two hours after onset of symptoms Professor Christian Mueller - - PowerPoint PPT Presentation

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two hours after onset of symptoms
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two hours after onset of symptoms Professor Christian Mueller - - PowerPoint PPT Presentation

Sep 02, 2023 273 likes •560 views

The patient with 30 min chest pain presenting at the ER two hours after onset of symptoms Professor Christian Mueller Disclosures Swiss National Science Foundation . . .. Research support / travel support / consulting fees from

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The patient with 30 min chest pain presenting at the ER two hours after onset of symptoms Professor Christian Mueller

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Disclosures

  • Swiss National Science Foundation
  • .
  • .

..

  • Research support / travel support / consulting fees from

several diagnostic and pharmaceutical companies

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Cardiovascular Research Institute Basel

Patient case presentation #1

  • 48 year old gentleman
  • Since 2 hours chest pain, «burning», duration > 30 minutes, VAS 9/10
  • Transient radiation to both arms, 1st episode, concomitant slight dyspnea
  • No medical history, no medication
  • Risk factors: heavy smoker, 60py
  • Hotel night manager, married.
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Cardiovascular Research Institute Basel

Patient case presentation #1

ECG at presentation

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Cardiovascular Research Institute Basel

Patient case presentation #1

  • hs-cTnT Values
  • 0h: 38ng/L
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Cardiovascular Research Institute Basel

Patient case presentation #1

  • What would you do next?

1.Monitor & 2nd hs-cTn at 3 hour 2.Monitor & 2nd hs-cTn at 1 hour 3.Go directly to cath lab 4.Coro-CT

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Cardiovascular Research Institute Basel

Patient case presentation #1

  • What would you do next?

1.Monitor & 2nd hs-cTn at 3 hour 2.Monitor & 2nd hs-cTn at 1 hour 3.Go directly to cath lab 4.Coro-CT

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Cardiovascular Research Institute Basel

Patient case presentation #1

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Cardiovascular Research Institute Basel

Patient case presentation #1

  • hs-cTnT Values
  • 0h: 38ng/L
  • 1h: 106 ng/L
  • 2h: 258 ng/L
  • 3h: 436 ng/L
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Cardiovascular Research Institute Basel

Patient case presentation #1

  • Take home message #1
  • Young patient, no previous history of CV disease
  • Typical chest pain for 2 hours
  • Baseline hs-cTnT = 3-times 99th percentile
  • PPV about 90% for AMI
  • Go directly to cath lab

Roffi M, et al. Eur Heart J 2016 Mueller C, et al. Eur Heart J Acute Cardiovasc Care 2016 Möckel M, et al. Eur Heart J Acute Cardiovasc Care 2016

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Cardiovascular Research Institute Basel

Patient case presentation #2

  • 76 year old gentleman
  • chest pain after lunch, constant «pressure» for 1.5 hours, VAS 7/10, slight

intermittent radiation to the neck, no dyspnea

  • complete pain relief after iv morphine 3mg
  • In general in good shape, still working in car industry
  • Risk factors: hypertension
  • Medication: Alfuzosin (Alpha-1-Blocker)
  • Chronic renal impairment
  • eGFR 46 ml/min (CKD-EPI)
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Cardiovascular Research Institute Basel

Patient case presentation #2

ECG at presentation

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Cardiovascular Research Institute Basel

Patient case presentation #2

  • hs-cTnT Values
  • 0h: 22 ng/L
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Cardiovascular Research Institute Basel

Patient case presentation #2

  • What would you do next?

1.Monitor & 2nd hs-cTn at 3 hour 2.Monitor & 2nd hs-cTn at 1 hour 3.Go directly to cath lab 4.Coro-CT

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Cardiovascular Research Institute Basel

Patient case presentation #2

  • What would you do next?

1.Monitor & 2nd hs-cTn at 3 hour 2.Monitor & 2nd hs-cTn at 1 hour 3.Go directly to cath lab 4.Coro-CT

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Cardiovascular Research Institute Basel

Patient case presentation #2

  • hs-cTnT Values
  • 0h: 22 ng/L
  • 1h: 35 ng/L
  • 2h: 42 ng/L
  • CCU & Coronary Angiography
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Cardiovascular Research Institute Basel

Patient case presentation #2

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Cardiovascular Research Institute Basel

Patient case presentation #2

  • Take home message #2
  • Older patient, possible cardiac comorbidities
  • Baseline hs-cTnT ≤ 2-times 99th percentile
  • PPV about 60% for AMI
  • 2nd hs-cTnT at 1 hour: Delta 7 ng/L
  • PPV about 90% for AMI

Roffi M, et al. Eur Heart J 2016 Mueller C, et al. Eur Heart J Acute Cardiovasc Care 2016 Möckel M, et al. Eur Heart J Acute Cardiovasc Care 2016

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Cardiovascular Research Institute Basel

Patient case presentation #3

  • 61 year old gentleman,
  • Since 2 hours chest pain, «pressure» , duration = 30 minutes, VAS 4/10
  • Constant radiation to the left arm, relief of pain while lying down
  • Intermittent AF, PVI 4 years ago, known mitral regurgitation
  • Risk factors: history of smoking, hypercholesterolemia
  • Medication: None
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Cardiovascular Research Institute Basel

Patient case presentation #3

ECG at presentation

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Cardiovascular Research Institute Basel

Patient case presentation #3

  • hs-cTnT Values
  • 0h: 3 ng/L
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Cardiovascular Research Institute Basel

Patient case presentation #3

  • What would you do next?

1.Monitor & 2nd hs-cTn at 3 hour 2.Monitor & 2nd hs-cTn at 1 hour 3.Go directly to cath lab 4.Coro-CT

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Cardiovascular Research Institute Basel

Patient case presentation #3

  • What would you do next?

1.Monitor & 2nd hs-cTn at 3 hour 2.Monitor & 2nd hs-cTn at 1 hour 3.Go directly to cath lab 4.Coro-CT

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Cardiovascular Research Institute Basel

Patient case presentation #3

  • hs-cTnT Values
  • 0h: 3 ng/L
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Cardiovascular Research Institute Basel

Patient case presentation #3

  • hs-cTnT Values
  • 0h: 3 ng/L
  • 1h: 4 ng/L
  • 3h: 4 ng/L
  • Patient discharged, 7 days later myocardial perfusion imaging (MPI)
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Stress

SRS = 0 SSS = 0 SDS = 0 LVEF: 56% Ca-Score: 7 (Agatston)

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Patient case presentation #3

  • Take home message #3
  • Baseline hs-cTnT ≤ 3 ng/L is very low
  • PPV <5% for AMI
  • Would allow immediate rule out if CPO ≥ 3 hour
  • CPO is 2 hour, rule out at 1 hour

Roffi M, et al. Eur Heart J 2016; Shah AS, et al; Lancet 2015 Mueller C, et al. Eur Heart J Acute Cardiovasc Care 2016 Möckel M, et al. Eur Heart J Acute Cardiovasc Care 2016