Disclosures Management of the Chest Pain Astra Zeneca Advisory - - PDF document

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Disclosures Management of the Chest Pain Astra Zeneca Advisory - - PDF document

Jul 12, 2023 547 likes •699 views

12/16/16 Management of the Chest Pain Management of the Chest Pain Patient in the ED in 2016 Patient in the ED in 2017 EA Amsterdam, MD EA Amsterdam, MD Distinguished Professor, Internal Medicine Distinguished Professor, Internal Medicine

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SLIDE 1

12/16/16 1 Management of the Chest Pain Patient in the ED in 2016

EA Amsterdam, MD Distinguished Professor, Internal Medicine Associate Chief (academic affairs) Cardiovascular Medicine Master Clinician Teacher UC Davis School of Medicine, Sacramento, CA

Management of the Chest Pain Patient in the ED in 2017

EA Amsterdam, MD Distinguished Professor, Internal Medicine Associate Chief (academic affairs) Cardiovascular Medicine Master Clinician Teacher UC Davis School of Medicine, Sacramento, CA

Management of the Chest Pain Patient in the ED in 2017

EA Amsterdam, MD Distinguished Professor, Internal Medicine Associate Chief (academic affairs) Cardiovascular Medicine Master Clinician Teacher UC Davis School of Medicine, Sacramento, CA

Disclosures

  • Astra Zeneca – Advisory Board
  • Relypsa – Advisory Board
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SLIDE 2

12/16/16 2 “The best in this kind are but shadows…”

Shakespeare, Midsummer Night’s Dream

Conflicts

My only conflicts are inner conflicts and I don’t care to share them!

Approach to the Patient with Chest Pain in the ED

  • Magnitude of the problem
  • Goal of evaluation
  • Identification of low risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols

Approach to the Patient with Chest Pain in the ED

  • Magnitude of the problem
  • Goal of evaluation
  • Identification of low risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols
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SLIDE 3

12/16/16 3

Low Risk Chest Pain

  • Magnitude of the problem
  • Goal of evaluation
  • Low risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols

Patient with chest pain in ED

Magnitude of the Problem

  • >7,000,000 ED visits/yr in US for chest pain
  • Minority are for CVD
  • Usually no specific diagnosis, no M&M
  • Single largest group of patients

– Anxiety, panic, somatoform disorder

National Trend in Admissions for Chest Pain Evaluation: 2006-2013

YEAR

5,4

ED chest pain evaluations: 2006 5.4 million 2013 7.1 million

Spectrum of Patients Presenting to ED with Acute Chest Pain

(>7,000,000/yr)

STEMI <5%

Reperfusion

Non-STE ACS 20-30%

Antiischemic Rx

Low Risk Chest Pain 65-75%

Accelerated Dx Protocol (ADP)

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SLIDE 4

12/16/16 4

STEMI <5%

Reperfusion

Non-STE ACS 20-30%

Antiischemic Rx

Low Risk Chest Pain 65-75%

Accelerated Dx Protocol (ADP)

Low Risk Chest Pain

  • Magnitude of the problem
  • Goal of evaluation
  • Low Risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols

Goal

  • To exclude acute CVD event
  • Not to exclude CAD!!!
  • Confirm safety of discharge

–For outpatient management

Goal

Avert:

Inappropriate Discharges

Missed ACS (2.3%, Pope, NEJM 2000) Medicolegal liability

Inappropriate Admissions

Inefficient resource utilization Major expense to system

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SLIDE 5

12/16/16 5

Low Risk Chest Pain

  • Magnitude of the problem
  • Goal of evaluation
  • Low risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols

Spectrum of Patients Presenting to ED with Acute Chest Pain

(>7,000,000/yr)

STEMI <5%

Reperfusion

Non-STE ACS 20-30%

Antiischemic Rx

Low Risk Chest Pain 65-75%

Accelerated Dx Protocol (ADP)

Acute CP Evaluation: Low Risk

<5% Probability of ACS

–History – Typical or atypical CP –Exam – Clinically stable –ECG – Normal (or unchanged) –Troponin - Negative (x1-2)

