F ALLING
THROUGH THE CRACKS ?
E XPANDING
OUR APPROACH TO
ACUTE CORONARY SYNDROMES
012-0400-PM 5/15
O UR PRESENTERS
Frank Peacock, MD, FACEP
Manuel Cerqueira, MD, FACC, FAHA, MASNC
Professor, Emergency Medicine
Associate Chair and Research Director
Baylor College of Medicine
Professor of Radiology and Medicine
Cleveland Clinic Lerner College of Medicine of
Case Western Reserve University
Chairman, Department of Nuclear Medicine,
Imaging Institute
Staff Cardiologist, Heart and Vascular Institute
Cleveland Clinic
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D ISCLOSURES
Frank Peacock, MD, FACEP
• Advisory board
– Astellas Pharma
• Speakers bureau
– Astellas Pharma
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D ISCLOSURES
Manuel Cerqueira, MD, FACC, FAHA, MASNC
• Advisory board
– Astellas Pharma
– Adenosine Therapeutics
– FluoroPharma
• Speakers bureau
– Astellas Pharma
– GE Healthcare
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I MPORTANT INFORMATION
• This is a non–product-related program
• No specific products will be discussed and
no product-related questions will be answered
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H AVE YOU SEEN J ANE ?
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J ANE PRESENTS TO YOUR EMERGENCY DEPARTMENT (ED)
• 47 years old
• Comes in vomiting at 7 PM
• She may have eaten
some “bad tuna”
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S HE UNDERGOES THE USUAL TESTING
• Assessment of electrolytes and
complete blood count
• ECG completely normal
• Gets an IV
- 4 mg ondansetron
- 1 liter normal saline
• 4 hours later (11 PM), Jane
feels better
• Diagnosis: food poisoning
• She’s discharged home
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B UT A FEW HOURS LATER , SHE GETS WORSE
• At 6 AM, Jane collapses, 911 is called
• Paramedics arrive within 4 minutes
• Jane is found in ventricular
tachycardia and defibrillated
• 17 minutes after arrest, she returns
to normal sinus rhythm
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S HE’ S RUSHED BACK TO THE HOSPITAL
• Prehospital ECG transmitted
• Jane is taken straight to cath lab
• Door-to-balloon time: 27 minutes
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But it’s too little too late
Jane does not survive
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W E CAN DO MORE
• Jane received relatively standard evaluation
• But we missed Jane’s ACS because:
– She didn’t report chest pain
– Her ECG was normal
• How should we work up patients who present to the ED with
possible ACS?
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L ET ’ S TAKE A LOOK AT …
• Chest pain and ECG
• Risk stratification tools in the ED
• Biomarker testing in the ED
• Myocardial perfusion imaging (MPI) and the ED
• MPI case studies
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A UDIENCE RESPONSE
What is your current role at your facility?
Choose all that apply.
1. Nurse Manager/Director
2. Medical Director
3. Emergency Physician
4. High-level Administrator
5. Cardiologist
6. Hospitalist
7. Cardiovascular Coordinator/
Service Line Administrator
8. Physician’s Assistant
9. Nurse Practitioner
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C HEST PAIN AND ECG
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AHA STATEMENT ON CHEST PAIN TESTING
SYMPTOMS SUGGESTIVE OF ACUTE CORONARY SYNDROME (ACS)
Noncardiac diagnosis
Chronic stable angina
Treatment as indicated
by alternative
diagnosis
See ACC/AHA
Guidelines for Chronic
Stable Angina
Possible ACS
Definite ACS
Nondiagnostic ECG
Normal initial cardiac markers
See ACC/AHA
Guidelines for Non-ST
Elevation ACS
See ACC/AHA Guidelines
for ST Elevation Acute
Myocardial Infarction
Observe
Serial ECGs, cardiac markers
IF NEGATIVE
Consider MPI to
identify rest ischemia
IF POSITIVE
IF POSITIVE
Study to provoke
ischemia or detect
anatomic CAD
IF NEGATIVE
IF NEGATIVE
Outpatient follow-up
Adapted from Amsterdam EA, et al. Circulation 2010;122:1756-1776.
