DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN

DIFFERENTIATING THE PATIENT WITH UNDIFFERENTIATED CHEST PAIN

Objectives Gain competence in evaluating chest pain Recognize features of moderate risk unstable angina Review initial management of UA and moderate to high risk NSTEMI

Chest Pain 9% of all ED Visits 300,000 500,000 Canadians present to ED each year with chest pain ACS is 2 nd leading cause of death, affecting 100,000 Canadians annually 25 40% admitted 13 23% have ACS < 5% have STEMI < 25% Non STE ACS 75% non ACS chest pain Missed MI rates (2 3%) www.cdc.gov/nchs/data/databriefs/db43.pdf, JAMA 1993;270:1211 6, Medicine 2009;88:307 13 NEJM 2000;342:1187 95, Ann Intern Med. 1998; 129:845 55, NEJM 2000; 342:1163 70

DDx Aortic dissection Pulmonary embolism Pericarditis/myocarditis Pneumothorax Esophageal rupture Takotsubo cardiomyopathy

What is UA/NSTEMI? Subset of ACS usually caused by atherosclerotic CAD and associated with increased risk of MI and cardiac death Often presents with chest pain or discomfort ECG: ST segment depression or T wave inversion positive biomarkers of necrosis (e.g. Tn) in the absence of ST segment elevation Anderson JL et al. Circulation 2011;e426 579.

What is UA and NSTEMI? Presentation Working Dx Ischemic Discomfort Acute Coronary Syndrome ECG Cardiac Biomarker No ST Elevation [ Non ST ACS ] UA NSTEMI ST Elevation Final Dx Unstable Angina Myocardial Infarction NQMI Qw MI UA vs NSTEMI Troponin Anderson JL et al. Circulation 2011;e426 579.

ACS Management Considerations Onset of UA/NSTEMI Initial recognition and management in the Emergency Department Risk Stratification Immediate Management Management Prior to UA/NSTEMI Hospital Management Medications Conservative versus Invasive Strategy Special Groups Preparation for discharge Secondary Prevention/ Long Term Management Anderson JL et al. Circulation 2011;e426 579.

Case Study

Mrs. Chan: Case 60 year old woman Squeezing chest pain, intermittent throughout the day, lasting longer each interval SOB and anxiety Had about two weeks of CP on exertion (climbing stairs) Overweight, hypertensive, hyperlipidemia, low HDL Family history of ischemic heart disease and serious hypertension On ASA, statin and BB Your Thoughts? What is Mrs. Chan s differential diagnosis?

Mrs. Chan: Admission ECG

Mrs. Chan: Admission Tests Immediate: ECG: Normal Physical Exam: Normal Tn test NORMAL Moderate risk per TIMI score What other investigations does Mrs. Chan need? (in ED or outpatient setting) Does she need admission or could she be managed as an outpatient? Would a chest pain unit be useful for this patient?

Mrs. Chan: Case Evolution 2 nd Tn test POSITIVE Does Mrs. Chan need admission? What is your treatment strategy? OAP AC Timing of cardiac catheterization Interventions

NICE Guidelines Person diagnosed with UA or NSTEMI Providing information Initial treatment Risk assessment Person at lower risk Low risk Intermediate, high or highest risk Conservative management Ischemia testing before discharge Coronary angiography Advising pts about the choice of revascularization strategy PCI Coronary artery bypass grafting Rehabilitation and discharge planning National Institute for Health and Care Excellence

CCS Recommendations for NSTEMI/UA Early treatment with P2Y 12 inhibitor in moderate to high risk NSTEMI patient* ASA 81 mg daily Indefinite Therapy PCI Add ticagrelor for 12 months CABG Surgery Add ticagrelor for 12 months Patient ineligible for ticagrelor Add clopidogrel for 12 months (consider 150 mg/day for 6 days if PCI performed) Medical Therapy (no CABG, no PCI) Add ticagrelor for 12 months

CCS Antiplatelet Guidelines Define Optimal Use of OAP in ACS In NSTEMI/UA pre treatment with ticagrelor beneficial for pts undergoing PCI, CABG or with medical management only In some cases, defining the anatomy earlier may be an option before selection of the DAPT

In Hospital Mortality Decreases with Guidelines Adherence 8 6.36 N=64,775 with NSTEACS p<0.001 In hospital Mortality of Patients (%) 6 4 5.06 4.63 4.17 2 0 <66% 66 74% 75 79% 80% HOSPITAL COMPOSITE ADHERENCE QUARTILES N=21,588 from 315 U.S. hospitals participating for 3 quarters Every 10% in guidelines adherence 11% in mortality Peterson et al JAMA 2006;295:1912 20.

Factors Associated with Improved Guidelines Adherence Survey: 316 hospitals Independent predictors of guideline adherence: Administrative commitment to Quality Improvement Collaboration between ED physicians and hospital administration Adequate support (nurse, pharmacist) Specified protocol driven ACS management algorithm Adapted from Mehta et al Am Heart J 2006;152:648 60

Key Messages ACS is the second leading cause of death in Canada UA/NSTEMI is a subset of ACS associated with increased risk of MI and cardiac death CCS guidelines recommend initial management with ASA, PCI/CABG and ticagrelor for moderate to high risk NSTEMI patients

Thank You! Content for this program has been developed by the following steering committee: Dr. Anil Chopra, Dr. Jean Grégoire, Dr. Anil Gupta, Dr. Eddy Lang, and Dr. Robert Welsh COMMERCIAL SUPPORT ACKNOWLEDGEMENT: THIS EDUCATIONAL ACTIVITY IS SUPPORTED BY AN INDEPENDENT EDUCATIONAL GRANT FROM ASTRAZENECA and BAYER CANADA