La vraie vie du coronarien L’entrée dans la maladie “Approche non invasive” Eric Durand Service de Cardiologie, INSERM U1096 CHU de Rouen Un symptôme, des é.ologies mul.ples … Amsterdam et al Low-Risk Patients Presenting With Chest Pain 1759 Table 2. Common Causes of Acute Chest Pain System Cardiovascular Pulmonary Syndrome Clinical Description Presenting Features Stable angina Retrosternal pressure, heaviness, burning; may radiate to arms, neck, jaw Provoked by physical or emotional stress Unstable angina Same as stable angina but usually more severe and prolonged Occurs at rest or with minimal exertion Acute MI Same as angina but usually more severe Usually Ն30-min duration; associated symptoms include dyspnea, weakness, diaphoresis Aortic dissection Sudden severe pain, may radiate to back Commonly associated with hypertension or connective tissue disease Pericarditis Pleuritic pain, worse in supine position Fever, pericardial friction rub PE Sudden onset of pain and dyspnea; pain may be pleuritic with pulmonary infarction Dyspnea, tachypnea, tachycardia Pneumonia May be associated with localized pleuritic pain Cough, fever, crackles Spontaneous pneumothorax Unilateral pleuritic pain associated with dyspnea Sudden onset of symptoms Esophageal reflux Burning retrosternal and epigastric discomfort Aggravated by large meals and postprandial recumbency Peptic ulcer Prolonged epigastric or retrosternal burning Relieved by antacid or food L’é.ologie coronaire est la plus fréquente mais ne représente que 15-‐20% des cas !!! Gastrointestinal Biliary disease Right-upper-quadrant pain Unprovoked or following meal Pancreatitis Intense epigastric and retrosternal pain Associated with alcoholism, elevated triglycerides Costochondritis Fleeting localized pain, may be intense May be reproducible by pressure to affected site Cervical disc disease Sudden fleeting pain May be reproduced by movement of neck Somatoform disorders; sudden fleeting pain; may be reproduced by movement of neck Symptoms are atypical for any organ system Symptoms may persist despite negative evaluations of multiple organ systems Une première DT: stable ou instable ??? Musculoskeletal Psychological Adapted from Table 49 by Cannon and Lee in Braunwald’s Heart Disease.8 Copyright 2008, Elsevier. Haut risque Douleur thoracique ET ECG anormal ET/OU Troponine é Risque faible à intermédiaire La face cachée de l’iceberg … Douleur thoracique ET ECG non-‐contribu.f ET cycle de troponine normal 5% 10% 85% ity hospital on December 26, 2013 derably from day to day and even during the same day. Definitions of typical and atypical angina have been previously pubshed and are summarized in Table 4.50 Atypical angina is most freuently chest pain resembling that of typical angina in location and haracter, that is responsive to nitrates but has no precipitating actors. Often, the pain is described as starting at rest from a low evel of intensity, which slowly intensifies, remains at its maximum or up to 15 min and then slowly decreases in intensity. This characeristic description should alert the clinician to the possibility that oronary vasospasm is present.51 Another atypical presentation is ain of anginal location and quality, which is triggered by exertion Prévalence de la maladie coronaire en fonc.on de l’âge et ESC Guidelines des caractéris.ques de la douleur tests commonly used to Table 13 Clinical pre-test probabilitiesa in patients 108 onary artery disease with stable chest pain symptoms Table 4 Traditional clinical classification of chest pain 96 96 Typical angina Meets all three of the following characteristics: Diagnosis of• substernal CAD chest discomfort of characteristic Typical angina Atypical angina Age Men Women Men Women Men Women 85–90 30–39 59 28 29 10 18 5 80–88 40–49 69 37 38 14 25 8 73–92 63–87 50–59 77 47 49 20 34 12 79–83 Probabilité 82–86 60–69 84 58 59 28 44 17 79–88 81–91 élevée 70–79 89 68 69 37 54 24 72–79 92–95 modérée >80 93 76 78 47 65 32 90–91 75–84 67–94 61–85 95–99 64–83 très faible quality and duration; • provoked by exertion or emotional stress; • relieved by rest and/or nitrates within minutes. Sensitivity (%) Atypical angina (probable) 45–50 Meets two of these characteristics. 