Decision-Making Criteria

Question 1

Purpose of TIMI Risk Score?

Answer 1

Estimates mortality for patients with UA (unstable angina) and non-STEMI

Can be used to help risk stratify patients with presumed ischemic chest pain

Question 2

TIMI Risk Score criteria?

Answer 2

1. Age (65+)
2. ASA use in past 7 days
3. Angina (severe, 2+ episodes in 24 hours)
4. Cardiac enzymes (+ cardiac marker)
5. Coronary risk factors (3+, HTN, Hypercholesterolemia, DM, family hx CAD, current smoker)
6. Known CAD (stenosis 50+%)
7. EKG ST changes (0.5+ mm)

+1 for each

0-1: lower risk of adverse outcome; risk is not 0

Question 3

Purpose of HEART Score?

Answer 3

Designed to predict the likelihood of ACS in the patient presenting to the emergency department with acute chest pain

Use in patients 21+ y/o with symptoms suggestive of ACS

Do not use if new STEMI 1+ mm or other new EKG changes, hypotension, life expectancy less than 1 year, or non-cardiac medical/surgical/psychiatric illness determined by the provider to require admission

Any ED patient with chest pain that the physicians deems appropriate for an ACS work-up

Question 4

HEART Score criteria (broad categories)

Answer 4

1. History
2. EKG
3. Age
4. Risk factors
5. Initial troponin

Question 5

Management per HEART score?

Answer 5

0-3: 0.9-1.7% risk of adverse cardiac event (serial troponins, discharge if negative)
4-6: 12-16.6% risk (admitted)
7+: 50-65% risk (candidates for early invasive measures)

If high risk, serial troponins. If positive -> cardiology consult and admission. If negative -> admit for observation.

Question 6

When should PERC rule for PE be used?

Answer 6

Patients where the diagnosis of PE is being considered, but the patient is deemed low-risk (by gestalt)

Question 7

PERC rule?

Answer 7

If any of these is true, fail PERC.

1. Age 50+
2. HR 100+
3. O2 sat on RA <95%
4. Unilateral leg swelling
5. Hemoptysis
6. Recent surgery or trauma (up to 4 weeks ago requiring general anesthesia)
7. Prior PE or DVT
8. Hormone use (OCs, HRT, estrogenic hormones)

Question 8

Purpose of Wells’ Criteria for PE and when to use?

Answer 8

Risk stratifies patients for PE, provides an estimate of pre-test probability

Question 9

Wells’ Criteria for PE?

Answer 9

1. Clinical signs and symptoms of DVT +3
2. PE is #1 diagnosis or is equally likely +3
3. HR >100 +1.5
4. Immobilization at least 3 days OR surgery in previous 4 weeks +1.5
5. Previous, objectively diagnosed PE or DVT +1.5
6. Hemoptysis +1
7. Malignancy with treatment within 6 months or palliative +1

Low risk: <2 points
Moderate risk: 2-6 points
High risk: >6 points

or

0-4: PE unlikely (with D-Dimer)
5+: PE likely (with CTA)

Question 10

Wells’ Criteria for DVT?

Answer 10

1. Active cancer
2. Bedridden recently >3 days or major surgery within 12 weeks
3. Calf swelling >3 cm compared to other leg
4. Collateral (non-varicose) superficial veins present
5. Entire leg swollen
6. Localized tenderness along deep venous system
7. Pitting edema confined to symptomatic leg
8. Paralysis, paresis, or recent plaster immobilization of lower extremity
9. Previously documented DVT
10. Alternative diagnosis to DVT as likely or more likely (-2 points)

All others: +1 point

Score:
0 or lower: DVT unlikely, D-Dimer test, then U/S if positive
1-2: moderate risk, high-sensitivity D-Dimer. If positive, U/S
3+: high risk, U/S, still get a D-Dimer to risk stratify