Chest Pain Risk Stratification | The Heart Course W/ Amal Mattu, MD

so we're going to talk about chest pain risk stratification something that i'm sure all of us in acute care medicine are um are always dealing with always trying to figure out what's the optimal way of risk ratifying patients with low risk chest pain the the term lower chest pain is kind of a misnomer because that's what we worry the most about these so-called low-risk chest pain patients and specifically we're going to be talking about low risk for acs so we're not talking about lowers for pe we're talking about acs here let's jump right into a case and we're going to go back a few years to 2012 this is a real case which um i know of from 2012 i'll talk about how i came to know about this patient this is a 36 year old woman who presents you the emergency problem with sharp chest pain this morning while she's at work she's actually sitting at her desk when she kind of looked bad and her co-workers made her come into the emergency department she herself i don't think she would have come in had it not been for her co-workers and here's a bit more information she had some nausea she actually vomited once she said she got dizzy one of my favorite words and when she said dizzy she meant lightheaded so we're not heading down a vertigo pathway all right she got a little lightheaded she broke out in a bit of a sweat there's no radiation no shortness of breath she actually says that she's had a few episodes over the past few days although now she's sitting in front of you totally asymptomatic feels fine she smokes a half pack per day of cigarettes really doesn't have any other known cardiac risk factors her blood pressure's a little bit elevated 150 over 90 which is like many patients in the ed on a normal day that's relative hypotension we'd be starting her on some epi and her exams pretty much normal ekg just shows nsj non-specific junk so you can't ship her up to the cath lab she doesn't have a stemi she's not going straight to the ccu this is a pretty common patient how many of you have seen this patient during your last shift right everybody multiple times and my question then for you is what do you do at least to think about you don't have to raise your hand but what do you do when you see this all too common patient we'll make this multiple choice let me give you some choices here all right what's your plan number one admit or obsta-patient and pretend you're not sitting in a lecture on risk stratification and you didn't just have a med mal type of lecture a little while ago but with that patient you usually admit them and then get the stress test or coronary cta choice number two get some serial troponins and then send her for outpatient stress test in the next 72 hours or how about just serial troponins and then just have her follow up in the next week or so with the primary care doc see what your opponent is then yeah you're done you just discharge it without any further recommendations for a workup or maybe just one troponin or ekg is non-specific atypical symptoms all just get one troponin and then be done with it or maybe just discharge now i'm so not worried about acs i'm not even to do anything more than the ekg no troponins no labs or anything like that maybe a chest x-ray chest x-ray is okay or maybe how about choice number seven pretend you never saw her right stick that chart at the bottom go see the ankle pain and hope that your partner picks up that patient right well i work in in a uh inner city system with probably about 70 doc staffing a number of different hospitals and honestly i would say that amongst my colleagues they would choose every one of these maybe including seven all right so so this is really common and when i pose this question outside of lectures you know there's really a lot of disparity amongst what people normally do with this now i'll tell you why there's some disparity i've highlighted some of the things that which to me sound a bit reassuring on this case so first of all it's a 36 year old woman relatively low risk we talked about issues with um with atypical presentations before but still 36 year old women are at lower risk than if it were say a 65 year old man it was sharp i've learned that the word sharp is lower risk than if she said pressure it occurred at rest i'd be a lot more worried if she said she was walking up the stairs when she got pain no radiation no shortness of breath i'm happy about that she's had a few episodes over the past couple of days and yet she's still alive that's got to be good right and now she's asymptomatic i'm glad to hear that there is not much in terms of cardiac risk and the ekg doesn't show obvious abnormalities so all of these things i'm pretty happy about but then spinning this around there's also a few things up here that i'm kind of worried about all right i'm gonna highlight rest again so the reason i'm highlighting rest now as being concerning is because what what's rest pain called that's unstable angina right isn't that what we learned that's one of the definitions for unstable anxiousness and maybe that's not good you know she didn't have radiation or shortness of breath but she did get nauseous and she vomited once vomiting's not good and she broke out in a sweat i hate when patients break out in sweats sweats is really really bad she got some lightheadedness what else she's had a few episodes i'm going to highlight that as being concerning now because that could also be unstable angina right unstable angina comes and goes and maybe that's unstable angina