80–85 Lacks or meets only one or none of the characteristics. Non-anginal chest pain faible Non-anginal pain ECG ¼ electrocardiogram; PTP ¼ pre-test probability; SCAD ¼ stable coronary artery disease. a Montalescot G et al. Eur Heart J 2013;34:2949-‐3003 Apport de l’ECG ? •  Seuls 5% des pa.ents consultant pour DT ont un ECG anormal •  Un ECG percri.que normal n’élimine pas une occlusion coronaire aiguë (A. circonflexe) •  Un ECG post-‐cri.que normal n’élimine pas un SCA •  En cas de premier ECG “normal” à l’admission: –  IDM dans 2% des cas en l’absence d’antécédent coronarien –  IDM dans 4% en cas d’antécédent coronarien •  SCAST-‐: 50% des pa.ents ont un premier ECG normal ! Place de la troponine … RAPID TESTING FOR CARDIAC 773 pts consécubfs avec DT aiguë (<12h) sans ST+ Deux dosages de la troponine I et T TROPONIN T OR TROPONIN I 47 IDM (6,1%) et 315 « angor instable » (40,8%) TABLE 1. NUMBERS OF DEATHS AND NONFATAL ACUTE MYOCARDIAL INFARCTIONS OCCURRING IN THE HOSPITAL AND WITHIN 30 DAYS AFTER DISCHARGE, ACCORDING TO TROPONIN STATUS. EVENT Death in hospital Acute myocardial in farction in hospital Death after discharge Acute myocardial in farction after discharge All events TROPONIN I– TROPONIN I– TROPONIN T– TROPONIN T– POSITIVE NEGATIVE POSITIVE NEGATIVE (N ‫ ؍‬171) (N ‫ ؍‬602) (N ‫ ؍‬123) (N ‫ ؍‬650) 11 9 0 0 9 7 2 2 8 4 1 1 7 4 2 1 32 2 27 7 BY ELEVATED TABLE 2. CARDIAC EVENTS AS PREDICTED Hamm CW et al, N Engl J Med 1997;337:1648-‐53 Place de la troponine … Mortality at 42 Days (% of patients) T RO P O N I N I L EV E L S TO P R E D I C T T H E R I S K O F M O RTA L I T Y I N AC U T E C O RO N A RY SY N D RO M E S 7.5 8 7 6.0 6 5 4 3.4 3.7 3 2 1 0 1.7 1.0 831 0 to Ͻ0.4 174 148 134 50 0.4 to Ͻ1.0 1.0 to Ͻ2.0 2.0 to Ͻ5.0 5.0 to Ͻ9.0 67 у9.0 Cardiac Troponin I (ng/ml) RISK RATIO 95% CONFIDENCE 1.0 — 1.8 0.5 – 6.7 3.5 1.2 – 10.6 3.9 1.3 – 11.7 6.2 1.7 – 22.3 7.8 2.6 – 23.0 INTERVAL Figure 3. Mortality Rates at 42 Days According to the Level of Cardiac Troponin I Measured at Enrollment. Mortality rates at 42 days (without adjustment for base-line characteristics) are shown for ranges of Antman of EM et al, N Eare ngl the J Med 1996;335:1342-‐9 cardiac troponin I levels measured at base line. The numbers at the bottom each bar num- Place de la troponine aux urgences 1047 pabents > 30 ans avec DT récente. Évènements à 72 heures: Décès, Choc cardiogénique, TV ou FV, BAV, Pontage, Angioplasbe 95 100 90 91 80 80 pourcentage 94 70 60 50 40 52 47 Major cardiac event 40 30 MI 19 20 10 0 Sensibilité Spécificité VPP VPN Polanczyk et al, J Am Coll Cardiol 1998;32:8-‐14 Arbre décisionnel Examens non invasifs Que disent les recommandabons ? 2962 Table 12 Characteristics of tests commonly used to diagnose the presence of coronary artery disease Table 13 Clinical pre-test probabil with stable chest pain symptoms108 Diagnosis of CAD Sensitivity (%) Typical angina Atypical angina Age Men Women Men Wom Exercise ECG a, 91, 94, 95 45–50 85–90 30–39 59 28 29 10 Exercise stress echocardiography 96 80–85 80–88 40–49 69 37 38 14 Exercise stress SPECT96-99 73–92 63–87 50–59 77 47 49 20 Dobutamine stress echocardiography96 79–83 82–86 60–69 84 58 59 28 79–88 81–91 70–79 89 68 69 37 Vasodilator stress echocardiography 96 72–79 92–95 >80 93 76 78 47 Vasodilator stress SPECT 96, 99 90–91 75–84 Vasodilator stress MRI b,98, 100-102 67–94 61–85 Coronary CTAc,103-105 95–99 64–83 Vasodilator stress PET97, 99, 106 81–97 74–91 Dobutamine stress MRIb,100 CAD ¼ coronary artery disease; CTA ¼ computed tomography angiography; ECG ¼ electrocardiogram; MRI ¼ magnetic resonance imaging; PET ¼ positron emission tomography; SPECT ¼ single photon emission computed tomography. a Results without/with minimal referral bias. b Results obtained in populations with medium-to-high prevalence of disease without compensation for referral bias. c Results obtained in populations with low-to-medium prevalence of disease. ECG ¼ electrocardiogram; PTP ¼ pre-test probabilit artery disease. a Probabilities of obstructive coronary disease shown patients aged 35, 45, 55, 65, 75 and 85 years. † Groups in white boxes have a PTP ,15% and henc further