This is a Short and Sweet Title

Falling through the cracks?Expanding our approach to acute coronary syndromes012-0400-PM 5/151012-0400-PM 5/15Frank Peacock, MD, FACEPProfessor, Emergency Medicine Associate Chair and Research Director Baylor College of MedicineOur presentersManuel Cerqueira, MD, FACC, FAHA, MASNCProfessor of Radiology and MedicineCleveland Clinic Lerner College of Medicine of Case Western Reserve UniversityChairman, Department of Nuclear Medicine,Imaging Institute Staff Cardiologist, Heart and Vascular Institute Cleveland Clinic012-0400-PM 5/152012-0400-PM 5/15Frank Peacock, MD, FACEP

Advisory boardAstellas PharmaSpeakers bureauAstellas Pharma

Disclosures012-0400-PM 5/153012-0400-PM 5/15DisclosuresManuel Cerqueira, MD, FACC, FAHA, MASNC

Advisory boardAstellas PharmaAdenosine TherapeuticsFluoroPharmaSpeakers bureauAstellas PharmaGE Healthcare

012-0400-PM 5/154012-0400-PM 5/15This is a nonproduct-related programNo specific products will be discussed and no product-related questions will be answeredImportant information012-0400-PM 5/155012-0400-PM 5/15

Have you seen Jane?012-0400-PM 5/15012-0400-PM 5/156Have you seen Jane?012-0400-PM 5/15

47 years old Comes in vomiting at 7 PMShe may have eaten some bad tunaJane presents to your emergency department (ED)012-0400-PM 5/15012-0400-PM 5/15Jane Presents to Your EDShes 47 years old She comes in vomiting at 7 PM She may have eaten some bad tuna at dinner

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Assessment of electrolytes and complete blood countECG completely normalGets an IV4 mg ondansetron1 liter normal saline4 hours later (11 PM), Jane feels betterDiagnosis: food poisoningShes discharged homeShe undergoes the usual testing 012-0400-PM 5/15012-0400-PM 5/15She Undergoes the Usual TestingAssessment of electrolytes and complete blood countECG completely normalGets an IV4 mg ondansetron1 liter normal saline4 hours later (11 PM), patient feels betterDiagnosis: food poisoningShes discharged home

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At 6 AM, Jane collapses, 911 is calledParamedics arrive within 4 minutes Jane is found in ventricular tachycardia and defibrillated17 minutes after arrest, she returns to normal sinus rhythm But a few hours later, she gets worse012-0400-PM 5/15But a Few Hours Later, She Gets Worse At 6 AM, she collapses, and 911 is called Paramedics arrive within 4 minutes She is found in ventricular tachycardia and defibrillated 17 minutes after arrest, she returns to normal sinus rhythm

9012-0400-PM 5/15Prehospital ECG transmittedJane is taken straight to cath labDoor-to-balloon time: 27 minutesShes rushed back to the hospital

012-0400-PM 5/15Shes Rushed Back to the HospitalPrehospital ECG transmittedShes taken straight to the cath labDoor-to-balloon time: 27 minutes

10012-0400-PM 5/15But its too little too late

Jane does not survive 012-0400-PM 5/15But its too little too lateJane does not survive 11012-0400-PM 5/15We can do moreJane received relatively standard evaluation But we missed Janes ACS because: She didnt report chest pain Her ECG was normalHow should we work up patients who present to the ED with possible ACS?

012-0400-PM 5/15We Can Do MoreJane received relatively standard evaluation But we missed Janes ACS because: She didnt report chest pain Her ECG was normalHow should we work up patients who present to the ED with possible ACS?