she doesn't have much in terms of cardiac risk but she does smoke a half-pack pretty easy and she's a bit hypertensive so maybe she's got previously undiagnosed hypertension so maybe she's got two cardiac risk factors there and i'm going to highlight the ekg again it's not diagnostic but on the other hand it's also not normal all right i'd feel a little bit better if it were truly normal but there's some non-specific stuff up there so there's some things that have us a bit concerned some things that are making us feel a little bit better and the result of all this is that when you look at what people do with these patients their workups are all over the map right some will do choice number one and admit clearly admit to the icu and push for stress testing and everything some people won't do much of anything and i don't know if there's any nurses here but our nurses get particularly frustrated with the work up they try to start the work up at triage and the workup that they initiate will depend on who the attending is the residents do the same thing they know that if you're working with this attendant he hates your opponents if you're working with this attending a person's got a pair of nick yet san troponis on them right it's all over the map um and so the residents will order things based on and when you guys were in training you probably did the same thing depending on who's working all right so there's a lot of confusion let's go back to the case i mentioned this is a real case what actually happened here well the ekg was okay so what did the doc do here the physician said you know what i'm gonna get a chest x-ray that sounds reasonable labs you also got a d dimer all right that's reasonable everything turned out normal the cbc the chem 50 the d-dimer um even got a troponin the troponin was negative and so the patient's told follow up with your doctor no specific recommendations no mandatory stress tests but pretty decent work up all right including a troponin figure if she's had on and off chest pain for two days we're going to see a bump in troponin well what ends up happening is the next day she had a cardiac arrest and she died 36 year old woman and that's how i came to know her this ended up in litigation and i was trying to help with defense of this case autopsy showed a massive mi with an occluded lad 36 years old without much in terms of cardiac risk factors all right so there's johnny lawsuit gets filed all right and what exactly is the plaintiff side going to contend and what i would say is that probably until 2016 this is how every one of these cases would go so their contention is the following or actually our defense was the following she had an atypical history that puts her at lower risk it's relatively low cardiac risk the ekg was not diagnostic this is what we're trying to argue she even got a troponin and it was negative so this is our defense about how we're trying to say you know it's reasonable for the physician to have not thought about cardiac disease here all right what does the plaintiff side say plaintiff says wait a second you started this goes back to your question you started the work up by sending at your opponent and yet you didn't follow the guidelines all right you obviously were concerned enough to start a work up and then you didn't go all the way the guidelines were not followed these are national guidelines that are written by world-renowned physicians all over the world especially in the u.s since we're talking about the u.s guidelines that say if you're going to start the work up if you're worried about one of these so-called low-rise patients you need to follow the guidelines what makes you think that you're smarter than all these nationally um published people who have written these guidelines by the way the guidelines are also endorsed by every major society and there's even emergency physicians that are authors of these guidelines what makes you think that you're smarter all right and this resulted in an upper six-figure settlement and when i got brought into the case to help defend it i was a bit despondent to find out that the defense attorney pretty much already told me you know what we're going to lose his case your job is to help with damage control your job is to minimize the settlement all right so it's kind of disappointing to find out that they already knows that we're going to lose this case and my job is just to see how low we can get the settlement all right again every case ended up going that way all right so again your honor before you settle on judgment we like to know how much money there is in the universe it's certainly not a court that you want to be in all right well what's the deal with the guidelines all right we'll talk a little bit about what the guidelines say in just a moment but up until around 2015 2016 what i would see in all these cases and i've probably been involved in maybe about 60 acs related cases chest pain and acs cases over the past 12 years or so right and the consistent thing that gets brought up in litigation over and over and also in the med mao literature is number one acs is not just mi all right we could rule out mi like that just send your opponents on everybody you'll roll with rule out mi acs is mi but it's also ischemia troponins only rule out mi to rule out ischemia you need to do a provocative test like a stress test or the guidelines allow you to substitute a coronary cta if you can't get a stress test all right now again this is all pre 2015 2016. so if you're starting to get it a bit despondent hang in there