Non invasive cardiac testing for acute coronary syndrome

Non-Invasive Tests for
Acute Coronary Syndrome
Rebekah Crawford
March 2016

 A little over 50 years ago, my father had a heart
attack. He was driven to the hospital by friends after
having “indigestion” for 2 days. He spent 2 weeks as an
inpatient on an unmonitored rehabilitation ward and
was treated principally with warfarin and digitalis. He
was lucky and survived, but in that era, more than 20%
of patients with an acute myocardial infarction died.
Vevrotec 2008

 By the late 1960s, cardiovascular disease
accounted for a 56% of all deaths. Steady decline
to 30% of all deaths in 2013.
 Coronary heart disease is the leading cause of
death in Australian men and women
 Kills 54 Australians each day, or one Australian
every 27 minutes
Heart Foundation, Australia

Overview
 Chest pain pathway
 Risk stratification
 Non-invasive cardiac investigations

!SCGH!Acute!Coronary!Syndrome!(ACS)!Assessment!and!Treatment!Algorithm!
!
Consider!important!differentials!such!as!
Aortic!dissection,!PE,!pneumothorax!…!
!
Immediate!12!lead!ECG!–!review!by!ED!reg!or!
consultant!within!10!minutes!
• ST!elevation!>1mm!in!2!contiguous!limb!leads!or!
• ST!elevation!>2mm!in!2!contiguous!chest!leads!
• New!LBBB!(for!discussion!with!cardiology!consultant)!
!
!
!
• Clinical!history!
• Examination!
• Initial!troponin!
• ECG!(repeat!every!20!mins!if!ongoing!pain)!
• CXR!
• Evaluate!clinical!likelihood!of!ACS!using!!!
?!!
• Consider!other!causes!and!investigate!
appropriately!
• Ensure!aspirin!300mg!given!
• GTN!(SL!then!IV!if!required)!(beware'hypotension,'
phosphodiesterase'inhibitors'(Sildenafil),'severe'AS)!
• Other!analgesia!–!e.g.!titrated!morphine!
!
If!the!first!troponin!is!taken!>4!hours!after!maximal!pain!and!is!negative,!repeat!troponin!is!not!required!(consider!as!serial!troponin!negative!patient).!
STEMI! STEMI!
• Triage!1!or!2!as!per!ACEM!guidelines!!
• Direct!to!resuscitation!area!
• Monitor!ECG!and!O2!stats!
• Observations!–!BP!(bilateral!if!dissection!considered),!temp,!pulse,!resps,!SpO2,!pain!assessment!
• Bloods!–!FBP,!U&E,!BSL,!troponin!(take!purple,!green!and!blue!top!(so!senior!doctor!can!add!D[dimer!if!indicated))!
• CXR!
• Aspirin!300mg!unless!already!given!or!contraindicated!
• Oxygen!only!if!hypoxia!(SpO2!<93%)!or!shock;!if!there!in!hypercapnoeic!resp!failure!aim!at!sats!88[92%.!
!
!
· !
o ischaemic!/!dynamic!changes!!!
o if!in!doubt!seek!senior!opinion!!
!
·
o Ischaemic!sounding!chest!pain!on!minimal!exertion!!
o Recent!acceleration!of!angina!pattern!or!!threshold!!
o Ongoing!ischaemic!sounding!chest!pain!
!
·
o Syncope!
o Systolic!BP!less!than!90mm!Hg!(not!due!to!GTN)!
o Haemodynamic!instability!(shock)!
o Signs!and!symptoms!heart!failure!/!pulmonary!oedema!
o Recent!PCI!less!than!6!months!or!prior!CABG!
o Sustained!arrhythmia!VT!(>3!beats)!/!any!VF!
EDACS!Score!<16!and!No!high!risk!features!!
EDU'slip,'ED'review'after'2nd'troponin'/'ECG!
EDACS!Score!≥!16!and!No!high!risk!features!