IF POSITIVE
Admit to hospital
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TIMI RISK SCORE : 2- WEEK MACE
THROMBOSIS IN MYOCARDIAL INFARCTION
– Age 65 years
– 3 risk factors for CAD
– Significant coronary stenosis
(eg, prior 50%)
– ST-segment deviation on ECG
– Severe angina (eg, 2 angina
events in previous 24 hours)
– Use of ASA in last 7 days
– Elevated serum cardiac
markers CK-MB or troponin
RATE OF COMPOSITE ENDPOINT
(DAYS 1-14), %
• Risk
40.9
45
factors1:
40
35
30
26.2
25
19.9
20
13.2
15
8.3
10
5
0
4.7
0/1
2
3
4
5
6/7
NUMBER OF RISK FACTORS
Each risk factor is assigned 1 point, and the total represents a given patient’s TIMI Risk Score1
Event rates (all-cause mortality, MI, or urgent revascularization) increase with each
1-point increase in score (P<0.001 by chi-square test for trend)1
MACE = major adverse cardiac event.
1. Antman EM, et al. JAMA 2000;284:835-842.
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ECG: STANDARD PROTOCOL
• AHA/ACC guidelines: ECG within 10 minutes of arrival at ED1
EASY
1. Amsterdam EA, et al. J Am Coll Cardiol 2014;64:e139-e228.
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H OW ACCURATE IS 12- LEAD ECG?
In a retrospective study of 1684 patients
(majority male Caucasian)1:
12%
1. Masoudi FA, et al. Circulation 2006;114:1565-1571.
had a high-risk ECG abnormality that was missed in the ED
(range across hospitals: 5.6%-15.1%)
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R ISK STRATIFICATION
TOOLS IN THE ED
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P RETEST ODDS ARE CRITICALLY IMPORTANT
Hypothetical Example
• Test 95% specific, 95% sensitive
– When positive, wrong 5% of the time
– When negative, wrong 5% of the time
• Population: 80% diseased
– 20% disease free
– 5% false positive rate = 1 false positive
– 1 in 100 diagnosed with a disease they do not have
• Population: 2% diseased
– 98% disease free
– 5% false positive rate = 4.9 false positive
– ~5 in 100 diagnosed with a disease they do not have
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E ARLY RISK STRATIFICATION OF NSTE-ACS
1. AMSTERDAM EA, ET AL. J AM COLL CARDIOL 2014;64:E139-E228.
RECOMMENDATIONS
COR
LOE
Perform rapid determination of likelihood of ACS, including a 12-lead ECG within 10 min of arrival at an
emergency facility, in patients whose symptoms suggest ACS
I
C
Perform serial ECGs at 15- to 30-min intervals during the first hour in symptomatic patients with initial
nondiagnostic ECG
I
C
Measure cardiac troponin (cTnl or CTnT) in all patients with symptoms consistent with ACS
I
A
Measure serial cardiac troponin I or T at presentation and 3–6 h after symptom onset in all patients with
symptoms consistent with ACS
I
A
Use risk scores to assess prognosis in patients with NSTE-ACS
I
A
Risk-stratification models can be useful in management
IIa
B
Obtain supplemental electrocardiographic leads V7 to V9 in patients with initial nondiagnostic ECG at
intermediate/high risk for ACS
IIa
B
Continuous monitoring with 12-lead ECG may be a reasonable alternative with initial nondiagnostic ECG in
patients at intermediate/high risk for ACS
IIb
B
BNP or NT–pro-BNP may be considered to assess risk in patients with suspected ACS
IIb
B
ACS = acute coronary syndrome; BNP = B-type natriuretic peptide; COR = Class of Recommendation; cTnl = cardiac troponin I; cTnT = cardiac troponin T; ECG = electrocardiogram;
LOE = Level of Evidence; NSTE-ACS = non–ST-elevation acute coronary syndrome; and NT–pro-BNP = N-terminal pro–B-type natriuretic peptide.
