ΑΣΘΕΝΕΙΣ ΧΑΜΗΛΟΥ ΚΙΝΔΥΝΟΥ ΜΕ ΠΡΟΚΑΡΔΙΟ ΑΛΓΟΣ ΣΤΑ ΕΠΕΙΓΟΝΤΑ ΠΕΡΙΣΤΑΤΙΚΑ. ΣΥΓΧΡΟΝΗ ΘΕΩΡΗΣΗ.

Transcript

1 ΑΣΘΕΝΕΙΣ ΧΑΜΗΛΟΥ ΚΙΝΔΥΝΟΥ ΜΕ ΠΡΟΚΑΡΔΙΟ ΑΛΓΟΣ ΣΤΑ ΕΠΕΙΓΟΝΤΑ ΠΕΡΙΣΤΑΤΙΚΑ. ΣΥΓΧΡΟΝΗ ΘΕΩΡΗΣΗ. AΘΑΝΑΣΙΟΣ Ν. ΚΑΡΤΑΛΗΣ ΚΑΡΔΙΟΛΟΓΟΣ ΕΠΙΜΕΛΗΤΗΣ Α, ΓΕΝΙΚΟ ΝΟΣΟΚΟΜΕΙΟ ΧΙΟΥ

2 ΔΗΛΩΣΗ ΣΥΜΦΕΡΟΝΤΩΝ (-)

3 Failure to detect acute coronary syndrome (ACS) and inadvertent discharge of such patients from the ED may exceed 2%

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6 CHEST PAIN DIAGNOSIS AT ED 50% 5-1 0% STE 15% OCD % 10% UA Από το σύνολο των ασθενών µε προκάρδιο άλγος που θα προσέλθουν στα ΤΕΠ στο 5 10% θα τεθεί η διάγνωση STEMI, στο 15 20% NSTEMI, στο 10% ασταθής στηθάγχη, στο 15% άλλες καρδιακές νόσοι (περικαρδίτιδα, µυοκαρδίτιδα, Τako- Tsubo καρδιοµυοπάθεια, σπασµός στεφανιαίων, ταχυαρρυθµία, υπερτασική κρίση) ενώ στο 50% θα τεθεί η διάγνωση µη καρδιακού νοσήµατος (πνευµονική εµβολή, πλευρίτιδα, πνευµοθώρακας, διαχωριστικό ανεύρυσµα αορτής, µυοσκελετικό άλγος, νοσήµατα του πεπτικού, αγχώδεις εκδηλώσεις). STEMI NSTEMI UA OCD NCD

7 H αρχική διαγνωστική προσπέλαση του ασθενούς στηρίζεται σε τρεις βασικούς άξονες: 1. Την κλινική εικόνα και φυσική εξέταση. 2. Το ηλεκτροκαρδιογράφηµα (ΗΚΓ). 3. Τη χρήση βιοδεικτών µυοκαρδιακής βλάβης (κυρίως τροπονίνης).

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9 CHARACTER OF CHEST PAIN Likelihood ratios for MI based on components of the chest pain history Description of pain LR (95%) Descriptions increasing the likelihood of MI Radiation to R arm/shoulder 4.7 (1.9-12) Radiation to both arms/shoulders 4.1 ( ) Exertional 2.4 ( ) Radiation to L arm 2.3 ( ) Associated with diaphoresis 2.0 ( ) Associated with nausea or vomiting 1.9 ( ) Worse than previous angina or similar 1.8 ( ) to previous MI Described as pressure 1.3 ( ) Descriptions decreasing the likelihood of MI Pleuritic 0.2 ( ) Positional 0.3 ( ) Sharp 0.3 ( ) Reproducible with palpation 0.3 ( ) Inframammary location 0.8 ( ) Non exertional 0.8 ( ) Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294:

