Transcript Acute heart failure caused by acute coronary syndrome

Managing Acute Heart Failure in the Emergency Department
Patient Case Study
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Initial Diagnosis
and Care Plan
Case Introduction
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Revised Diagnosis
and Care Plan
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6
Glossary
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Questions
Case Details
and Initial Triage
Diagnostic
Results
Author:
Judd Hollander, MD
Teaching Points
Discussion and Conclusions
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Case
Introduction
Case Details
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
CASE INTRODUCTION
Judd E. Hollander, MD
Professor, Department of Emergency Medicine,
Sidney Kimmel College of Medicine, Thomas
Jefferson University (Philadelphia, PA; USA)
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Associate Dean for Strategic Health Initiatives
Vice Chair of Finance and Healthcare
Enterprises
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Case
Introduction
CASE INTRODUCTION
Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Background
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This is the ED of an academic affiliated
hospital on the outskirts of a large urban city.
You are a board certified emergency physician
with 9 years experience
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You have 1 family medicine resident on duty,
a full complement of nurses, and it takes
30 minutes to get a stat cardiology consult.
You do not have a cath lab
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Any intensive care level patient must be
transferred to the university hospital which is
10 miles away but can take up to an hour by
ambulance during rush hour
ED=Emergency Department
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Initial Diagnosis
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Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
ECG Obtained
at Triage
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Past History, Allergy
History, Medications,
and Social History
History of Present Illness
and Review of systems
Chief Complaint
and Vital Signs
Physical
Examination
CASE DETAILS
AND INITIAL TRIAGE
Author:
Judd Hollander, MD
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CASE DETAILS
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Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Chief Complaint
“Chest pain and shortness of breath”
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The ambulance was called to an office
building where they found a 51 year old male
with history of HTN and DM complaining of
chest pain and shortness of breath
DM=diabetes mellitus; HTN=hypertension
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Vital Signs
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BP: 160/92 mmHg
HR: 101 bpm
RR: 24 brpm
Afebrile
O2 sat: 94% room air
BP=blood pressure; bpm=beats per minute; brpm=breaths per minute; HR=heart rate; RR=respiration rate
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Initial Diagnosis
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Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
History of Present Illness
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The patient was well until 3 days ago when he
had onset of exertional substernal chest pain,
initially relieved by rest. Yesterday he had an
episode that lasted 3 hours. When he awoke
this morning he was short of breath and
needed to go to the window for air. He went to
work anyway and then developed more chest
pain and called the ambulance. The chest
pain has now been present for 40 minutes
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Review of Systems
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Entirely negative except as reviewed in the
history of present illness
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ECG Obtained at Triage
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QUESTION
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ECG: Interpretation
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The ECG shows sinus rhythm with some
ectopic beats, a left axis and lateral T wave
inversions
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It is not a normal ECG but there is no definite
ischemia present
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Past History
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Hypertension
Diabetes mellitus (Type 2)
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Revised Diagnosis
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Allergy History, Medications,
and Social History
Allergies
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NKDA
Social History
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Tobacco 2 ppd for
35 years
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Lives in Colorado
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began using
marijuana
edibles in
the past year
NKDA=no known drug allergies; ppd=packs per day
Current Medications
• Insulin 12 units of 70/30
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Teaching Points
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Physical Examination
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Slightly tachypneic appearing
JVP to 8 cm
Crackles at bilateral lung bases
Heart sounds difficult to hear (due to noisy ED)
No pedal edema
Otherwise unremarkable exam
ER=emergency department; JVP=jugular venous distention
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Clinical Impression
(Initial Diagnosis)
and Differential
Diagnosis
Initial Plan of Care
INITIAL DIAGNOSIS
AND CARE PLAN
Author:
Judd Hollander, MD
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INITIAL DIAGNOSIS
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Initial Diagnosis
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Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Clinical Impression
(Initial Diagnosis)
and Differential Diagnosis
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51 year old male with DM, HTN and mild HF
on exam with concern for possible ACS based
upon progressive chest pain syndrome
ACS=acute coronary syndrome; DM=diabetes mellitus; HF=heart failure; HTN=hypertension
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INITIAL DIAGNOSIS
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Case Details
and Initial Triage
Initial Diagnosis
and Care Plan
Diagnostic
Results
Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Initial Plan of Care
Diagnostic
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Basic labs (WBC; Hb, electrolytes, creatinine)
Troponin
BNP
CXR
Therapeutic
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Treat AHF
– furosemide 20 mg i.v.
Treat possible ACS
– aspirin 325 mg orally
– nitroglycerin, sublingual for pain
ACS=acute coronary syndrome; BNP=B-type natriuretic peptide; CXR=chest X ray; Hb=hemoglobin; HF=heart
failure; WBC=white blood cell
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Lab Results
Chest X Ray
DIAGNOSTIC RESULTS
Author:
Judd Hollander, MD
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Lab Results
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Hemoglobin
WBC
Creatinine
NT-proBNP*
Initial troponin T#
13.4 g/dL
6.3 mg/dL
1.1 mg/dL
4,425 pg/mL (ULN, <450 pg/mL)
0.06 ng/mL
*Roche assay, normal range: <125 pg/mL (<75 years); <450 pg/mL (≥75 years). The upper limit of normal (ULN)
range of NT-proBNP values: <450 pg/mL.
