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Core Content In Urgent Care Medicine

Institute of Urgent Care Medicine © 2009www.UrgentCareCME.com 1

Urgent Care Management of

Acute Coronary Syndrome

Michael B. Weinstock, MDClinical Assistant Professor of Emergency Medicine

The Ohio State University College of Medicine

Medical Director and ED Attending

Mt. Carmel St. Ann’s Emergency Department

Columbus, Ohio

Disclosure:

Reports no financial interests relevant to this presentation

Supported by an Educational Grant from

Evaluation Of Chest Pain In The Urgent Care:

How To Find A Needle In A Haystack

Objectives

1. List the 6 life threatening causes of chest pain

2. Recognize special populations who present atypically for acute coronary syndrome (ACS)

3. Recognize unusual symptoms of ACS

4. Use the Pulmonary Embolism Rule-out Criteria (PERC) rule to clinically exclude PE

5. Be aware of the unusual presentations of aortic dissection

Six Life Threatening Causes Of Chest Pain

1. Myocardial infarction/ischemia

2. Aortic dissection

3. Pericardial tamponade

4. Tension pneumothorax

5. Pulmonary embolism

6. Esophageal rupture

Myocardial Infarction/Ischemia

THE

BIG

DADDY

Why Worried?

• 1.25 million AMIs per year in the U.S.

• 80% present to the emergency department

• Recent studies: 2-5% AMIs sent home

• The norm is atypical presentation



Medical School

• Everything I ever needed to know I learned in medical school…

Relative Risk – Clinical Factors Change The Probability Of MI

• Radiation of pain

– Left arm – LR 2.3

– Right shoulder – 2.9

– Both arms – LR 7.1


• Pleuritic chest pain – LR 0.2


• Sweating – LR 2.0


• Chest pain reproduced with palpation –LR 0.2-0.4

How Do We Localize The High Risk Patients?

• The two step approach



The Two Step Approach

1. Identify high risk patients

2. Review their evaluation before they leave the Urgent Care

The Front Door-Back Door Approach

1. Evaluate from symptoms based perspective

2. Evaluate from diagnosis based perspective

Front Door (Symptom Based):1. Evaluate chief complaint (OLD CAAAR)

– Onset

– Location

– Duration

– Character

– Aggravating factors

– Alleviating factors

– Associated symptoms

– Radiation

Back Door (Diagnosis Based):

2. Evaluate in diagnosis specific fashion

– Think ‘6 life threatening causes of chest pain’ in each patient where diagnostic uncertainty remains

– Evaluate for each diagnosis with H&P/ROS

Six Life Threatening Causes Of Chest Pain – Bedside Diagnosis

Myocardial infarction/ischemia

Aortic dissection

Pulmonary embolism

Pericardial tamponade

Tension pneumothorax

Six Life Threatening Causes Of Chest Pain – Bedside Diagnosis

Myocardial infarction/ischemia

Aortic dissection

Pulmonary embolism

Pericardial tamponade

Tension pneumothorax

Esophageal rupture



Case

Studies

Case One

37-Year-Old Man With Chest Pain

37-Year-Old Male With CP• Hx: Tight CP with SOB which began during the

night. Worse with eating. Decreased appetite associated SOB. Worse with exertion.

• PCP recently Dx GERD and prescribed Omeprazole (Prilosec®)

• Was admitted to hospital 7 weeks previous for chest pain and had negative stress test

• Sister with hx MI

• PE: Normal

37-Year-Old Male With CP

• ECG: NSR and T wave inversion in aVL and Q waves in V1 and V2 and nonspecific ST changes

• CXR: Normal

Questions To Approach?

• GI cocktail?


• How to factor recent negative stress test into cardiac risk?




• How does age factor into cardiac risk?

