Chief Complaint: Chest Pain - POMA 2019
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Chief Complaint: Chest
Pain
POMA 2019
Chris Morgan, DO FACC
Interventional Cardiology
Heritage Valley Health System
Beaver, PA
#POMAD8
#ChoosePOMA
1
Disclosures
• None
#POMAD8
#ChoosePOMA
2
Outline
• Overview of chest pain
• Etiologies
• Obtaining a history
• Physical exam
• Workup
• Testing
#POMAD8
#ChoosePOMA
3
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 1
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Overview
• Chest pain is one of the most common reasons for patients
seeking care in the ambulatory and emergency settings
• Accounts for roughly 8 million ER visits annually in the United
States
• Typically treated as ACS but only 15-20% of patients actually
have ACS, 10% have stable angina
• 1/3-1/2 of patients have musculoskeletal pain, 10-20% have
gastrointestinal pain, 5% have respiratory issues
• Diagnosis of ACS estimated to be missed in 2% of patients
• Must be a balance between cost and appropriate workup based
on risk and expected results
#POMAD8
#ChoosePOMA
4
Meet Our Patients
• Mrs. Jones
– 51 year old female with diet controlled HTN, positive
family history of CAD, not premature
– Runs 2-3 miles per day
– Works in an accounting office
• Mr. Smith
– 41 year old male with no prior history/family history,
takes no medications
– Works out daily including 3 miles of cardio and weight
training
#POMAD8
#ChoosePOMA
5
Acute Coronary Syndrome (ACS)
• Consists of ST elevation myocardial
infarction (STEMI), non-ST elevation
myocardial infarction (NSTEMI), and
unstable angina (UA)
• Different spectrum from differentiating
types of chest pain
#POMAD8
#ChoosePOMA
6
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 2
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Debunking
• Myth #1: positive troponin = NSTEMI/ACS
• Myth #2: chest pain = ACS
• Myth #3: positive troponin = heparin drip
#POMAD8
#ChoosePOMA
7
Definitions of Chest Pain/Angina
• Typical chest pain – 1) heavy chest pressure
or squeezing, burning feeling or difficulty
breathing, 2) increases with exertion or
stress, 3) relief with nitroglycerin or rest
• All 3 present to be classified as typical
• 1-2 present for atypical
• 0 present for noncardiac
#POMAD8
#ChoosePOMA
8
Anginal Equivalents
• Some patients present with jaw pain,
epigastric pain, shoulder pain, nausea,
dyspnea
• Women, older patients, and diabetics may
have more atypical presentations
#POMAD8
#ChoosePOMA
9
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 3
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Nerves
• Visceral
– Enter spinal cords at several levels leading to
poor localization
– Includes heart, blood vessels, esophagus,
visceral pleura
• Parietal
– Able to localize stimulus such as pain
– Includes dermis and parietal pleura
#POMAD8
#ChoosePOMA
10
Defining pain
• Pleuritic – sharp pain worsened with breathing
movement or coughing
• Epigastric – primary or sole location in the
middle or lower abdominal region
• Musculoskeletal – pain reproducible with
movement or palpation in specific locations
• Other factors include constant pain (hours to
days) and very brief episodes of pain (seconds)
#POMAD8
#ChoosePOMA
11
Risk Table
Nonanginal Atypical Typical
Age Men Women Men Women Men Women
30-39 Very Low Very Low Intermediate Very Low Intermediate Intermediate
40-49 Intermediate Very Low Intermediate Low High Intermediate
50-59 Intermediate Low Intermediate Intermediate High Intermediate
≥60 Intermediate Intermediate Intermediate Intermediate High High
#POMAD8
#ChoosePOMA
12
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 4
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
HIGH LIKELIHOOD INTERMEDIATE LIKELIHOOD LOW LIKELIHOOD
FEATURE Absence of High- or
Absence of High-Likelihood
Intermediate-Likelihood
Any of the Following Features and Presence of Any
Features but May Have Any of
of the Following
the Following
1.•
1.•
2.Chest or left arm pain or 1.•
2.Chest or left arm pain or
discomfort as the chief symptom 2.Probable ischemic symptoms in
discomfort as the chief symptom
3.• the absence of any of the
reproducing documented
History 4.Age >70 yr intermediate- likelihood
previous angina
5.• characteristics
3.•
6.Male sex 3.•
4.Known history of coronary
7.• 4.Recent cocaine use
artery disease, including MI
