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Chapter 6

The Chest Pain Summit

Colin Kaide, MD, Mike Palacci, MD, Barbara Backus, MD, Erik Hess, MD, Ezra Amsterdam, MD, Douglas Van Fossen, MD, Rob Orman, MD, Mike Weinstock, MD, and Cam Berg, MD
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A consensus summit with world experts and primary researchers focused on the question, “After a negative ED evaluation for ACS, is an expedited outpatient evaluation a safe alternative to admission?”

 

Pearls:

  • There has been a change in thinking about the need for a stress test within 72 hours for a low-risk patient with chest pain.  The goal should be outpatient follow-up in the very near future, hopefully in a few days.

  • The decision regarding provocative testing can be made after a shared decision-making conversation between the patient and follow-up provider.

  • The 5 day risk of death for someone discharged from the ED with a NSTEMI is 0.02%, or 1 in 5,000.

  • Patients who undergo cardiovascular testing for the evaluation of low-risk chest pain have a much higher rate of downstream testing yet no change in the rate of acute myocardial infarction.

 

  • One of the most widely discussed topics in EM over the past few years has been the evaluation, risk stratification, and disposition of low-risk chest pain patients.  Largely due to the focused and insightful research of people such as Cam Berg (who introduced a decision pathway using the TIMI score), Barbra Backus (the HEART score), Eric Hess and his team (shared decision-making model/graphical representation of chest pain risk), and Mike Weinstock (adding CRACE to MACE as an outcome measure), our knowledge of what actually happens to different chest pain cohorts in the short term has gone from guesswork to legitimate numbers that can inform conversations.  

  • On September 26, 2018, a consensus conference with world experts and primary researchers focused on providing a unified answer to the question, “After a negative ED evaluation for ACS, is an expedited outpatient evaluation a safe alternative to admission?”  At this Adena Chest Pain Summit, a unified approach to low risk chest pain became not just something some of us did or thought a good idea, but something we embraced as a specialty.  This episode of ERCAST distills down to 30 minutes some of the most relevant ideas presented at this all day conference.

  • What is the prognosis for low risk chest pain patients who are sent home after a negative ED workup?  More specifically, what’s the short-term risk of death if someone is discharged from the ED with a NSTEMI?

    • Colin Kaide:  

      • A recent study of 38,000 patients looked at the cumulative incidence of sudden cardiac death after NSTEMI with a median follow-up of 12.1 months.  The risk of death was 0.79% at 6 months and increased to 2% at 18 months.

      • In the ED, we’re most interested in what happens in the immediate follow-up period, during the timeframe in which we can get the patient to the next level of care.  After extrapolating the data in this study, the 5 day risk of death after a NSTEMI was 0.02%, or 1 in 5,000.

      • Hess PL, et al  Sudden Cardiac Death After Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Cardiol. 2016  Apr 1;1(1):73-9. PMID: 27437658

  • How helpful is a stress test in predicting who is at higher risk of sudden death after a NSTEMI?  

    • Mike Palacci:

      • A study published in 2017 evaluated the effects of cardiovascular testing (noninvasive imaging or coronary angiography) on the rates of acute MI or need for revascularization for ED chest pain patients.

        • They found that patients who had cardiovascular testing had a much higher rate of downstream testing.  For every thousand patients who had a stress test of a coronary CT angiogram, there were 90 additional angiograms and 10 additional angioplasty procedures.

        • Despite all of this extra downstream testing, there was no change in the rate of acute myocardial infarction.

        • Sandhu AT, et al. Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA Intern Med. 2017 Aug 1;177(8):1175-1182. PMID: 28654959

      • A 2018 study examined the benefit of noninvasive testing compared with clinical evaluation alone (ECG, biomarkers, history, and exam).

        • They looked at a thousand ED patients with negative biomarkers and nonischemic ECGs, comparing those who did and those who did not have noninvasive testing.  

        • Chest pain patients who had noninvasive testing done had a longer length of stay, more cardiac caths, higher median costs, more radiation exposure, and more angioplasty procedures on the index visit.

        • At 28 days, those who had had noninvasive testing had no change in return visits and no change in major adverse cardiac events (MACE), angioplasty or CABG.

        • Reinhardt SW, et al. Noninvasive Cardiac Testing vs Clinical Evaluation Alone in Acute Chest Pain: A Secondary Analysis of the ROMICAT-II Randomized Clinical Trial. JAMA Intern Med. 2018 Feb 1;178(2):212-219. PMID: 29138794

      • These studies suggest that noninvasive testing in the low-risk chest pain patient is of questionable benefit.  Though stress tests increased downstream testing, they did not change the rates of important clinical outcomes.

  • How do we select low-risk chest pain patients in the ED?  

    • Barbra Backus:

      • We can identify three groups of patients based on their HEART score.

        • Low risk (score 0-3)

        • Intermediate risk (score 4-6)

        • High risk (score 7-10)

      • Validation studies have shown that the risk of MACE for low risk patients within 45 days is 1.9%, and the risk of death is 0.05% (1 in 2000).

        • The risk of death is all-cause mortality.  Interestingly, of the low-risk patients who died, none of them had a clear cardiac death.   

