best of the best in cardiology - chairman's welcome ... · department of emergency medicine...

Amal Mattu, MD, FAAEM

Professor and Vice Chair

Director, Emergency Cardiology Fellowship

Department of Emergency Medicine

University of Maryland School of Medicine

Best of the Best in Cardiology

Recent Articles You’ve Got to Know!!

Disclosure

I have no financial relationships to disclose.

Outline

• What we won’t talk about:

– Resuscitation, cardiac arrest

– Post-arrest care

– Afib and dispositions

– 2013 ACS Tx updates

– Syncope

[Other speakers will address these topics]

Outline

ACS Evaluation

• ACS testing

• Rapid rule-out protocols

• Predictors of ACS

• Gender issues

• ECG topics

Not a journal club!

Slide PDF: lectures.umem.org/Mattu

Questions? [email protected]

Question…

What’s the most important lab test in all of emergency medicine?

Troponin

Case…

• 55 yo man with history of CHF and renal insufficiency presents with SOB, mild chest ache – ECG: LVH + NSJ – Diagnosed with CHF exacerbation but TN

level is slightly elevated – Is this also an acute MI?

• Sepsis, stroke, renal patients, etc.

Troponin

How to Interpret Elevated Cardiac Troponin Levels

(Mahajan, et al. Circulation 2011) ACCF 2012 Expert Consensus Document

on Practical Considerations in the Interpretation of Troponin Elevations

(Newby, et al. JACC 2012)

Troponin

Mahajan, et al. Circulation 2011

Troponin

• Pro: earlier dx of AMI, earlier rule out of non-MI

• Con: Increased sensitivity but decreased specificity

Troponin

• Newest assay (Body, et al. JACC 2011) – [Super-] “highly-sensitive” TN (HS-TN)

could pick up AMI at time of arrival!

Troponin

• Newest assay (Body, et al. JACC 2011) – 94% of pts with HS-TN level 3-14 ng/L

were eventually judged to NOT have MI – 48% of pts with HS-TN level > 14 ng/L

were eventually judged to NOT have MI

– If TN negative strongly rules out MI – If TN positive ???

Troponin

Newby, et al. JACC 2012

Troponin

• Elevated TNs in many of these non-MI conditions provide prognostic information…but no therapeutic change – Sepsis – Stroke – PE – Renal failure – Etc.

Troponin

• So how do you diagnose true ACS-MI? – These are the ones that need the “typical

treatments”… • Antiplatelet medications • Anticoagulants • Invasive therapies • Etc.

Troponin

ESC/ACCF/AHA/WHF Expert Consensus Document: Third Universal Definition of Myocardial Infarction

(Thygesen, et al. Circulation 2012)

Troponin

Criteria for acute MI •Detection of rise and/or fall of cardiac biomarkers (preferably cTN) with at least 1 value > 99th percentile upper reference limit + one of the following:

– Sx’s of ischemia – Diagnostic ECG – Positive imaging new loss of myocardium

or new regional WMA – ID intracoronary thrombus (cath, autopsy)

Troponin

Criteria for acute MI •Detection of rise

> 20% rise (> 99% URL) with serial sampling 3-6 hours apart “Relying on a single TN value should be avoided in favor of serial testing” [unless the pretest probability is very high or ECG is diagnostic]

Troponin

Criteria for acute MI •“Smoldering pattern” is more likely caused by non-AMI causes

– Renal failure – CHF – Myocarditis – Infiltrative diseases – Etc.

Troponin

Mahajan, et al. Circulation 2011

Troponin

• Bottom line: – Determine pre-test likelihood of AMI before

ordering the test – If low PTL (equivocal HPI or ECG), serial

TNs will be needed delays in the ED

(don’t order the test!) – Single TN elevation is no longer diagnostic

Troponin

•Jesse RL. On the Relative Value of an Assay Versus That of a Test

(JACC 2010) –“When TN was a lousy assay it was a great test, but now that it’s becoming a great assay, it’s getting to be a lousy test.”

Summary

Troponin testing in the ED

• Very non-specific in isolation

• Determine PTL of AMI before ordering the test

– If PTL is low and test positive, will often need serial testing

• TN most helpful when negative


Case…

45 yo man presents with chest tightness this AM while at work (at rest).

