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Low Risk Chest Pain Strategies Carol Lynn Clark MD MBA FACEP Associate Director of Research Department of Emergency Medicine Beaumont Health System Professor Oakland university William Beaumont School Of Medicine September, 2014

Disclosures • Hospital research support from Biocryst, Cardiorentis, Genentech, Glaxo Smith Kline, Janssen, Nexbio, Novartis, Portola, Lundbeck, Pfizer, Radiometer • Advisory boards for Astellas, Janssen, Pfizer, Society of Cardiovascular Patient Care

Objectives

Coronary Artery Disease

• Discuss the evaluation of chest pain in the Emergency Department and Observation Unit • Discuss risk stratification of chest pain patients • Discuss usefulness of Coronary CT Angiograms

• Estimated 620,000 New MIs each year • Nearly 300,000 Recurrent MIs each year • 150,000 Silent MIs each year • 1 in 6 Deaths each year from CAD

Chest Pain

Those two percent:

• > 8,000,000 visits annually for chest pain • 5% have ST Elevation MI (STEMI) • 25% have NON ST Elevation MI(NSTEMI) • 2% Missed MI RATE

• Have a 2 fold adjusted mortality rate over hospitalized MIs • Highest pay out awarded for malpractice cases • Are what we are looking for… Needle in a haystack?

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Chest Pain

Chest Pain Evaluation

• 10 % ED visits • 25% of Hospitalizations • 85% do not have final diagnosis of Acute Coronary Syndrome • A lot of costs to find that needle! • HELP?

• Starts with a History and Physical • Rule out other life threatening illness • Assess for Pulmonary Embolus, Pneumonia, Dissection. Asthma/COPD, Pneumothorax, Trauma • Ask the right questions • Do a physical exam • Assess their risk for cardiac disease/ events

Hollander, History and Physical

TIMI Risk score 1 Point Each

Non-cardiac Pain: 16.8 %, Still had MACE • Costochondritis: 6 % MACE • Alternative Dx: 4% MACE, still!

• Age > 65 years old • Greater Than3 Coronary Risk Factors • Known CAD, > 50 % Stenosis • Aspirin Use last 7 days • Severe Angina last 24 hours, greater than 2 events or persistent • ECG ≥ 0.05 mV on ECG • Positive Cardiac Markers,(originally CPKMB and Troponin)

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So be careful!

MACE= Major Adverse Cardiac Events

CAD Risk Factors

TIMI Risk Rate of Death or MI at 14 Days 25

Rate Percent

• Family History Coronary Artery Disease • Hypertension • Hypercholesterolemia • Diabetes • Smoker

TIMI Risk Score

20 15 percent

10 5 0 0/1

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3

4

5

7

TIMI Risk Score Problem is still a 2.9 % risk with 0/1 TIMI Risk Score!

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TIMI RISK SCORE: Death or MI Within 14 days • 0/1, 2.9 % risk • 2, 2.9% Risk • 3, 4.7 % Risk • 4, 6.7 % Risk • 5, 11.5 % Risk • 6/7, 19.4 % Risk

Than et al., ADAPT Trial • 1,975 patients • Used a 2 hour Accelerated Diagnostic Protocol • Contemporary troponins • TIMI score 0-1 • MACE at 30 days

Those numbers may be old? With newer serial troponins?

ADAPT Trial: TIMI Score 0 Advanced Diagnostic Protocol (ADP) • 0, 2 hour conventional troponins only plus ECG • 1975 patients, 392 qualified for ADP TIMI Score =0 • 302 Had MACE in 30 days overall, 15.3 % • If only TIMI score and ECG (no troponins) used, 3.2 % MACE at 30 days •

Than et al., ADAPT Trial

ADAPT Trial: TIMI Score 0

392 found to be low risk by: • TIMI score 0 • No new ischemic changes on ECG • 0 and 2 hour negative Troponins • Only 1 in ADP group within 30 days, TIMI 0, had MACE, .25%,

• Sensitivity of 99.7 % • Negative Predictive Value, 99.7% • Specificity of 23.4 % • Positive Predictive Value 19.0 % • Only 1 False Negative

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ADAPT Trial: TIMI Score 0-1

So TIMI Risk 0, 0/1

• Increased inclusion to 38.4 % • Added an additional 9 false negatives • Sensitivity 97.0%, • Negative Predictive Value 98.8% • Specificity of 44.8 % • Positive Predictive Value 24.1 %

• So TIMI Risk 0 Probable Ok to do serial enzymes and Close Follow-up • TIMI Risk 0/1 Maybe ok if you can get them to follow-up closely, • Or at least can go to additional testing early • At least talk numbers with the patient !

TIMI Risk Score 2/3

TIMI Score >3

• 2.9 % to 4.7% Risk, needs further testing • Should undergo serial enzymes and some provocative testing • Perfect patients for EDOU • Soft 3s with cardiology consult • Obvious ischemic ECG or positive markers or HARD 3s should be admitted to the hospital

• High Risk patients • Cardiac Step-down • IV Nitrates • Anticoagulation • Aspirin, Clopidogrel

Troponin

Troponin

• Only marker you need now • 99th percentile cutoff • Watch for change, delta troponins • Only time to get a CPK-MB is if the cardiologist wants it • Some help to follow reperfusion after procedure

• Any positive troponin has been shown to have increased mortality • May be Myocardial Infarction, Myocarditis, Pulmonary Embolus • Something is causing a leak • Even in End stage Renal Disease it is a bad thing • So if patient is having chest pain and an elevated troponin, admit the patient

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Troponin • May miss on first set of markers if chest pain is very early • If no provocative test planned should do serial markers • If provocative testing can do shorter, 0, 2 or 3 hour and then provocative test • If no provocative testing planned, patients that are not cath eligible, should do longer rule out, 0,3,6 hours

So :

So in up to this point : The Ones you think Are, Aren't… and the Ones You Think Aren’t Are! So do the workup!

