Chest Pain: New Methods Applied to an Old Problem Amad Zineldine, MD, FACC March 10, 2012.

Chest Pain: New Methods Chest Pain: New Methods Applied to an Old ProblemApplied to an Old Problem

Amad Zineldine, MD, FACCAmad Zineldine, MD, FACC

March 10, 2012March 10, 2012

Chest PainChest Pain

• 2 million hospitalizations annually with cost of 2 million hospitalizations annually with cost of more than $8 billionmore than $8 billion

• Cardiac etiology found in less than one thirdCardiac etiology found in less than one third

• 2% of patients with acute MI are unrecognized and 2% of patients with acute MI are unrecognized and discharged from the EDdischarged from the ED

Chest Pain in the Emergency Chest Pain in the Emergency DepartmentDepartment

• 5 million annual ED visits for chest pain5 million annual ED visits for chest pain

• Treatments for ACS are time sensitiveTreatments for ACS are time sensitive

• About 2-4% of acute MIs are missed in the EDAbout 2-4% of acute MIs are missed in the ED

• Number one cause of ED related malpracticeNumber one cause of ED related malpractice

• Strong bias for admissionStrong bias for admission

GoalsGoals

1.1. Rapid recognition of management of true ACSRapid recognition of management of true ACS

2.2. Recognition of other life-threatening causes of chest Recognition of other life-threatening causes of chest painpain

• Aortic dissectionAortic dissection• Pulmonary embolismPulmonary embolism• Tension pneumothoraxTension pneumothorax

3.3. Minimize cost and hospitalization in patients with Minimize cost and hospitalization in patients with chest pain of benign etiology.chest pain of benign etiology.

Atherothrombosis Timeline

Endothelial DysfunctionEndothelial Dysfunction

From first decade From third decade From fourth decade

Growth mainly by lipid accumulationGrowth mainly by lipid accumulation Thrombosis,Thrombosis,hematomahematoma

Adapted from Stary HC et al. Adapted from Stary HC et al. CirculationCirculation. 1995;92:1355-1374.. 1995;92:1355-1374.

EndothelialEndothelialDysfunctionDysfunction

FattyFattyStreakStreak

IntermediateIntermediateLesionLesion AtheromaAtheroma FibrousFibrous

PlaquePlaqueComplicatedComplicated

Lesion/RuptureLesion/Rupture

MIMI

IschemicIschemicstrokestroke

UnstableUnstableanginaangina

Smooth muscleSmooth muscleand collagenand collagen

Vulnerable Plaque - Vulnerable Plaque - CharacteristicsCharacteristics

• ““Thin-cap fiberoatheroma”Thin-cap fiberoatheroma”

• Mildly stenoticMildly stenotic

• Lipid-rich, necrotic coreLipid-rich, necrotic core

• Thin fibrous capThin fibrous cap

• Presence of inflammatory Presence of inflammatory cellscells

Plaque RupturePlaque Rupture

Chest Pain: Clinical Chest Pain: Clinical DiagnosisDiagnosis

Chest Pain PresentationChest Pain Presentation

Recurrent Recurrent EpisodicEpisodic

AcuteAcute PersisitentPersisitent

MultipleMultiple

EpisodesEpisodes

One One episodeepisode

One One episodeepisode

Minutes Minutes

Pain-freePain-free

Minute-Minute-HoursHours

Pain-freePain-free

Days-WeeksDays-Weeks

Pain-ongoingPain-ongoing

Recurrent Episodic Chest PainRecurrent Episodic Chest PainDifferent DiagnosisDifferent Diagnosis

• AnginaAngina• PericarditisPericarditis• Pulmonary embolism or Pulmonary embolism or

hypertensionhypertension• PleuritisPleuritis• Esophageal reflux, ulcer or spasm Esophageal reflux, ulcer or spasm

cholecystitis, pancreatitischolecystitis, pancreatitis• Cervical disk disease athritisCervical disk disease athritis• CostochondritisCostochondritis• Intercostal muscle crampsIntercostal muscle cramps• Breast diseaseBreast disease• Anxiety attacks Anxiety attacks