• Mild SOB, nausea, lightheaded • No sweats, radiation, or vomiting • Resolved after 20 minutes, now asymp. • Smokes ½ ppd, no other CRFs • No PMD (? Lipid profile) • PE: 150/95, exam normal

Case…

What’s your plan? 1.Admit for workup (turf the risk) 2.Rule out MI and get outpatient stress 3.Rule out MI and discharge, no further

workup 4.Discharge without any workup

Case…

Why all the debate about these patients?

Case…

AHA: Testing of Low-Risk Patients Presenting to the ED

with Chest Pain (Circulation 2010)

Case…

Case…

• Can we discharge patients without provocative testing? Or without plan for early outpatient testing?

• Is it defensible to not follow the guidelines?

Rapid Rule Out Protocols

2-hour rule-out protocols • Than M, Cullen L, et al. Lancet 2011 • Than M, Cullen L, et al. JACC 2012 • Aldous SJ, et al. (incl. Than & Cullen), Am

Heart J 2012


2-hour rule-out protocols • Patients meeting the criteria have < 1%

risk of adverse events at 30 days • Probably acceptable to discharge without

plans for outpatient provocative testing if they meet criteria


2-hour rule-out protocols • Criteria

– TIMI score 0 – No new ischemic ECG findings – TN negative at 0 and 2 hours after arrival


2-hour rule-out protocols • TIMI score 0 = NONE of the following

– Age > 65 – 3 or more CRFs (not incl. male sex) – Use of ASA within 7 days – Significant known coronary stenosis > 50% – Severe angina, e.g., > 2 angina events in past

24h or persisting discomfort (subjective!) – ST-segment deviation > 0.5 mm – Increased TN or CK-MB at arrival


Clinical Predition Rule for 30d ACEs (Hess,…Stiell, et al. Ann Emerg Med 2012)

– Absence of 5 predictors • Ischemic ECG not known to be old • Hx/o CAD • “Typical pain” (subjective!) • Elevated initial or 6h TN level • Age > 50

– Rule was 100% sensitive


Problems • 2-hour TN rules need validation by other

groups • Hess, Stiell study needs validation • Still incorporate subjectivity

• Are these now defensible?

Summary

• Troponin testing in the ED…very sensitive = very non-specific

– Consider PTL before ordering


– Becoming defensible (my opinion)


Case…


• Mild SOB, nausea, lightheaded • No sweats, radiation, vomiting • Resolved after 20 minutes, now asymp. • History of CAD, “feels like my prior MI” • ECG: NSJ

Case…

What’s your plan? 1.Admit for workup (turf the risk) 2.Rule out MI and get outpatient stress 3.Rule out MI and discharge 4.Discharge without workup

Case…

• This patient was admitted, full workup was negative for ACS.

• What historical features are useful??

ACS vs. Non-ACS Presentations

• Pelter, et al. Am J Emerg Med 2012. • Body, et al. Resuscitation 2010. • Swap, et al. JAMA 2005. • Panju, et al. JAMA 1998.


Summary of the data for patients with CP: • Pressure, tightness, squeezing • Pain occurring at rest • “Like my prior ischemia” • Associated SOB • Associated lightheadedness • Associated nausea

All non-specific! No change in LRs


4 factors decreased LR for rule-in for ACS • Pain described as pleuritic • Pain described as sharp • Pain described as reproducible • Pain described as positional

• Note that decrease ≠ rule out!


4 factors increased LR for rule-in for ACS • Pain that radiates

– Bilateral > right >> left

• Pain with diaphoresis – Observed >> reported

• Pain with exertion • Pain with vomiting (not nausea!)


Takehome points: • You must worry if patient had CP with

radiation, diaphoresis, exertion, vomiting

• If considering discharge home, ask about and document pleuritic, sharp, reproducible, positional – Document absence of the 4 “worries” also

Summary

• TN…the D-Dimer of the 2000s?


– Becoming defensible (my opinion)

• Worry radn, diaphoresis, w/exertion,

vomiting

• D/C? document pleuritic, sharp,

reproducible, positional


Case…


• Mild SOB, nausea, lightheaded • No sweats, radiation, vomiting • Resolved after 20 minutes, now asymp. • Smokes ½ ppd, no other CRFs • No PMD (? Lipid profile) • PE: 150/95, exam normal

Case…

35 yo woman presents with chest tightness this AM while at work

• Mild SOB, nausea, severe malaise • No sweats, radiation, vomiting • Resolved after 20 minutes, now asymp. • Smokes ½ ppd, no other CRFs • + PMD no other medical problems

• Premenopausal • PE: 150/95, exam normal

Questions…

45 yo man case vs. 35 yo woman case

• Which patient is more likely to rule in?