8.Diabetes mellitus
1.•
2.Transient mitral regurgitation 1.•
1.•
Examination murmur, hypotension, 2.Chest discomfort reproduced by
2.Extracardiac vascular disease
diaphoresis, pulmonary edema, palpation
or rales
1.• 1.• 1.•
2.New or presumably new 2.Fixed Q waves 2.T wave flattening or inversion
transient ST-segment deviation 3.• 0.1 mV 4.Normal ECG
1.•
1.• 1.•
#POMAD8
Cardiac markers 2.Elevated cardiac cTnI, cTnT, or
2.Normal 2.Normal #ChoosePOMA
CK-MB
13
Nonischemic Cardiovascular Psychiatric
Aortic dissection* Affective disorders (ex. Depression)
Myocarditis Anxiety disorders
Pericarditis Somatoform disorders
Thought disorders (ex fixed delusions)
Gastrointestinal
Biliary Chest Wall
Cholangitis Cervical disc disease
Cholecystitis Costochondritis
Choledocholithiasis Fibrositis
Colic Herpes zoster (shingles)
Esophageal Neuropathic pain
Esophagitis Rib fracture
Spasm Sternoclavicular arthritis
Reflux Pulmonary
Rupture* Pleuritis
Pancreatitis Pneumonia
Peptic ulcer disease Pulmonary embolus* #POMAD8
Nonperforating or perforating* Tension pneumothorax* #ChoosePOMA
14
Pericarditis
• Visceral and most of parietal pericardium is insensitive
to pain
• Pain occurs due to involvement of the pleura
• Pain usually occurs while changing position, breathing
(especially deep) and coughing
• Can cause substernal pain mimicking MI
• Central diaphragm involvement manifests as pain in
shoulders and neck
• More lateral diaphragm involvement manifests as pain
in the upper abdomen and back
#POMAD8
#ChoosePOMA
15
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 5
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Acute Aortic Dissection
• Sudden onset of excruciating ripping pain
• Location depends on initiation site and direction of
dissection
– Ascending dissection – anterior chest pain
– Descending dissection – posterior chest/back pain
• Overall, fairly rare
• Tend to occur with risk factors such as pregnancy
(ascending), HTN (descending), collagen vascular
disease (CVD; ie Marfan, ED), bicuspid aortic valve
#POMAD8
#ChoosePOMA
16
Aortic Dissection
#POMAD8
#ChoosePOMA
17
Pulmonary Embolism
• Sudden onset dyspnea and pleuritic chest pain
• Incidence is 1/1000, likely underestimate as some are
asymptomatic
• Massive PE can cause severe substernal chest pain
due to distension of the PA
• Smaller emboli tend to cause pulmonary infarction
and irritation of the pleura
• Hemodynamically significant emboli can cause
hypotension, syncope and right heart failure
#POMAD8
#ChoosePOMA
18
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 6
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
PE
#POMAD8
#ChoosePOMA
19
Pulmonary Etiologies
• Usually produce dyspnea and pleuritic symptoms
• Location typically reflects site of disease
• Pneumonia can cause pain over the involved lung
• Pneumothorax usually sudden onset associated with
dyspnea
– Primary occurs in tall, thin, young men
– Secondary can occur in COPD, asthma, CF
• Asthma exacerbations can cause chest tightness
#POMAD8
#ChoosePOMA
20
Pneumothorax
#POMAD8
#ChoosePOMA
21
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 7
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Gastrointestinal Etiologies
• GERD – one of the most common mimickers of chest
pain
– Exacerbated by alcohol, aspirin and foods
– Usually worse when recumbent
– Relieved when sitting up or use of H2 blockers/PPIs
• Esophageal spasm – can improve with nitroglycerin
• Mallory-Weiss tears/Boerhaave syndrome – can occur
with prolonged vomiting
• PUD – onset usually 60-90 minutes after eating and
rapidly responds to acid-reducing therapy; usually
epigastric
• Pancreatitis – epigastric with radiation to back
• Cholecystitis – crampy, colicky pain in RUQ
#POMAD8
#ChoosePOMA
22
“The Others”
• Musculoskeletal etiologies
– Costochondritis
– Herpes zoster (shingles)
– Heavy exercise or labor
• Psychiatric etiologies
– Panic or anxiety disorders
– Brought on by stress or environmental triggers
#POMAD8
#ChoosePOMA
23
Meet Our Patients
• Mrs. Jones
– Has complained of off and on pain in the chest for about 3
weeks
– No exacerbating or remitting factors
– Has not gotten worse
• Mr. Smith
– Has complained of pain since this morning
– Started as he walked back up the driveway in subzero
temperatures after getting the newspaper
– Went away as he sat down to read the paper