– Intermediate Risk - >65 yo, DM, CKD, CAD

Low Risk Is Not No Risk “Confirmatory” test to further reduce risk

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12/16/16 6

Acute Chest Pain Evaluation

  • Goal of evaluation
  • Magnitude of the problem
  • Low risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols

Multimarker BMIPP

Scientific Statement of the American Heart Association

“Confirmatory” Tests

  • Functional
  • Neg. Predictive Value

– Treadmill Ex–T >99% – MPS (sestamibi, stress) >99% – Stress Echo ~95%

  • Anatomic

– CTCA >99%

– (MRI)

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12/16/16 7

“Confirmatory” Tests

  • Functional
  • Neg. Predictive Value

– Treadmill Ex–T >99% – MPS (sestamibi, stress) >99% – Stress Echo ~95%

  • Anatomic

– CTCA >99%

– (MRI)

  • No. Pts

% % Pos

Neg PV

Po Pos PV PV Adverse Events

Ts Tsakonis 28 28 17. 17.8 100% 100%

  • Ke

Kerns et al 32 32 100% 100%

  • Lew

Lewis/Am

Amsterdam

93 13.0 100% 46% Gi Gibler et al 782 782 1. 1.2 99% 99% 44% 44% Gi Gibler et al 100 100 7 100% 100% 0% 0% Za Zalenski 224 224 8 98% 98% 16% 16% Po Polanczyk 276 276 24 24 98% 98% 15% 15% Kirk et al 212 12.5 100% 57%

Amsterdam et et al al 1000

13 98% 33%

Treadmill Exercise Testing in CPUs

Amsterdam et al, Circ 2010

30 d-1 yr

  • No. Pts

% % Pos

Neg PV

Po Pos PV PV Adverse Events

Ts Tsakonis 28 28 17. 17.8 100% 100%

  • Ke

Kerns et al 32 32 100% 100%

  • Lew

Lewis/Am

Amsterdam

93 13.0 100% 46% Gi Gibler et al 782 782 1. 1.2 99% 99% 44% 44% Gi Gibler et al 100 100 7 100% 100% 0% 0% Za Zalenski 224 224 8 98% 98% 16% 16% Po Polanczyk 276 276 24 24 98% 98% 15% 15% Kirk et al 212 12.5 100% 57%

Amsterdam et et al al 1000

13 98% 33%

Treadmill Exercise Testing in CPUs

Amsterdam et al, Circ 2010

30 d-5yr

Accelerated diagnostic protocol (ADP)

  • Serial ECGs
  • Cardiac injury markers (Tn)
  • (Confirmatory test)
  • LOS 2-12 hrs
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12/16/16 8

Acute Chest Pain Evaluation

  • Goal of evaluation
  • Magnitude of the problem
  • Low risk
  • “Confirmatory” tests
  • CPU and accelerated diagnostic protocols

Chest Pain Unit

  • Physical structure
  • “Virtual” Unit (UCDMC)

–Accelerated diagnostic protocol (ADP)

  • Serial ECGs
  • Cardiac injury markers
  • LOS 2-12hrs

Accelerated Diagnostic Protocol ED

Clinically Stable Negative ECG/Markers

CPU

Low Risk

Accelerated Diagnostic Protocol CPU

Serial ECGs, Markers (1-2 sets)

To exclude ischemia/necrosis at rest

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12/16/16 9

Accelerated Diagnostic Protocol CPU

Serial ECGs, Markers (1-2 sets)

if negative

“Confirmatory” test Accelerated Diagnostic Protocol CPU

Serial ECGs, Markers (1-2 sets)

if negative

Confirmatory test

To exclude inducible ischemia or anatomic CAD

Accelerated Diagnostic Protocol CPU

Serial ECGs, Markers (1-2 sets)

if negative

Confirmatory test

Discharge

w/follow-up

Admit

if negative if positive

UCDMC CPU

  • >20 years, >10,000 patients

– Elderly/young, M/F, +/- CAD, antianginal drugs, DM. CKD – TIMI risk score not applied in CPU patients

  • ACC/AHA guidelines

– ETT

  • If ECG WNL and patient can exercise
  • 1/3 of our patients require a different test
  • Negative Predictive Value 99.7%
  • (No confirmatory test?)
  • At other ctrs - MPS, Stress Echo, CTA
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SLIDE 10

12/16/16 10

Early ETT: Exercise-Induced Chest Pain?