      • A criticism of the HEART score has been that the original study was based on a small group of patients.  Therefore, Backus and an international team did a review of all of the literature, including over 20 studies and 40,000 patients.  They found that patients with a HEART score of 0-3 (45% of the ED population) had a MACE rate of 2.2% and a risk of death of 0.1% (1 in 1000).

      • These results are based on a single troponin on arrival.  Simon Mahler developed the HEART Pathway that uses the arrival troponin and a second 3 hour troponin.  If both troponins are negative, the short term risk of MACE falls to under 1%.

  • Cameron Berg and his group in Minnesota have been using a low-risk accelerated diagnostic pathway for several years.  They recently submitted a study for publication.

    • They did a pre- and post study following implementation of their diagnostic pathway.  Prior to using the pathway, 51% of ED chest pain patients were admitted to the hospital (the national average is 50%).  After the pathway was instituted, admissions plummeted to 17%.

    • Of the 35,000 patients who were discharged from the ED during a 4 year study period, 9 died within 5 days.  Only 1 of the 9 seems to be a true ED “miss”.

      • 4 were actually diagnosed with an acute MI at the time of their index ED encounter and left against medical advice.

      • 3 had been hospice patients at the time of their initial presentation.  They were discharged from the ED after negative evaluations and died in hospice of their underlying disease.

      • One died in the operating room 2 days after the index ED visit.  She was having a port placed and died after her vena cava was lacerated.

      • Only one patient died of a cardiac cause following a negative ED evaluation including two negative troponins.

  • Many ED providers have a risk tolerance of zero when it comes to evaluating patients with chest pain -- their goal is a zero miss rate for adverse events.  But what about the patient? What do they think when presented with a choice of admission vs. discharge?

    • Erik Hess:

      • Hess addressed this question by developing a patient decision aid that communicated with  patients their risk for an adverse cardiac event, engaging the patient in the decision-making process.  Patients were randomized to decision-making using this tool vs. letting the clinician interact with the patient according to their usual practice.

        • The scripting includes informing patients about how we’re really good at diagnosing a heart attack, but not quite as good at determining if symptoms are a warning sign for a future heart attack.  

        • The decision aid has a visual representation of risk with 100 silhouettes.  99 are blue and 1 is red. The red one depicts the short-term bad outcome and the text on the aid says, “For every 100 people like you who came to the emergency department with chest pain, 1 had a heart attack or a pre-heart attack within 45 days of their ED visit.  99 did not.”

        • The tool not only communicated low risk to the patient, but it also made the physicians more aware of what the risk really looked like.

      • This tool was tested in 6 sites and showed that:

        • patients were much more knowledgeable about their risk and their available management options,

        • clinicians made greater efforts in engaging patients in the decision-making process,

          • there was a decrease in observation and admission rates as well as a reduction in the 30 day rate of stress testing, and

        • there were no major missed adverse cardiac events in either arm of the trial.

  • Although the 2010 American Heart Association/American College of Cardiology Guidelines recommend an outpatient exercise treadmill test within 72 hours of an ED visit for low-risk chest pain patients, recent data does not support that rapid treadmill testing (or even CT angiography) improves outcome in low-risk patients.  Are providers putting themselves at medicolegal risk if they don’t arrange for a provocative study within 72 hours?  And what happens when patients see a cardiologist in follow-up?

    • Ezra Amsterdam:

      • “Most patients who come to the ED with chest pain are categorized as low risk for acute coronary syndrome or other life-threatening cause of chest pain.”  

      • “The management after the patient can leave is decided by the patient and the doctor together, with shared decision-making.”  There is no mandate that a functional study is required, only that the follow-up doctor and the patient have a conversation about the follow-up plan.

      • “Low-risk patients should be discharged from the ED within hours.  It should not take days to recognize, evaluate, and discharge a low-risk patient.”

    • Douglas Van Fossen:

      • In his cardiology practice, Van Fossen spends most of his time discussing primary prevention and risk factor modification with low-risk chest pain patients.  Following a shared decision-making conversation, most of these patients don’t end of getting a functional study.

      • He acknowledges that sometimes he orders a stress test for psychological reasons.  A stress test that is completely negative can be beneficial for the patient’s psyche; the normal result may prevent additional ED visits for chest pain.

  • What benefit does percutaneous coronary intervention (PCI) confer to the patient?

    • Douglas Van Fossen:

      • PCI procedures are palliative.  When a patient has a 99% stenosis, PCI reestablishes a level of flow by reducing the obstruction to less than 70%.  This alleviates angina symptoms, but doesn’t prevent infarcts.

      • A recent study evaluated the efficacy of PCI in patients with stable angina.  All patients underwent an angiogram, and those with single vessel stenosis of ≥70% were randomized to either PCI or a sham PCI.  They found that PCI did not confer improved exercise tolerance at 6 weeks compared with a placebo procedure.

Al-Lamee, Rasha, et al. "Percutaneous coronary intervention in stable angina (ORBITA): a double-blind, randomised controlled trial." The Lancet 391.10115 (2018): 31-40.PMID: 29103656

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