10 Nitroglycerine in ER Chest Pain Annals of Internal Medicine 2003 Improvement in chest pain with nitroglycerine proved: 35% Sensitive 30% Specific Ann Intern Med. 2003;139: Canadian Journal of Emergency Medicine 2006 Improvement in chest pain with nitroglycerine proved: 72% Sensitive 37% Specific Can J Emerg Med 2006;8(3):164-9

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12 Knowledge of a previously normal stress test should not affect clinical decision making in the ED because patients with a prior normal stress test are at the same risk of 30-day adverse cardiovascular events as patients who have not previously undergone stress testing. Stress testing does not assess whether non obstructive plaque existing at the time of the test will subsequently rupture, leading to ischemia. On the other hand, prior invasive coronary angiography results are useful for risk stratification of patients. Patients with no or minimal (<25%) stenosis have an excellent long-term prognosis, with 90% free from single vessel disease and >98% free from myocardial infarction nearly a decade later. Recent coronary angiography with normal or minimally diseased vessels makes the possibility of an ACS extremely unlikely, unlike a recent negative stress test, which is still associated with a 5% event rate at 30 days.

13 ECG Normal ECG: >60% Diagnostic ECG <5-10% Patients with normal or nonspecific ECGs still have a 5% to 28% incidence of ACS. ST elevation 1mm in two or more contiguous leads or new LBBB, in the appropriate clinical context, is suggestive of STEMI. ST depression 0.5 mm in two or more contiguous leads, in the appropriate clinical context, is suggestive of NSTE-ACS and linked to adverse prognosis. ST depression combined with transient ST elevation identifies a high-risk subgroup. Isolated T-wave inversion on admission has not been associated with worse prognosis compared with the absence of ECG abnormalities, it frequently triggers a more rapid diagnosis and treatment. Characteristic ECG changes in pericarditis.

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15 0h-3h rule-out algorithm of non-st-elevation ACS using high-sensitivity cardiac troponin assays 5-fold

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18 Because endogenous stress seems to be nearly invariably present at the onset of AMI, copeptin helps to improve the sensitivity of ctn at early ED presentation. The incremental benefits of copeptin exist within the first 2 hours of arrival. The less sensitive the ctn assay is, the higher the incremental value of copeptin for the early rule-out of AMI is. The incremental value may be substantial if a conventional ctn assay is used. Copeptin has neither disease (AMI) nor organ (heart) specificity and therefore is helpful only in the AMI rule-out process. It is not useful to rule in AMI. Circulation. 2016;134: CK-MB shows a more rapid decline after MI as compared with cardiac troponin and may provide added value for the timing of myocardial injury and the detection of early reinfarction. Hollander et al August 16, 2016 The routine use of copeptin as an additional biomarker for the early rule-out of MI is recommended whenever sensitive or high-sensitivity cardiac troponin assays are

19 CHEST RADIOGRAPH A chest radiograph is usually performed in pts suspected of having an ACS, as alternative diagnoses such as aortic dissection, pulmonary embolism, pneumothorax, acute pericardial disease, pleuritis, pneumonia and pneumomediastinum may be detected.