2.0%

n = 318

Accelerated Dx Protocol in Low Risk Women Presenting with CP

  • N = 212, <50 yo, no DM/smoking
  • ED - Clinically stable, normal ECG and markers
  • ETT or stress imaging - 171, No Confirmatory Test = 41
  • Neg CPU evaluation in all patients, all directly discharged
  • 5 yr FU 2 fatalities (PPCM, pancreatitis)
  • Conclusion: All CP patients do not

require confirmatory testing

Eddin and Amsterdam, JACC, 2012

Evolving Concepts in CPU Evaluation

  • “Avoidable Utilization of the CPOU: Evaluation of

Very Low Risk Patients”, Mahler et al, CritPathCard 12:59;2013

  • “Chest Pain in the ED: The Case Against Our

Current Practice of Routine Noninvasive Testing”,

Prasad et al, Arch Int Med 172:1306;2012

2 hr ADP, No Predischarge Test

  • TIMI score 0, ECG neg, hs-Ti neg at 0 and 2 hr.
  • NPV >99.6% at 30 days. Than, Lancet, 2012
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12/16/16 11

In the current state of our knowledge, it is reasonable to call for a halt to routine cardiac testing in favor of physician discretion in selection of patients for predischarge testing.

JAMAIntMed 2014

No Predischarge Test UC Davis

  • If low risk criteria fulfilled

–40% pts discharged with no confirmatory test –LOS in CPU 2-12 hr –NPV >99.7% at 30 d. FU (1 event in 1138 pts)

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12/16/16 12

CTA in the ED

  • 12 studies (2005-2012)
  • N = 5865 pts, 30-81 y.o.
  • NPV 96-100% (ED and >1 yr)
  • PPV 13-87%
  • LOS 7-21 hrs
  • Radiation 5-18 mSv

Schlett et al, JACCi 2011;4:461

ROMICAT

ED ETT – 99.7% NPV Discharge in <6 hr. Cost $1200 (UCDMC)

38% of patients did not qualify for CTCA

Radiation

  • 10-20 mSv exposure = 1 new Ca for

every 500-1000 scans

  • US National Research Council on

ionizing radiation (2005)

CTA in ED – Exclusions

CTA ETT

CAD- h/o MI, PCI or CABG YES NO CKD YES NO COPD YES NO Allergy to contrast/ shellfish YES NO BMI ≥39 kg/m2 YES NO Contraindication to β-blocker YES NO Pregnancy YES NO Inability to hold breath YES NO HR >90 bpm YES NO CT imaging within past 48 hours YES NO Normal CTA/cor angiography in previous year YES NO Cocaine use within past 48 hours YES NO Radiographic abnormalities YES NO

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12/16/16 13

Exclusions

12%

Standard of Care?

50%52% 46%

CTA in ED

(More than half of studies do not include % exclusions)

CTA for Chest Pain Patients in the ED The gold standard

OR…

The Midas touch?

CTA: Issues

  • NPV

– Equal to (not higher than) usual protocols in low/intermed risk pts

  • LOS

– Shorter than usual care – But longer than No Test protocols and ADPs

  • Cost

– Immediate cost less than usual care – But not less than ADPs or No Test protocols – Downstream $ may be higher with no benefit

  • Radiation

– Not negligible

  • CTA as screening test for low/interm risk CP pts

– Medically and scientifically not justifiable

S

  • Patient to ED with chest pain

Length of Stay – ED Chest Pain Patients

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SLIDE 14

12/16/16 14 Revascularization after CTA for Low Risk ED CP Patients

Usual Care (%) CTA (%) Goldstein 1.0 5.0 CT-STAT 2.4 3.6 Litt 1.3 2.7 ROMICAT-II 4.2 6.4

Gibbons, J Nuc Card 2012;19:404

Summary

  • Low/interm risk - ID on presentation
  • Goal – Exclude ACS (not exclude CAD)
  • Evaluation - ADP, Confirmatory test
  • All patients do not require confirmatory test
  • CTA – Selected patients only!