or there's some brownies in the back to hold you over till we get to the good news all right most litigation doesn't occur from missed mi we don't get sued because we're missing mis we get sued because we're missing unstable angina we're missing ischemia which then a day or two later then goes on to develop the or hours later then goes on to develop the influx that's why i said earlier about half the cases i've been involved in were patients that had negative troponins on the chart they weren't infarcting at the time the physician was taking care of him they infarcted a little while later but our job is not to just rule out the infarct right now but also to rule out what might be infarcting a little while later secondly traditionally national guidelines call for troponins for ruling out mi but the provocative test or the coronary cta all right and the guidelines generally are used as a surrogate for standard of care now guidelines were never intended to be used as standard of care guidelines are just guidelines or things to think about but that's not how jury see it right and a half decent plaintiff attorney can very easily pull out the guidelines and say this is the standard of care it's not that difficult to convince a lay jury that this document which is endorsed by all of these national societies and has 150 references and world-renowned authors that represent standard of care and this physician thought he was smarter than all of these other physicians he went rogue and that's why mrs jones is dead and these three kids have no mother anymore all right so here's the guidelines i'm going to blow parts of this up for you in just a second this is an algorithm which essentially represents what the guidelines have traditionally been again maybe up until just a couple years ago all right so what these guidelines say at the very top if you have symptoms suggestive of acs you're supposed to put people in one of three different groups now i've crossed out chronic stable angina that's a little bit more relevant to outpatient medicine but the three other boxes we're supposed to take patients and put them into one of three boxes on the far left is non-cardiac diagnosis this patient's history and physical is so clearly not cardiac i'm not even going to start a workup it's completely reproduced chest pain they just got punched in the chest i don't know something clearly non-cardiac anybody who'd reasonably look at the chart would say yeah i'm not going to work them up either those are pretty easy cases right on the far right is definite acs the patient's got chest pressure diaphoresis radiating down the arm that patient's clearly coming into the hospital nobody is going to cause any argument about that those are pretty easy cases also the tough cases are box number two right down the middle where it says possible acs like the case we started with there's just a few things that make you worried and a few things that are not so worrisome and what do you do with those patients you know you try to admit them maybe you're even going to get some argument there we've all been in that boat all right so box two is where all the problems come in so what do the guidelines say you're supposed to do if they fall into that middle zone well what the guidelines say you're supposed to do is you get the ekg and if it's diagnostic well then they go over to box three definite acs piece of cake but typically they're in box two because their initial ekg and their initial troponins are unremarkable and if the initial troponin is unremarkable what are you supposed to do next well you can come down here where it says consider myocardial perfusion imaging right which is a fantastic idea how many people here can get a sesta maybe during your shift all right so one person okay probably about 10 years ago it was all the rage in the literature and there were more hospitals doing sesta mibs it's it's actually quite a good test if somebody's actively having pain you inject the tracer send them over to radiology they get the test and maybe test and you can rule them out pretty quickly the problem is we don't have that available too much any longer some people never had it even at my big tertiary care medical center you know i can i probably get one sesame per year and it has to be perfectly timed it has to be like a monday or tuesday morning that they come in and the lab has to be not busy because they turn that troponin around real quickly ekg's not diagnostic and then i get them over to radiology to inject the tracer before their 10 30 lunch begins all right and then they have to get the final read done before 3 30 because that's when the radiologists are heading home all right so that happens about once a year from me and when it happens it's great all right it used to be more common about 10 years ago when the literature was pushing it but it's not very common so that box mpi if you can get it it's fantastic but most of the time we can't get it so what do you do instead well you get serial ekgs and serial markers that's what the guidelines say you're supposed to do if those are positive piece of cake they go to box three they get definitely admitted all right that's easy well what happens if your serial markers and serial ekgs are still not diagnostic well the next step is not to go home it doesn't say you get to go home the next step is not go home the next step is you need to do the provocative test or the mpi all right so patient comes in non-diagnostic you get one ekg once your opponent there's al it's all negative or non-diagnostic next