20 Σε ασθενείς µε προκάρδιο άλγος στα επείγοντα εκτός από τα οξέα στεφανιαία σύνδροµα πρέπει άµεσα να αποκλειστούν 3 ακόµα απειλητικά για τη ζωή νοσήµατα: Πνευµονική εµβολή, Πνευµοθώρακας υπό τάση και Διαχωριστικό Ανεύρυσµα αορτής. Σύµφωνα και µε τις πρόσφατες κατευθυντήριες οδηγίες της Ευρωπαϊκής Καρδιολογικής Εταιρείας για τα οξέα ισχαιµικά σύνδροµα το διαθωρακικό υπερηχοκαρδιογράφηµα συνιστάται να είναι διαθέσιµο στα ΤΕΠ και στις µονάδες θωρακικού π ό ν ο υ. Η δ ι ε ν έ ρ γ ε ι α τ ο υ υπερηχοκαρδιογραφήµατος µπορεί να συµβάλει στη διάγνωση της µυοκαρδιακής ισχαιµίας ή νέκρωσης, άλλων καρδιακών νοσηµάτων (περικαρδίτιδας) ή να αναδείξει άλλα επικίνδυνα για τη ζωή νοσήµατα (διαχωριστικό ανεύρυσµα, πνευµονική εµβολή). Ειδικά σε ασθενείς που το θωρακικό άλγος συνεχίζει και το ΗΚΓ είναι µη διαγνωστικό για οξεία µυοκαρδιακή ισχαιµία, είναι ε π ι β ε β λ η µ έ ν η η ά µ ε σ η δ ι ε ν έ ρ γ ε ι α υπερηχοκαρδιογραφήµατος ακόµα και η διενέργεια αξονικής αγγειογραφίας για τον αποκλεισµό διαχωριστικού ανευρύσµατος ή πνευµονικής If aortic dissection or pulmonary embolism is suspected, echocardiography, D-dimer assessment and CT angiography should be implemented according to the respective ESC guidelines.

21 RISK SCORES Φυσιολογικές τιµές βιοδεικτών (τροπονίνης) και ΗΚΓ χωρίς ισχαιµικού τύπου διαταραχές, δεν αποκλείουν τη διάγνωση της ασταθούς στηθάγχης, µε δεδοµένο ότι είναι ένα οξύ ισχαιµικό σύνδροµο χωρίς µυοκαρδιακή νέκρωση. Τα τελευταία χρόνια υπάρχουν διαθέσιµα αρκετά scores που είναι χρήσιµα στον προσδιορισµό των ασθενών που είναι χαµηλού κινδύνου και εποµένως µε σχετική ασφάλεια µπορούν ταχέως να αποµακρυνθούν από τα ΤΕΠ. Θεωρείται ότι αυτά τα scores υπερτερούν σε σχέση µε την απλή κρίση ενός ιατρού ΤΕΠ.

22 J. Hollander et al. Circulation;134: August 16, 2016.

23 THE HEART SCORE OUTPERFORMS AT LOW RISK THRESHOLDS T h e H e a r t S c o r e w a s developed in an ED setting in all patients with chest pain and not just ACS patients. Sun B et al. Circulation 2015: 8,255 patients > ROC Curve = HEART 0.75 vs TIMI 0.68 Backus et al Current Cardiology Reviews 2011 > c-statistic = HEART 0.9 vs TIMI 0.65 TIMI: Simple to use, but has a poor predictive power (i.e. c-statistic 0.65). PURSUIT: Does not include troponin assays as part of score and the majority of the score is dependent on patient age. GRACE: Very complex to use and a large portion of the score is dependent on the patient age. Also patients not divided into different risk groups.

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25 HEART Score for chest pain patients 1.6% score 3, 30 45d MACE Rate 1.6%

26 HEART Score of 0 3 / 30 45d MACE Rate 1.6% 11 Trials with >17,000 patients Almost 40% identified as low risk CAN WE DO BETTER THAN 1.6% MACE? HEART score+ 2nd troponin HEART Pathway* *C. Miller et al, Evaluation of patients with chest pain at low risk for ACS- UpToDate, May 2016

27 CHEST PAIN IN ED Evaluation is a continuous process and new information at any time can alter a patient s risk category. RISK SCORES RISK SCORES SEE NEXT SLIDE CLINICAL OBSERVATION/ NON INVASIVE TESTS LOW RISK INTERMEDIATE RISK HIGH RISK ADMISSION/ INVASIVE STRATEGIES

28 CLINICAL PRESENTATION / ECG(-) BIOMARKERS CLINICAL (-) / LOW PRE TEST RISK PROBABILITY SCORE (PTP) LOW RISK PTS DISCHARGE AND FOLLOW UP STRESS TEST NON INVASIVE IMANGING CT - CORONARY ARTERIOGRAPHY

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30 Diagnosis of CAD is established Investigate other causes Admission / Invasive strategies

