Acute Chest PainAcute Chest Pain

DENNIS FOLEYDENNIS FOLEY

MEDICAL COLLEGE MEDICAL COLLEGE WISCONSINWISCONSIN

Acute Coronary SyndromeAcute Coronary Syndrome

UNSTABLE ANGINAUNSTABLE ANGINA

NON ST ELEVATION MI ( NSTEMI )NON ST ELEVATION MI ( NSTEMI )

ST ELEVATION MI ( STEMI )ST ELEVATION MI ( STEMI )

Coronary ThrombosisCoronary Thrombosis

VULNERABLE PLAQUEVULNERABLE PLAQUEPATHOPHYSIOLOGYPATHOPHYSIOLOGY

PLAQUE RUPTUREPLAQUE RUPTURE

THROMBOGENIC SURFACETHROMBOGENIC SURFACE

PLATELET AGGREGATIONPLATELET AGGREGATION

THROMBUS FORMATIONTHROMBUS FORMATION

TIMI Risk ProfileTIMI Risk Profile

AGE > 65AGE > 65

3 OR > CARDIAC RISK FACTORS3 OR > CARDIAC RISK FACTORS

ST DEVIATIONST DEVIATION

ASPIRIN USE WITHIN 7 DAYSASPIRIN USE WITHIN 7 DAYS

HISTORY OF CORONARY STENOSISHISTORY OF CORONARY STENOSIS

ELEVATED TROPONIN LEVELSELEVATED TROPONIN LEVELS

Coronary OcclusionCoronary Occlusion

ETIOLOGYETIOLOGY

VULNERABLE PLAQUE RUPTUREVULNERABLE PLAQUE RUPTURE

CORONARY ARTERY DISSECTIONCORONARY ARTERY DISSECTION

TRAUMATRAUMA

IN STENT THROMBOSISIN STENT THROMBOSIS

CORONARY ARTERY ANOMALIESCORONARY ARTERY ANOMALIES

Cardiac Risk ProfileCardiac Risk Profile

TIMI RISK SCORE ( US/ NSTEMI )TIMI RISK SCORE ( US/ NSTEMI )SCORESCORE MACE MACE RISK CATEGORYRISK CATEGORY0/10/1 5%5% LOWLOW22 8%8% LOWLOW33 13%13% MODERATEMODERATE44 20%20% MODERATEMODERATE55 26%26% HIGHHIGH6/76/7 41%41% HIGHHIGH

Coronary ThrombosisCoronary Thrombosis

OUTCOMEOUTCOME

STEMI STEMI -- 90% 90%

NSTEMI NSTEMI -- 35 35 –– 75 %75 %

STABLE ANGINA STABLE ANGINA –– 1 %1 %

Acute Coronary SyndromeAcute Coronary Syndrome

OUTCOMEOUTCOME

PRIOR TO MID 80PRIOR TO MID 80’’ssMYOCARDIAL INFARCT 40%MYOCARDIAL INFARCT 40%

MORTALITY RATE 17%MORTALITY RATE 17%

MID 80MID 80’’s TO CURRENT s TO CURRENT 49% DECREASE IN MORTALITY RATE49% DECREASE IN MORTALITY RATE

Imaging Studies in ACSImaging Studies in ACS

RADIONUCLEIDE PERFUSION STUDYRADIONUCLEIDE PERFUSION STUDY

NORMAL RESTING PERFUSION NORMAL RESTING PERFUSION STUDY HAS NPV > 90%STUDY HAS NPV > 90%

Laboratory Studies in ACSLaboratory Studies in ACS

TROPONIN 1 TROPONIN 1

CK MBCK MB

BASIC METABOLIC PROFILE BASIC METABOLIC PROFILE

C REACIVE PROTEINC REACIVE PROTEIN

ESRESR

Treatment ( 1 )Treatment ( 1 )

PRE HOSPITAL CAREPRE HOSPITAL CARE

EKGEKG

NGT, OXYGEN, ASPIRINNGT, OXYGEN, ASPIRIN

THROMBOLYSISTHROMBOLYSIS

Treatment ( 2 )Treatment ( 2 )

ED CAREED CARE

STEMISTEMIREPERFUSION THERAPYREPERFUSION THERAPY

PHARMACOLOGICAL PHARMACOLOGICAL

CATHETER BASEDCATHETER BASED

NSTEMINSTEMIANTI ISCHEMIC THERAPYANTI ISCHEMIC THERAPY

PCI WHEN APPROPRIATEPCI WHEN APPROPRIATE

ED CareED Care

GOALSGOALS

IDENTIFICATION OF PATIENTS IDENTIFICATION OF PATIENTS WITH STEMIWITH STEMI

EXCLUSION OF OTHER CAUSES OF EXCLUSION OF OTHER CAUSES OF NON ISCHEMIC CHEST PAINNON ISCHEMIC CHEST PAIN

STRATIFICATION OF PATIENTS STRATIFICATION OF PATIENTS WITH ACS INTO LOW AND HIGH WITH ACS INTO LOW AND HIGH RISK GROUPSRISK GROUPS