step get more ekgs and another set of markers if those are still negative they don't go home the next step is to get a provocative test or coronary cta now the caveat here is that the guidelines do specifically say that if somebody is low risk you can get the the stress test within 72 hours so they do allow you to discharge low risk patients home as long as you're scheduling that that stress test within 72 hours but they don't exactly say they don't clearly say what low risk is they just say if they're low risk but what happens is if you send them home and they die in 48 hours everyone's going to argue well clearly they didn't meet low risk criteria they should never have been sent home the guidelines say low risk only goes home and then gets a stress test within 72 hours and they don't define what low risk is so that's where all the argument is so the bottom line is if you're going to start the workup you need to go all the way you don't you don't do it kind of half-heartedly all right so can we discharge patients without provocative testing is it defensible to not follow the guidelines and are the guidelines standard of care well again who decides malpractice in a in a medical malpractice case who decides standard of care it's not the judge it's not the experts it's not the attorneys it's the jury consisting of not your peers these are people whose medical expertise is based on watching chicago hope and rescue 9-1-1 and if they're a little older maybe er most of the time focusing on george clooney perhaps all right not not really the medicine so it's people who don't really understand and i'll tell you it's a piece of cake to convince a jury that that document as i've said which has world-renowned authors and 150 160 references and is endorsed by all these major societies and at least one of the authors is an emergency physician it's very easy to say this is how you're supposed to to manage low-risk chest pain all right is it possible to not follow the standard of care absolutely it absolutely is but if you're not going to follow the guidelines you need to have validated literature to back you up so for example i don't follow acls all right if somebody's got got v-tac or v-fib what i don't follow acls to a t there's a few things that i'll do in acls but a lot of acls has been shown to be wrong so if somebody said well document two how come you're not following acls i'd have a stack of literature this big saying these are the articles which tell me why acls is not standard of care and these are the articles which say why i'm not going to follow acls all the way to the end all right there's good validated literature to say why you don't have to do certain things but what about with low-risk chest pain pre-2016 if you don't follow the guidelines and somebody says what allowed you to not follow the guidelines show me the validated literature that said you could deter from the guidelines you'd pretty much have an empty hand all right so in other words this is oftentimes what i refer to as my mr miyagi rule all right everybody remembers the karate kid from the 1980s not the more recent kung fu kid with will smith's son good movie but it's not the karate kid all right the original karate kid in 1980 you remember when when mr miyagi is sitting down with daniel son before daniel sons beginning his training he sits down with daniel sign and says daniel son man walk left side of road okay man walk right side of road okay man walk down middle road squish like grape right and then he said karate same way my accent's not too good but karate same way right here the karate do or karate do not karate it squished like grape and then he said acs evaluation same way you know he did it was on the director's cut check it out all right so same thing if you're going to start the work up you go all the way otherwise don't start and honestly pre-2016 again it's a lot easier to defend cases where patients come in with atypical symptoms they get an ekg nobody again nobody argues about the ekg it's part of so many workups right i've never heard an argument about getting an ekg but you do history physical ekg and document why you're not worried about it and send that person home compared to the same exact scenario history physical unremarkable ekg let's get one troponin is negative and then send the patient home it's easier to defend the case where there was no troponin sent than the case where there was one or two troponins that were negative and then sent home because invariably they go right to that algorithm and say doctor you started the pathway you opened the door to the workup and you didn't close the door at the very end you just did your work up and the lawyers come and squish you like a grape all right case after case after case after case all right it's easier to defend not even starting the work up right you might still get sued but it's easier to defend that case all right well i keep saying 2016 and why is that do we now finally have validated literature to say you know what we probably don't need to exactly follow the guidelines with a provocative test or coronary cta in every single case all right in fact we've now got literature suggesting that maybe those guidelines are actually harmful believe it or not all right so how can it be that a stress test is harmful or coronary cta is harmful well let me pose this question to you all right what's the purpose of doing a provocative test or coronary cta in the first place like what where did this idea come from what what good is a provocative test what what's the purpose of