Evaluating Chest Pain What Are the Risks?   Jeffrey E. Keller MD
Badger Correctional Medicine
We Belong In Your Jail!
The Dilemma of Chest Pain• On the one hand: I don’t want the words  “Chest Pain” to become a get-out-of-jail-free  card.• ...
Objectives• Review Pathology and Terminology• Chest Pain Risk Assessment  – Historical Risk Factors  – Typical Presentatio...
Objectives• How can Cardiac Blood tests help you?• How can EKGs help you?• Setting up Chest Pain protocols in your  instit...
Atherosclerosis• The build up of plaque  in the coronary arteries  obstructs flow.
Angina• Coronary flow is  restricted at high flow  states.• Stable Angina.   – Predictable• Unstable Angina.   – Pre-MI pain
Myocardial infarction• Coronary flow is  suddenly cut off by a  clot.• This results in death of  heart muscle.• STEMI• Non...
ACS is a process stretching from stable   angina to myocardial infarction.
ACS ContinuumAtherosclerosis----        Angina-----            Unstable Angina------                Myocardial Infarction-...
Risk Stratification• Risk Stratification is the  process by which we  assess the risk involved  in any situation.• Which o...
Risk Stratification•   What is an acceptable “Miss Rate?”•   Ranges between 2-6%•   Cannot do better than 2%•   Attempts t...
Risk Assessment Step OneDoes the patient have Atherosclerotic           heart disease?• Known Coronary Heart Disease• Othe...
ACS PresentationTypical MI: Substernal, heavy, radiates to arms  and neck/jaw, sweaty, SOB, nausea, urge to  defecate.Typi...
Atypical PresentationAtypical: Other pain patterns (like not substernal—   off to the side), localized pain, pleuritic pai...
Physical Examination–   Ausculation rarely    helpful–   Rarely—pulmonary    edema–   Diaphoresis, gray.–   Overall gestal...
Assigning Risk—High or Low• 56 year old who had coronary stents placed  five years ago now states he has substernal  chest...
Is H & P Alone Accurate?• 2-4% miss rate.• Scoring systems do no  better.• Goldman’s Criteria.• Can tests improve on  this?
Bayesian Analysis• How much will a test change probability?• Sometimes it does, sometimes it does not and  sometimes it ma...
Bayesian Analysis• Step one—assign a risk based on history and  physical• Step two—do a test and, depending on  whether it...
Tests– Sensitivity: How accurate is the test at finding  the disease.– False negative: When a test fails to find the  dise...
Core Concepts• Tests can be harmful as well as helpful.• Incidence of false positive and false negative  are related to th...
ACS Tests• Overall incidence of disease in the community.• Sensitivity and specificity of the test.• What is the potential...
Troponin I• Troponin is released by  damaged heart muscle.• Levels over 0.5 are  almost always  diagnostic of acute MI.• I...
Troponin– ER protocol: 3 sets in 6 hours.– False positive: Intermediate result >0.1 and <0.5– False negative: Angina. Earl...
Normal Troponin SeriesAtherosclerosis----        Angina-----            Unstable Angina------                Myocardial In...
Troponin case• 56 year old who had coronary stents placed  five years ago now states he has had  substernal chest pain goi...
EKGs• Normal• STEMI pattern• Nonspecific
Normal EKG
Acute STEMI
STEMI?
STEMI?
Nonspecific EKG
Limitations of EKGs• Sometimes they are normal in people having  an MI.• Sometimes they are abnormal in people who  are no...
EKG Summary• EKGs must be interpreted with the initial Risk  Assessment in mind.• If a patient initially was high risk and...
Do Chest Pain tests help?– High Risk patient, positive test: Confirms what  we know. Consult a cardiologist.– High Risk, n...
Further work up required•   Stress EKG•   Thallium stress EKG•   Angiogram•   CT angiogram•   Cardiology Consultation
Documentation•   Historical Risk factors•   History of Typical or Atypical symptoms.•   Physical Exam•   Assessment•   Alt...
Chest Pain• One of the scariest complaints we confront.• In actual fact, chest pain carries less long term  risk than do o...
Chest Pain in Corrections• Everyone here can pretty accurately assign  risk based on a patient’s risk factors,  symptoms a...
Cardiac Marker recommendations• Use only Troponin I.• If you order one, you have to order at least  one more at least thre...
EKG in CorrectionsDo not make these two mistakes:Do not assume that a normal EKG means that the patient has a normal heart...
Review: Case #1• 21 year old who complains of stabbing in his  chest “like needles” plus numbness of both of  his legs. He...
Review Case # 2• 56 year old who had coronary stents placed  five years ago now states he has substernal  chest pain going...
Review Case # 3• A 24 year old comes into the jail high on  Methamphetamine. He complains of chest  pain. His heart rate i...
Review case # 4• A 36 year old man comes to the jail medical  clinic stating that he has had chest pain  steadily for the ...
Review case # 4• A 61 year old diabetic man states that he gets  a little short of breath off an on during the  day. He ha...
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Chest Pain Evaluation in Corrections

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  • If you do this, you will get a LOT of inmates complaining of chest pain.
