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Chest Pain: New Methods Applied to an Old Problem. Jon W. Wahrenberger, MD December 2, 2002. Chest Pain. 5 Million emergency department visits 2 million hospitalizations annually with cost of more than $8 billion Cardiac etiology found in less than one third

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chest pain new methods applied to an old problem

Chest Pain: New Methods Applied to an Old Problem

Jon W. Wahrenberger, MD

December 2, 2002

chest pain
Chest Pain
  • 5 Million emergency department visits
  • 2 million hospitalizations annually with cost of more than $8 billion
  • Cardiac etiology found in less than one third
  • 2% of patients with acute MI are unrecognized and discharged from the ED
chest pain3
Chest Pain
  • Rapid Dx &Tx = saved muscle = improved outcome
  • Largest category of loss from malpractice litigation in the emergency department
goals
Goals
  • Rapid recognition of management of true ACS
  • Recognition of other life-threatening causes of chest pain
    • Aortic dissection
    • Pulmonary embolism
    • Tension pneumothorax
  • Minimize cost and hospitalization in patients with chest pain of benign etiology.
audience question
Audience Question

What feature best predicts a cardiac etiology to chest pain?

  • Location in chest
  • Character or quality of discomfort
  • Response to Nitroglycerin
  • Relationship to exertion
chest pain diagnosis
Chest Pain Diagnosis
  • Clinical diagnosis
  • Diagnosis using computer algorithms
  • Chest pain centers
classic angina
“Classic” Angina
  • Location: central chest
  • Quality: squeezing, pressure, heaviness
  • Radiation: arm(s), neck, jaw
  • Associated symptoms: dyspnea, diaphoresis, nausea
  • Eliciting factors: exertion
  • Relieving factors: rest, nitroglycerin
differential diagnosis
Musculoskeletal

Gastrointestinal

Cardiac

Psychiatric

Pulmonary

Other/unknown

Differential Diagnosis
cardiovascular chest pain
Coronary Heart Disease

Stable angina pectoris

Unstable angina

Myocardial infarction

Coronary Vasomotor Disease

Variant angina

Microvascular angina

Pericarditis

Myocarditis

Valvular Heart Disease

Aortic stenosis

Mitral stenosis

Hypertrophic cardiomyopathy

Aortic Dissection

Post-pericardiotomy

Cardiovascular Chest Pain
immediate goals
Immediate Goals
  • Cardiac or not?
  • If cardiac, how to manage?
chest pain diagnosis what are we seeking
Chest Pain Diagnosis: What are we Seeking?
  • Pathologic: MI or No MI
  • Management Based: ST Elevation MI or not?
  • Prognostic
  • Anatomic: Correlating with cath findings
  • Functional: Correlating with ischemia
  • Detailed Diagnosis
traditional classification of pts with cp
Group 1

MI with ST elevation or new LBBB

MI without ST elevation

Group 2

Unstable angina-high risk

Unstable angina – low risk

Non-ischemic chest pain

Traditional Classification of Pts with CP
ideal categorization of patients with cp
Group 1

MI with ST elevation

New LBBB

Primary PCI

or

Thrombolytics

Group 2

MI without ST elevation and no LBBB

Unstable angina – high risk

Heparin,

GP IIbIIIa inhibitor

Ideal Categorization of Patients with CP

Group 3

Unstable angina – low risk

Heparin,

admission

Group 4

Non-cardiac chest pain

Discharge

or

Treat as condition warrants

clinical evaluation of chest pain meta analysis
Clinical Evaluation of Chest Pain:Meta Analysis
  • Medline search from 1980-1998
  • Inclusion Criteria:
    • Evaluation of pts thought to have cardiac ischemia
    • Tool: history, PE, ECG
    • Outcome assessed: MI or no MI
    • Sample size > 200 patients
  • Statistical methods: pool studies and determine likelihood ratios

Panju, et al. JAMA 1998;280:14:1256-1263

likelihood ratio
“Likelihood Ratio”
  • Likelihood ratio expresses the odds that a given level of a diagnostic test result would be expected in a patient with (as opposed to without) the target disorder

Sacket, et al. Clinical Epidemiology

features decreasing likelihood of ami
Features Decreasing Likelihood of AMI

Panju, et al. JAMA 1998;280:14:1256-1263

ecg findings increasing likelihood of ami
ECG Findings Increasing Likelihood of AMI

Panju, et al. JAMA 1998;280:14:1256-1263

clinical symptoms and mi in patient with non diagnostic ecg
Clinical Symptoms and MI in Patient with Non-diagnostic ECG

Goal: measure ability of clinical features to predict AMI or ACS in those with non-diagnostic ECG

Study Population: 893 pts presenting to large teaching hospital in the UK with suspected AMI or ACS.