So if you do need a further test?

• Good history and physical • Cardiac markers and ECG • Repeat markers and ECGs • Risk Stratify • Do the workup • Get provocative testing in all but the very low risk patients

When can a Coronary CT Angiogram (CCTA) help?

Goldstein et al., CT STAT

Goldstein et al, CT STAT

• 699 Patients, 361 CCTA, 338 Stress MPI • TIMI 0-4 • LOS, 2.9 hours vs. 6.3 hours median • Costs, $2,137 vs. $3,458 median • MACE 30 days, no significant difference • 64 slice to 320 slice, Standard MPI

• 26 cases to cath, 76.9 % consistent with CCTA • 2 Revisited ED • One revisit with normal cath • 1 with benign palpitations, no further workup • CCTA group: 5.2% clinical events in 6 months, 14 revascularizations

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Goldstein et al, CT STAT

Goldstein et al., CT STAT

• MPI group, 22 Cath, 54.5 % consistent with MPI • 4 revisited ED • 1 normal cath, 3 non cardiac chest pain • MPI Group: 3.7 % clinical events 6 months, 8 revascularizations

• NO clinical difference in early or late outcomes • Similar cath numbers on index visit • Similar AMI numbers • Lower radiation in CCTA group, 11.5 mSV verses 12.8 mSV

Goldstein et al, CT STAT

Hoffmann Et al., ROMICAT 11

• More rapid diagnosis, 54 % time reduction to diagnosis • Time reduction = Cost reduction • Similar cost of studies themselves • Zero mortality at 6 months both groups

• Randomized to initial CCTA or Standard evaluation • After CCTA could have anything at discretion of local physician • 40-74 years of age, BMI < 40 • No other exclusions, i.e. contrast allergy etc. to CCTA

Hoffmann Et al., ROMICAT 11

Hoffmann Et al., ROMICAT 11

• Low/ Intermediate Chest Pain • 985 patients, 501 CCTA, 499 Standard Care • Length of Stay Reduced by 7.6 hours • Time to diagnosis decreased in CCTA group • Discharged directly from ED, 47% CCTA vs. 12% Standard group

• CCTA group more downstream testing • Higher radiation exposure due to above • Similar cumulative cost of care due to above • Majority in standard group did not get MPI SPECT testing ( reason for lower radiation) • Long term follow-up?

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Hoffman et al., ROMICAT 11

Curry et al., Triage…Coronary CT…

• 8% overall Acute Coronary Syndrome • More MACE in SOC group, .4% vs. 1.2%, but not powered to evaluate, • More Invasive Procedures in CCTA group: 11% vs. 7% index, 12% vs. 8% through 28 day follow-up

• 529 patients • CCTA in patients with low risk of ACS, TIMI ≤ 2, Normal ECG normal troponins, pain less than 20 minutes • Decreased LOS, 14 vs. 28.8 hours 88.4 % discharged from ED: neg. 317, mild disease 151 • 2% MACE in discharged patients • One mild, MACE @23 days total occlusion

CURY et al., Triage…Coronary CT…

CURY et al., Triage…Coronary CT…

• 4.7% (25) had moderate stenosis and 68 % (17) underwent further testing • 9 underwent MPI, all negative • Mod. CCTA, 7 direct to cath, 6 >50%, 5 PCI • 0 MACE • Don’t really know difference? Why who went where?

• 6.8% (36) had > 70% stenosis on CCTA • 9 underwent MPI, 7 positive, 6 to cath • 23 directly to cath, 21 positive > 70% • Of the 36 >70% , 27 cath, PCI 17, MACE 3 • 8.3 % MACE in > 70 % stenosis patients • 47% PCI in > 70 % stenosis • Again don’t know who and why for PCI ?

CURY et al., Triage…Coronary CT…

So what we know?

• 3.2 % (17) of 529 low risk patient got PCI • TIMI 0-2 • So not sure who was a 0, a 1 or a 2? • Who were the 6.8 %? • Not sure of breakdown of who had what in the PCI group? • No mention of bypass grafting?

• Negative CCTAs appear very good in all studies • Moderate CCTAs should likely have functional action test added at least • Severe should probably go to cath

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What we know?

Coronary CT Angiogram (CCTA)

• Maybe more invasive procedures in CCTA patients, good or bad • Good if saves future damage, bad if just doing more with no better long term outcomes? • Decreases LOS in ED, important in crowding • If negative… less radiation • Radiation, 1-3 mSV

So CCTA Radiation is less than 25 % of MPI Stress Test Radiation

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Currently about 1-3 Millisieverts of radiation Radiation dose increases with BMI and Heart Rate Do not need calcium scoring

Coronary CT Angiogram (CCTA) •

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Stress Importance of Beta-blockade to lower heart rate The higher the BMI the more important it is to slow the heart rate

MPI Stress test around 10-12 Millisieverts radiation

Beta- Blocker For CCTA •

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The excitement of feeling the input of dye increases the heart rate Diagnostic quality is dependent on beta-blockade Dose should be checked by hand grip for adequate blockade before going to CCTA Hand squeeze for 30 seconds, use heart rate

Lopressor Dosing Pre CCTA Heart Rate >65

BP>90

Heart Rate 55-65

BP>90

Heart Rate