12012-0400-PM 5/15Lets take a look atChest pain and ECGRisk stratification tools in the EDBiomarker testing in the EDMyocardial perfusion imaging (MPI) and the EDMPI case studies

012-0400-PM 5/15Lets take a look atChest pain and ECGRisk stratification tools in the EDBiomarker testing in the EDMyocardial perfusion imaging (MPI) and the EDMPI case studies13012-0400-PM 5/15Audience responseWhat is your current role at your facility?Choose all that apply.Nurse Manager/DirectorMedical DirectorEmergency PhysicianHigh-level AdministratorCardiologistHospitalistCardiovascular Coordinator/Service Line AdministratorPhysicians AssistantNurse Practitioner012-0400-PM 5/15Audience ResponseWhat is your current role at your facility? Choose all that apply.Nurse Manager/DirectorMedical DirectorEmergency PhysicianHigh-level AdministratorCardiologistHospitalistCardiovascular Coordinator/Service Line AdministratorPhysicians AssistantNurse Practitioner

14012-0400-PM 5/15Chest pain and ECG012-0400-PM 5/1515012-0400-PM 5/15AHA statement on chest pain testing Adapted from Amsterdam EA, et al. Circulation 2010;122:1756-1776.SYMPTOMS SUGGESTIVE OF ACUTE CORONARY SYNDROME (ACS)Noncardiac diagnosisTreatment as indicated by alternative diagnosisChronic stable anginaSee ACC/AHA Guidelines for Chronic Stable AnginaPossible ACS Definite ACSSee ACC/AHA Guidelines for Non-ST Elevation ACS See ACC/AHA Guidelines for ST Elevation Acute Myocardial InfarctionNondiagnostic ECG Normal initial cardiac markers Observe Serial ECGs, cardiac markersConsider MPI to identify rest ischemiaOutpatient follow-up Admit to hospital IF NEGATIVEIF POSITIVEIF NEGATIVEIF POSITIVEIF POSITIVEIF NEGATIVEStudy to provoke ischemia or detect anatomic CAD012-0400-PM 5/15AHA Statement on Chest Pain TestingHeres the flowchart from the AHA statement on testing low-risk patients who come into your facility with chest pain

ReferenceAmsterdam EA, et al. Circulation 2010;122:1756-1776.

16012-0400-PM 5/15Risk factors1:Age 65 years3 risk factors for CADSignificant coronary stenosis (eg, prior 50%)ST-segment deviation on ECGSevere angina (eg, 2 angina events in previous 24 hours)Use of ASA in last 7 daysElevated serum cardiac markers CK-MB or troponinTIMI risk score: 2-week MACEMACE = major adverse cardiac event.1. Antman EM, et al. JAMA 2000;284:835-842.THROMBOSIS IN MYOCARDIAL INFARCTION Each risk factor is assigned 1 point, and the total represents a given patients TIMI Risk Score1 Event rates (all-cause mortality, MI, or urgent revascularization) increase with each 1-point increase in score (P100-500500-10001000-2500>2500BNP, pg/mL012-0400-PM 5/15Risk-Adjusted Acute In-Hospital Mortality by BNPThe CRUSADE database shows that risk-adjusted mortality rates increased for each BNP group compared with BNP 1001

ReferencePeacock F. Rev Cardiovasc Med 2010;11:S45-S50.

32012-0400-PM 5/15Troponin and BNP vs in-hospital mortality*Troponin upper limit of normal (ULN) ratio (to standardize results across hospitals) = troponin results/hospital ULN. 1. Peacock F. Rev Cardiovasc Med 2010;11(suppl 2):S45-S50.TROPONIN BY ULN RATIO*100-500>25001000-2000500-1000>100ULN 10BNP was a better predictor of in-hospital mortality than troponin1

BNP, pg/mL012-0400-PM 5/15Troponin and BNP vs In-Hospital MortalityThe CRUSADE database shows that BNP was a better predictor of in-hospital mortality than troponin, and the increase in mortality associated with increasing the absolute marker value was greater for BNP than troponin11.1% to 17.2% mortality from the lowest to highest BNP vs 4.5% to 8.2% from lowest to highest Tn ratio

Reference1. Peacock F. Rev Cardiovasc Med 2010;11(suppl 2):S45-S50.

