Short Stay Management of Chest Pain (eBook)

Preface 5
References 7
Contents 9
Contributors 11
Epidemiology and Demography of Coronary Artery Disease 13
History of the Study of Epidemiology and Coronary Artery Disease 14
Cardiovascular Disease Statistics 15
Coronary Artery Disease Statistics 17
Risk Factors of CAD 20
Hypertension 20
Physical Inactivity 20
Tobacco Use 22
Hyperlipidemia 22
Overweight and Obesity 23
Diabetes 23
References 25
Financial Impact of Acute Coronary Syndromes: The Need for New Care Delivery Models 26
Introduction 26
The High Costs of Cardiovascular Disease 27
The Chest Pain Dilemma 28
Historical Perspective of CPU 29
Forces Affecting Cardiac Care Reimbursement 30
Reimbursement for Chest Pain and ACS 32
Clinical and Fiscal Rational for a CPU 33
Re-engineering the Chest Pain Delivery Model-New Solutions 35
Measuring Changes Is Critical 43
Conclusion 44
References 45
Why Have a Chest Pain Unit? 47
Background on Why Chest Pain Units Are Needed 48
So Why Not Admit All ‘‘Suspect’’ Chest Pain Patients? 49
What Is a Chest Pain Center? What Is a Chest Pain Unit? 50
Why Have a Chest Pain Unit? 51
Reduction in Mortality and Morbidity Risk for ACS Patients 52
Reduction in Unnecessary Inpatient Admissions, Costs, and Length of Stay for Chest Pain Patients 54
Improved Patient and Physician Satisfaction 57
Improved Hospital Resource Utilization - Increased Capacity, Decreased Ambulance Diversion, Fewer Patients that Leave ED Without Being Seen 58
Economic Benefits - More Cost-Effective, Decreased Compliance Risk, More Equitable Admissions, New Service Line, Marketing Advantage, Decreased Liability Risk 59
Summary 62
References 62
Pathophysiology and Definition of the Acute Coronary Syndromes 65
Spectrum of the Acute Coronary Syndromes 66
Vulnerable Plaque and Plaque Rupture 68
Inflammation and Morphology 68
Coronary Thrombosis 70
Degree of Coronary Stenosis 71
Clinicopathologic Correlations 72
Nonatherosclerotic Causes of MI 74
Conclusions 74
References 74
Emergency Department Presentation 76
Arrival to ED 76
Classical Presentations of Acute Coronary Syndrome 77
Confounders 79
Differential Diagnosis 81
Guideline Recommendations 83
Cardiac Biomarkers 84
References 85
Risk Stratification: History, Physical, and EKG 88
Introduction 88
History and Risk Factors 89
Physical Examination 90
Electrocardiogram 91
Risk Prediction Tools 94
References 96
Cardiac Markers: A Chest Pain Center Focus 100
Introduction 101
Cardiac Necrosis Markers 102
Cardiac Troponin T and Cardiac Troponin I 102
Diagnosis of Myocardial Infarction 102
Early Risk Stratification 104
Clinical Decision Making 105
CK-MB Measurement 106
Myoglobin 107
Ischemia and Risk Stratification Markers 107
Ischemia-Modified Albumin 108
Myeloperoxidase 108
High-Sensitivity C-Reactive Protein 109
B-Type Natriuretic Peptide and N-Terminal proBNP 110
Future Development 111
Point-of-Care Testing for Cardiac Biomarkers 111
Clinical Confounders for Biomarker Testing 112
Renal Insufficiency and End-Stage Renal Disease 113
Blunt Chest Trauma 114
Pulmonary Embolism 114
Chemotherapy 114
Recent Cardiac Procedures 115
Reinfarction 116
Panels 117
Future Developments 117
References 118
Risk Stratification Using Scoring Systems 123
Goldman Risk Score 123
ACI-TIPI 125
Artificial Neural Networks 126
TIMI Risk Score 127
PURSUIT Risk Score 129
GRACE Risk Score 129
Clinical Impression 130
References 131
Emergency Department Disposition of Patients Presenting with Chest Pain 133