Study Protocol:

History, PE, ECG & CXR

Baseline CK-MB, Trop T at six hours

If enzymes negative, stress test and discharge

Reference: Goodacre, et al. Acad. Emerg Med 2002;9:20308

clinical symptoms and acs mi in patient with non diagnostic ecg
Pain site

Radiation

Nature

Duration

Associated symptoms

Pleuritic Nature

Response to exercise

Chest wall tenderness

Response to NTG

Clinical Symptoms and ACS/MI in Patient with Non-diagnostic ECG
  • Endpoints:
    • AMI by WHO criteria
    • ACS defined by AMI on presentation or w/i 6 mo.

Reference: Goodacre, et al. Acad. Emerg Med 2002;9:20308

clinical symptoms and acs mi in patient with non diagnostic ecg24
Clinical Symptoms and ACS/MI in Patient with Non-diagnostic ECG

Reference: Goodacre, et al. Acad. Emerg Med 2002;9:20308

clinical symptoms and angiographic disease
Clinical Symptoms and Angiographic Disease
  • Goal: determine correlation between clinical characteristics and angiographic disease
  • Population:
    • 65 of 1022 patients undergoing angiography and with normal coronaries
    • 65 consecutive age-matched controls and with angiographic CAD (> 70 diameter narrowing)
  • Method: all patients interviewed within 24 hours of angiogram by interviewers blinded to angio results

Reference: Cook, et al. Heart 1997;78:142-6

clinical symptoms and angiographic disease27
Clinical Symptoms and Angiographic Disease

Results:

  • No correlation between site of pain, radiation, quality of pain, or relief with NTG and presence of disease
  • Only four clinical variables separated groups:

a. Reproducibility with exercise (10/10 v. 1-9/10)

b. Lack of rest symptoms (0-1/10 v. 2-10/10)

    • Duration of 5 minutes or less (5 min. v > 5 min)
    • Age (<55 v. ≥55)

Reference: Cook, et al. Heart 1997;78:142-6

clinical symptoms and angiographic disease28
Clinical Symptoms and Angiographic Disease

Reference: Cook, et al. Heart 1997;78:142-6

chest pain evaluation based on prognosis
Chest Pain: Evaluation Based on Prognosis

Prediction of Risk for Patients with Unstable Angina

Evidence Report/Technology Assessment No. 31

Agency for Healthcare Research and Quality

ahrq meta analysis
AHRQ Meta Analysis
  • MEDLINE search 1966-1998 of studies performing multivariate analysis of clinical and/or ECG predictors of adverse clinical events in patients with suspected or diagnosed unstable angina.
  • Separate analysis of predictive value of troponin and Chest Pain Units
ahrq meta analysis31
AHRQ Meta Analysis

Clinical Predictors:

  • Demographics (age, sex, ethnicity)
  • Medical history (prior MI, CHF, diabetes, etc)
  • Symptom Characteristics
  • Initial Exam findings
  • Initial ECG features

Outcomes: Cardiac death, MI, other major cardiac complications

ahrq meta analysis32
AHRQ Meta Analysis
  • Demographic features correlating with poor prognosis:
    • Increasing age
    • Male gender
  • Prior Medical Conditions:
    • Prior MI
    • Diabetes
    • (Prior CHF, HTN, smoking)

1

ahrq meta analysis33
AHRQ Meta Analysis
  • Symptom characteristics: not predictors
  • Initial exam features:
    • Low BP
    • CHF
    • Cardiogenic shock

1

clinical diagnosis of chest pain
Clinical Diagnosis of Chest Pain
  • Location, quality of pain generally not predictive of cardiac cause
  • Response to nitroglycerine not a reliable predictor
  • While radiation and associated symptoms may be predictive, their sensitivity and specificity are quite low
  • More than a history and physical are needed!
chest pain diagnosis35
Chest Pain Diagnosis
  • Clinical diagnosis
  • Diagnosis using computer algorithms
  • Chest pain center
computer guided chest pain diagnosis
Computer Guided Chest Pain Diagnosis
  • Goldman Chest Pain Protocol
  • Acute Coronary Ischemia Time-insensitive Predictive instrument (ACI-TIPI)
goldman chest pain protocol
Goldman Chest Pain Protocol
  • Computer derived decision aid
  • Designed to improve triage to CCU
  • Initially developed in prospective study of 1379 patients presenting with acute chest pain
  • “Recursive partitioning” used to divide subjects into subgroups correlating with high or low risk of MI

Goldman, et al. N Engl J Med 1982;307:588-96

goldman chest pain protocol38
Goldman Chest Pain Protocol

Goldman, et al. N Engl J Med 1982;307:588-96

goldman chest pain protocol39
Goldman Chest Pain Protocol
  • Validated prospectively in second trial of 4770 patients

