Short Stay Management of Chest Pain (Contemporary Cardiology)

Preface
Contents
Contributors
Epidemiology and Demographics of Coronary Artery Disease
	1 A Brief History of Coronary Artery Disease
	2 History of Coronary Artery Disease Epidemiology
	3 Total Cardiovascular Disease Statistics
		3.1 Prevalence
		3.2 Mortality
	4 Coronary Artery Disease Statistics
		4.1 Prevalence
		4.2 Incidence
		4.3 Mortality
	5 Risk Factors Associated with CAD
		5.1 Hypertension
		5.2 Physical Inactivity
		5.3 Smoking/Tobacco Use
		5.4 Overweight and Obesity
		5.5 Hyperlipidemia
		5.6 Diabetes
	6 Conclusion
	References
The Financial Impact of Acute Coronary Syndromes
	1 Introduction
	2 Frequency/Burden of Disease of ACS by Demographics
	3 Costs of ACS
	4 Cost Analysis of Risk Stratification Tools
	5 Emergency Department Observation Units
	6 Novel ACS Evaluation Innovation Cost Analysis
	7 Conclusion
	References
Reimbursement Considerations: Chest Pain Observation
	1 Chest Pain Observation: Professional Reimbursement Considerations
	2 General Physician Documentation Requirements
	3 Calendar Day Coding Scenarios
	4 Chest Pain Observation: Admitted and Discharged on the Same Day
	5 Medicare Time Requirements for 99234–99236
	6 Chest Pain Observation: Admitted and Discharged on Different Calendar Days
		6.1 Day 1: The First Day
		6.2 The Middle Day(s)
		6.3 The Discharge Day
	7 Evaluation and Management Service Documentation Requirements
	8 Documentation Requirements 99218/99234 (Low Complexity Medical Decision-Making)
	9 Documentation Requirements 99219/99220/99235/99236 (Moderate and High Complexity MDM)
	10 Observation Services CPT Typical Times
	11 Chest Pain Observation Unit Reimbursement
	12 Additional Diagnostic Services
	Reference
Why Have Chest Pain Patients in a Short Stay Unit?
	1 Background
	2 What Is a Short Stay Unit?
	3 Why Have Short Stay Units?
	4 Which Chest Pain Patients Should Go to SSU?
	5 Why Chest Pain Patients Should Be in Short Stay Unit
	6 Improved Outcomes
	7 Conclusion
	References
Value of Accreditation for Chest Pain Centers
	1 Accreditation Options
	2 Facility Leadership
	3 Community Outreach
	4 Pre-hospital Care
	5 Early Stabilization
	6 Acute Care
	7 Transitions of Care
	8 Clinical Quality
	9 Conclusions
	References
Pathophysiology and Definition of the Acute Coronary Syndromes
	1 Spectrum of the Acute Coronary Syndromes
	2 Myocardial Injury Vs. Myocardial Infarction (MI)
	3 Vulnerable Plaque and Plaque Rupture
		3.1 Inflammation and Morphology
		3.2 Coronary Thrombosis
		3.3 Degree of Coronary Stenosis
	4 Clinico-Pathologic Correlations
	5 Conclusions
	References
Chest Pain Risk Stratification by History, Physical Examination, and ECG
	1 Introduction
	2 History
	3 Physical Examination
	4 ECG
	References
The Role of Biomarkers in Chest Pain Evaluation
	1 Introduction
		1.1 MI Subtypes
			1.1.1 Type 1
			1.1.2 Type 2
			1.1.3 Type 3
			1.1.4 Types 4 and 5
				Cardiac Necrosis Markers
		1.2 Contemporary Troponin
		1.3 Highly Sensitive Troponin Assays
		1.4 Early Risk Stratification and Diagnosis of MI
		1.5 Rapid Rule-Out Pathways
		1.6 Rule-Out at Presentation
		1.7 Rule-Out by 0/1-h Algorithm
		1.8 Rule-Out by 0/3-h Algorithm
	2 Newer Ischemia Markers
		2.1 Ischemia Modified Albumin
		2.2 Myeloperoxidase
		2.3 High-Sensitivity C-Reactive Protein
		2.4 B-type Natriuretic Peptide and N-terminal proBNP
		2.5 Future Development
	3 Point of Care Testing for Cardiac Biomarkers
	4 Future Developments
	References
Emergency Department Presentation of Chest Pain
	1 Arrival to ED
	2 Presentations of Acute Coronary Syndrome
	3 Confounders and Atypical Presentations
	4 Differential Diagnosis
		4.1 Aortic Dissection
		4.2 Pulmonary Embolism
		4.3 Esophageal Rupture
		4.4 Spontaneous Pneumothorax
	5 Electrocardiogram Analysis
	References
Risk Scoring Systems: Are They Necessary?