Cardiac Cardiac

{{Pulmonary Pulmonary

{{Gastrointestinal Gastrointestinal

{{ Musculoskeletal Musculoskeletal

{{Other Other {{

Cardio Vascular Risk FactorsCardio Vascular Risk Factors

• HypertentionHypertention

• SmokingSmoking

• ObesityObesity

• Physical InactivityPhysical Inactivity

• DyslipidemiaDyslipidemia

• Microalbuminuria or GFR <60 Microalbuminuria or GFR <60

• Age Age

• Family History of Premature CVDFamily History of Premature CVD

Cardiovascular Chest PainCardiovascular Chest Pain

• Coronary Heart DiseaseCoronary Heart Disease– Stable angina pectorisStable angina pectoris– Unstable anginaUnstable angina– Myocardial infarctionMyocardial infarction

• Coronary Vasomotor Coronary Vasomotor DiseaseDisease– Variant anginaVariant angina– Microvascular anginaMicrovascular angina

• PericarditisPericarditis

• MyocarditisMyocarditis

• Valvular Heart DiseaseValvular Heart Disease– Aortic stenosisAortic stenosis– Mitral stenosisMitral stenosis– Hypertrophic Hypertrophic

cardiomyopathycardiomyopathy

• Aortic DissectionAortic Dissection

• Post-pericardiotomyPost-pericardiotomy

Recurrent Episodic Chest PainRecurrent Episodic Chest Pain

LocationLocation QualityQuality DurationDurationAggravating & Aggravating &

Relieving FactorsRelieving FactorsAssociated Associated

Signs/SymptonsSigns/Symptons

Stable AnginaStable Angina SubsternalSubsternal Pressure Pressure SqueezingSqueezing

2-20”2-20” ↑ExerciseExercise

↓Rest/NTGRest/NTG

S4,MR,SOBS4,MR,SOB

PericarditisPericarditis Sternal or ApicalSternal or Apical Sharp Sharp stabbingstabbing

Minutes- DaysMinutes- Days ↑Breathing,supineBreathing,supine

↓Sitting upSitting up

Pericardial rubPericardial rub

Pulmonary Pulmonary EmbolismEmbolism

Substernal or over Substernal or over infarctioninfarction

Angina like or Angina like or pleurticpleurtic

Sudden onsetSudden onset<60”<60”

↑+/- Breathing+/- Breathing SOB, RR, HR, pleural SOB, RR, HR, pleural rub, hemoptysisrub, hemoptysis

PleuritisPleuritis Localized over Localized over involved areainvolved area

pleurticpleurtic Minutes- DaysMinutes- Days ↑BreathingBreathing SOB,cough, fever, SOB,cough, fever, pleural rubpleural rub

RefluxReflux Substernal Substernal epigastricepigastric

BurningBurning 10-60”10-60” ↑<60” after meal<60” after meal

↑Sitting anti acidSitting anti acid

Bitter, sour tasteBitter, sour taste

CholecystitisCholecystitis Epigastric RUQEpigastric RUQ Aching Aching colickycolicky

Minutes- HoursMinutes- Hours ↑60-90” after meal60-90” after meal Abdominal tendernessAbdominal tenderness

MussculoskelatalMussculoskelatal VariableVariable AchingAching VariableVariable ↑movementmovement h/o muscular h/o muscular exertion,injuryexertion,injury

AnxietyAnxiety Often apicalOften apical variablevariable Variable fleetingVariable fleeting situationalsituational Chest wall tendernessChest wall tenderness

• Chest Pain May Be Dangerous or BenignChest Pain May Be Dangerous or Benign– angina Vs strained muscle angina Vs strained muscle

• Severity of Pain Severity of Disease Severity of Pain Severity of Disease – angina can be mild angina can be mild – costochondritis can be severecostochondritis can be severe