31 LOW RISK PTS CLINICAL PRESENTATION / ECG(-) BIOMARKERS CLINICAL (-) / LOW PRE TEST RISK PROBABILITY SCORE (PTP) At some lower threshold of pretest probability the clinician is more likely to cause harm by further testing. DISCHARGE AND FOLLOW UP PTP <15, Heart pathway<3 STRESS TEST NON INVASIVE IMAGING CT - CORONARY ARTERIOGRAPHY

32 LOW ]RISK PTS Stress imaging is preferred over exercise ECG due to its greater diagnostic accuracy. Various studies have shown that normal exercise, dobutamine or dipyridamole stress echocardiograms have high negative predictive value for ischaemia and are associated with excellent patient outcomes. Moreover, stress echocardiography demonstrated superior prognostic value over exercise ECG.

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37 Judd E. Hollander, MD Martin Than, MBBS Christian Mueller, Circulation;134: MD, August 16, 2016.

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39 No test: pts TOTAL: pts

40 Using data from the present analysis, we estimate that for every 27 patients who undergo Myocardial Perfusion Scintigraphy instead of an initial strategy of no testing, 1 patient will undergo an unnecessary catheterization, and for every 71 patients who undergo CCTA instead of no testing, 1 individual will undergo an unnecessary catheterization. For patients receiving an initial noninvasive test, Stress Echocardiography (SE) was associated with the lowest rate of downstream catheterizations and revascularization procedures. This finding suggests that, of the noninvasive testing strategies, SE is the most efficacious in this population of patients. Furthermore, the significant increase in revascularization associated with Myocardial Perfusion Scintigraphy, CCTA, and Exercise Electrocardiography without a concomitant reduction in MI suggests that overdiagnosis is a legitimate concern in this patient population. Conclusions: More studies need to be conducted to clarify the best testing strategy for low-risk patients being evaluated for chest pain in the ED.

41 ΣΥΜΠΕΡΑΣΜΑΤΑ Ι Υπάρχουν τρεις διαφορετικές επιλογές αντιµετώπισης των ασθενών χαµηλού κινδύνου(φυσιολογικό ΗΚΓ και αρνητικές τροπονίνες) µε προκάρδιο άλγος στα ΤΕΠ. Η προεξεταστική πιθανότητα για στεφανιαία νόσο, η κλινική αξιολόγηση και η χρήση του HEART pathway µπορούν να συµβάλλουν στη σωστή διαχείριση αυτών των ασθενών. 1. H συµβατική κλασσική επιλογή είναι, µετά από παρακολούθηση για λίγες ώρες στα ΤΕΠ, ο ασθενής να αποχωρήσει και να επανεκτιµηθεί σε 72 ώρες. 2. Ο δεύτερος δρόµος είναι, ο ασθενής χαµηλού κινδύνου στον οποίο παραµένει η κλινική υποψία για οξύ ισχαιµικό επεισόδιο µετά από ώρες παρακολούθησης και διενέργειας νέας τροπονίνης και ΗΚΓ, να υποβληθεί σε stress test. Προτείνεται η δυναµική υπερηχοκαρδιογραφια ή το σπινθηρογράφηµα µυοκαρδίου, αντί ΗΚΓ δοκιµασίας σε κυλιόµενο τάπητα, λόγω υψηλότερης διαγνωστικής ακρίβειας. 3. H αξονική στεφανιογραφία είναι µια τρίτη επιλογή για την αξιολόγηση των χαµηλού κινδύνου ασθενών µε προκάρδιο άλγος στα ΤΕΠ. Μειώνει τον αριθµό εισαγωγών και επιτρέπει την ταχύτερη διαγνωστική προσπέλαση των ασθενών στα ΤΕΠ. Επιπλέον, ανιχνεύει τη στεφανιαία νόσο και έχει την καλύτερη αρνητική προγνωστική αξία για στεφανιαία νόσο από όλες τις διαγνωστικές εξετάσεις. Από την άλλη, αυξάνει τον αριθµό των ασθενών που θα υποβληθούν σε στεφανιογραφία και επαναιµάτωση, χωρίς να είναι αναγκαίο. Δυστυχώς, στην Ελλάδα της οικονοµικής κρίσης, η επιλογή της αξονικής στεφανιογραφίας για τη διαλογή των ασθενών χαµηλού κινδύνου µε προκάρδιο άλγος στα ΤΕΠ φαίνεται εξωπραγµατική, ενώ στα προηγµένα οικονοµικά