Outcome

ED course

• Labs: Troponin 5.9 (nl 0.0-0.27) = Acute MI

• Disposition: Admitted

• Testing: Inpatient cath shows CAD stent

Lessons

• Patients want to be well

• Sensitivity of stress test - poor

• Importance of risk factors – Sister with hx. of disease

• Assoc symptoms: SOB and worse with exertion

Framingham Risk Factors

1. Family history

2. Diabetes

3. Cigarette smoking

4. HTN

5. Hyperchoesterolemia

6. Male gender

7. Age > 55-years-old

ACS In Young Patients

• Patients < 45 years-old

• 10% of myocardial infarctions in the U.S. occur in patients < 45 years-old

• Atherosclerotic disease was noted in 17% of teenagers on autopsy

Question

• What % of patients 24-39 years-old presenting with chest pain ruled-in for ACS?



ACS In Young Patients – Answer:

• 5.4% of patients 24-39 years-old presenting with chest pain ruled-in for ACS

How To Avoid Missing MI In Young Patients?

• Index of suspicion

• Evaluation of risk factors

• H&P

• H&P

• H&P!

…and

How To Avoid Missing MI In Young Patients?

• Don’t listen to the paramedics…

• Don’t listen to the nurses…

• Don’t listen to the patient??…

Special Populations: DM• Up to 40% present atypically

– Dyspnea

– Confusion

– Emesis

– Fatigue

• More likely have adverse outcomes from ACS

• Diabetic patient with ACS and negative enzymes have the same risk of adverse outcomes as non-diabetic patients with ACS and positive enzymes

Special Populations: Cocaine

• Independent risk factor for atherosclerotic heart disease and MI

• Cocaine accounts for up to 25% of acute MIs in patients < 45 years-old

• Cocaine can induce coronary vasoconstriction, increased platelet aggregation, and/or adrenergic stimulation that lead to dysrhythmias and ischemia

Special Populations: Cocaine

• Chronic use of cocaine is associated with MI as well, causing markedly accelerated atherogenesis and subsequent early MI

• Cocaine users have a seven-fold increased risk of MI



Question

• What percent of cocaine users presenting to the ED with chest pain will rule-in for myocardial infarction?

Answer

• 6% of cocaine users presenting to the ED with chest pain will rule-in for myocardial infarction

Special Populations: Lupus

• Women < 45 years-old with increased risk of early MI as high as fifty-fold

• Atherosclerosis is likely multifactorial, related to systemic inflammation and dyslipidemias

Special Populations: Renal Disease

• Independent risk factor for atherosclerosis

– Dyslipidemias

– Homocysteinemia

– Elevated levels of lipoprotein (a)

– Increased platelet aggregation

– Chronic inflammation

Case Two

81-Year-Old Woman With Abdominal Pain

81-Year-Old With Abdominal Pain

• Time: 13:15

• HPI: Epigastric abdominal pain radiating to back

• Nausea

• States feels like her GERD




• ROS: No fever or chills.

• She denies any weakness or shortness of breath

• Denies fever, n/v, chest pain, SOB, cough, rhinorrhea, sore throat, dysuria, HA, numbness, dizziness, LOC, diaphoresis

• PAST MEDICAL HISTORY:

• Allergies: No known allergies

• Medications: HCTZ, Simvastatin (Zocor®), Clonidine, Verapamil

• Past medical history: Ulcer disease, HTN

• Past surgical history: Appendectomy, knee surgery, bladder suspension, eye surgery

VITAL SIGNS

Time Temp (F) Pulse Resp Syst Diast O2 Sat

13:47 98.4 74 18 130 68

17:20 84 18 155 69 98


• CONSTITUTIONAL: Well-appearing; A&O X 3

• NECK: No JVD

• RESP: Breath sounds clear and equal bilaterally

• CARD: RRR without m/r/g

• ABDM: Moderate pain at epigastric area, elsewhere non-tender, soft, r/r/g, no pulsatile mass

• CHEST: No pain with palpation

• EXT: Pulses intact, no p. edema or calf muscle pain


• 14:13 –WBC count elevated 18,000

• 14:25 – Acute abdominal series nonspecific gas pattern

• 16:45 – Becomes diaphoretic…

• What is the next step?