• Anatomy PainAnatomy Pain– hiatus hernia refluxhiatus hernia reflux– CAD anginaCAD angina

• Two condition often coexistTwo condition often coexist– reflux esophagitis and anginareflux esophagitis and angina– anxiety and arthritisanxiety and arthritis

Chest PainChest PainScope of the ProblemScope of the Problem

Chest PainChest PainScope of the ProblemScope of the Problem

• Chest pain is commonChest pain is common

• Angina is common +/- lethalAngina is common +/- lethal

• But …But …

……Most chest pain is not anginaMost chest pain is not angina

““Classic” AnginaClassic” Angina

• Location: central chestLocation: central chest

• Quality: squeezing, pressure, heavinessQuality: squeezing, pressure, heaviness

• Radiation: arm(s), neck, jawRadiation: arm(s), neck, jaw

• Associated symptoms: dyspnea, diaphoresis, nauseaAssociated symptoms: dyspnea, diaphoresis, nausea

• Eliciting factors: exertionEliciting factors: exertion

• Relieving factors: rest, nitroglycerinRelieving factors: rest, nitroglycerin

Recurrent Episodic Chest PainRecurrent Episodic Chest Pain

Typically …Typically …

Angina is not typicalAngina is not typical

Recurrent Episodic Chest PainRecurrent Episodic Chest PainProbability (Bayesian) AnalysisProbability (Bayesian) Analysis

• Chest Pain TypeChest Pain Type

• Age, GenderAge, Gender

• Risk FactorsRisk Factors– DM, lipids, HTN, family history, smokingDM, lipids, HTN, family history, smoking

• ECGECG

Recurrent Episodic Chest PainRecurrent Episodic Chest Pain11stst Step Step

History, Physical,ECG

Probable AnginaProbable Angina> 80%> 80%

Possible AnginaPossible Angina10-80%10-80%

Angina UnlikelyAngina Unlikely< 10%< 10%

Recurrent Episodic Chest PainRecurrent Episodic Chest PainChest Pain TypesChest Pain Types

1) Central Chest

2) 2-20 Minutes

3) Precipitated by activity

4) Reilved by rest

Typical= all 4 features

Atypical= 2-3 features

Nonanginal= 0-1 feature

Probability of CAD

Recurrent Episodic Chest PainRecurrent Episodic Chest Pain22ndnd Step Step

H/P, ECGH/P, ECG

Probable AnginaProbable Angina> 80%> 80%

Possible AnginaPossible Angina10-80%10-80%

Angina UnlikelyAngina Unlikely< 10%< 10%

Noncardiac Dx.Noncardiac Dx.treattreat

No Dx.No Dx.? Stress test? Stress test

CardiacCardiacStress TestStress Test

UnstableUnstableadmitadmit

StableStabletreattreat

Recurrent Episodic Chest PainRecurrent Episodic Chest Pain33rdrd Step Step

H/P, ECGH/P, ECG

Probable AnginaProbable Angina> 80%> 80%

Possible AnginaPossible Angina10-80%10-80%

Angina UnlikelyAngina Unlikely< 10%< 10%

Noncardiac Dx.Noncardiac Dx.treattreat

No Dx.No Dx.? Stress test? Stress test

CardiacCardiacStress TestStress Test

UnstableUnstableadmitadmit

StableStabletreattreat

PositivePositiveDx. Uncertain:Dx. Uncertain:

? cath? cath

NegativeNegativeNot anginaNot angina

PositivePositive AnginaAngina

NegativeNegative?Gi. Pulmonary ?Gi. Pulmonary musculoskelatalmusculoskelatal

Audience QuestionAudience Question

What feature best predicts a cardiac etiology to chest What feature best predicts a cardiac etiology to chest pain?pain?