!!
EDU'slip,'call'for'cardiology'review''
where!non[ACS!cause!of!raised!troponin!is!likely!!
Ix!for!PE,!dissection,!AF,!sepsis,!renal!failure…!!
Appropriate'booking'slip'as'soon'as'possible'
!
·
Inform!cardiology!reg,!put!in!booking!slip!and!send!
to!ward!when!bed!ready!(as!per!admission!policy)!
*!!If!unstable!cardiology!review!in!ED!is!required!!
· !
" !!
!!!!!!!Inform!cardiology!reg!as!for!≤!80!yo!group!
" !!
!!!!!!!MAU!admit!!
· !!
Non[invasive!strategy!appropriate![!admit!MAU!
!
· Where!there!is!disagreement!or!delay!the!ED!
consultant!or!SR!may!admit!at!their!discretion!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
1. Initial!negative!
troponin!becomes!
positive!!
2. If!initial!troponin!was!
slightly!raised!and!
alternative!diagnosis!
was!being!considered!
but!not!found,!and!
troponin!rises!>50%!
from!baseline!!
!
Manage!as!High!risk!ACS!
group!(see!box!above!right)!
· Ensure!aspirin!300mg!
· Ticagrelor!180mg!load!then!90mg!bd!unless!
contraindication!(if!bradycardia!<50!use!
Clopidogrel!600mg!load!then!75mg!daily)!
· No!Enoxaparin!in!ED!unless!specified!by!
cardiology!!
· No!need!for!B[blocker!in!ED!(esp!not!IV)!
!
!
!
1. Negative!serial!
troponin!
2. Serial!ECG!not!
ischaemic!
3. Low!risk!ACS!group!
!
Alternate!diagnosis!likely!
on!clinical!assessment.!
!
Probable!Non[ACS.!
!
Manage!other!causes,!
likely!discharge.!
GP!follow!up.!
!
!
!
1. Negative!serial!
troponin!
2. Serial!ECG!not!
ischaemic!
3. Low!risk!ACS!group!!
!
Alternate!diagnosis!not!
apparent.!!
Risk!major!adverse!cardiac!
event!<1/100!!
Give!written!advice,!
return!if!further!pain,!!!
GP!review,!further!Ix!
discretionary.!
!
!
!
1. Minimally!raised!stable!
troponin!(<50%!rise)!
!
Clinically!considered!
unlikely!to!be!of!ACS!origin!
!!
Investigate!and!manage!
other!conditions!and!admit!
as!appropriate.!
!
Reconsider!NSTEMI!as!
possible!diagnosis!&!seek!
cardiol!review!if!ACS!
remains!a!possibility!
!
1. Negative!serial!troponin!!!
2. Serial!ECG!not!ischaemic!
3. No!high!risk!features!
4. Not!low!risk!ACS!group!
because!EDACS!>=16!
Cardiology!review!and!
expedited!investigation!either!
as!inpatient!or!outpatient.!
!
Cardiology!reg!will!arrange!
investigation!and!follow!up!
18[45! +!2!
46[50! +!4!
51[55! +!6!
56[60! +!8!
61[65! +!10!
66[70! +!12!
71[75! +!14!
76[80! +!16!
81[85! +!18!
86+! +!20!
!
SCORE!1!+!SCORE!2!=! !
*Risk!factors:!family history of premature CAD, dyslipidaemia, diabetes,
hypertension, current smoker.
**Pain that caused presentation to hospital.!
Male!sex! +!6!
Aged!18[50!years!and!either:!
· Known!coronary!artery!disease!or!
· 3!or!more!risk!factors*!
!
+!4!
Symptoms!and!signs! !
· Diaphoresis! +!3!
Radiates!to!arm!or!shoulder! +!5!
Pain**!occurred!or!worsened!with!
inspiration!
[!4!
Pain**!is!reproduced!by!palpation! [!6!
! !
!
Assess
Care!
!
Reviewed!and!agreed!to!by!SCGH!Emergency!Medicine,!Cardiology,!Medical!Assessment!Unit!and!Clinical!Biochemistry!January!2015.!!!!!!!!Designed!by!Dr!James!Rippey.!!!!!!!For!review!2018.!