• Which patient is more likely to be missed if having an MI?

• Which patient, if admitted for MI, is more likely to die?

Gender Differences in ACS

Association of Age and Sex With MI Symptom Presentation and In-Hospital Mortality

(Canto, et al. JAMA 2012) • Studied

– Relationship of age and sex – Presence/absence of CP at arrival – Above influences on hospital survival


• National Registry of MI – Evaluated > 1 million MI patients – 42% were women – LOTS of patients in each subgroup


• Key findings in all-comers – 50% of patients (men or women) > 75 yo

had not CP – Greater differences in presentation between

men and women were in the younger patients


• Key findings in young patients (< 45 yo) worth noting – Almost 20% of women with MI had no CP

• 13% of men with MI had no CP – Young women had slightly higher in-hospital

mortality than young men, but… – Young women without CP had higher much

higher in-hospital mortality than men without CP (15% vs. 10%)


• Prior study by Canto, et al. (JAMA 2000) – MI patients (all-comers) admitted without

CP had higher in-hospital mortality than those with CP • 23% vs. 9%


• Takehome points – Young women DO have MIs – Young people DO often present without CP

• Especially women – Young women do worse than young men – Painless presentations are HIGH RISK for

death (and misdiagnosis)

Summary

• TN…the WBC of the 2000s?

• Consider using RROPs

• Radn, sweat, w/exertion, vom. worry!

• Young women DO have MIs

– Beware painless presentations

– Beware severe malaise


• 58 yo man presents to the ED c/o CP, nausea, and dyspnea

• VS: Afeb, HR 70, RR 22, 145/90, 97% • Exam: uncomfortable

– Normal cardiopulmonary exam – ECG…

Case…

Case…

• ECG: NSR, LBBB • Most recent “old” ECG was normal…

6 months ago

• Chest pain with a presumed new LBBB = STEMI equivalent = activate the cath lab….right?

Case…

• Which patients need emergent reperfusion (i.e. STAT CLA or lytics)? – Chest pain or concerning symptoms + ECG

• ECG Criteria –STE in 2 contiguous leads, OR –Posterior STEMI, OR –New LBBB ??

–LBBB with Sgarbossa criteria?

Case…

• Recent increasing literature indicating that new LBBB does NOT predict a high likelihood of AMI/acute thrombosis – Chang, et al. Am J Emerg Med 2009 – Kontos, et al. Am Heart J 2011 – Jain, et al. Am J Cardiol 2011 – Mehta, et al. J Electrocardiol 2012

New LBBB and AMI

Evolving Considerations in the Management of Patients with LBBB and Suspected MI

(Neeland, et al. JACC 2012)

New LBBB and AMI

Left Bundle Branch Block and Acute MI (Neeland, et al. JACC 2012) • Traditional concept of “new LBBB =

STEMI equivalent” (i.e. needs STAT reperfusion) – Based on very poor data – Based on assumption that LBBB obviates all

possibility of interpretation for ischemia

New LBBB and AMI

Left Bundle Branch Block and Acute MI (Neeland, et al. JACC 2012) • Traditional concept of “new LBBB =

STEMI equivalent” (i.e. needs STAT reperfusion) – Based on very poor data – Based on assumption that LBBB obviates all

possibility of interpretation for ischemia

New LBBB and AMI

Wrong!

Left Bundle Branch Block and Acute MI (Neeland, et al. JACC 2012) • Increasing data: LBBB should be

considered a STEMI equivalent only if… – Patient is hemodynamically unstable or has

acute heart failure, OR – Patient has concordant ST segment changes

(Sgarbossa rules A or B)

New LBBB and AMI

Normal LBBB

Sgarbossa A

Sgarbossa B

Proposed algorithm for suspected MI and LBBB

New LBBB and AMI

Takehome points: • New LBBB in the absence of

hemodynamic instability or Sgarbossa concordance is unlikely to be a true STEMI equivalent – Guidelines will probably be changing

• Talk to your cardiologists about this literature…do they still want the CLA?

New LBBB and AMI

Summary

• TN…I’m probably leaking some now



• Beware women with malaise!

• New LBBB + CP ≠ AMI unless sick or Sgarbossa A-B


Case…

• 58 yo woman presents with sharp left sided pain, dyspnea, and diaphoresis

• CRFs: smokes, htn, DM

• PE RFs: COPD, prior hx/o cancer

• Exam: Afeb, HR 100, RR 22, BP 135/70, pox 96%

• ECG…

Case…

What’s the Dx?