Adapted from Amsterdam EA, et al. J Am Coll Cardiol 2014;64:e139-e228.
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GRACE: RISK ASSESSMENT FOR MORTALITY AFTER ACS
1. FIND POINTS
FOR EACH PREDICTIVE FACTOR:
KILLIP
CLASS
POINTS
SBP,
mm Hg
POINTS
HEART RATE,
BEATS/MIN
POINTS
AGE, Y
POINTS
CREATININE LEVEL,
mg/dL
POINTS
I
0
≤80
58
≤50
0
≤30
0
0-0.39
1
II
20
80-99
53
50-69
3
30-39
8
0.40-0.79
4
III
39
100-119
43
70-89
9
40-49
25
0.80-1.19
7
IV
59
120-139
34
90-109
15
50-59
41
1.20-1.59
10
140-159
24
110-149
24
60-69
58
1.60-1.99
13
160-199
10
150-199
38
70-79
75
2.00-3.99
21
≥200
0
≥200
46
80-89
91
>4.0
28
≥90
100
KILLIP CLASS
POINTS
Cardiac Arrest at Admission
39
ST-Segment Deviation
28
Elevated Cardiac Enzyme Levels
14
2. SUM POINTS FOR
Killip
Class
3. LOOK
+
SBP
ALL PREDICTIVE FACTORS:
+
Heart
Rate
+
Age
+
Creatinine
Level
+
UP RISK CORRESPONDING TO TOTAL POINTS:
+
Cardiac
Arrest at
Admission
ST-Segment
Deviation
+
Elevated Cardiac
Enzyme Levels
=
Total
Points
TOTAL POINTS
≤60
70
80
90
100
110
120
130
140
150
160
170
180
190
200
210
220
230
240 ≥250
PROBABILITY OF
IN-HOSPITAL DEATH, %
≤0.2
0.3
0.4
0.6
0.8
1.1
1.6
2.1
2.9
3.9
5.4
7.3
9.8
13
18
23
29
36
44
Adapted from Granger CB, et al. Arch Intern Med 2003;163:2345-2353.
≥52
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TIMI RISK SCORE : 2- WEEK MACE
THROMBOSIS IN MYOCARDIAL INFARCTION
– Age 65 years
– 3 risk factors for CAD
– Significant coronary stenosis
(eg, prior 50%)
– ST-segment deviation on ECG
– Severe angina (eg, 2 angina
events in previous 24 hours)
– Use of ASA in last 7 days
– Elevated serum cardiac
markers CK-MB or troponin
RATE OF COMPOSITE ENDPOINT
(DAYS 1-14), %
• Risk
40.9
45
factors1:
40
35
30
26.2
25
19.9
20
13.2
15
8.3
10
5
0
4.7
0/1
2
3
4
5
6/7
NUMBER OF RISK FACTORS
Each risk factor is assigned 1 point, and the total represents a given patient’s TIMI Risk Score1
Event rates (all-cause mortality, MI, or urgent revascularization) increase with each
1-point increase in score (P<0.001 by chi-square test for trend)1
MACE = major adverse cardiac event.