– Wife made him come in
#POMAD8
#ChoosePOMA
24
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 8
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Evaluation
• Usually begins prior to seeing the physician/extender
• Triage of great importance either over the phone or in
ED setting
• ACC/AHA suggests immediate assessment in patients
with
– Chest pain
– Persistent dyspnea
– Persistent heartburn
– Pain radiating to jaw, back, shoulder
– Syncope
#POMAD8
#ChoosePOMA
25
Initial Evaluation
• Clinical stability
• Immediate prognosis
• Safety of triage options
#POMAD8
#ChoosePOMA
26
History taking
• Define their chest pain
– Onset
– Location
– Quality
– Duration
– Radiation
– Exacerbating factors
– Remitting factors
– Associated symptoms
• Have they ever had anything like this before?
– History tends to repeat itself
#POMAD8
#ChoosePOMA
27
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 9
“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Risk Factors
• Smoking
• Hypertension
• Hyperlipidemia
• Lack of physical activity
• Diets high in fat and salt
• Abdominal obesity
• Family history of premature CAD (prior to age 55 in
males and 65 in females)
• Previous diagnosis of CAD or PAD
#POMAD8
#ChoosePOMA
28
Physical Exam
• General appearance
• Vital signs
– Blood pressure
– Heart rate
– Respiratory rate
• Heart and lung exam
• Assess for signs of extracardiac vascular disease
– Carotid bruit
– Peripheral pulses
#POMAD8
#ChoosePOMA
29
Vitals
• Blood pressure
– Hypertension – may elude to presence of dissection
– Hypotension – may represent right sided heart failure due to RV
infarct from MI or failure from PE
– Discrepancy – aortic dissection
• Heart rate
– Tachycardia – may represent presence of shock/underfilled state;
includes arrhythmia
– Bradycardia – seen in inferior MIs
• Respiratory rate
– Tachypnea – sign of heart failure or due to PE
#POMAD8
#ChoosePOMA
30
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 10“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Heart Exam
• Presence of systolic murmur
• Can represent new mitral regurgitation in MI involving
the posterior descending branch of the dominant
coronary artery
– Single blood supply makes it more prone to rupture during
infarction
• Murmur can also represent ventricular septal rupture
• Echocardiography and right heart catheterization can
differentiate
#POMAD8
#ChoosePOMA
31
Heart Exam
• Diastolic murmur – aortic insufficiency due to
aortic dissection
• Accentuated P2 – PE due to increased
pulmonary artery pressure
• Friction rub – pericarditis
– Post MI rub typically occurs >2 weeks post MI
• Muffled heart sounds
– Pericardial effusion – primary or due to dissection
#POMAD8
#ChoosePOMA
32
Lung Exam
• Rales
– Bilateral may represent heart failure
– Unilateral may represent severe mitral
regurgitation
• Absent breath sounds – pneumothorax
• Deep breaths – evaluate for pleuritic pain
#POMAD8
#ChoosePOMA
33
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 11“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
ECG
• Fastest test to rule out overt ACS (STEMI)
• Those with unstable angina may have a
normal ECG
• 1-5% of patients may have a normal ECG
upon presentation which may progress
during the ER workup
• Recommended to obtain within 10 minutes
of hospital arrival
• Pre-hospital ECG very beneficial
#POMAD8
#ChoosePOMA
34
Value of ECG Findings
ECG Finding
New ST elevation ≥1 mm
New Q wave
Any ST elevation
New conduction defect
New ST depression
Any Q wave
Any ST depression
T wave peaking and/or
Inversion ≥1 mm
New T wave inversion
Any conduction defect
#POMAD8
#ChoosePOMA
35
ECG
• ST elevation
– 1 mm in all leads except V2 and V3
– V2 and V3 – 2 mm in men ≥40, 2.5 mm in men“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
ECG
• Dynamic ST changes
– Changes occurring during active episodes of
chest pain but resolving when pain abates have
high predictive value
• Tachycardia
• S1 Q3 T3 – most commonly cited ECG
manifestation in PE
– RBBB, rightward axis, T wave inversions V1-4
#POMAD8
#ChoosePOMA
37
ECG
• Diffuse ST elevation – pericarditis
– Usually has some degree of PR depression
• LBBB no longer considered a STEMI
equivalent
– Studies show that less than ½ of patients with
suspected MI and LBBB actually have an MI
– 2004 guidelines updated in 2013
• Compare to prior!!
