Chest Pain R/O MI

[brainfailure]

So when do you guys give beta-blockers, lovenox/heparin, or IIbs? I mean, does every chest pain r/o MI get some lovenox? Obviously, if someone has true unstable angina or STEMI or something, thats one thing. But what about the 60yr old chest painers that have an OK story, some risk factors, no EKG changes and a negative first set of enzymes that you're gonna send to the observation unit? Does it change if the have had a history of CAD in the past? Do you guys use TIMI scores to help make those decisions?

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[GeneralVeers]

So when do you guys give beta-blockers, lovenox/heparin, or IIbs? I mean, does every chest pain r/o MI get some lovenox? Obviously, if someone has true unstable angina or STEMI or something, thats one thing. But what about the 60yr old chest painers that have an OK story, some risk factors, no EKG changes and a negative first set of enzymes that you're gonna send to the observation unit? Does it change if the have had a history of CAD in the past? Do you guys use TIMI scores to help make those decisions?

I give Plavix or Lovenox if I'm convinced it's ACS. They have to have significant chest pain, a good story and/or EKG changes or elevated Troponin.

Beta blockers should be given to every chest pain admission unless there's a contraindication.

 

[southerndoc]

Beta blockers should be given to every chest pain admission unless there's a contraindication.

Routine beta blocker administration in acute MI patients is being phased out. Beta blocker use in acute MI has been associated with significantly worse morbidity in patients who go to the cath lab. Patients are more likely to require IABP or other invasive interventions. Our support of beta blocker use in AMI was primarily during the era of thrombolytics.

This is why beta blocker use in acute MI is no longer a core measure.

 

[Apollyon]

This is why beta blocker use in acute MI is no longer a core measure.

You get big props for being very up to date (this core measure was disposed of as of 1 April 2009), but, ever cognizant, the JCAHO stated that beta blockers are still appropriate for certain patients, including patients with AMI.

 

[12R34Y]

I most certainly do not give lovenox/plavix/heparin/beta blocker to all chest pain r/o's. If I didn't work in an urban/county hospital I'd probably never admit most of them anyway. My suburban/rural moonlighting gigs I would always just set them up with a stress the next day or f/u with they card/pcp the next day after talking with them on the phone.

ASA is the greatest life saver for any presumed ACS anyway. I do that for everyone, but definately no to the beta blocker. If I do give a beta blocker for ACS it is almost certainly a low dose PO.

People get heparinzed if increased trops, ekg change (if no old ekg then ekg must have some abnormality and not just lvh with repol changes) OR if story is sooooo amazing fantastical and they have history of stents/cabg etc...maybe they came 1-2 hours into pain and wouldn't expect to see much change yet. they also get heparinized.

The one thing I've realized is that chest pain is probably the single most varied workup between providers. Some are one-setters, some are two-setters, some are heparanizers etc....

very varied.

later

 

[GeneralVeers]

I still get dinged as a "core measure fallout" if I don't give B-blocker to Acute MI patients without documenting a contraindication. Has this changed at the JCAHO level or is this current literature?

 

[southerndoc]

I still get dinged as a "core measure fallout" if I don't give B-blocker to Acute MI patients without documenting a contraindication. Has this changed at the JCAHO level or is this current literature?

Effective 1 April 2009, beta blockers are no longer required to be administered upon hospital admission. I think they are still required for hospital discharge. The AMI-6 is the only thing that changed from the Joint Commission to my knowledge.

 

[Jeff698]

Baring an incredible story or awe inspiring ECG abnormalities, I only heparanize my NSTEMIs. STEMIs may or may not get it depending on if they're going to our cath lab (then they do + IIbIIIa) or being transfered (then they don't get anything but ASA and plavix to cut down on transfer time due to pump issues enroute).

I just had the core measure discussion with my hospitalist today. I've been looking for reasons to avoid giving them lately after seeing mounting evidence that they increase mortality in CHF or cardiogenic shock patients, many of whom present without early evidence of badness. I was glad to learn that it no longer listed.

I agree, there is HUGE variability in physician practice in this area. I send lots of chest pain patients home while some of my partners seem to admit anyone with discomfort between their knees and chin. Perhaps I just haven't been burned yet.

Take care,
Jeff

 

[southerndoc]

I've been looking for reasons to avoid giving them lately after seeing mounting evidence that they increase mortality in CHF or cardiogenic shock patients, many of whom present without early evidence of badness. I was glad to learn that it no longer listed.

It's my understanding that beta blockers reduce mortality, but increase morbidity. More likely to have cardiogenic shock requiring IABP.

 

[Apollyon]

Due wholly to Marvin the Martian's bringing it to my attention, I brought it to the attention of our medical director, who stated we would change in the health system on June 1.

I got the straight dope from the Joint Commission website (www.jointcommission.org), which has a link to core measures. Whoever writes this stuff is slick - the position paper states that, while metrics are not a surrogate for clinical care, "end-users" (I am not kidding) often use them in just that way.

The no Bbx is the only change. This time.

 

[TysonCook]

No BB here either, as noted above, it will stop soon. No heparin unless trop and ekg changes.

 

[dchristismi]

We are also getting away from BB - our group made it common knowledge that as of April 1st, TJC changed their minds on what was important. I had shifted to using a small dose PO anyway in the last few months.

Our cards guys like to make the IIB/IIA/Plavix call, so we mostly heparinize and let them do the rest.

 

[po' boy]

keep in mind that beta blockers screw up ability to stress within 12 hours. i generally only give them if they're going to the lab or on request by admitting MD.
yes to heparin. yes to ASA always. plavix per Cards request, same with IIB/IIIAs.

 

[Arcan57]

Yes to ASA, no to heparin unless documented hx of CAD presenting with anginal pain or ST segment changes/+troponin. I give metoprolol 25mg po to patients with documented CAD to appease our hospitalists. I'll continue plavix if already on, otherwise will leave that and IIb/IIIa to cards.

 

[kungfufishing]

I don't give BB routinely. In fact, in our place, the only people I do give them to regularly are the cardiac CT candidates, because apparently the study is better if their HR is lower.

 

[Seaglass]

I don't give BB routinely. In fact, in our place, the only people I do give them to regularly are the cardiac CT candidates, because apparently the study is better if their HR is lower.

It does allow for better images and lower radiation dosage.