1. Antman EM, et al. JAMA 2000;284:835-842.
012-0400-PM 5/15
HEART SCORE FOR MACE 1
HISTORY: Highly suspicious = 2, Moderately = 1, Slightly = 0
ECG: Significant ST depression = 2, Nonspecific repolarization disturbance = 1, Normal =
0
AGE: ≥65 = 2, 45-65 = 1, <45 = 0
RISK FACTORS: ≥3 Risk factors or history of atherosclerosis = 2,
1-2 Risk factors = 1, No risk factors = 0
TROPONIN: >2x Normal limit = 2, 1-2x Normal limit = 1,
≤ Normal limit = 0
Low risk = 0-3;
2.5% MACE risk
1. Backus BE, et al. Curr Cardiol Rev 2011;7(1):2-8
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B IOMARKER TESTING
IN THE ED
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A 2- HOUR DIAGNOSTIC PROTOCOL
FOR CHEST PAIN PATIENTS
ADPa
PATIENTS
30-DAY MACE (PRIMARY ENDPOINT)
90.2% (n=3230)
11.7% (n=418)
9.8% (n=352)
0.08% (n=3)
PATIENTS
30-DAY MACE (PRIMARY ENDPOINT)
POSITIVE
80% (n=1583)
15% (n=301)
NEGATIVE
20% (n=392)
0.25% (n=1)
POSITIVE
NEGATIVE
ADP (ECG + TIMIb
+ troponin)c
ADP = accelerated diagnostic protocol; ASPECT = 2-Hour Diagnostic Protocol to Assess Patients With Chest Pain Symptoms in the Asia-Pacific Region;
ADAPT = 2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker.
a ADP was negative if TIMI score was 0 and if electrocardiograph (ECG) and point of care (POC) biomarkers (troponin, creatinine kinase MG, and myoglobin)
were all negative. If TIMI score was ≥1 or any other parameter was positive, then ADP was positive.
b ECG alone: any new ischemia was positive.
c ADP was negative if TIMI score was 0 and ECG and cardiac Troponin-I (cTnI) were all negative. If TIMI score was ≥1 or any other parameter was positive, then
ADP was positive.
1. Than M, et al. Lancet 2011;377:1077-1084. 2. Than M, et al. J Am Coll Cardiol 2012;59:2091-2098.
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ADAPT AND APACE: 30- DAY MACE
ADAPT (n=1635)1,a
TIMI
SN
NPVc
0
100%
100%
≤1
(98.5-100)
(98.8-100)
99.2%
99.7%
(97.1-99.8)
(98.9-99.9)
APACE (n= 909)1,b
SN
NPV
99.4%
99.7%
(96.5-100)
APACE = Advantageous Predictors of Acute Coronary Syndromes Evaluation; SN = sensitivity; NPV = negative predictive value.
a 247 patients (15.1%) had a MACE within 30 days (primary endpoint).
b 156 patients (17.2%) had a MACE within 30 days (primary endpoint).
c Sensitivity, specificity, and negative predictive value for TIMI=0 in the primary cohort were 100% (95% CI: 98.5% to 100%), 23.1% (95% CI:
20.9% to 25.3%), and 100% (95% CI: 98.8% to 100%), respectively. Sensitivity, specificity, and negative predictive value for TIMI≤1 in the
primary cohort were 99.2 (95% CI: 97.1 to 99.8), 48.7 (95% CI: 46.1 to 51.3), and 99.7 (95% CI: 98.9 to 99.9), respectively.
1. Cullen L, et al. J Am Coll Cardiol 2013;62:1242-1249.
(98.4-100)
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A DVANTAGEOUS P REDICTORS OF
A CUTE C ORONARY S YNDROMES
E VALUATION (APACE) 1
Study
• A prospective study of 872 unselected patients with chest
pain was done to develop and validate an algorithm for
rapid “rule-out” and “rule-in” of acute MI
• hs-cTnT was measured in a blinded fashion at presentation
and at 1 hour
• Primary endpoint was death within 30 days
Results
• There were 12 deaths within 30 days
• AMI was the final diagnosis in 17% of patients
• 60% of patients were rule-out; 17% were rule-in; 23% were in
the "observation zone”
1. Reichlin T, et al. Arch Intern Med 2012;172(16):1211-1218. doi:10.1001/archinternmed.2012.3698.
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Low-Risk Patients a, %
L OW - RISK PATIENTS
50
41.5
40
30
20
20
9.8
10
0
ASPECT 1,a
ADAPT 2,a
APACE 3,b
a Definition
of low-risk patients: TIMI risk score=0
of low-risk patients: TIMI risk score=0 or ≤1
1. Than M, et al. Lancet 2011;377:1077-1084. 2. Than M, et al. J Am Coll Cardiol 2012;59:2091-2098. 3. Cullen L, et al. J Am Coll Cardiol 2013;62:1242-1249.
b Definition
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BNP AND IN - HOSPITAL MORTALITY
• CRUSADE database shows hospital mortality increasing directly with increasing BNP1,a
IN-HOSPITAL MORTALITY, %
25%
20%
15%
10%
5%
0%
0
500
1000 1500 2000 2500 3000 3500 4000 4500 5000
BNP VALUE
a Dotted
lines = 95% CI.