#POMAD8
#ChoosePOMA
38
#POMAD8
#ChoosePOMA
39
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 13“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
#POMAD8
#ChoosePOMA
40
#POMAD8
#ChoosePOMA
41
#POMAD8
#ChoosePOMA
42
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 14“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
#POMAD8
#ChoosePOMA
43
#POMAD8
#ChoosePOMA
44
Chest X-ray
• Can show pneumothorax
• Presence of pulmonary edema – heart
failure
• Look for widened mediastinum – aortic
dissection
• Hampton hump/Westermark sign - PE
#POMAD8
#ChoosePOMA
45
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 15“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Biomarkers
• Troponin
– T or I
• Cardiac specific troponin
– cTnT or cTnI
• CK-MB
• Myoglobin
• CRP
• D-dimer
#POMAD8
#ChoosePOMA
46
Marker Initial Rise Peak Return to
Normal
Troponin 2-4 hours 10-24 hours 5-10 days
CK-MB 3-4 hours 10-24 hours 2-4 days
LDH 10 hours 24-72 hours 14 days
#POMAD8
Myoglobin 1-2 hours 4-8 hours 24 hours #ChoosePOMA
47
Troponin
• Evolved over the years
• Prior troponin assays were not specific for
cardiac muscle
• Led to false positive results which, in turn,
led to excess use of resources
• Differentiation between T and I
#POMAD8
#ChoosePOMA
48
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 16“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Cardiac Troponin
• Most sensitive and specific biomarker,
therefore, preferred for cardiac muscle injury
• False positive findings are rare
• Always signifies some sort of myocardial injury
– ACS, defibrillation, myocarditis, myocardial
contusion, tachyarrhythmia, LV/RV strain, HTN
emergency, extreme exercise, transplant rejection,
sepsis
• Cleared more slowly in renal dysfunction
– TnI may be elevated chronically in stage IV/V CKD
#POMAD8
#ChoosePOMA
49
Cardiac Troponin
• Studies based on 12 hour sampling
– >95% sensitive and 90% specific
– Single sample – 70% sensitive & 75% specific
• Further studies have used a second troponin 3 hours
after the initial troponin
– 96% NPV initial, 99% NPV at 3 hours
• JACC Nov, 2018
– Generation 5 cardiac troponin T (cTnT)
– Median time from symptom onset – 10.2 hrs
#POMAD8
#ChoosePOMA
50
REACTION-US
#POMAD8
#ChoosePOMA
51
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 17“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
High Sensitivity cTnT (hs-cTnT)
• JACC Nov. 2018
• Sub-analysis of PROMISE trial
– Primarily looked at coronary CTA in low to
intermediate risk patients with chest pain
• 1800 symptomatic ambulatory patients
• Found that higher levels of hs-cTnT correlated
with higher likelihood of coronary calcification
as well as more diffuse and obstructive CAD
#POMAD8
#ChoosePOMA
52
High Sensitivity cTnT (hs-cTnT)
• Earlier study investigated hs-cTnT levels in
patients who ruled in for NSTEMI/UA
– NSTEMI - 72% had baseline levels above the
99th percentile, 28% had levels above the limit
of detection at baseline
– UA – 44% had baseline levels above the 99th
percentile, 52% had levels above the limit of
detection at baseline
Can correlate better with burden of ischemia
#POMAD8
#ChoosePOMA
53
ED Setting
• ¼ of patients had undetectable levels with
100% NPV
• High-sensitivity assays are more
quantifiable and may allow for better triage
of chest pain patients
• Significance of lower levels will need to be
defined for future use
• Mainly used in Europe at this time
#POMAD8
#ChoosePOMA
54
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 18“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
• Retrospective sub-analysis of TOTAL-AMI