doing the stress test well right you want to see if you can reproduce symptoms right well again maybe it's fun to to reproduce pain in someone i don't know but what exactly are we are we proving why are we trying to do that essentially what we're doing is we're trying to see if we can reproduce ischemia because the presumption is that if somebody has recurrent ischemia in other words if we plop them on a treadmill and increase their myocardial oxygen demand and you want to see if the supply meets the demand if the supply doesn't meet the demand because they've got a big lesion they develop chest pain ischemia on ekg and so the purpose of the stress test is it's an indirect way of finding out whether somebody has big coronary lesions well again who cares if somebody's got big lesions what difference does it make why do we even care if somebody has lesions so what if you've got lesions well the reason we care about it is because we can do something about it right if somebody's got lesions we can send them for pci and put a stent in them not we but the cardiologist or maybe they get a bypass and the presumption is if you put a stint and open up the lesion or do a bypass give them new vessels they're going to have a better outcome that's the whole purpose of doing the stress test because you want to find out whether in the end they're going to end up needing a pci or cabbage and the reason that they need a pcr cabbage is because they're going to do better with pci or cabbage all right what what if for example what if i told you that if they have a positive stress test they're going to get a pci or cabbage but hey by the way pci and cabbage turn out to be totally unnecessary procedures and don't improve outcomes would you still want them to do that of course not all right so hold that thought for just a second all right is there enough evidence now to stray from the guidelines well here's a couple of articles that i'm just going to summarize and these two articles were published in 2017 but there's probably been at least a half dozen more articles showing exactly the same data over the past several years actually going back about 10 years all right and let's look at the data so this first article they looked at a thousand patients presenting to the ed with chest pain that was not obviously ischemic so it wasn't a slam dunk ischemic patient and they compared clinical evaluation um in other words they compared history physical ekg all unremarkable so i'm done go home we're done versus history physical ekg they're all non-diagnostic and therefore i'm sending you for a stress test or coronary cta that's the traditional workup right so they compared people that didn't get coronary cta or stress versus people that did get coronary cta or stress test and what did they find was there any difference well first of all the people that got the stress tested coronary cta had higher length of state losses length of stay higher cost and increased rates of further testing and they also looked at 28 day major adverse cardiac event what did they find well length of stay was higher when they got mandatory testing no surprise cost is higher no surprise more people ended up getting pci's more people got cabbage ns is non-significant so it wasn't a big significant difference so the bottom line is the people that had unremarkable history physical ekg who had no testing versus people that had unremarkable history physical ekg and mandatory testing there's no difference in any of these parameters but what about major adverse cardiac event surely the people that got the stress testing had better rates of major adverse cardiac events at 28 days not so no difference in rates of adverse events after a month right well here's a study where they said you know what let's not just look at one month outcome let's look at one year outcome 900 000 patients history physical ekg unremarkable and that's all you're gonna get versus history physical ekg non-diagnostic and you have to get a stress test all right and let's compare how they do in one month and also let's see how they do at a year clearly the people that have the mandatory stress test are going to have better outcomes because they're going to end up going for pci and cabbage and that's going to be associated with better outcomes well what they found is that at a year the people that had the mandatory stress test had more angiograms no surprise more additional revascularizations no surprise more acute mi admissions they had more admissions for mi after getting the stress test and uh and interventions slightly more there's no significant difference at 30 days same thing right so the bottom line here is that when you take patients that have fairly unremarkable history physical ekg workups and you force them to go through the national guidelines with the mandatory stress test it increases their length of stay it increased the costs it increased the number of invasive procedures that they end up getting but their outcome at one year is no different so why are we doing these tests in people that are low risk right and again there's at least a half dozen other articles just in the past few years that have found the same results as these two articles i'm not going to go through all six of them i'll just show you these two as a representative in fact here's some of the articles article after article after article showing stress tests do not predict the need for invasive therapy and even invasive therapy in low risk patients doesn't improve their outcome all right now if somebody's high risk then