42 ΣΥΜΠΕΡΑΣΜΑΤΑ ΙΙ Οι ασθενείς χαµηλού κινδύνου µε προκάρδιο άλγος στα ΤΕΠ αποτελούν µια κλασική διαγνωστική πρόκληση. Η ανάγκη για τον εντοπισµό και τη θεραπεία µιας µειοψηφίας των ασθενών µε δυνητικά απειλητικές για τη ζωή παθολογικές καταστάσεις (ΟΕΜ, πνευµονική εµβολή, διαχωριστικό ανεύρυσµα, πνευµοθώρακας υπό τάση, κ.τ.λ) πρέπει να σταθµίζεται έναντι της ανάγκης να αποφευχθούν περιττές διαγνωστικές εξετάσεις ή εισαγωγή στο Νοσοκοµείο για την πλειοψηφία των ασθενών που έχουν κάποια ακίνδυνη νοσολογική οντότητα. Δεν υπάρχει αλάνθαστη προσέγγιση σε αυτή την πρόκληση, αλλά θωρακισµένοι µε τη γνώση των πλεονεκτηµάτων και των περιορισµών των διαθέσιµων διαγνωστικών εξετάσεων µπορούµε να βελτιστοποιήσουµε τη διαγνωστική µας αποτελεσµατικότητα.

43 ΣΑΣ ΕΥΧΑΡΙΣΤΩ ΓΙΑ ΤΗΝ ΠΡΟΣΟΧΗ ΣΑΣ

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46 ABOUT TROPONINS Rising or falling ctn levels differentiate acute from chronic myocardial injury. The larger the absolute ctn change within 1, 2, or 3 hours is, the higher the likelihood of the presence of AMI is. Troponins do not apply to patients who present so early, that the troponin would not be elevated, even in the setting of AMI, nor do they apply to patients with short-lived episodes of ischemic pain who have UA without myocardial necrosis. Elevations up to 3-fold the upper reference limit may be associated with a board spectrum of conditions.

47 For example, the latest improvements in CT technology, primarily dual-source CT, allow a subsecond no-breath-hold exam, overcoming heart rate limitations and obviating the administration of beta blockers. In the future, evaluation of ACS in the emergency department may include routine assessment by dual-source CCTA for low- to intermediate-risk patients presenting with acute chest pain.

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54 Four randomized controlled trials (RCTs) have tested MDCT (n¼1869 patients) vs. ESC Guidelines 277 by guest on September 7, 2016http://eurheartj.oxfordjournals.org/Downloaded from usual care (n¼1397) in the triage of low- to intermediate-risk patients presenting with acute chest pain to emergency departments without signs of ischaemia on ECG and/or inconclusive cardiac troponins At a follow-up of 1 6 months, there were no deaths, and a meta-analysis demonstrated comparable outcomes with the two approaches (i.e. no difference in the incidence of MI, postdischarge emergency department visits or rehospitalizations) and showedthatmdctwasassociatedwithareductioninemergencydepartment costs and length of stay.80 However, none of these studies used high-sensitivity cardiac troponin assays, which also may reduce hospital stay. It was also noted that MDCT was associated with anincrease in the use of invasive angiography {8.4% vs. 6.3%; odds ratio [OR]1.36[95%confidenceinterval(CI)1.03,1.80],P¼0.030}.