Goldman et al. N Engl J Med. 1988;318:797-803

goldman chest pain protocol40
Goldman Chest Pain Protocol
  • Advantages:
    • Higher specificity than MD
  • Disadvantages:
    • Predicts only AMI (not USA)
    • Never shown to alter:
      • Hospitalization rate
      • Length of stay
      • Cost
aci tipi acute coronary ischemia time insensitive predictive instrument
ACI-TIPI(Acute coronary ischemia time-insensitive predictive instrument)
  • Predictive protocol incorporated into electrocardiogram with automatic results
  • “Time insensitive” so can be used either retro- or prospectively

Selker, et al. Ann Intern Med 1998;129: 845-55

aci tipi clinical variables
Age

Sex

Presence of absence of chest pain or pressure of left arm pain

Chest pain as most important symptom

ECG Q waves or not

Presence and degree of ST elevation or depression

Presence or absence of T-wave elevation or inversion

ACI-TIPI: Clinical Variables

Selker, et al. Ann Intern Med 1998;129: 845-55

aci tipi
ACI-TIPI
  • Validated in 3 trials:
    • UCLA Harbor Medical Center N= 189
    • University of Geneva N=605
    • ACI-TIPI Trial N= 10,689
aci tipi trial
ACI-TIPI Trial
  • Clinical trial at 10 U.S. hospitals
  • ACI-TIPI protocol installed in all ED electrocardiograph machines
  • Clinical intervention: 7 alternating months of:
    • ACI-TIPI probability of ischemia provided
    • ACI-TIPI probability of ischemia not provided
  • 10,689 patients enrolled

Selker, et al. Ann Intern Med. 1998;129:845-55

aci tipi trial results47
ACI-TIPI Trial Results
  • No difference in 30 day mortality
  • No difference in in-hospital complications
  • No difference in re-hospitalization rates
chest pain diagnosis48
Chest Pain Diagnosis
  • Clinical diagnosis
  • Diagnosis using computer algorithms
  • Chest pain centers
chest pain in the emergency department
Chest Pain in the Emergency Department
  • 5 million annual ED visits for chest pain
  • About one fourth have true ACS
  • Treatments for ACS are time sensitive
  • About 2-4% of acute MIs are missed in the ED
  • Number one cause of ED related malpractice
  • Strong bias for admission
chest pain units
Chest Pain Units
  • Goal: accurately determine presence or absence of acute myocardial ischemia
    • Rapid efficient treatment of AMI
    • Avoid unnecessary hospitalization (and cost)
    • Avoid inappropriate discharge
  • Logistics: Often associated with and staffed by Emergency room and include telemetry and resuscitation equipment
chest pain units51
Chest Pain Units
  • Heart attack program
  • Diagnostic (observational) program to rule out MI
  • Educational outreach program
diagnostic strategies in acs
Out of hospital ECG

Continuous/serial ECG

Exercise stress ECG

CPK (presentation)

CPK (serial)

CK-MB (presentation)

CK-MB (serial)

Myoglobin (presentation)

Myoglobin (serial)

Troponin I (presentation)

Troponin I (serial)

Troponin T (presentation)

Troponin T (serial)

Rest echocardiography

Stress echocardiography

Sestamibi (rest)

ACI-TIPI

Goldman Chest Pain Protocol

Algorithms/protocols

Computer based decision aids

Diagnostic Strategies in ACS
slide53

University of Cincinnati

“Heart ER” Strategy

perfusion imaging vs echo
Perfusion Imaging vs. Echo
  • Study Group: 145 of 2838 patients admitted for r/o MI and in whom both MPI and echo were performed in ED
  • Intervention:
    • Resting SPECT Tc-99m Sestamibi imaging in ED
    • Resting 2-dimensional echocardiography in ED
  • Endpoint: Myocardial Infarction by enzymes

Kontos, et al. Am Heart J. 2002;143:659-67

perfusion imaging vs echo56
Perfusion Imaging vs. Echo

Sensitivity (%)

Kontos, et al. Am Heart J. 2002;143:659-67

randomized trials of chest pain units
Randomized Trials of Chest Pain Units

From Agency for Healthcare Research and Quality Report, 2000

randomized trials of chest pain units58
Randomized Trials of Chest Pain Units

Chest pain evaluation unit versus usual care

From Agency for Healthcare Research and Quality Report, 2000

conclusions
Conclusions
  • Clinical characteristics are the least accurate predictor of the etiology of chest pain
  • Pattern of pain may be most reliable
  • Accurate diagnosis and management requires use of clinical history, ECG, and other highly specific marker of ischemia or infarction
  • Computer aided algorithms may improve diagnostic accuracy and reduce missed dx
conclusions continued
Conclusions (continued)
  • Chest pain units need further study but may be helpful in:
    • Reducing unnecessary hospitalization
    • Reducing cost