So What Does It Really Mean?

Cardiac Investigation in and out of the Emergency Department

Dr Kyle KophamelSir Charles Gairdner HospitalCME 25/09/2014

Vetrovec, 2008A 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

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.

How to interpret elevated cardiac troponin levels. Circulation 2011. Mahajan and Jarolim.

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. -

Myocardial Perfusion Scan

-AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.

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.

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CT Coronary Angiography

Stress Cardiac MRI

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So who goes where?Hx, Exam, ECG

Clinical Suspicion Observation vs Admission

Troponin Timing

Risk stratification TIMI National Heart Foundation HEART score EDACS - ADP

TIMIAge >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

TIMI% risk at 14 days of all causes of mortality,

new/recurrent MI or ischaemia requiring PCI0-1 = 4.7%2 = 8.3%3 = 13.2%4 = 19.9%5 = 26.2%6-7 = 40.9%

NHF AustraliaHigh Risk

CCU admission

Intermediate RiskProvocative testing prior to discharge

Low RiskOutpatient care

HEART scoreHistory

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

Cases and DiscussionA Charlies perspective….

Accelerated diagnostic protocol.

Take HomeRisk stratification

Gustalt and Scoring (HEART)

Safety of Accelerated of Diagnostic Protocols

Timely follow up arrangementGP vs Cardiologist