testing. † Groups in blue boxes have a PTP of 15 – 65%. They c feasible as the initial test. However, if local expertise a non-invasive imaging based test for ischaemia this wou superior diagnostic capabilities of such tests. In young should be considered. † Groups in light red boxes have PTPs between 66 –8 non-invasive imaging functional test for making a diagn † In groups in dark red boxes the PTP is .85% and o Place de l’ECG d’effort Amsterdam EA et al. J Am Coll Cardiol 2002;40:251-‐6. Scanner coronaire Hoffmann U et al. Circulation 2006;114:2251-60 ESC Guidelines Tests non invasifs selon la probabilité d’être coronarien monly used to y disease Table 13 Clinical pre-test probabilitiesa in patients with stable chest pain symptoms108 CAD Typical angina Atypical angina Age Men Women Men Women Men Women 85–90 30–39 59 28 29 10 18 5 80–88 40–49 69 37 38 14 25 8 63–87 50–59 77 47 49 20 34 12 82–86 60–69 84 58 59 28 44 17 81–91 70–79 89 68 69 37 54 24 92–95 >80 93 76 78 47 65 32 ) 75–84 Non-anginal pain Proba < 15% Pas d’autres tests Proba: 15-‐65% ECG d’effort en 1ière intenbon ou test d’ischémie ou coroscanner Downloaded from ht ECG ¼ electrocardiogram; PTP ¼ pre-test probability; SCAD ¼ stable coronary Proba: 66-‐85% artery disease. a test d’ischémie 64–83 Coronarographie Probabilities of obstructive coronary disease shown reflect the estimates for (autres que ECG 75 and 85 years. d’emblée patients aged 35, 45, 55, 65, 74–91 † Groups in white boxes have d’effort) a PTP ,15% and hence can be managed without further testing. † Groups in blue boxes have a PTP of 15 – 65%. They could have an exercise ECG if aphy angiography; Montalescot feasible as the initial test. However, if local expertise and availability permit aG et al. Eur Heart J 2013;34:2949-‐3003 ing; PET ¼ positron 61–85 Test d’ischémie ou Coroscanner ?: Etude PEPSI (1) Pabents avec DT récente avec ECG normal et cycle de troponine négabf Coroscanner (CCTA) et Echographie-‐Dobutamine (DES) Coronarographie (test de référence) si un des examens posibfs ou 2 examens non-‐contribubfs Parameters Mean age year Female sex N, (%) No. of cardiovascular risk factors N, (%) 0 or 1 2 or 3 >3 GRACE score N, (%) <108 109-‐140 >140 TIMI score N, (%) 1 2 >3 N = 217 57.0 ± 11.2 73 (33.6%) 69 (31.8%) 87 (40.1%) 11 (5.1%) 149 (68.7%) 66 (30.4%) 2 (0.9%) 43 (19.8%) 89 (41.0%) 85 (39.2%) 217 recruited pabents 12 pabents had CCTA or DSE alone CCTA and DSE negabve (N=108) 205 pabents had CCTA and DSE CCTA and/or DES posibve (N=62) CCTA and DES non-‐ contribubve (N=4) CCTA negabve and DES non contribubve (N= 21) DES negabve and CCTA non contribubve (N=10) Durand E et al. Soumis Test d’ischémie ou Coroscanner ? Etude PEPSI (2) 18 pabents were treated by PCI, 4 by CABG, and other pabents (n=15) were only medically treated Conclusions (1) •  Les pa.ents ayant un ECG et/ou une troponine anormale ne posent en pra.que aucun problème diagnos.que mais ceci ne concerne qu’une minorité de cas (15% des cas environ) •  L’évaluabon diagnosbque d’un pabent avec DT récente repose sur deux points essen.els: –  ne pas se limiter à une approche « minimaliste » associant clinique, ECG et cycle de troponine pour infirmer un SCA –  ne pas réaliser une coronarographie chez tous les pabents •  Le taux d’événement grave à court terme (décès, infarctus) est faible mais non nul en cas troponine normale Conclusions (2) •  Une minorité de pa.ents nécessite d’emblée une coronarographie (« homme >70 ans avec DT typique ») et une minorité de pa.ents ne nécessite aucune explora.on complémentaire (« femme jeune < 40 ans avec DT atypique ») •  La majorité des pa.ents doit être évaluée par un test non invasif fonc.onnel (test d’ischémie) ou anatomique (coroscanner): –  Le choix des examens dépend de la probabilité pré-‐test (âge, caractérisbques des DT, ATCD coronarien), de la disponibilité des examens et de l’experbse de chaque centre –  Le scanner coronaire occupe une place de choix pour éliminer une pathologie coronaire car sa sensibilité et sa VPN > tests foncbonnels. –  Un scanner anormal (faible spécificité) nécessite soit des explorabons complémentaires (test foncbonnel) ou une confirmabon par une coronarographie