Acute Coronary SyndromeAcute Coronary Syndrome

EKG GATED CT EXCLUDEDEKG GATED CT EXCLUDED

SHOCK, TACHYCARDIA, SHOCK, TACHYCARDIA,

ARRYTHMIAARRYTHMIA

HIGH TIMI RISK SCOREHIGH TIMI RISK SCORE

? KNOWN CAD , PRIOR CABG? KNOWN CAD , PRIOR CABG

Coronary Angiography Gated Coronary Angiography Gated Freeze FrameFreeze Frame

10 20 30

Contrast

Saline

6 ML/ SEC 12 SECS

6 ML/ SEC 8 SECS

64 X 0.625 MM, 1.0, 0.35 SECS , 2 CM/ SECS

186 +/- 98

222 +/- 102

270 +/- 85

335+/- 78375+/-95

337+/-77

LAD CPR

LCX CPR

RCA LMCA CIRCCPR

CPR

LAD

MIP

LAD CPR

LIMA

LIMA CPR

LIMA LAD ANAST SLAB MIP

RCA STENT SLAB MIP

RCA CPR

LAD STENT FOLLOW UP

Diagnostic Accuracy Diagnostic Accuracy 64 MDCT64 MDCT

SensSens SpecSpec PPVPPV NPVNPV PrevPrev

CORECORE 8585 9090 9191 8383 56%56%

ACCURACY ACCURACY 9595 8383 6464 9999 25%25%

Miller JM et al NEJM 2008: 359; 232Miller JM et al NEJM 2008: 359; 232--23362336

BudoffBudoff MJ et al. JACC . 2008: 52MJ et al. JACC . 2008: 52

Diagnostic AccuracyDiagnostic Accuracy64 MDCT 64 MDCT

( Meta Analysis )( Meta Analysis )

28 STUDIES, STRICT CRITERIA,28 STUDIES, STRICT CRITERIA,

1,286 PATIENTS1,286 PATIENTS

SensSens SpecSpec PPVPPV NPVNPV

PtPt 9999 8989 9393 100100

SegSeg 9090 9797 7676 9999

MowatMowat G et al. Heart 2008: 94; 1386G et al. Heart 2008: 94; 1386--13931393

RomicatRomicat TrialTrial

368 PATIENTS368 PATIENTS

CHEST PAIN > 5 MINCHEST PAIN > 5 MIN

NEG TROPONINS, EKGNEG TROPONINS, EKG

EVALUATION FOR STENOSIS > 50%EVALUATION FOR STENOSIS > 50%

END POINT: MI, UAS, MACEEND POINT: MI, UAS, MACE

RomicatRomicat TrialTrial

RESULTSRESULTS

NO PLAQUE, 50%NO PLAQUE, 50%

PLAQUE < 50%, 31%PLAQUE < 50%, 31%

PLAQUE > 50%, 19%PLAQUE > 50%, 19%

NO CAD, NO CAD, SensSens 100%, NPV 100%100%, NPV 100%

CAD, CAD, SensSens 77%, NPV 98%77%, NPV 98%

Triple Rule OutTriple Rule Out

TECHNIQUETECHNIQUE

NON GATED PULMONARY / AORTANON GATED PULMONARY / AORTA

GATED PULMONARY/ LEFT GATED PULMONARY/ LEFT HEART/ AORTAHEART/ AORTA

GATED LEFT HEART/ AORTA, NON GATED LEFT HEART/ AORTA, NON GATED PULMONARYGATED PULMONARY

Non Gated Pulmonary/ AortaNon Gated Pulmonary/ Aorta

Gated Left Heart / AortaGated Left Heart / Aorta

Gated Left Heart / AortaGated Left Heart / Aorta

Non Gated Right Heart/ PulmonaryNon Gated Right Heart/ Pulmonary

Gated MDCT in ACSGated MDCT in ACS

APPLICATION APPLICATION LOW TO MODERATE RISK LOW TO MODERATE RISK PATIENTS WITH ACUTE CHEST PATIENTS WITH ACUTE CHEST PAIN, NEGATIVE TROPONINS AND PAIN, NEGATIVE TROPONINS AND EKGEKGHIGH NPV IN EXCLUDING ACSHIGH NPV IN EXCLUDING ACSCOST EFFECTIVE WITH EARLY COST EFFECTIVE WITH EARLY DISCHARGE OF PATIENTS WITH DISCHARGE OF PATIENTS WITH NEGATIVE STUDIESNEGATIVE STUDIES