Cardiac investigations for acute coronary syndrome
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Cardiac investigations for acute coronary syndrome
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Cardiac investigations for acute coronary syndrome
- 1. So What Does It Really Mean? Cardiac Investigation in and out of the Emergency Department Dr Kyle Kophamel Sir Charles Gairdner Hospital CME 25/09/2014
- 2. Vetrovec, 2008 A little over 50 years ago, my father had a heart attack. He was driven to the hospital by friends after having “indigestion” for 2 days. He spent 2 weeks as an inpatient on an unmonitored rehabilitation ward and was treated principally with warfarin and digitalis. He was lucky and survived, but in that era, more than 20% of patients with an acute myocardial infarction died Improving Reperfusion in patients with Myocardial Infarction. Vetrovec. 2008
- 3. Cardiac Investigations History Examination ECG Troponin Exercise Stress Test Stress ECHO Myocardial Perfusion Scan Stress Cardiac MRI CT Coronary Angiogram Coronary Angiography AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.
- 4. How to interpret elevated cardiac troponin levels. Circulation 2011. Mahajan and Jarolim.
- 5. Exercise Treadmill Test -Smart EM. Stress Testing Summary - Fleishman MD. Podcast and Notes Summary. -AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.
- 6. Myocardial Perfusion Scan -AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.
- 7. CT Coronary Angiography -CT Angiography for Safe Discharge of patients with Possible Acute Coronary Syndromes. Litt et al. New England journal of Medicine,2012 -AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al. -
- 10. So who goes where? Hx, Exam, ECG Clinical Suspicion Observation vs Admission Troponin Timing Risk stratification TIMI National Heart Foundation HEART score EDACS - ADP -
- 11. TIMI Age >65 >3 Cardiac Risk factors Known CAD - >50% stenosis Elevated troponin Aspirin use in last 7 days >2 episodes of angina in last 24 hours ST changes at least 0.5mm
- 12. TIMI % risk at 14 days of all causes of mortality, new/recurrent MI or ischaemia requiring PCI 0-1 = 4.7% 2 = 8.3% 3 = 13.2% 4 = 19.9% 5 = 26.2% 6-7 = 40.9%
- 13. NHF Australia High Risk CCU admission Intermediate Risk Provocative testing prior to discharge Low Risk Outpatient care
- 14. HEART score History ECG Age Risk factors Troponin -A prospective validation of the HEART score for chest pain patient at the emergency department. Backus et al. International journal Cardiology. 2013 -Chest pain in the emergency department: The value of the heart score. Six. Backus. Neth. Heart Journal. 2008
- 15. Cases and Discussion A Charlies perspective…. Accelerated diagnostic protocol.
- 16. Take Home Risk stratification Gustalt and Scoring (HEART) Safety of Accelerated of Diagnostic Protocols Timely follow up arrangement GP vs Cardiologist
Hinweis der Redaktion
- High sensitivity troponin has allowed us t o develop accelerated diagnostic protocols
- SMART EM – thing of the past. Low risk – high FP. High risk – High FN Sens: 68% Spec 77%. Should be used in combination – ie with stress ECHO SMART EM stress testing summary
- Thalium 201 or technetium 99 labeled to sestamibi. Limitations of scans include FP 2’ to artifactual perfusion defecits.
- Cardiac Risk – FH, DM, HTN, lipids, Smoking
- High risk applies if have any one or more of: repetitive or prolonged (>10 min) chest pain; raised troponin I or T on arrival or at 6 / 9 hours; ECG changes; haemodynamic compromise with SBP <90 mmHg, cool peripheries, sweating, Killip Class >1 heart failure; new-onset mitral regurgitation; VT; syncope; LVEF <40%; prior PCI in last 6 months or prior CABG ever; and diabetes or chronic renal failure (eGFR <60ml/min) with typical ACS symptoms. They all need CCU. Intermediate risk applies if have no high-risk features + had chest pain in last 48 hrs that occurred at rest or was repetitive or prolonged, but now resolved; age > 65 yrs; known CAD eg prior AMI; ≥ 2 risk factors of hypertension / family history / smoker / hyperlipidaemia; and diabetes or chronic renal failure (eGFR <60ml/min) but atypical ACS symptoms. They should all have a stress test (exercise ECG or myocardial perfusion scan) before discharge, providing serial cardiac enzymes and ECGs were normal on arrival and at 6 / 9 hrs. Low risk only applies to patients with clinical features consistent with ACS without intermediate or high-risk features (see above); and also a neg troponin + normal ECG at 0 and 6 / 9 hours. They do not need immediate stress testing, but can be discharged to outpatient care
- History – suspicious – high/mod/slightly ECG – st depression/non specific depol/normal Age – 65/45-65/<45 Risk lipids/htn/DM/smoking/FH/obesity - >3/1-3/0 Trop - >3x/1-3x/< normal limit
- Ordering of outpatient investigations. Cardiology review. ADP