1. Peacock F. Rev Cardiovasc Med 2010;11(suppl 2):S45-S50.
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R ISK - ADJUSTED ACUTE IN - HOSPITAL
MORTALITY BY BNP
• Mortality rates increased for each BNP group compared with BNP ≤1001
9.3
(4.5-19.2)
10
MORTALITY ODDS RATIO (95% CI)
9
8
6.3
(3.2-12.4)
7
6
4.2
(2.2-7.9)
5
4
3
2.8
(1.6-5.0)
2
1
0
>100-500
500-1000
1000-2500
>2500
BNP, pg/mL
1. Peacock F. Rev Cardiovasc Med 2010;11(suppl 2):S45-S50.
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T ROPONIN AND BNP VS
IN - HOSPITAL MORTALITY
• BNP was a better predictor of in-hospital mortality than troponin1
MORTALITY, %
20
15
ULN >10
10
ULN 5-10
ULN 2-5
5
ULN 1-2
ULN <1
0
>2500
1000-2000 500-1000 100-500
>100
BNP, pg/mL
*Troponin upper limit of normal (ULN) ratio (to standardize results across hospitals) = troponin results/hospital ULN.
1. Peacock F. Rev Cardiovasc Med 2010;11(suppl 2):S45-S50.
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Y OUR PATIENT HAS POSSIBLE ACS—
NOW WHAT ? 1
• Accelerated diagnostic ED protocols
– ACS ruled out = discharge
– Requires urgent treatment = admit
• Nondiagnostic findings
– Confirmatory testing to exclude ischemia—eg, exercise ECG,
MPI, echocardiography
• Inability to exercise, baseline ECG abnormalities,
or uninterpretable ECG = imaging test
1. Amsterdam EA, et al. Circulation 2010;122:1756-1776.
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A UDIENCE RESPONSE
What cardiac testing modality do you use most
at your facility for chest pain patients?
1. Exercise ECG Stress Testing
2. Stress Echocardiography
3. Myocardial Perfusion Imaging
4. Cardiac CT Angiography
5. Cardiac Magnetic Resonance Imaging
6. Calcium Scoring
7. Invasive Coronary Angiography
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MPI
AND THE
ED
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S AMPLE MPI PROTOCOLS
• Patient with chest pain routed to the
observation unit/chest pain unit
• May be referred for an MPI by the
consulting cardiologist or ED physician
• Timing of MPI might be affected by the
patient’s symptoms and stability or the
availability of the camera or staff1
1. Amsterdam EA, et al. Circulation 2010;122:1756-1776.
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S AMPLE MPI PROTOCOLS ( CONT .)
• Acute rest MPI1:
– Patient is injected with radiotracer while still experiencing symptoms; imaging
delayed until after stabilization
– Normal images may allow patient to be discharged with instructions for
appropriate follow-up
• In a retrospective analysis, 4145 patients evaluated in the ED chest
pain unit who underwent a stress-only SPECT MPI (n=2340) were
compared to those who underwent rest-stress studies (n=1805)
during the same time2
– The average age was 57.9 years, 38.5% male, and most had an intermediate or
low pretest risk of CAD (87.7%) with an average follow-up of 35.9±20.9 months
– 11 deaths occurred in the stress-only group (0.5%) at 1 year follow-up
compared to 13 deaths in the rest-stress group (1.1%)
1. Amsterdam EA, et al. Circulation 2010;122:1756-1776. 2. Duvall WL, et al. J Emerg Med 2012;42:642-650.
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ED AND NUCLEAR LAB COMMUNICATION
• Information needs to be conveyed as quickly as possible
– Direct phone call
– Electronic medical record
– Call medical professional immediately to discuss test
results and document conversation
• Decision to admit or discharge is made by consulting
cardiologist/hospitalist or attending physicians
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A UDIENCE RESPONSE
What do you think is the most important limitation
of MPI in chest pain protocols?