we're not questioning that if somebody's high risk then they need a pci or or a stint but if somebody's low risk meaning history physical and ekg are not diagnostic why are we following these guidelines that are saying you need a mandatory stress test when all it's been shown to do is increase the number of procedures with potential complications by the way whenever somebody gets a stent what other drug do they need to be put on clopidogrel right aspirin and clopidogrel for the next year have any of you ever seen a clopidog clopidogrel complication all the time right so this doesn't even take into account the adverse effects from the anticoagulants in any platelet medications um this test specifically looked at coronary cta and take a look at what the take-home message was compared with existing standards of care for evaluation acute chest pain coronary ct angiography is associated with similar rates of major adverse events but higher rates of um revascularization so we routinely get coronary ctas in these low-risk patients all it does is increase the number of patients that go for pci and stents without improving outcomes and by the way also driving up the costs right so pretty interesting stuff so what in the world are we doing this is an interesting billboard how the lawyers look at things just because you did it doesn't mean you're guilty right all right so question right there we'll we'll talk about some of those variables in just a bit all right in terms of the hpi all right so why is this happening i thought that stress testing was the gold standard stress test positive they've got to get the test stress test negative then you're off the hook well we know provocative testing's not perfect all right everybody knows that poor sensitivity all right it's not um it's not perfect in general no matter what stress test you look at they have about an 80 to 85 percent at best sensitivity for picking up big coronary lesions so they're going to miss big lesions but what we weren't taught is that stress tests and especially coronary cta bless you especially coronary cta has very imperfect specificity also take a look at this study from 2012 take a look at the specificities they've got about 75 on average specificity so i already knew they weren't perfectly sensitive but i didn't know how non-specific they were what that means is that there's a tremendous number of false positives in these especially in these low-risk patients so you send people so if we take everybody in here and i'm going to assume everybody here is healthy you're not having any symptoms if i send everybody in this room for a stress test some of you are going to have false positive stress tests right what happens if you have a false positive stress test you go for a calf an unnecessary calf with all of those complications is it possible that you might have a false positive cast absolutely what happens if you have a false positive calf you get an unnecessary stint or maybe an unnecessary bypass surgery both of those have been well documented in the literature as well and it all starts with an unnecessary stress test which leads to all the rest of this what happens when you use a poorly specific test in a low-risk population you get a lot of false positives right that's basic statistics if you take a poor specificity test and apply it to a low-risk population you're more likely to get a false positive than a true positive all right lots of false positives and what happens when you get a false positive you go for unnecessary cath and possibly even unnecessary cabbage it's documented in the literature you guys remember this test called d dimer remember when d-dimer was introduced to us we were doing too many coronary ctas so they said hey there's this great blood test that you can use and it doesn't have great specificity but it's got really great sensitivity so if you use d dimer to help you decide whether to do a cta to look for a p e it's going to decrease the number of cts without missing anything so that was in the d dimer was given to us we were told to start using d dimers what happened to the rate of ctas it went up because people started using d-dimer in low-risk patients and what happens when you use a poorly specific test in a low-risk population a lot of false positives so the number of patients getting ctas increased we were never supposed to use d-dimer in low-risk patients that's the wrong group of patients to use it in you're supposed to use d dimer in intermediate risk patients all right in fact from the national guidelines this is from the annals of internal medicine the american college of physicians the biggest medical organization in the world put together an algorithm just a couple of years ago reminding us how we're supposed to use d dimer take a look at this algorithm pre-test probability if the pre-test probability is load you get a d-dimer no you use the perk rule you only use d-dimer when you've got an intermediate pre-test probability that's when you use the d-dimer so when your well score or revised geneva score is intermediate that's the patient use the d dimer not the low risk patient because if you use it a low risk patient you're going to increase the number of false positives and that's going to result in unnecessary ctas same thing applies to new to stress testing stress testing is not for patients that are low risk it was sold to us that way which is completely wrong it's meant for patients with intermediate risk so do we have any guidelines to back up what i'm saying we finally do this is the most recent asap clinical