– Goal is to study the mechanisms and
implications of different subtypes of MI and
comorbidities
• Excluded patients with planned admissions,
MI within 8 weeks, missing information,
and patients who had coronary intervention
#POMAD8
#ChoosePOMA
55
• If your troponin was elevated, your risk for
future events was higher
• As troponin rises, risk also rises
• Comorbidities added to risk of MAE
– Lower BMI, diabetes, renal dysfunction, COPD,
previous CV disease, malignancies
• Don’t write non-ACS patient’s off
• Plan for close follow up from the ER
#POMAD8
#ChoosePOMA
56
#POMAD8
#ChoosePOMA
57
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 19“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Creatine Kinase (CK)
• CK is not specific to cardiac muscle
– Found in skeletal muscle, tongue, diaphragm, small
intestine, uterus and prostate
• CK-MB was the biomarker of choice prior to
troponin assays
• Used as a ratio of CK-MB to CK
– Factors in the skeletal muscle component of CK
– Disadvantage – CK-MB present in skeletal muscle in
conditions such as muscular dystrophy, high
performance athletics, rhabdomyolysis
#POMAD8
#ChoosePOMA
58
Creatine Kinase (CK)
• Elevations common in ED patients due to
higher use of alcohol and trauma
• Shorter half-life in circulation
– Allows for gauging timing of MI, new or
recurrence
• Used less frequently at this point
#POMAD8
#ChoosePOMA
59
Other Markers
• Myoglobin
– Smaller size molecule allowing for more rapid
clearing
– Non-specific to cardiac tissue
• C-reactive protein (CRP)
– Also non-specific and elevated in a variety of
medical conditions
– May be some implication for high sensitivity
CRP (hsCRP) in the future
#POMAD8
#ChoosePOMA
60
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 20“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Other Markers
• Ischemia-modified albumin (IMA)
– Reduced cobalt binding in the setting of ischemia
– JACC 2013 – study examined use of IMA prior to
angiography to gauge severity of CAD
– Use still remains unclear
• D-dimer
– >99% NPV for PE in low risk patient; high risk
patient should consider imaging
– 96% NPV for aortic dissection
#POMAD8
#ChoosePOMA
61
Other Markers
• B-type natriuretic peptides (BNP and N-
terminal pro-BNP
– Released in the setting of increased ventricular
wall stress
– Can rise in setting of transient myocardial
ischemia as well
– Increased levels during ACS correlates with
worse prognosis
#POMAD8
#ChoosePOMA
62
Emerging Biomarkers
Growth differentiation factor-15 TGF-beta cytokine released from cardiomyocytes after
ischemia and reperfusion injury
Heart-type fatty acid-binding protein Cytoplasmic protein involved in intracellular uptake and
buffering of free fatty acids in myocardium
Myeloperoxidase Hemeprotein released during degranulation of
neutrophils and some monocytes
Pregnancy-associated plasma protein A Matrix metalloproteinase abundantly expressed in eroded
and ruptured plaque but absent in stable plaque
Placental growth factor VEGF member that is strongly upregulated in
plaques/primary inflammatory instigator of plaque
instability
Secretory phospholipase A2 Hydrolyzes phospholipids to generate lysophospholipids
and fatty acids
Interleukin-6 Stimulator of hepatic synthesis of CRP
Chemokine ligand-5 and ligand-18 Mediators of monocyte recruitment induced by ischemia
#POMAD8
#ChoosePOMA
63
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 21“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Next step
• Do our patients need to be managed in the
outpatient/ED/inpatient settings?