1. Unfamiliarity of MPI by ED physician
2. Other tests more readily available
3. Radiation exposure
4. Logistical challenges—eg, time of day,
location of nuclear lab, staff availability
5. Other
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M P I C A S E S TU D Y 1
Chest pain in patient with
abnormal baseline ECG
Case study of MD Cerqueira, MD
012-0400-PM 5/15
MPI
CASE STUDY
1
P ATIENT HISTORY
• 49-year-old man seen in the ED after 2 days of
intermittent chest pain unrelated to effort
• Cardiac risk factors
–
–
–
–
Hypertension
Hyperlipidemia but on no medications
Diabetes mellitus
No prior cardiac evaluation
• Current medications
– ASA daily
– Beta-blocker
Case study of MD Cerqueira, MD
012-0400-PM 5/15
MPI
CASE STUDY
1
W ORKUP
• Physical exam
– BP: 142/84 mm Hg
– HR: 75 bpm
– Chest: No tenderness
– Lungs: Clear
– Heart: No murmurs
– Extremities: No edema
Case study of MD Cerqueira, MD
012-0400-PM 5/15
MPI
CASE STUDY
1
W ORKUP ( CONT .)
• Baseline ECG showed increased voltage and diffuse T-wave inversions
consistent with strain pattern, which had been noted on prior ECG
• Cardiac markers x2 were negative for acute myocardial ischemia
Case study of MD Cerqueira, MD
012-0400-PM 5/15
TIMI RISK SCORE : 2- WEEK MACE
THROMBOSIS IN MYOCARDIAL INFARCTION
– Age 65 years
– 3 risk factors for CAD
– Significant coronary stenosis
(eg, prior 50%)
– ST-segment deviation on ECG
– Severe angina (eg, 2 angina
events in previous 24 hours)
– Use of ASA in last 7 days
– Elevated serum cardiac
markers CK-MB or troponin
RATE OF COMPOSITE ENDPOINT
(DAYS 1-14), %
• Risk
40.9
45
factors1:
40
35
30
26.2
25
19.9
20
13.2
15
8.3
10
5
0
4.7
0/1
2
3
4
5
6/7
NUMBER OF RISK FACTORS
Each risk factor is assigned 1 point, and the total represents a given patient’s TIMI Risk Score1
Event rates (all-cause mortality, MI, or urgent revascularization) increase with each
1-point increase in score (P<0.001 by chi-square test for trend)1
MACE = major adverse cardiac event.
1. Antman EM, et al. JAMA 2000;284:835-842.
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A UDIENCE RESPONSE
What is the next step for this patient?