policy published in 2018 and here's what it says the test threshold a point of probability at which the harms associated with elevates your opponent testing and up exceed the risk of untreated disease has been estimated to be approximately two percent for patients presenting with suspected cardiac chest pain many patients may be receiving extensive diagnostic workouts for acs in which the harms exceed the potential benefit reading through this essentially what they say is that if you do your history physical ekg and your pre-test probability of acs is 2 or less if you send them for a stress test you're more likely to have a false positive stress test than a true positive stress test you're more likely to induce more harm than benefit by sending these patients to stress testing when they are low risk the biggest organization in emergency medicine has taken a bold step forward and said stop doing stress tests in low-risk patients do not routinely use further diagnostic testing either coronary cta or stress testing or myocardial perfusion imaging prior to discharge in low-risk patients in whom acutemi has been ruled out to reduce the 38 mace risk stop doing stress testing when the pre-test probability is 2 or less because you're more likely to get false positive stress tests and that's going to be associated with an increase in harm you now have backing from the biggest em organization in the world to say you know what when they say show me the literature to say why you didn't follow the guidelines you now have a clinical policy from the biggest em organization in the world with good data to back you up you now have something in your hands so the next question that you may be asking well you know you're saying two percent how in the world can we predict if somebody's risk is two percent are is there any way that we can tell if somebody's risk is two percent or less the heart score now i heard you heard a little bit earlier about the heart score during the lunch session and i wasn't here but i heard that they weren't necessarily real great or positive about the hard score if you want to use the edac score fine if you want to use the timmy or adapt score fine just make sure you're using a validated protocol all right i'm a big fan of the heart score because it's easy and i love mnemonics h-e-a-r-t i can remember that all right even without having to pull out my smartphone i can remember what h-e-a-r-t stands for and it's the most highly published and most validated accelerated diagnostic protocol in the world in our specialty all right here's the heart score for those people that are not familiar with it five scores h-e-a-r-t each one of these gets up to two points and what and when you add up the points using one conventional troponin this is the original data all right not even highly sensitive troponin they used a normal troponin and they used it at the time of arrival if somebody has a heart score of three or less their rate of major adverse event at six weeks was under two percent so you now have a validated and internationally externally validated score that can predict when your patient is under two percent risk right if one point seven percent is too high for you you can get a second troponin multiple studies have validated if you want get a second troponin at three hours after arrival if the second troponin is also less than or is also normal so heart score is three or less and now you've got two negative troponins your rate of adverse event at one month is less than one percent it's about point six percent all right i always like to recommend getting a second ekg also with that second component so we've got internationally externally validated scores that can tell you when you're patient has less than two percent risk and therefore is going to get more harm than benefit by the mandatory stress test or coronary cta all right and this is the most recent article that came out looking at the heart pathway the heart pathway is the term that refers to getting a troponin arrival and then another one at three hours after arrival heart score is endorsed by the aha it's also endorsed in acls in the chapter on acs it's endorsing the asap clinical policy that we just talked about it's talked about in numerous other articles internationally journals everywhere it's internationally prospectively and externally validated all right the edac score is also validated the adapt score is also validated the vancouver chest pain rule is pretty much validated so i'm not going to say you've got to use a hard score but just make sure you're using if you're using a score make sure that you're using one that has been externally validated and any of those in my opinion would meet standard of care so quick take-home points there is markedly increasing literature supporting the idea that we do not have to routinely be following stress testing or coronary cta in low-risk patients who meet one of these validated accelerated diagnostic protocols because routinely doing that is associated with increased length of stay increased cost increased subsequent invasive procedures and no reduction in the rate of major adverse cardiac events so why bother setting up for pci and cabbage if you know it's not associated with an improvement in outcome it doesn't make any sense all right so question again are these now defensible i would say absolutely yes with a couple caveats all right number one you've got to use it correctly i mentioned this yesterday or earlier today if you're going to use the accelerated diagnostic protocol use it the way