Immediate!12!lead!ECG!–!review!by!ED!reg!or!
consultant!within!10!minutes!
• ST!elevation!>1mm!in!2!contiguous!limb!leads!or!
• ST!elevation!>2mm!in!2!contiguous!chest!leads!
• New!LBBB!(for!discussion!with!cardiology!consultant)!
!
!
!
• Clinical!history!
• Examination!
• Initial!troponin!
• ECG!(repeat!every!20!mins!if!ongoing!pain)!
• CXR!
• Evaluate!clinical!likelihood!of!ACS!using!!!
?!!
• Consider!other!causes!and!investigate!
appropriately!
• Ensure!aspirin!300mg!given!
• GTN!(SL!then!IV!if!required)!(beware'hypotension,'
phosphodiesterase'inhibitors'(Sildenafil),'severe'AS)!
• Other!analgesia!–!e.g.!titrated!morphine!
!
If!the!first!troponin!is!taken!>4!hours!after!maximal!pain!and!is!negative,!repeat!troponin!is!not!required!(consider!as!serial!troponin!negative!patient).!
STEMI! STEMI!
!
!
· !
o ischaemic!/!dynamic!changes!!!
o if!in!doubt!seek!senior!opinion!!
!
·
o Ischaemic!sounding!chest!pain!on!minimal!exertion!!
o Recent!acceleration!of!angina!pattern!or!!threshold!!
o Ongoing!ischaemic!sounding!chest!pain!
!
·
o Syncope!
o Systolic!BP!less!than!90mm!Hg!(not!due!to!GTN)!
o Haemodynamic!instability!(shock)!
o Signs!and!symptoms!heart!failure!/!pulmonary!oedema!
o Recent!PCI!less!than!6!months!or!prior!CABG!
o Sustained!arrhythmia!VT!(>3!beats)!/!any!VF!
EDACS!Score!<16!and!No!high!risk!features!!
EDU'slip,'ED'review'after'2nd'troponin'/'ECG!
EDACS!Score!≥!16!and!No!high!risk!features!
!!
EDU'slip,'call'for'cardiology'review''
where!non[ACS!cause!of!raised!troponin!is!likely!!
Ix!for!PE,!dissection,!AF,!sepsis,!renal!failure…!!
Appropriate'booking'slip'as'soon'as'possible'
!
·
Inform!cardiology!reg,!put!in!booking!slip!and!send!
to!ward!when!bed!ready!(as!per!admission!policy)!
*!!If!unstable!cardiology!review!in!ED!is!required!!
· !
" !!
18[45! +!2!
46[50! +!4!
51[55! +!6!
56[60! +!8!
61[65! +!10!
66[70! +!12!
71[75! +!14!
76[80! +!16!
81[85! +!18!
86+! +!20!
!
SCORE!1!+!SCORE!2!=! !
*Risk!factors:!familyhistory of prematureCAD,dyslipidaemia,diabetes,
hypertension,currentsmoker.
**Painthatcausedpresentationto hospital.!
Male!sex! +!6!
Aged!18[50!years!and!either:!
· Known!coronary!artery!disease!or!
· 3!or!more!risk!factors*!
!
+!4!
Symptoms!and!signs! !
· Diaphoresis! +!3!
Radiates!to!arm!or!shoulder! +!5!
Pain**!occurred!or!worsened!with!
inspiration!
[!4!
Pain**!is!reproduced!by!palpation! [!6!
! !
!
Assess !

TIMI score
 Age ≥ 65
 Aspirin use in the last 7 days
 At least 2 episodes of angina within the last 24hrs
 ST changes of at least 0.5mm in contiguous leads
 Elevated serum cardiac biomarkers
 Known Coronary Artery Disease
 At least 3 risk factors for CAD
"The TIMI Risk Score for Unstable Angina/Non–ST Elevation MI", JAMA, 2000

% risk at 14 days of: all-cause mortality, new or
recurrent MI, or severe recurrent ischemia requiring
urgent revascularization
 Score of 0-1 = 4.7% risk
 Score of 2 = 8.3% risk
 Score of 6-7 = at least 40.9% risk