1. Admit to hospital
2. Urgent invasive coronary angiography
3. Immediate exercise treadmill
(ETT) stress test
4. Discharge home with a follow-up
exercise stress imaging study
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MPI
CASE STUDY
1
N EXT STEPS
• Patient was discharged home
• Exercise stress imaging study scheduled 3 days later
Case study courtesy of MD Cerqueira, MD
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M P I CASE ST UDY 1
K EY POINTS
• Based on his workup, this patient was not
experiencing an AMI and was appropriately
discharged
– T-wave inversions that had been noted on a
prior ECG
– Normal exam and vitals
– Cardiac markers negative twice
• Given his ECG abnormalities and hypertension,
he was referred for follow-up with SPECT MPI as
confirmatory testing
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M P I C A S E S TU D Y 2
SPECT MPI in a 59-year-old man
with renal insufficiency
Case study and images courtesy of MI Travin, MD
012-0400-PM 5/15
MPI
CASE STUDY
2
P ATIENT HISTORY
• 59-year-old man hospitalized after experiencing 3 days of intermittent chest pain and
shortness of breath
• Cardiac risk factors
– Hypertension (on beta-blocker)
– Hyperlipidemia
– Diabetes mellitus
– Takes ASA daily
– Has prior AMI
• Stage 3 chronic kidney disease
– Creatinine: 2.7 mg/dL
– Glomerular filtration rate: 31 mL/min/1.73 m2
Case study and images courtesy of MI Travin, MD
012-0400-PM 5/15
MPI
CASE STUDY
2
W ORKUP
•
Initial troponin I: 0.02 ng/mL
•
Physical exam
–
BP 182/84 mm Hg
–
HR 108 bpm
•
Baseline ECG showed T-wave inversions in leads I and aVL
•
Cardiac markers were negative for AMI
•
On day 4, the patient was referred by an attending physician for SPECT MPI
•
Because the patient had limited exercise tolerance, pharmacologic stress SPECT MPI
was chosen
Case study and images courtesy of MI Travin, MD
012-0400-PM 5/15
TIMI RISK SCORE : 2- WEEK MACE
THROMBOSIS IN MYOCARDIAL INFARCTION
– Age 65 years
– 3 risk factors for CAD
– Significant coronary stenosis
(eg, prior 50%)
– ST-segment deviation on ECG
– Severe angina (eg, 2 angina
events in previous 24 hours)
– Use of ASA in last 7 days
– Elevated serum cardiac
markers CK-MB or troponin
RATE OF COMPOSITE ENDPOINT
(DAYS 1-14), %
• Risk
40.9
45
factors1:
40
35
30
26.2
25
19.9
20
13.2
15
8.3
10
5
0
4.7
0/1
2
3
4
5
6/7
NUMBER OF RISK FACTORS
Each risk factor is assigned 1 point, and the total represents a given patient’s TIMI Risk Score1
Event rates (all-cause mortality, MI, or urgent revascularization) increase with each
1-point increase in score (P<0.001 by chi-square test for trend)1
MACE = major adverse cardiac event.
1. Antman EM, et al. JAMA 2000;284:835-842.
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MPI
CASE STUDY
2
P HARMACOLOGIC STRESS SPECT MPI
• Patient underwent dual-isotope
(rest Tl-201/stress Tc-99m sestamibi) SPECT MPI
• Pharmacologic stress utilized
– No chest discomfort
– No ischemic ECG changes
• The patient complained of shortness of breath,
which resolved without treatment approximately
6 minutes after administration of pharmacologic stress
• Hemodynamics
– HR: 79 → 93 bpm
– BP: 159/81 → 148/82 mm Hg
Case study and images courtesy of MI Travin, MD
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MPI
CASE STUDY
2
P OLAR PLOT DISPLAY
• Mild-moderate global
LV systolic dysfunction
with EF = 42%
• Summed stress score
(SSS) = 13
• Summed difference
score (SDS) = 11
Case study and images courtesy of MI Travin, MD
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M P I CASE ST UDY 2
K EY POINTS
• An abnormal SPECT result is a predictor of all-cause
mortality in patients with renal insufficiency1
– Adds independent and incremental information to clinical, GFR,
and exercise variables
• MPI is a strong predictor of all-cause mortality in patients
with end-stage renal disease2
– Abnormal MPI results independently predicted worse survival and
provided more powerful prognostic data than angiography
• MPI provides effective risk stratification across the entire
spectrum of renal failure3
– Renal function and MPI have additive value in risk-stratifying patients
with suspected CAD
1. Al-Mallah MH, et al. Circ Cardiovasc Imaging 2009;2:429-436. 2. Venkataraman R, et al. Am J Cardiol 2008;102:1451-1456.