#POMAD8
#ChoosePOMA
64
#POMAD8
#ChoosePOMA
65
#POMAD8
#ChoosePOMA
66
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 22“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Developed a decade
ago in the
Netherlands
Proven to be a safe
way to triage chest
pain in the ER
setting
#POMAD8
#ChoosePOMA
67
Outpatient management
• Echocardiography
• Stress testing
– Exercise only testing
– Exercise or pharmacologic testing with echo or
nuclear imaging
• Computed tomography (CT)
– Calcium score
– Cardiac CTA
#POMAD8
#ChoosePOMA
68
Ischemic Cascade
#POMAD8
#ChoosePOMA
69
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 23“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Echocardiography
• Assess for systolic and diastolic dysfunction
• Assess for pericardial
effusion/enhancement
• Assess valvular function
• Ancillary findings such as pleural
effusion/aortic dilatation
#POMAD8
#ChoosePOMA
70
Stress Testing Modalities
Stress testing
Echo
Non-imaging Imaging CT-PET
Nuclear
Exercise Exercise
Regadenoson
Adenosine
Dobutamine #POMAD8
#ChoosePOMA
71
Stress Echo
• Very good specificity
• Exercise or dobutamine
• Almost always approved by insurance
• No radiation
#POMAD8
#ChoosePOMA
72
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 24“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Stress Echo
#POMAD8
#ChoosePOMA
73
Cath
#POMAD8
#ChoosePOMA
74
Nuclear Stress
• Exercise
– Coronary dilatation at 2-3x normal
– Allows assessment of functional capacity, heart
rate and blood pressure response and electrical
changes
• Pharmacological
– Allows for maximum coronary dilatation at 4-
6x normal
– Side effects from vasodilator agents
#POMAD8
#ChoosePOMA
75
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 25“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Nuclear Stress
#POMAD8
#ChoosePOMA
76
Coronary Calcium Score
• Typically used in asymptomatic, lower risk patients
• Detects stable plaques which contain diffuse amounts of calcium
• Interpretation based on age, sex, ethnicity, and standard cardiac risk
factors
• Increased risk for CAD
– 2-fold for scores up to 100
– 11-fold for scores over 1000
• Appropriate use criteria support the use in patients with:
– Intermediate level of CHD risk (10% to 20% over 10 years)
– Young patients with a low to intermediate risk (6% to 10% over 10 years)
– Low-risk patients with a family history of premature CHD
#POMAD8
#ChoosePOMA
77
Cardiac CTA
• Can be used to rapidly assess for ACS or
unstable plaque at risk for rupture
– Positive vessel remodeling
– Low-attenuation plaque with high lipid content
• Sensitivity of 87% to 99% and specificity of
93% to 96%
• Improved since initial trials with use of dual-
sources and retrospective gating
#POMAD8
#ChoosePOMA
78
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 26“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Cardiac CTA
• PROMISE trial – CTA (anatomical testing)
equivocal to functional testing in low to
intermediate risk patients
• Optimal test for low to intermediate risk patients
– Low calcium burden
• Assessment for patency of bypass grafts
– Minimal motion
– Large size
#POMAD8
#ChoosePOMA
79
What do we do with our patients??
• Mrs. Jones
• Mr. Smith
#POMAD8
Name Of Presentation Page: 80
#ChoosePOMA
80
Teasing It All Out
• Sudden onset and severe
– ACS, PE, aortic dissection, pneumothorax
• Pleuritic pain
– PE, pericarditis, pneumothorax, MSK
• Improved with nitroglycerin
– ACS, esophageal spasm
• Patients with low probability of ACS should have as little
workup as safely possible to avoid unnecessary tests,
hospitalizations, procedures, and complications
#POMAD8
#ChoosePOMA
81
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 27“Chief Complaint: Chest Pain”
Christopher M. Morgan, DO
Questions?
#POMAD8
#ChoosePOMA
82
POMA District VIII 32nd Annual Educational Winter Seminar
January 31-February 3, 2019 28You can also read