HEART score
 History
 ECG
 Age
 Risk factors
 Troponin
A prospective validation of the HEART score for chest pain
patients at the emergency department. Int J Cardio 2013

Treadmill Stress Electrocardiography
 Patient selection criteria
- Able to exercise
- ECG: No ST changes / arrhythmia
- Negative cardiac injury markers
 Procedure
- Bruce or modified Bruce protocol
 End points
- Symptom-limited
- Ischemia
 Result
- Positive: 0.10 mV of horizontal ST-segment depression
- Negative: No exercise-induced abnormalities at 85% MPHR
- Nondiagnostic: unable to reach 85% MPHR

 Recommended within 72hrs of discharge
 Pts recommended to be started on precautionary medical
therapy while waiting for stress test 1
 Cost-effective
 Need to be able to exercise
 Doesn’t identify pts with ACS missed by enzyme testing2
 Lowest sensitivity of all stress tests: risk of false negative
test
1. Testing of Low-Risk Patients Presenting to the Emergency Department
With Chest Pain A Scientific Statement From the American Heart
Association, Circulation. 2010
2. Immediate exercise testing to evaluate low-risk patients presenting to
the emergency department with chest pain J Am Coll Cardiol. 2002

Stress ECHO
 Appropriate for patients with an intermediate pre-test
probability of CAD, no dynamic ECG changes and negative
serial cardiac enzymes
 Allows assessment of exercise capacity, structure and
function of heart
 Better sensitivity than exercise ECG (85% vs 43%) but similar
specificity (95%) 1
 Helpful for patients who can’t exercise
 Good positive predictive value
1. Assessment of patients with low-risk chest pain in the emergency department: Head-to-head comparison of
exercise stress echocardiography and exercise myocardial SPECT. Heart J. 2005
2. Prognostic value of predischarge dobutamine stress echocardiography in chest pain patients with a negative
cardiac troponin T. J Am Coll Cardiol. 2003

Myocardial Perfusion Imaging
 For patients with possible ACS, with no ECG changes, negative
initial troponin and ongoing (or recent) chest pain
 Stress myocardial perfusion scan –
 Higher sensitivity than exercise ECG testing 1
 High negative predictive value (99%) for 30 day ACS 2
 Sensitivity diminishes after symptoms resolve – greatest
sensitivity during symptoms
 Results sometimes confounded by soft-tissue artefacts.
1 Early detection of myocardial ischaemia in the emergency department by rest or exercise (99m)Tc tracer myocardial SPET in patients with
chest pain and non-diagnostic ECG. Epub 2001
2 The Erlanger chest pain evaluation protocol: a one-year experience with serial 12-lead ECG monitoring, two-hour delta serum marker
measurements, and selective nuclear stress testing to identify and exclude acute coronary syndromes. Ann Emerg Med. 2002

CT Coronary Angiogram (CTCA)
 CTCA provides anatomic rather than functional information
 Has a strong negative predictive value 99.3 in excluding
major adverse cardiac outcomes
 Good for excluding CHD if calcium burden is likely low
 Disadvantages
 Radiation Risk
 Use of contrast (renal impairment)
 Functional effect of stenosis not assessed
A meta-analysis of 64-section coronary CT angiography findings for predicting 30-day major adverse cardiac
events in patients presenting with symptoms suggestive of acute coronary syndrome. Acad Radiol. 2011

Cardiovascular MRI
 Insufficient data to support its use at this stage
 Potentially offers the capability of being able to identify: regional
wall motion abnormalities, perfusion defects, MI, and CAD without
ionizing radiation.
 Rest / Stress cMRI
 Disadvantages
 Costs
 Availability
 Claustrophobia
 Needs further evaluation/studies
Stress cardiac magnetic resonance imaging with observation unit care reduces cost for patients
with emergent chest pain: a randomized trial. Ann Emerg Med. 2010

Summary
 Detailed chest pain history
 Risk stratification
 Ensure timely follow-up
 Organise appropriate outpatient investigations

Non invasive cardiac testing for acute coronary syndrome

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