33012-0400-PM 5/15Accelerated diagnostic ED protocolsACS ruled out = dischargeRequires urgent treatment = admitNondiagnostic findingsConfirmatory testing to exclude ischemiaeg, exercise ECG, MPI, echocardiographyInability to exercise, baseline ECG abnormalities, or uninterpretable ECG = imaging testYour patient has possible ACSnow what?11. Amsterdam EA, et al. Circulation 2010;122:1756-1776. 012-0400-PM 5/15Your patient has possible ACSnow what?1Youve run your accelerated ED protocols to figure out who can be safely discharged and who requires admission for treatmentWhat about the patient whose findings are nondiagnostic?According to the AHA, patients with a nondiagnostic workup should be referred for confirmatory testing with exercise ECG or cardiac imaging with a modality such as MPI or echocardiographyExercise ECG criteria are the patients ability to exercise and a normal baseline ECG that allows interpretation of exercise-induced ST-segment changesIf the patient doesnt meet these criteria, an imaging test can be ordered with or without stress

Reference1. Amsterdam EA, et al. Circulation 2010;122:1756-1776.

34012-0400-PM 5/15What cardiac testing modality do you use most at your facility for chest pain patients?Exercise ECG Stress TestingStress EchocardiographyMyocardial Perfusion ImagingCardiac CT AngiographyCardiac Magnetic Resonance ImagingCalcium ScoringInvasive Coronary AngiographyAudience response012-0400-PM 5/15Audience ResponseWhat cardiac testing modality do you use most at your facility for chest pain patients?Exercise ECG Stress TestingStress EchocardiographyMyocardial Perfusion ImagingCardiac CT AngiographyCardiac Magnetic Resonance ImagingCalcium ScoringInvasive Coronary Angiography

35012-0400-PM 5/15MPI and the ED012-0400-PM 5/1536MPI and the EDLets take a look at MPI for confirmatory testing012-0400-PM 5/15Sample MPI protocols1. Amsterdam EA, et al. Circulation 2010;122:1756-1776.

Patient with chest pain routed to the observation unit/chest pain unitMay be referred for an MPI by the consulting cardiologist or ED physicianTiming of MPI might be affected by the patients symptoms and stability or the availability of the camera or staff1

012-0400-PM 5/15Sample MPI ProtocolsPatient with chest pain routed to the observation unit/chest pain unit May be referred for an MPI by the consulting cardiologist or ED physicianTiming of MPI might be affected by the patients symptoms and stability or the availability of the camera or staff1

ReferenceAmsterdam EA, et al. Circulation 2010;122:1756-1776.

37012-0400-PM 5/15Acute rest MPI1: Patient is injected with radiotracer while still experiencing symptoms; imaging delayed until after stabilization Normal images may allow patient to be discharged with instructions for appropriate follow-up In a retrospective analysis, 4145 patients evaluated in the ED chest pain unit who underwent a stress-only SPECT MPI (n=2340) were compared to those who underwent rest-stress studies (n=1805) during the same time2The average age was 57.9 years, 38.5% male, and most had an intermediate or low pretest risk of CAD (87.7%) with an average follow-up of 35.920.9 months11 deaths occurred in the stress-only group (0.5%) at 1 year follow-up compared to 13 deaths in the rest-stress group (1.1%)Sample MPI protocols (cont.)1. Amsterdam EA, et al. Circulation 2010;122:1756-1776. 2. Duvall WL, et al. J Emerg Med 2012;42:642-650. 012-0400-PM 5/15Sample MPI Protocols (cont.)Acute rest MPI1: Patient is injected with radiotracer while still experiencing symptoms; imaging delayed until after stabilization Normal images may allow patient to be discharged with instructions for appropriate follow-up In a retrospective analysis, 4145 patients evaluated in the ED chest pain unit who underwent a stress-only SPECT MPI (n=2340) were compared to those who underwent rest-stress studies (n=1805) during the same time2Acute rest MPI1: The average age was 57.9 years, 38.5% male, and most had an intermediate or low pretest risk of CAD (87.7%) with an average follow-up of 35.920.9 months11 deaths occurred in the stress-only group (0.5%) at 1 year follow-up compared to 13 deaths in the rest-stress group (1.1%)