A.A. Location in chestLocation in chest

B.B. Character or quality of discomfortCharacter or quality of discomfort

C.C. Response to NitroglycerinResponse to Nitroglycerin

D.D. Relationship to exertionRelationship to exertion

Clinical Diagnosis of Chest PainClinical Diagnosis of Chest Pain

• Location, quality of pain generally not predictive of Location, quality of pain generally not predictive of cardiac causecardiac cause

• Response to nitroglycerine not a reliable predictorResponse to nitroglycerine not a reliable predictor

• While radiation and associated symptoms may be While radiation and associated symptoms may be predictive, their sensitivity and specificity are quite predictive, their sensitivity and specificity are quite lowlow

• More than a history and physical are needed!More than a history and physical are needed!

Noninvasive TestingNoninvasive Testing

StressorStressor

• ExerciseExercise

• DipyridamoleDipyridamole

• AdenosineAdenosine

• LexiscanLexiscan

• DobutamineDobutamine

Measure of IschemiaMeasure of Ischemia

• AnginaAngina

• ECG ST-segment changeECG ST-segment change

• Nuclear perfusion defectNuclear perfusion defect

• Echo wall motion abnormalityEcho wall motion abnormality

Noninvasive TestingNoninvasive Testing

• MortalityMortality = 1/10,000 = 1/10,000

• ContraindictionsContraindictions

- unstable angina/acute MI- unstable angina/acute MI

- untreated life threatening- untreated life threatening

- advance AV block- advance AV block

- severe aortic stenosis- severe aortic stenosis

- severe hypertrophic cardiomyopathy- severe hypertrophic cardiomyopathy

- uncontrolled hypertension- uncontrolled hypertension

Noninvasive TestingNoninvasive TestingExercise TerminationExercise Termination

Symptom Symptom LimitedLimited

Physician Physician LimitedLimited

DyspneaDyspnea

FatigueFatigue

DizzinessDizziness

Chest PainChest Pain

ST-changeST-change

ArrhythmiaArrhythmia

Hypotension Hypotension

Noninvasive TestingNoninvasive TestingExercise Test InterpretationExercise Test Interpretation

• ST-segment changeST-segment change

• AnginaAngina

IntesityIntesity

work-ratework-rate

HRHR

Noninvasive TestingNoninvasive TestingExercise Electrocardiography LimitationsExercise Electrocardiography Limitations

• False PositivesFalse Positives

- digoxin- digoxin

- LVH- LVH

- rest ST-depression- rest ST-depression •UninterpretablUninterpretablee

- LBBB- LBBB

- Ventrical - Ventrical PacingPacing

• False False NegativesNegatives

Noninvasive TestingNoninvasive TestingExercise Myocardial Perfusion ImagingExercise Myocardial Perfusion Imaging

RadionuclidesRadionuclides

ThalliumThallium

SestamibiSestamibi

Tetrofosmin Tetrofosmin

Uptake & Blood Uptake & Blood FlowFlow

Perfusion Perfusion agentsagents

Noninvasive TestingNoninvasive TestingExercise Myocardial Perfusion ImagingExercise Myocardial Perfusion Imaging

with ECG Gatingwith ECG Gating

perfusionperfusion

Normal

Ischemia

infarct

fuction

EF

wall motion

thickening

Noninvasive TestingNoninvasive Testingpharmacologic imagingpharmacologic imaging

DobutamineDobutamine

↑ HR, contractility

↑ O2,

demand

↑ coronary

perfusion

Vasodilaters Dipyridamole,Adenosine,

Lexiscan

Noninvasive TestingNoninvasive Testingpharmacologic imagingpharmacologic imaging

ContraindicationsContraindications

Bronchospasm

advanced AV block

theophylline

Arrhythmias

Severe HCM

dipyridamole/adenosine

Dobutamine Dobutamine

Noninvasive TestingNoninvasive TestingIschemic Heart DiseaseIschemic Heart Disease

What is the Probability of CAD?

Noninvasive TestingNoninvasive TestingWhat is the Probability of CAD?

Test

Patient Pre-test Probability

Sensitivity Specify

Post-test Probability

Noninvasive TestingNoninvasive TestingWhat is the Probability of CAD?