3. Hakeem A, et al. Circulation 2008;118:2540-2549.
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M P I C A S E S TU D Y 3
SPECT MPI in a 76-year-old man
with prior coronary artery
bypass grafting surgery
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
P ATIENT HISTORY
• 76-year-old male presenting to ED with exertional chest pain and
shortness of breath
– Weight: 175 lb
– Height: 69″
– BMI: 26.3 kg/m2
– Former smoker
• Cardiac risk factors
– Hypertension
– Hyperlipidemia
– Polycythemia vera
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
P ATIENT HISTORY ( CONT .)
• Coronary artery bypass grafting (CABG) in 1997
– RIMA to LAD/D1, SVG to RCA
• Non−ST-elevation myocardial infarction
(NSTEMI) in 1998
– Bare metal stent (BMS) RI 1998,
POBA SVG-RCA anastomosis
• Benign prostatic hyperplasia
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
W ORKUP
• Cholesterol:
–
–
–
–
TC: 93
HDL: 24
LDL: 50
TG: 93
• Glucose: 117 mg/dL
• HbA1c: 5.7%
• Creatinine: 0.83 mg/dL
• C-reactive protein: 3.5
• ECG: Normal sinus rhythm, right bundle-branch block
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
R EFERRED FOR PHARMACOLOGIC STRESS S PECT MPI
• Hemodynamics
– HR: 78 → 102 bpm
– BP: 160/90 → 179/90 mm Hg
• Symptoms
– 3/10 chest and throat discomfort
• ECG changes
– None
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
R OTATING PLANAR IMAGES
What do these images show?
• Normal heart size
• No motion or attenuation;
good liver clearance;
no GI activity interference
• No extracardiac abnormalities
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
SPECT IMAGES
What do these images show?
• Apical and inferior wall
peri-infarct ischemia
• Basal and midcavity
inferior infarction
• Global EF = 69%
• Inferior wall hypokinesis
EF = ejection fraction.
Case study and images courtesy of MD Cerqueira, MD
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MPI
CASE STUDY
3
C ORONARY ANGIOGRAPHY AND PCI
• Based on MPI results, patient was referred for coronary
angiography
• Native coronary vessels occluded proximally
• RCA-SVG 80% distal, right posterior ventricular branch 50%
mid
• RIMA to mid-LAD skip to diagonal widely patent
• Diffuse disease in the distal LAD after the anastomosis,
providing distal RCA collateral flow
• LV gram EF = 50%, with trivial mitral regurgitation and
moderate hypokinesis of the inferior wall
• PCI was performed: SVG-RCA
EF = ejection fraction; LAD = left anterior descending artery; LV = left ventricular; PCI = percutaneous intervention; RCA-SVG = right coronary artery to
saphenous vein graft; RIMA = right internal mammary artery.
Case study and images courtesy of MD Cerqueira, MD
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M P I CASE ST UDY 3
K EY POINTS
• MPI identified peri-infarct ischemia in this patient
– Prompted coronary angiography
• Coronary angiography correctly identified the specific vessel/vein
graft involved and guided management
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R UN YOUR ED PROTOCOL AND
CONSIDER MPI
• Chest pain can be absent in up to 35% of patients
experiencing an MI1
• Use accelerated ED protocols to help identify patients who
can be discharged and who should be admitted2
• Risk stratification tools and cardiac biomarkers are an
important part of ED workup
• For patients whose workups are nondiagnostic but may
have ACS, perform confirmatory testing2
– Exercise ECG if the patient can exercise and has a normal,
interpretable ECG
• In patients who cannot exercise or have an abnormal or
uninterpretable ECG, use MPI as confirmatory testing2
1. Canto JG, et al. JAMA 2012;307:813-822. 2. Amsterdam EA, et al. Circulation 2010;122:1756-1776.
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Q&A
Frank Peacock, MD
Manuel Cerqueira, MD
Professor, Emergency Medicine
Associate Chair and Research Director
Baylor College of Medicine
Professor of Radiology and Medicine
Cleveland Clinic Lerner College of
Medicine of Case Western Reserve
University
Chairman, Department of Nuclear
Medicine, Imaging Institute
Staff Cardiologist, Heart and Vascular
Institute Cleveland Clinic
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T HANK YOU
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