PE and the ECG

• New T-wave inversions are very common in cases of large PEs

• Especially common in anteroseptal leads

• Marriott and other others:

– Simultaneous TWIs in anteroseptal + inferior leads is HIGHLY specific for acute pulmonary hypertension (= PE)

PE and the ECG

Simultaneous T-Wave Inversions in Anterior and Inferior Leads

(Witting, et al. J Emerg Med 2012)

• Simultaneous TWIs in inferior + anteroseptal leads are not common, but are very specific for PE

• [usually large PE, RV strain]

Pulmonary Embolism

PE Simulating ACS Case 2

Baseline ECG


Courtesy Dr. Veronica Pei

Takehome points

• Simultaneous TWIs in the inferior + anteroseptal leads = PE until proven otherwise

PE and the ECG

Summary

• TN…often elevated in PE! (means little)



• Women are confusing…get the ECG!

• New LBBB + CP ≠ AMI unless sick or Sgarbossa A-B

• PE often mimics ACS with TWIs


Case…

• 84 yo man presents with chest pain, dyspnea, vomiting, near-syncope

• Looks like a “real one”

Case…

ACS with LMCA Stenosis

Normal ECG

aVR — The Forgotten

12th Lead

• The ECG literature indicates that in the setting of ACS, STE in aVR indicates LMCA stenosis, prox LAD stenosis, or triple vessel disease

(all of these are BAD!)


12th Lead

• The ECG literature indicates that in the setting of ACS…

– STE in aVR + aVL LMCA stenosis

– STE in aVR > STE in V1 LMCA stenosis

– The greater the amount of STE in aVR, the more likely LMCA stenosis


12th Lead

• What literature?

– Google “aVR-the forgotten 12th lead”

– Williamson, Am J Emerg Med 2006

– Rokos, Am Heart J 2010

• Indications for appropriate cath lab activation


12th Lead


– Nikus, J Electrocardiology 2008

– Kosuge, Am J Cardiol 2011 (clopidogrel)


12th Lead


– Nikus, Pahlm, Wagner, et al. J Electrocard 2010

• Electrocardiographic classification of acute coronary syndromes: a review by a committee of the International Society for Holter and Non-Invasive Electrocardiology

• (pages 93, 97-98)


12th Lead


– Nikus, Pahlm, Wagner, et al. J Electrocard 2011

• Report of the third International Society for Holter and Non-invasive Electrocardiology working group on improved electrocardiographic criteria for acute and chronic ischemic heart disease

• (page 85)


12th Lead


– Wagner, Macfarlane, Wellens, etc., Circulation and JACC 2009

• AHA/ACCF/HRS Recommendations for the Standardization and Interpretation of the ECG: Part VI: Acute Ischemia/Infarction: A Scientific Statement From…

• (Circ page e266; JACC p1007)


12th Lead

• Most recent

– Taglieri, Am J Cardiol 2011 (clopidogrel)

– Hennings, Am J Emerg Med 2012

“A New Electrocardiographic Criteria for Emergent Reperfusion Therapy”

• High mortality without immediate PCI

• Medical therapy (including lytics) does not appear to improve mortality

• Emergent PCI may decrease mortality significantly

– Time delay to PCI is the only predictor of survival

• Immediate transfer for PCI if necessary!


70 yo man with palpitations…?

SVT, VR 200

STE aVR LMCA stenosis

• Only apply this rule when you see ischemic STs elsewhere in the ECG

– Doesn’t apply to SVTs (ST changes are common with SVTs, no clinical relevance)

– Doesn’t apply to asymptomatic patients without ischemia

• Note: can be normal in LBBB and also severe LVH (discordant STE)

Takehome points

Studies in AMI/ACS show…

– STE in both aVR and aVL LMCA stenosis

– STE in aVR > STE in V1 LMCA stenosis

These patients have better outcomes with PCI (PTCA, stent, or CABG)\

Now treat aggressively

Future STEMI equivalent (CLA)?

STE aVR LMCA stenosis

Summary

• TN…means little in isolation



• Beware atypical presentations in women

• New LBBB + CP ≠ AMI unless…

• PE often mimics ACS with TWIs

• STE in aVR educate your consultants


Thanks! Lectures.umem.org/Mattu

questions? [email protected]

best of the best in cardiology - chairman's welcome ... · department of emergency medicine...

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