position Shortly after physician arrival, the patient experienced VF arrest CPR > 6 defibrillations > ROSC Don t underestimate the eyeball test! Trust your gut. Emergent coronary angiography POBA to acute, thrombotic occlusion of a non-dominant RCA DES to a long 90% stenosis of the Ramus Intermedius Good recovery, preserved left ventricular function, no Q waves 8

9 Take-home Points: Pre-test Probability can be quickly, easily determined A careful History & Physical is essential in triage & risk assessment Use of validated risk scores is guideline-recommended And as easy as grabbing your phone... Don t underestimate the power of gestalt Despite our best efforts, patients don t always follow the rules Keep an open mind, & a wide differential! 9