ReferencesAmsterdam EA, et al. Circulation 2010;122:1756-1776. Duvall WL, et al. J Emerg Med 2012;42:642-650. 38012-0400-PM 5/15Information needs to be conveyed as quickly as possibleDirect phone callElectronic medical recordCall medical professional immediately to discuss test results and document conversationDecision to admit or discharge is made by consulting cardiologist/hospitalist or attending physicians ED and nuclear lab communication 012-0400-PM 5/15ED and Nuclear Lab CommunicationInformation needs to be conveyed as quickly as possibleDirect phone callElectronic medical recordCall medical professional and document conversationDecision to admit or discharge is made by consulting cardiologist/hospitalist or attending physicians

39012-0400-PM 5/15What do you think is the most important limitation of MPI in chest pain protocols?Unfamiliarity of MPI by ED physicianOther tests more readily availableRadiation exposureLogistical challengeseg, time of day, location of nuclear lab, staff availabilityOtherAudience response012-0400-PM 5/15Audience ResponseWhat do you think is the most important limitation of MPI in chest pain protocols?Unfamiliarity of MPI by ED physicianOther tests more readily availableRadiation exposureLogistical challengeseg, time of day, location of nuclear lab, staff availabilityOther40012-0400-PM 5/15MPI case study 1Chest pain in patient with abnormal baseline ECGCase study of MD Cerqueira, MD

012-0400-PM 5/1541MPI Case StudyLets take a look at a case study of a chest pain patient with an abnormal baseline ECG012-0400-PM 5/1549-year-old man seen in the ED after 2 days of intermittent chest pain unrelated to effortCardiac risk factorsHypertensionHyperlipidemia but on no medicationsDiabetes mellitusNo prior cardiac evaluationCurrent medicationsASA dailyBeta-blockerPatient historyCase study of MD Cerqueira, MDMPI case study 1012-0400-PM 5/1542MPI Case Study 1: Patient History49-year-old man seen in the ED after 2 days of intermittent chest pain unrelated to effortCardiac risk factorsHypertension (on beta-blocker)Hyperlipidemia but on no medicationsDiabetes mellitusNo prior cardiac evaluationCurrent medicationsTakes ASA dailyTakes beta-blocker

012-0400-PM 5/15Physical examBP: 142/84 mm HgHR: 75 bpmChest: No tendernessLungs: ClearHeart: No murmursExtremities: No edemaWorkupCase study of MD Cerqueira, MDMPI case study 1012-0400-PM 5/1543MPI Case Study 1: WorkupPhysical examBP: 142/84 mm HgHR: 75 bpmChest: No tendernessLungs: ClearHeart: No murmursExtremities: No edema

012-0400-PM 5/15Baseline ECG showed increased voltage and diffuse T-wave inversions consistent with strain pattern, which had been noted on prior ECGCardiac markers x2 were negative for acute myocardial ischemiaWorkup (cont.)Case study of MD Cerqueira, MDMPI case study 1012-0400-PM 5/1544MPI Case Study 1: Workup (cont.)Baseline ECG showed increased voltage and diffuse T-wave inversions consistent with strain pattern, which had been noted on prior ECGCardiac markers 2 were negative for acute myocardial ischemia

012-0400-PM 5/15Risk factors1:Age 65 years3 risk factors for CADSignificant coronary stenosis (eg, prior 50%)ST-segment deviation on ECGSevere angina (eg, 2 angina events in previous 24 hours)Use of ASA in last 7 daysElevated serum cardiac markers CK-MB or troponinTIMI risk score: 2-week MACEMACE = major adverse cardiac event.1. Antman EM, et al. JAMA 2000;284:835-842.THROMBOSIS IN MYOCARDIAL INFARCTION Each risk factor is assigned 1 point, and the total represents a given patients TIMI Risk Score1 Event rates (all-cause mortality, MI, or urgent revascularization) increase with each 1-point increase in score (P