	1 Introduction
	2 TIMI
	3 GRACE
	4 EDACS-ADP
	5 HEART
	6 ADAPT
	7 NOTR
	8 VCPR
	9 Clinical Impression
	References
Emergency Department Disposition of Patients Presenting with Chest Pain
	1 Introduction
	2 Risk Stratification
	3 Inpatient Disposition
		3.1 STEMI
		3.2 NSTEMI
		3.3 Delayed vs. Early PCI
	4 Observation Unit Disposition
		4.1 Appropriate Patients
	5 Outpatient Follow-Up Disposition [Discharge from the ED]
		5.1 The HEART Pathway
		5.2 European Society of Cardiology
	6 Special Considerations in Disposition
		6.1 Known Coronary Artery Disease
			6.1.1 Women
		6.2 Cocaine Induced Chest Pain
	7 Conclusions
	References
Short Stay Unit Requirements
	1 Introduction and Short Stay Unit Concept
	2 Location
	3 Administration and Oversight
	4 Staffing
	5 Equipment and Supplies
	6 Conclusion
	References
Medical Therapy in Patients Managed in a Chest Pain Observation Unit
	1 Aspirin Therapy
	2 Anticoagulation
	3 Nitrates
	4 Beta Blockers
	5 Conclusion
	References
Provocative Testing
	1 Introduction
	2 Recognition of Low-Risk Patients
	3 Provocative Cardiac Testing
		3.1 Exercise Treadmill Testing
			3.1.1 Methods
			3.1.2 Utility
	4 Cardiac Stress Imaging Tests
		4.1 Stress Echocardiography
			4.1.1 Methods
			4.1.2 Utility
		4.2 Myocardial Perfusion Imaging
			4.2.1 Methods
			4.2.2 Utility
		4.3 Cardiac Magnetic Resonance
			4.3.1 Method
			4.3.2 Utility
	5 Summary
	References
Use of Multislice CT for the Evaluation of Patients with Chest Pain
	1 Overview of CT Technology
	2 Accuracy of Coronary CT Angiography
	3 Cost-Effectiveness of Coronary CT Angiography
	4 Safety Concerns of Coronary CT Angiography
	5 Calcium Scoring in Addition to the CCTA
	6 Coronary CTA and Identification of Unstable Plaques
	7 CT for Diagnosis of Pulmonary Embolism
	8 CT for Diagnosis of Aortic Dissection
	9 The “Triple Rule Out” CT Protocol
	10 Dedicated Coronary Vs. “Triple Rule Out” Scan Protocol: Radiation Dose Considerations
	11 Assessment for Noncardiac, Extravascular Pathology
	12 Coronary CTA Limitations and Protocol Considerations
	13 Conclusions
	References
Use of Magnetic Resonance Imaging for Evaluation of Patients with Chest Pain
	1 Overview of CMR Technology
	2 Safety Concerns
	3 CMR in Acute Coronary Syndrome
	4 CMR in Myocarditis
	5 CMR in Myocardial Infarction with Nonobstructed Coronary Arteries (MINOCA)
	6 CMR in Takotsubo Cardiomyopathy
	7 MRA in Aortic Dissection
	8 MRA in Pulmonary Embolism
	9 Conclusions
	References
		Suggested Reading
New Technologies for the Evaluation of Acute Coronary Syndromes: Magnetocardiography—The Next Generation of Super Electrocardiogram?
	1 Measuring Cardiac Activity
		1.1 The Electrocardiogram
		1.2 Magnetocardiography
	2 Magnetocardiography Recording Devices
	3 Magnetocardiography for Evaluation of Chest Pain
		3.1 Clinical Evidence of Magnetocardiography to Detect Cardiac Ischemia
		3.2 Magnetocardiography Parameters and Methods for Ischemia Detection
		3.3 Magnetocardiography Under Stress
		3.4 Magnetocardiography for the Triage of Emergency Department Patients with Acute Chest Pain
		3.5 Potential Impact of MCG on the Management of Chest Pain in the Emergency Department
	4 Summary
	Appendix
	References
Disposition from the Short Stay Unit
	1 Chest Pain Unit Patient Entry: Appropriate Patient Selection
		1.1 Exclusion of Patients at High Risk for Acute Coronary Syndrome
		1.2 Exclusion of Patients at Very Low Risk of Acute Coronary Syndrome
		1.3 Exclusion of Patients with Logistical and Nonmedical Barriers to Safe Discharge
	2 Indications for Hospitalization from the Short Stay Unit: Admission Triggers
		2.1 Assessment of Clinical Factors
			2.1.1 Heart Rate
			2.1.2 Blood Pressure
			2.1.3 Respiratory Distress and Hypoxia
			2.1.4 Recurrent Symptoms
		2.2 Abnormal ECG and Serum Cardiac Marker Testing
			2.2.1 Dynamic ECG Changes
			2.2.2 Continuous ECG Rhythm Monitoring
			2.2.3 ST Segment Changes
			2.2.4 T-Wave Changes
			2.2.5 Abnormal Cardiac Markers
		2.3 Provocative Testing and Advanced Imaging
		2.4 Reassessment of Functional Status at the End of the Chest Pain Unit Protocol
		2.5 Situations When Outpatient Medical Management Strategies for Patients with Known Coronary Artery Disease Are Appropriate
	3 Indications for Safe Discharge from the Chest Pain Unit
		3.1 Clinical Criteria
		3.2 Shared Decision-Making
		3.3 Discharge Planning and Establishment of Follow-Up
	4 Summary
	References
Examples of Chest Pain Accelerated Decision Pathways, Rule-Out ACS/ACS Protocols, Order Sets, and Discharge Instructions
	1 Accelerated Decision Pathway for Chest Pain Evaluation
	2 Chest Pain Order Set for Observation Unit
	3 Stemi Order Set
	4 Discharge Instructions: Chest Pain
	5 Discharge Instructions: Angina
		5.1 Managing Angina
		5.2 Managing Risk Factors
			5.2.1 Diet
			5.2.2 Physical Activity
			5.2.3 Weight Management
			5.2.4 Smoking
		5.3 When to Call 911
	6 Discharge Instructions: Heart Attack
		6.1 Diet
		6.2 Physical Activity
		6.3 Weight Management
		6.4 Smoking
	References
Correction to: Risk Scoring Systems: Are They Necessary?
	Correction to: Chapter 10 in: M. Pena et al. (eds.), Short Stay Management of Chest Pain, Contemporary Cardiology, https://doi.org/10.1007/978-3-031-05520-1_10
Index