What Was The Diagnosis?

1. GERD

2. ACS/MI

3. Pancreatitis

4. PE


6. Cardiac tamponade

7. Other?




ECG Acute inferior MI (ST elevation II, III, aVF with reciprocal changes)


• What happened?

Presentations Of ACS In Women

• Men with greater risk of ACS and MI

• Women at greater risk of misdiagnosis

• Up to 20% of women do not have chest pain

– N/V

– Abdominal pain

– Diaphoresis

– Dyspnea

Presentations Of ACS In Women

• More likely to have false negative stress tests

• More likely to have right sided radiation

• Less likely to have ECG performed

• ECG less likely to show changes specific for heart disease

Presentations Of ACS In Elderly

Question:

How often is there:

• Painless ACS in patients over 65

• Painless ACS in patients over 85



Presentations Of ACS In Elderly

• Painless ACS over 65 – 40%

• Painless ACS over 85 – 60-70%

• Anginal equivalents:• Dyspnea (most common)

• Diaphoresis

• Vomiting

• Neurological Sx inc. confusion, lethargy, weakness, syncope

ACS in Elderly

• When an ‘anginal equivalent’ is present in elderly patients even without chest pain Perform an ECG

Reflux or MI?• In 20% of cases, patients report indigestion-

type discomfort

• 30% of pts with ACS get pain relief with antacids

• Reflux esophagitis is the most common misdiagnosis in cases of missed ACS

• Relief of discomfort with antacids does not exclude a diagnosis of cardiac disease

Case Three

57-Year-Old Man With Back Pain

History

• 57-yr.-old man presents with 1 day of right back pain which started after he sat down on a bed

• No radiation to abdomen

• Resolved with acetaminophen then returned

• PMH: History of kidney stones

• PSH: Hip replacement 4 weeks ago

History - ROS

• Has noticed a “light cough”

• No n/v/d, abdominal pain, chest pain, palpitations, orthopnea, SOB, cough, hemoptysis, rhinorrhea, sore throat, ear pain, ear discharge, stiff neck, HA, paresthesias, dizziness, facial droop, slurred speech, LOC, skin rash, lymph node swelling, anemia, bruising, calf muscle pain, myalgias, muscle cramps, anxiety, increased stress



Physical Exam

• GENERAL: A&O X 3

– CARDIO: RRR; no m/r/g. Pulses are equal bilaterally, no peripheral edema

• RESP: Breath sounds clear and equal bilaterally; no wheezes, rhonchi, or rales

• ABD: Soft and nontender

Test Results

• TWO-VIEW CHEST: Minimal bibasilar atelectasis

• Urine dip stick: WNL

Thoughts??

• Evaluation

• Documentation

• Testing

• Disposition

Risk Management Issues With Initial Chart

1. Minimal ROS specific to back pain (i.e., urinary retention/incontinence, weight loss)

2. Complaint of cough not addressed in HOPI

3. PE: No examination of the back

4. No progress note

5. Medical decision making: Potential life threatening etiologies of symptoms addressed?

**VOTE**• What was the diagnosis?

• Kidney stone/ureterolithiasis

• AAA

• Cholecystitis

• Pancreatitis

• Intractable back pain

• Other?

