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Cardiac investigations for acute coronary syndrome

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Cardiac investigations for acute coronary syndrome

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Cardiac investigations for acute coronary syndrome

  1. 1. So What Does It Really Mean?  Cardiac Investigation in and out of the Emergency Department Dr Kyle Kophamel Sir Charles Gairdner Hospital CME 25/09/2014
  2. 2. Vetrovec, 2008  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 Improving Reperfusion in patients with Myocardial Infarction. Vetrovec. 2008
  3. 3. Cardiac Investigations  History  Examination  ECG  Troponin  Exercise Stress Test  Stress ECHO  Myocardial Perfusion Scan  Stress Cardiac MRI  CT Coronary Angiogram  Coronary Angiography AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.
  4. 4. How to interpret elevated cardiac troponin levels. Circulation 2011. Mahajan and Jarolim.
  5. 5. Exercise Treadmill Test -Smart EM. Stress Testing Summary - Fleishman MD. Podcast and Notes Summary. -AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.
  6. 6. Myocardial Perfusion Scan -AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al.
  7. 7. CT Coronary Angiography -CT Angiography for Safe Discharge of patients with Possible Acute Coronary Syndromes. Litt et al. New England journal of Medicine,2012 -AHA Scientific Statement. Testing of patients presenting to the Emergency Department with Chest Pain. Circulation July 2010. Ezra et al. -
  8. 8. CT Coronary Angiography
  9. 9. Stress Cardiac MRI
  10. 10. So who goes where?  Hx, Exam, ECG  Clinical Suspicion  Observation vs Admission  Troponin  Timing  Risk stratification  TIMI  National Heart Foundation  HEART score  EDACS - ADP -
  11. 11. TIMI  Age >65  >3 Cardiac Risk factors  Known CAD - >50% stenosis  Elevated troponin  Aspirin use in last 7 days  >2 episodes of angina in last 24 hours  ST changes at least 0.5mm
  12. 12. TIMI  % risk at 14 days of all causes of mortality, new/recurrent MI or ischaemia requiring PCI  0-1 = 4.7%  2 = 8.3%  3 = 13.2%  4 = 19.9%  5 = 26.2%  6-7 = 40.9%
  13. 13. NHF Australia  High Risk  CCU admission  Intermediate Risk  Provocative testing prior to discharge  Low Risk  Outpatient care
  14. 14. HEART score  History  ECG  Age  Risk factors  Troponin -A prospective validation of the HEART score for chest pain patient at the emergency department. Backus et al. International journal Cardiology. 2013 -Chest pain in the emergency department: The value of the heart score. Six. Backus. Neth. Heart Journal. 2008
  15. 15. Cases and Discussion  A Charlies perspective….  Accelerated diagnostic protocol.
  16. 16. Take Home  Risk stratification  Gustalt and Scoring (HEART)  Safety of Accelerated of Diagnostic Protocols  Timely follow up arrangement  GP vs Cardiologist

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