it was researched don't come up with your own scores don't go rogue with it all right use it the way it was published use it the way it's on your smartphone all right do a great history and document it we talked about that earlier i like the old car mnemonic i document my old car hpi on every chest pain and belly pain patient i've seen since i finished residency actually since i learned at medical school in the early 90s all right every time all right add the points and properly document them and then use a standardized approach to the h the biggest question or quantity that comes up is how do you come up with the score for the h the history the history part of the heart score is a bit subjective so what we've done is we've looked at the international literature there's a handful of really great articles and you know the classic history for acs is chest pressure tightness squeezing radiating to the left arm left neck left jaw with shortness of breath nausea vomiting diaphoresis lightheadedness it felt just like my previous um unstable angina everything i mentioned is classic but when you actually look at the the big studies at all the different factors i just mentioned this goes to your question right there's only four that have the highest predictive value for ruling in for acs so what we've done is we've taken these four and we use these four in our 14 hospital network around the state of maryland what are the four factors that have the highest predictive value for ruling in for acs chest pain plus diaphoresis chest pain that worsens with exertion chest pain that radiates and by the way bilateral radiation is the worst of all followed by radiation to the right side least concerning is radiation to the left side all right but we don't complicate things we just say if it radiates in either direction all right and then chest pain with vomiting not nausea but vomiting the descriptors tightness squeezing pressure they've all been shown to be non-specific associated shortness of breath has been shown to be non-specific associated nausea or lightheadedness non-specific the only four that have the highest predictive value are chest pain with diaphrasis chest pain with vomiting chest pain that worsens with exertion chest pain that radiates in either direction so what we do in our entire network is for the heart score the h score if sub we ask those four questions to every single patient and it gets documented in fact it's incorporated in our epic computer system you cannot evaluate patients with chest pain without answering those questions on the computer if you have none of those four you get a zero for h if you have one of those four you get a one if you have two or more you get two points and the maximum score is two so that's what we do within our system so we have a we have a literature-based very standardized approach which every physician in the entire university of maryland network follows and they ask those four questions to everybody and that's what we do that actually got brought up at a deposition one time almost as if it's become standard of care at least to that lawyer it was right so come up with some type of standardized approach to the h and don't go rogue with this and if you follow these things i believe it's very very defensible by the way both the plaintiff and defense attorneys know the heart score and i've seen them repeatedly ask about the heart score during the deposition now if you say we don't use the heart score then they're not going to ask you more about it but they will ask what you use instead and if you're not using something else instead they're going to pull out the guidelines so i suggest you start using an accelerated diagnostic protocol again take your pick amongst the various ones so question yeah we no we just do the same thing um even taking into account women having atypical risk factors in the original heart score they didn't exclude women so they as far as i'm concerned they're validated now i think it's important to have a lower threshold with atypical presentations but in terms of the actual heart score we're not changing anything all right you are allowed to have some gestalt and some subjective nature and and that's where that that kind of plays in all right quick take-home points increasing literature suggest that routine provocative testing or cta for low-risk chest pain when the risk is under two percent associated with increased length of stray increased cost increased subsequent invasive procedures no reduction in major adverse cardiac events all right now if the clinical evaluations suggest a higher risk then you send them for further testing so what i would advocate for if you're using the heart score again heart score is zero to three discharge no stress testing they follow up with their primary care physician and the most important thing you can do for those patients is aggressive risk factor modification get them into a smoking program get them into some type of diabetes training program get them on hypertensive get them into this either primary care doc so that they can get all that stuff started that's the most important thing you can do to decrease their risk heart score four to six those are the intermediate risk patients that i believe are most going to benefit from the stress test or the coronary cta heart score of seven or more they're all coming in for aggressive management all right

Channel: The Center for Medical Education

Views: 26,913

Keywords: emergency medicine

Id: HGyB4xGP3qU

Length: 46min 50sec (2810 seconds)

Published: Tue Dec 22 2020