Bounce Back – 15 Days Later

• ED return at 7PM with CC of RUQ pain

• No change in pain with different foods/fatty foods

• No pleuritic pain but occasionally takes a deep breath and feels a “catch”

• Used aspirin after the hip replacement for blood thinning



Bounce Back

• VitalsTime Temp(F) Rt. Pulse Resp Syst Diast O2 Sat Pain

Scale

19:18 98.1 O 87 16 138 83 93% 6

• EXAM:

– Abdomen: Soft and NT without r/r/g

– Back: Right muscular back pain with palpation

– EXT: No pain or swelling bilateral LE

Bounce Back

• Testing:

– CT pulm angiogram: Positive for pulmonary emboli with a saddle embolus on the right

Hospital Course

• Enoxaparin (Lovenox®), warfarin(Coumadin®)

• LE dopplers with large right sided DVT

• ECHO without RV strain

• Greenfield filter placement

• Hospital discharge

Front Door-Back Door Approach

• After HPI, perform specific evaluation for life threatening causes of chest pain

PERC Rule

• Low clinical gestalt + PERC rule negative =

<1-2% risk of PE

(Low clinical gestalt = Less than 15% chance of PE clinically)

Kline JA, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thrombosis Haemostasis2004;2:1247-1255.

PERC Rule1. Age < 50 years

2. Pulse < 100 bpm

3. SaO2 > 95%

4. No unilateral leg swelling

5. No hemoptysis

6. No recent trauma or surgery

7. No prior PE or DVT

8. No hormone use



Case Four

Multiple Cases Of Aortic Dissection

Litigation in Dissection

“In fact, difficulty in diagnosis, delayed diagnosis or failure to diagnose, are so common as to approach the norm for this disease, even in the best hands, rather than the exception.”

JA Elefteriades. Litigation in nontraumatic aortic diseases--a tempest in the malpractice maelstrom. Cardiology. 2008;109:263-72.

1. DeBakey type I and Stanford type A: Dissections that involve the proximal aorta, arch, and descending thoracic aorta.

2. DeBakey type II only involves the ascending aorta (inc. Stanford type A) 3. DeBakey type III and Stanford type B: Dissections that originate in the

descending thoracic and thoracoabdominal aorta regardless of any retrograde involvement of the arch. (Subdivided into a and b depending on abdominal aortic involvement)

Copyright @ 2009. CTSNet, Inc. Republished by permission.

Plain chest x-ray exhibiting acute type A dissection:1. Widened mediastinum2. Rightward tracheal displacement3. Irregular aortic contour - loss of aortic knob4. Indistinct aortopulmonary window5. Left pleural effusion.

http://cardiacsurgery.ctsnetbooks.org/content/vol2/issue2003/images/large/1095fig4.jpeg?ck=nck



CT arteriogram showing a nearly circumferential dissection flap (arrowhead) as a result of acute aortic transection

Aortic Dissection

• Mortality increases 1-2% per hour

• Diagnostic delay > 24 hours in 31% with proximal dissection and 53% distal dissection

• 15% have painless dissection

• 13% with aortic dissection had syncope as only symptom

• 1/3 patients with dissection will re-dissect, rupture, or extend dissection within 5 yrs

Aortic Dissection – Risk Factors

• Male

• HTN

• Cocaine

• CTD’s (Marfan’s, Ehler’s Danlos)

• Turner’s

• Polycystic kidney disease

• Family history

• ? Pregnancy

Marfan Syndrome

• Abraham Lincoln

• Mary Queen of Scots

• Charles de Gaulle

• Rachmananov

• Jonathan Larson (RENT)

• (possibly) Michael Phelps

Marfan Syndrome

• Tall

• Loose jointed, lanky frame

• Nearsightedness

• Aortic enlargement with thin walls

• Affects 1/5,000 to 1/10,000 people

http://cardiacsurgery.ctsnetbooks.org/content/vol2/issue2003/images/large/1095fig2.jpeg?ck=nck



Six Life Threatening Causes Of Chest Pain

1. Myocardial infarction/ischemia


3. Pericardial tamponade

4. Tension pneumothorax

5. Pulmonary embolism

6. Esophageal rupture

Summary

Chest pain mimics in high risk patients

Evaluate in diagnosis specific fashion (front door-back door)

Atypical presentation in special populations

Document progress note

Inform patient and family of diagnostic uncertainty

Questions?

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