ACS Risk Stratification Orientation.pptVIP

Courtesy A. Chandra, S. Stahmer, Alex Limkakeng Risk Stratification of Acute Coronary Syndrome Alex Limkakeng, MD Division of Emergency Medicine Duke University Medical Center Acknowledgement: Abhinav Chandra, MD, FACEP Or . . . “Why do we have to rule out all these people with chest pain?” A good question! Table of Content Epidemiology ED Risk Stratification History and Exam EKG Cardiac Markers Other Strategies The Future? Media/ Lay Press Epidemiology Epidemiology: $ 2-8% of AMI are d/c’d from ED Missed AMI’s account for: 20% of malpractice awards Most dollars paid in malpractice in EM Epidemiology: non-CP 434,877 patients with confirmed MI 33% without Chest Pain Older, 70 years old Women Diabetes CHF 23% in hospital mortality rate Cantos JG. JAMA. 2000;283:3223-3229. Why Risk Stratification? ED definitive diagnosis not possible Info from ED not enough Large numbers of patients presenting High prevalence of underlying disease High stakes Impracticality/danger of testing everyone w/ gold standard Risk Stratification Goals Identify patients who: Need time dependent therapies (PCI/lytics) High risk/may benefit from PCI/meds urgently Monitored in lower acuity settings Stable for delayed work-up/follow up Time dependent therapies ECG STEMI or new LBBB Cardiogenic shock due to MI “ICC express”: Door-ECG 10 minutes ECG to cath 25 minutes door to balloon/drug 90 min High risk/Urgent Dynamic ECG changes ST depression 1mm Marked symmetrical T wave inversion Troponin/MB positive History of MI/ CAD Definite angina M60, F 70 Monitor in lower acuity settings Normal or unchanged ECG Negative initial markers Angina: 60 M, 70 F Probable angina: 60M, 70 F Atypical chest pain in diabetics Atypical chest pain + 3 CAD risk factors ST change 1mm or T wave inversion Delayed work-up/follow up Stable ECG T wave flattening or inversion 1mm Negative serial cardiac markers Atypical chest pain CAD risk factors other than diabetes Provocative testing wnl Normal ECG/Young/Extreme