  • This build up is known as “gunk” Why do docs use big words? You get paid better for saying I used a scalpel to incise and drain a fluctuant erythematous cutaneous abscess than saying I poked a knife in the juicy red pus ball.”
  • Look upon angina as a warning signal from your body that you are getting ready to have an MI.
  • Tim Russert. Initial symptom was his MI. Hemmorhoid guy.
  • We must identify both whether a patient has ACS and then determine where on the continuum he lies.
  • Risk Stratification is different depending on who is doing the assessment and what the outcomes they are looking at. For example, a family physician risk stratifying for heart disease is looking at 10-20 years down the road and tells the patient to lose weight, stop smoking and decides whether to prescribe a statin. An ER physician stratifies the risk of the patient dying in the next 30 minutes and then asks, if the patient goes home, what the risk is of the patient dying in the next 30 days. In jails, when assessing a patient who comes to the clinic with chest pain, we are somewhat in between. What is the risk that the patient is having an event now and what is the risk that he will drop dead during the time of his incarceration.
  • Elephant sitting on chest story. Mahout. Bathroom resuscitation.
  • My missed MI, Impossible to be perfect.
  • The least teachable. It’s a “stand back and look” thing.
  • Pneumonia Costochondritis Pleurisy Musculo-skeletal pain Now that you have assigned risk, without doing any other tests, what would you do? ER and NSAIDS. I
  • One of the most studied topics in emergency medicine. Goldman
  • Gray hair. Tendinitis and x-rays. Skin cancer.
  • Pregnancy tests PSA
  • ER protocol: 3 sets in 6 hours. False positive: Intermediate result &gt;0.1 and &lt;0.5 False negative: Angina. Early MI.
  • In other words, if I were to look into the future and say “An inmate at one of your jails will die in jail in the next six months.” What is the risk that it would be a patient who complained of chest pain, then dies? Unlikely. It will be a suicide. Or a diabetic. Or a withdrawal patient.
  • Chest Pain Evaluation in Corrections

    1. 1. Evaluating Chest Pain What Are the Risks? Jeffrey E. Keller MD
    2. 2. Badger Correctional Medicine
    3. 3. We Belong In Your Jail!
    4. 4. The Dilemma of Chest Pain• On the one hand: I don’t want the words “Chest Pain” to become a get-out-of-jail-free card.• On the other hand: I don’t want to get the phone call that begins, “Do you remember that patient you saw yesterday?”
    5. 5. Objectives• Review Pathology and Terminology• Chest Pain Risk Assessment – Historical Risk Factors – Typical Presentation – Physical Examination
    6. 6. Objectives• How can Cardiac Blood tests help you?• How can EKGs help you?• Setting up Chest Pain protocols in your institution.
    7. 7. Atherosclerosis• The build up of plaque in the coronary arteries obstructs flow.
    8. 8. Angina• Coronary flow is restricted at high flow states.• Stable Angina. – Predictable• Unstable Angina. – Pre-MI pain
    9. 9. Myocardial infarction• Coronary flow is suddenly cut off by a clot.• This results in death of heart muscle.• STEMI• NonSTEMI
    10. 10. ACS is a process stretching from stable angina to myocardial infarction.
    11. 11. ACS ContinuumAtherosclerosis---- Angina----- Unstable Angina------ Myocardial Infarction------- Dead
    12. 12. Risk Stratification• Risk Stratification is the process by which we assess the risk involved in any situation.• Which of these has the highest risk of drowning?• Swimming the English Channel.• Sitting in a bathtub.
    13. 13. Risk Stratification• What is an acceptable “Miss Rate?”• Ranges between 2-6%• Cannot do better than 2%• Attempts to do better than this will harm more people than help.
    14. 14. Risk Assessment Step OneDoes the patient have Atherosclerotic heart disease?• Known Coronary Heart Disease• Other Atherosclerotic Process• Smoking, Age, Family History, Diabetes, Hypertension• Male, Obesity, Cholesterol
    15. 15. ACS PresentationTypical MI: Substernal, heavy, radiates to arms and neck/jaw, sweaty, SOB, nausea, urge to defecate.Typical Angina: Comes and goes, precipitated by heart working harder (exercise, eating, night), lasts only minutes and goes away.
    16. 16. Atypical PresentationAtypical: Other pain patterns (like not substernal— off to the side), localized pain, pleuritic pain, no radiation, no pain, just SOB, exercise intolerance, weakness, nothingWho has atypical symptoms? Older, women, diabetics, chronic disease.Who is more likely to have typical symptoms? Young, healthy males—precisely who we tend to have in correctional facilities
    17. 17. Physical Examination– Ausculation rarely helpful– Rarely—pulmonary edema– Diaphoresis, gray.– Overall gestalt of sick or not sick
    18. 18. Assigning Risk—High or Low• 56 year old who had coronary stents placed five years ago now states he has substernal chest pain going into his jaw. He looks grey and ill.• 21 year old who complains of stabbing in his chest “like needles” plus numbness of both of his legs. No risk factors. His sternum is tender to palpation.