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56 The HEART Score is more accurate than TIMI and specifically outperforms TIMI at low risk thresholds TIMI was not derived for an undifferentiated chest pain population in an ED setting. It was derived for patients who were already high risk to see if they would benefit from early invasive therapies. Using TIMI to determine low risk CP is like using a hammer to put a screw in.

57 Chest Pain in the ED Litigation Missed myocardial infarction represents approximately 10% of malpractice suits filed Missed myocardial infarction represents approximately 30% of the dollars paid out in malpractice claims Emerg Med News. 2006: 28(2); 20-7

58 Chest Pain: HPI P: pattern (temporal sequence) A: associated features SOB, N/V, diaphoresis Fever, cough, chills Neurologic symptoms I: initiation and improvement N: nature (quality)

59 Chest Pain in the ED At SFGH, 2.5% of all visits in patients >35 were for non-traumatic chest pain Of these, 37.6% were hospitalized, 45% of whom received significant diagnoses 10.7% MI 22.5% UA or Stable CAD 11.2% Serious Pulmonary Etiology 0.4% Aortic Dissection 0.3% Pulmonary Embolism Overall, approximately 16% of visits with serious etiology (Calculated) Kohn MA, et al. J Emerg Med. 2005;29(4):

60 Chest Pain: Physical Exam Vital signs - Hypoxia? Tachycardia? Hypertension? General appearance - Marfanoid? Carotids and JVP, check neck for crepitus Lungs Cardiac exam Thoracic cage - Trauma? Pectus excavatum? Abdominal exam - Hepatomegaly? Periphery - symmetric pulses? edema? Skin - dermatomal rash?

61 Adverse Cardiac Events (12 mo out) Patients discharged with chest pain of unclear origin: Abnormal ECG OR 9.5 ( ) Preexisting DM OR 7.1 ( ) Preexisting CAD OR 28.4 ( ) Ann Emerg Med Jan;43(1):59-67

62 Aortic Dissection: etiology Prevalence of major risk factors: Hypertension 50-90% Bicuspid AoV 9-13% Marfan syndrome 3-5%

63 Etiologies Myocardial ischemia or infarction Pulmonary embolus Pneumothorax Pericarditis Tamponade Pneumonia Aortic dissection Gastritis, peptic ulcer disease Musculo-skeletal Shingles

64 Summary Remember the Big Five life threatening causes of chest pain Acute coronary syndrome Aortic dissection Pulmonary embolism Tension pneumothorax Esophageal rupture ABCs; IV, O 2, monitor, pox The diagnosis of ACS/PE/dissection may be subtle.

65 he patient who presents with acute chest pain but considered to be low-risk for ACS poses significant challenges to the emergency clinician. As stated in the AHA Scientific Statement, most patients will not have disease; however, low-risk is not no-risk, and missed diagnoses of ACS may result in significant morbidity, mortality, and medicolegal liability. There is no inexpensive, accurate, and safe test for the diagnosis of noninfarction cardiac ischemia, and approximately one-third of patients diagnosed with MI do not have chest pain on presentation to the hospital.6 The NICE guideline makes the additional point that applying the test to patients who are less likely to have CAD also leads to more false-positive results and ultimately more testing for patients, which is associated with higher costs and possible complications associated with the additional tests he ETT has an approximate sensitivity of only 70% and specificity of 75%. 1 The test's performance indicates that it could miss nearly one-third of patients with ACS and falsely diagnose an equally significant number of patients as having disease. How could the AHA statement recommend ETT as the initial test of choice for the lowrisk chest pain patient while the British guideline recommends against its use? The explanation for this discrepancy may reside in the organizations assuming a different pretest probability of disease among the intended recipients of the test. In the case of the NICE guideline, they make clear that further testing for possible ACS among patients with stable chest pain is only indicated in those with a probability of disease from 10% to 90%. The NICE guideline lends greater support for the use of CTCA, citing a superior sensitivity of nearly 95% for detecting obstructive CAD, compared to functional testing.

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