#Roche Elecsys assay (4th generation troponin T), 99th percentile = 0.01 ng/mL
WBC = white blood cell count; NT-proBNP=N-terminal pro- B-type natriuretic peptide; ULN=upper limit of normal
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Chest X ray
Diagnostic
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Revised Diagnosis
Teaching Points
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Chest X ray:
Interpretation
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Chest X ray: Radiology Interpretation
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CXR=chest X ray
The CXR shows an enlarged heart, plump hilum and
some pulmonary vascular redistribution consistent
with mild heart failure
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Revised Clinical
Impression and
Differential Diagnoses
Ancillary Imaging
and Testing
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Revised Clinical
Impression and
Differential Diagnoses
Clinical
Course
1
REVISED DIAGNOSIS
AND CARE PLAN
Author:
Judd Hollander, MD
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REVISED DIAGNOSIS
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Initial Diagnosis
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Diagnostic
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Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Revised Clinical Impression
and Differential Diagnoses
• After reviewing the labs, ECG and CXR, the clinical
impression was:
– acute heart failure, possibly due to NSTEMI
– lateral T waves changes on ECG were new
– troponin was above ULN raising concern for acute
myocardial injury that might be NSTEMI. The
decision was made to repeat a troponin within
3 hours
CXR=chest X ray; ECG=electrocardiogram; NSTEMI=non-ST segment elevation myocardial infarction;
ULN=upper limit of normal
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Initial Diagnosis
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Revised Diagnosis
Teaching Points
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Ancillary Imaging and Testing
• The patient did NOT receive an
echocardiogram or any other ancillary imaging
in the ED
• Repeat ECG – unchanged from initial
• A repeat troponin test was carried out 3 hours
later while still in the ED
– 0.39 ng/mL (compared to 0.06 ng/mL)
ECG=electrocardiogram; ED=Emergency Department
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REVISED DIAGNOSIS
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Initial Diagnosis
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Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Revised Clinical Impression
and Differential Diagnoses
• After reviewing the labs, ECG and CXR, the clinical
impression was:
– AHF, possibly due to NSTEMI
– lateral T waves changes on ECG were new
– troponin was above ULN and rising
AHF=acute heart failure; CXR=chest X ray; ECG=electrocardiogram; NSTEMI=non-ST segment
elevation myocardial infarction; ULN=upper limit of normal
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Revised Diagnosis
Teaching Points
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Clinical Course
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Patient diagnosed with NSTEMI
– aspirin 325 mg orally
Echocardiogram next day in the CCU did not
reveal wall motion abnormality
Catheterization showed 90% occlusion of the
left circumflex coronary artery
– PCI completed successfully
CCU=coronary care unit; NSTEMI=non-ST segment elevation myocardial infarction; PCI=percutaneous
coronary intervention
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Discussion and
Conclusions
Local Variation
Teaching Points
TEACHING POINTS, DISCUSSION
AND CONCLUSIONS
Author:
Judd Hollander, MD
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Introduction
TEACHING POINTS,
DISCUSSION AND
CONCLUSIONS
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Initial Diagnosis
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Diagnostic
Results
Revised Diagnosis
Teaching Points
and Care Plan Discussion and Conclusions
Teaching Points
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Etiologies of a first episode of AHF differ from
recurrent episodes
– less likely medication noncompliance, dietary
indiscretion, etc.
– more likely to be ACS
Troponin release is ALWAYS myocardial injury
– determine if acute or chronic using delta
(change in values)
• this case was acute with rising troponins
– even if no delta
• any troponin is always worse than no
troponin
• more troponin is always worse than less
troponin
Don’t lose focus and forget about precipitating
cause of AHF
ACS=acute coronary syndrome; AHF=acute heart failure
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DISCUSSION AND
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Revised Diagnosis
Teaching Points
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Discussion and Conclusions
• This case should have received more aggressive
treatment for the precipitating factor – ACS in the ED
– antiplatelet agents
• aspirin and clopidogrel (or ticagrelor)
– anticoagulants
• LMWH or UFH indicated for ACS
– anti-ischemic agents
• oxygen might be reasonable here (sats in low
90’s)
• nitrates will help both ACS and AHF
ACS=acute coronary syndrome; AHF=acute heart failure; ED=emergency department;
LMWH=low molecular weight heparin; UFH=unfractionated heparin
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Initial Diagnosis
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Revised Diagnosis
Teaching Points
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Local Variation
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The treatment of ACS in the ED is widely
variable
– choice of antiplatelet agents
– choice of anticoagulants
– selection of agents that may be beneficial
when AHF is related to ACS/NSTEMI
– Cardiologist preferences influence the
initial treatment strategy
ACS=acute coronary syndrome; AHF=acute heart failure; NSTEMI=non-ST segment
elevation myocardial infarction
Glossary of terms
Acute Medicine
Also known as emergency medicine ward
CHA2DS2-VASC
A clinical prediction rule for estimation of
stroke risk in patients with atrial fibrillation
EHMRG
Emergency Heart Failure Mortality Risk Grade. A
tool that could be used to assess mortality risk at
discharge. Note, this tool has not been
prospectively validated. Clinical judgement is
important
CHEM7
US terminology. A basic metabolic panel
including Na, K, Cl−, HCO3− or CO2, blood
urea nitrogen, creatinine and glucose
GP
General practitioner. UK terminology.
The equivalent role in the US would be family
physician
Community heart failure team
UK terminology. A specialist community
heart failure nursing service working in
partnership with Hospital Trusts
R/O
Ruled out
Consultant
UK terminology. The equivalent role in the
US would be an attending/staff physician
C/O
Complaining of
Stat
statim (Latin) referring to speed
Specialist
UK terminology. See consultant