    19. 19. Is H & P Alone Accurate?• 2-4% miss rate.• Scoring systems do no better.• Goldman’s Criteria.• Can tests improve on this?
    20. 20. Bayesian Analysis• How much will a test change probability?• Sometimes it does, sometimes it does not and sometimes it makes things worse.• Assign a probability and then evaluate the test.
    21. 21. Bayesian Analysis• Step one—assign a risk based on history and physical• Step two—do a test and, depending on whether it is positive or negative, change the risk assessment.• Step three. Analyze whether the test has improved your risk assessment.
    22. 22. Tests– Sensitivity: How accurate is the test at finding the disease.– False negative: When a test fails to find the disease.– Specificity: How accurate is the test at excluding the healthy.– False Positive: When a test is positive in patients without the disease.
    23. 23. Core Concepts• Tests can be harmful as well as helpful.• Incidence of false positive and false negative are related to the overall incidence of the disease in the community.• The sensitivity and specificity of a test determine how much a test will change pre- test probability.
    24. 24. ACS Tests• Overall incidence of disease in the community.• Sensitivity and specificity of the test.• What is the potential harm?
    25. 25. Troponin I• Troponin is released by damaged heart muscle.• Levels over 0.5 are almost always diagnostic of acute MI.• It rises around three hours after the onset of the MI and stays up for several days.
    26. 26. Troponin– ER protocol: 3 sets in 6 hours.– False positive: Intermediate result >0.1 and <0.5– False negative: Angina. Early MI.
    27. 27. Normal Troponin SeriesAtherosclerosis---- Angina----- Unstable Angina------ Myocardial Infarction------- Dead
    28. 28. Troponin case• 56 year old who had coronary stents placed five years ago now states he has had substernal chest pain going into his jaw for the last 45 minutes. He looks grey and ill.• Troponin I is negative.• What have you learned?
    29. 29. EKGs• Normal• STEMI pattern• Nonspecific
    30. 30. Normal EKG
    31. 31. Acute STEMI
    32. 32. STEMI?
    33. 33. STEMI?
    34. 34. Nonspecific EKG
    35. 35. Limitations of EKGs• Sometimes they are normal in people having an MI.• Sometimes they are abnormal in people who are not having heart pain.• The machine readings are often inaccurate.
    36. 36. EKG Summary• EKGs must be interpreted with the initial Risk Assessment in mind.• If a patient initially was high risk and has a normal EKG, he is still at high risk.
    37. 37. Do Chest Pain tests help?– High Risk patient, positive test: Confirms what we know. Consult a cardiologist.– High Risk, negative test. Does not exclude disease. Does not lower risk much. Still must pursue further.– Low risk, negative test: Confirms what we already knew.– Low risk, Positive test: Likely a false positive, but now must pursue further evaluation.
    38. 38. Further work up required• Stress EKG• Thallium stress EKG• Angiogram• CT angiogram• Cardiology Consultation
    39. 39. Documentation• Historical Risk factors• History of Typical or Atypical symptoms.• Physical Exam• Assessment• Alternative diagnosis• Follow-up.
    40. 40. Chest Pain• One of the scariest complaints we confront.• In actual fact, chest pain carries less long term risk than do other common jail complaints: – Alcohol withdrawal – Drug dependency – Suicide.
    41. 41. Chest Pain in Corrections• Everyone here can pretty accurately assign risk based on a patient’s risk factors, symptoms and physical exam.• Using EKGs and Cardiac Markers to modify that assessment is tricky.• If you are going to use them, you must use them correctly.
    42. 42. Cardiac Marker recommendations• Use only Troponin I.• If you order one, you have to order at least one more at least three hours later.• If they are negative, you must follow them up with further testing.
    43. 43. EKG in CorrectionsDo not make these two mistakes:Do not assume that a normal EKG means that the patient has a normal heart.Do not do EKGs in patients with low risk.
    44. 44. Review: Case #1• 21 year old who complains of stabbing in his chest “like needles” plus numbness of both of his legs. He is short of breath.• Risk assessment for cardiac pain:• EKG?• Labs?• Consult?
    45. 45. Review Case # 2• 56 year old who had coronary stents placed five years ago now states he has substernal chest pain going into his jaw. He looks grey and ill.• Risk assessment for cardiac pain:• EKG?• Labs?• Consult?
    46. 46. Review Case # 3• A 24 year old comes into the jail high on Methamphetamine. He complains of chest pain. His heart rate is 140.• Risk assessment for cardiac pain:• EKG?• Labs?• Consult?
    47. 47. Review case # 4• A 36 year old man comes to the jail medical clinic stating that he has had chest pain steadily for the last four days. He points to his left sternal border. It hurts worse when he breathes. The pain radiates to his left arm.• Risk assessment for cardiac pain:• EKG?• Labs?• Consult?
    48. 48. Review case # 4• A 61 year old diabetic man states that he gets a little short of breath off an on during the day. He has no chest pain, but he states that sometimes he gets a cramp in his jaw. He has coronary stents placed 7 years ago. He feels fine right now.• Risk assessment for cardiac pain:• EKG?• Labs?• Consult?

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