Patient Pre Test Probability of Disease

Chest Pain Type

Age, Gender

Risk Factors

Rest ECG

TIMI Risk scoreTIMI Risk score

• Age > 65Age > 65

• Greater than 3 coronary risk factorsGreater than 3 coronary risk factors

• ST-segment deviationST-segment deviation

• Greater than 2 angina events in 24 hrs.Greater than 2 angina events in 24 hrs.

• Use of ASA within 7 daysUse of ASA within 7 days

• Increase in cardiac markersIncrease in cardiac markers

Indications for Stress TestingDiagnosis of CADRisk StratificationEvaluation of Therapy

Detection of CADPhysiologic Testing (with or without imaging) -Exercise: HR x BP product, METs -Preferred when possible

Pharmacologic Testing with Imaging-Unable to exercise

-Hyperemia: Adenosine, Dipyridamole,Lexiscan -for LBBB, paced rhythm -Dobutamine

Anatomic Testing -Cardiac CT/MR -Invasive Angiography

Exercise ECG Testing Without Imaging

Class I:

Intermediate pretest probabilityRBBB → still OK!< 1mm ST ↓ → still OK!

Class IIa

Vasospastic angina

• Calculating the Duke Treadmill ScoreCalculating the Duke Treadmill Score

Exercise Time (min)

5x Degree of ST Depr.

4x Angina Index

No Angina -0Angina during test -1Angina stopped test -2

• Indications for ImagingIndications for Imaging

• Baseline ECG abnormalities LBBB, paced Baseline ECG abnormalities LBBB, paced rhythm, LVH, WPW, digoxinrhythm, LVH, WPW, digoxin

• > 1 mm resting ST depression> 1 mm resting ST depression

• Inability to exerciseInability to exercise

• Intermediate Duke Treadmill ScoreIntermediate Duke Treadmill Score

• Assessment of viabilityAssessment of viability

• Localization of ischemia for PCILocalization of ischemia for PCI

• Comparing Stress Echo to Stress Radionuclide Comparing Stress Echo to Stress Radionuclide

↑ Specificity

Versatility

Convenience

Lower Cost

↑ Sensitivity

Echo

Radionuclide ↑ TechnicalSuccess

↑ Accuracywith ↓ LV

Higher Cost

• How Often Should I Order a Stress Test in a How Often Should I Order a Stress Test in a Patient with Chronic CAD?Patient with Chronic CAD?

For any clinical change

3-5 years after successful revascularization

Consider earlier testing for patients withdiabetes or for patients with incompleteRevascularization

Annual testing is not appropriate

• Cardiac CTCardiac CT

• Selected Appropriate IndicationsSelected Appropriate Indications

For detection of CAD in patients with acute chest pain or chest pain syndromes, intermediatepre-test likelihood of CAD, and other data non-diagnostic.

For detection of CAD in patients with new onset HF.

For non-invasive assessment of LIMA prior to re-operative cardiac surgery

• Calcium scoring for patients with low CHD Calcium scoring for patients with low CHD risk.risk.

• CT angiography for asymptomatic low or CT angiography for asymptomatic low or intermediate CHD risk patients.intermediate CHD risk patients.

• CT angiography for intermediate peri-CT angiography for intermediate peri-operative risk patients.operative risk patients.

• Routine CT angiography after CABG.Routine CT angiography after CABG.

Correlation of CTA and cardiac catheterization using our 64 slice CT

ConclusionsConclusions

• Clinical characteristics are the least accurate Clinical characteristics are the least accurate predictor of the etiology of chest painpredictor of the etiology of chest pain

• Pattern of pain may be most reliablePattern of pain may be most reliable

• Accurate diagnosis and management requires use Accurate diagnosis and management requires use of clinical history, ECG, and other highly specific of clinical history, ECG, and other highly specific marker of ischemia or infarctionmarker of ischemia or infarction

• Rapid Dx &Tx = saved muscle = improved outcomeRapid Dx &Tx = saved muscle = improved outcome