Assessment of Chest Pains in the ER - Assessment of Chest Pains in the Emergency Room

3/15/2018

            Assessment of Chest Pains in the
                          Emergency Room

Assessment of Chest Pains in the ER
                              Goals:
   Levin’s sign

                                 Identification or
                                  exclusion of acute
                                  coronary disease

                                 Accurate risk
                                  stratification

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Assessment of Chest Pains in the ER

                                 ESC 2016

Emergency Echocardiography
Advantages of echocardiography as a diagnostic tool in
  the emergency room:
 Safe and tolerable
 Easily reproducible
 Readily available (portability)
 Relatively low-cost
 No radiation

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Emergency Echocardiography
Philippine Heart Center Echocardiography Census (2011)
Total In-patient Echo                   4,407
Bedside Echo (ER and ICU)               1,110 (25%)
Intra-operative TEE (IOTEE)               221 ( 5%)

Top 3 indications for emergency echocardiography:
 Chest pains
 Dyspnea
 Hypotension

Emergency Echocardiography:
Acute Coronary Syndrome (ACS)
   Wall thickening abnormalities
   Evidence of ruptured intraventricular septum, LV
    free wall or papillary muscle (significant MR)
   LV systolic and diastolic functions
   Cardiac filling pressures
   Pulmonary arterial pressure

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Echo: Acute Myocardial Infarction
   Case

Systolic Function Assessment

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3D echo for LV analysis

            Full-volume reconstruction of the LV with EF computation

Doppler Tissue Imaging (DTI)
   E/Ea ratio – correlates well
    with LV filling pressure
   E/Ea ratio > 15
     Highly specific for elevated
      LA pressure
   E/Ea < 8
     Sensitive for normal LA
      pressure
                  Khouri et al, JASE March 2004

    E/Ea ratio < 10
      - PCWP < 15 mmHg
    E/Ea ratio > 15
      - PCWP > 20 mmHg

                  Nagueh et al. Circulation. 2000

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     Myocardial Contrast
     Echocardiography in the ER setting

Cardiac Computed Tomography Angiography
(CTA)

                      Bastarrika, et al. AJR, 2009

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Coronary CTA

 Double discharge rates from ER
 Shorten length of stay at the ER
 Reduced the likelihood of negative coronary catheterization
 Sensitivity 93.3% Specificity 89.9%

              Takakuwa KM,et al. Acad Radiol, 2011               Litt HL, et
al. N Eng J Med 2012
             Hoffmann U, et al. N Eng J Med 2012

Coronary CTA
   is an appropriate option for the low to intermediate risk
    with chest pains at ER

   Negative CTA is associated with a very low event rate,
    and discharge of patients from ER is safe

                                    ACC/ACR/AHA Concensus 2010

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Indications for CTA in ED

                     Hollander et al. Circulation 2010

                               Circulation 2010

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Cardiovascular Magnetic Resonance Imaging
(CMR)

         • CMR is highly accurate for the detection of ACS in the
           ER setting, and provides incremental value to initial
           risk assessment and traditional risk factors.

                                       Cury, et al. Circulation, 2010

Chest Pains in the Emergency Room

“Triple rule-out concept”:

   Acute coronary syndrome (myocardial ischemia or
    infarction)
   Aortic aortic syndrome (aortic dissection, intramural
    hematoma and rupturing aortic aneurysm)
   Pulmonary embolism

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Triple Rule-out by CT

                                 Bastarrika, et al. AJR, 2009

Triple rule-out CTA
 Requires higher scanning time and longer radiation
  exposure
 Volume of contrast used is high
 Coronary CT dedicated protocol provides excellent
  visualization of coronaries and proximal ascending
  aorta, but not well enough the pulmonary arteries

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Echo: Aortic Dissection
   Case

Emergency Echocardiography:
Aortic Dissection
TTE findings associated with aortic dissection
 Aortic insufficiency
 Enlarged aortic root (>3.5 cm at annulus or sino-tubular
  junction)
 Presence of pericardial effusion
 Infero-posterior wall motion abnormality (RCA territory)

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Emergency Echocardiography:
Aortic Dissection

   May require TEE to visualize distal ascending aorta,
    transverse and descending aorta

   Intimal flap seen on TTE would clinch a diagnosis of an
    aortic dissection

Emergency Echocardiography:
Aortic Dissection

Lack of definite signs on TTE/TEE does not exclude an
aortic dissection …

CLINICAL DATA still important !!!

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Cardiac CT-MRI: Aortic Dissection
- Complimentary tools to emergency echocardiography in
  the assessment of aortic dissection
- Cardiovascular CT-MRI “triple rule-out” capability is an
  advantage over other modalities
- Disadvantages: not readily available, non-portable,
  expensive, and requires highly skilled technician and staff

CT-MRI aortography

            Bastarikka et al. AJR, 2009

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Echo: Pulmonary Embolism
    Case

Pulmonary Embolism:
RV Systolic Overload
    Elevated right ventricular afterload leading to pulmonary
     hypertension and right heart failure
    Echocardiographic features:
1.   Dilated pulmonary artery, right ventricle and right atrium
2.   Hypokinetic right ventricle
3.   Moderate to severe TR with elevated pulmonary systolic
     arterial pressure
4.   Systolic septal flattening
5.   No significant left heart abnormality

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    RVEF by 3D Echocardiography

                Full-volume reconstruction of the right ventricle with
                EF computation

CMR: Pulmonary Embolism

    Computed Tomography                   CMR

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Summary
 Echocardiography is still the most commonly used and
  readily available diagnostic tool for patients having
  chest pains at the ER.
 CTA and CMR have important roles in the “triple rule-
  out” approach for patients presenting with chest pains
  at the emergency room.
 Use of CMR to detect ACS in patients presenting with
  chest pains in ER setting may not be practical.

            Thank You

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