Introduction 133
Risk Stratification 134
Who Warrants Immediate PCI or Thrombolysis? 135
Which Patients Require Hospitalization? 137
Patients Who May Warrant Early Intervention? 138
Which Patients Require Hospitalization or an Observation Unit? 139
Patients Appropriate for an Observation Unit 141
Patients Appropriate for Discharge 142
Special Considerations 143
Women 143
Diabetes Mellitus 143
Elderly 144
Cocaine and Methamphetamine-Induced Chest Pain 144
Conclusions 145
References 145
Short-Stay Unit Requirements 150
References 152
Medical Therapy in Patients Managed in a Chest Pain Observation Unit 153
Aspirin Therapy 153
Anticoagulation 154
Nitrates 155
Beta Blockers 155
Conclusion 156
References 156
Provocative Testing 160
Introduction 160
Patient Selection 162
Test Selection 163
Inability to Exercise 163
Baseline ECG Changes 164
Added Value of Cardiac Imaging 165
Recommendations for Choice of Diagnostic Test 165
Exercise Treadmill Testing 166
Test Performance and Interpretation 166
Prognostic Scores 169
Supervision and Post-Discharge Testing 169
Utility of Exercise Stress Testing in an ADP 170
Myocardial Perfusion Imaging 172
Practical Applications of Stress Imaging 173
Nonimaging Variables 174
Image Interpretation 175
Pharmacological Stress Imaging 176
Acute Rest Imaging 176
Incorporating Rest Imaging into an ADP 178
Echocardiography 180
Stress Echocardiography 181
Rest Echocardiography 182
Comparison of Stress Echocardiography and Stress MPI 182
Summary 184
References 185
Use of Multislice CT and MRI for the Evaluation of Patients with Chest Pain 190
Overview of CT Technology 191
The Accuracy of Coronary CT Angiography 191
Diagnostic Accuracy of CT in Emergency Department Patients with Acute Chest Pain - Initial Experience 191
Calcium Scoring in Addition to the CCTA 195
Coronary CTA and Identification of Unstable Plaques 196
The ‘‘Triple Rule-Out’’ CT Protocol 197
Dedicated Coronary vs. ‘‘Triple Rule-Out’’ Scan Protocol - Radiation Dose Considerations 201
Assessment for Non-Cardiac, Extravascular Pathology: Value Added 202
Coronary CTA Limitations and Protocol Considerations 203
The Use of Magnetic Resonance Imaging in the Emergency Department 204
Conclusions 205
Notes 206
References 206
Disposition from the Short Stay Unit 209
CPU Patient Entry: Appropriate Patient Selection for ‘‘Rule Out ACS’’ 210
Exclusion of Patients at High Risk for ACS or Adverse Cardiac Events If Discharged 210
Exclusion of Patients at Very Low Risk of ACS from Observation Strategies 211
Exclusion of Patients with Logistical and Nonmedical Barriers to Safe Discharge 211
Indications for Hospitalization from the Short Stay Unit: Admission Triggers 212
Assessment of Clinical Factors 213
Heart Rate 213
Blood Pressure 214
Respiratory Distress and Hypoxemia 214
Recurrent Ischemic Pain 214
Abnormal ECG and Serum Cardiac Marker Testing in the Observation Phase 214
Dynamic ECG Changes 214
Continuous ECG Rhythm Monitoring 215
ST Segment Changes 215
T-Wave Changes 215
Abnormal Cardiac Markers 216
Provocative Testing and Advanced Imaging 217
Reassessment of Functional Status at the End of the CPU Protocol 217
Situations When Outpatient Medical Management Strategies for Patients with Known Coronary Artery Disease Are Appropriate 218
Establishment of Follow-up 219
Summary 220
References 221
Examples of Patient Discharge Instructions, ACS Rule Out Protocols, and Order Sheets 222
Index 266