trop at baseline elevated

[BAM!]

One of my least favorite pt's is the 60yo with ESRD on HD and a chronically elevated trop. They come in for a discharge-able complaints, such as cough or mild flu-symptoms. Trop is slightly elevated, though at baseline. EKG unchanged. No discrete chest pain. What do you guys like to do with this patient. Anyone send them home?

Thx

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[The White Coat Investor]

One of my least favorite pt's is the 60yo with ESRD on HD and a chronically elevated trop. They come in for a discharge-able complaints, such as cough or mild flu-symptoms. Trop is slightly elevated, though at baseline. EKG unchanged. No discrete chest pain. What do you guys like to do with this patient. Anyone send them home?

Thx

Don't send trops in pt's with mild flu symptoms, especially with renal disease. If you accidentally do, send a second one to show it isn't going up. Then send them home.

 

[ERDude]

Best answer: Don't get trops for clearly non cardiac complaints (cough, flu)

Second Best - if the trop is baseline, EKG is non ischemic and the story seems very unlikely for cardiac - I don't do further cardiac eval.

 

[gman33]

As above, what is the trop for?
If you have enough suspicion to send it, you need to address it.
At least a second set along with repeat EKG before going home.

These patients are at very high risk for cardiac death, don't just blow it off and send home.
Eventually that will burn you.

I'd err on this side of admitting these patients if I had any suspicion.

 

[Groove]

The rule of thumb is to not order them unless you are ruling out cardiac ischemia but I get it...where it's almost reflexive to order on these patients as they rarely have completely normal EKG's and commonly have complaints that veer into the cardiac realm such as "sob" since they are often fluid overload. You can order a POC troponin such as iStat where the upper normal is likely ~0.8 and will probably come back negative but do so knowing that there is a paucity of literature in the utilization of POC T's to "rule out" ischemic disease. My hospital heavily pushes POC troponins for rule outs and I refuse to do it. I use standard central lab assays for all my rule outs. In fact, I don't do rule outs at all on this pt population if they come in with cardiac complaints.

So, if you accidentally ordered a troponin and get a mild troponinemia 2/2 ESRD, you need to be prepared to perform a delta (90h vs 2h vs 3h) and document that the elevated troponin is baseline in this pt with a neg delta and 2 unchanged EKGs with an HPI that is non worrisome for ACS. Anything else is playing with fire. Let's face it, most of these pt's have sig additional risk factors for CAD and are unlikely to have anything close to a TIMI 0.

All that being said, don't ever feel bad about admitting these pt's for a formal rule out and don't let anyone bully you into discharging them. This is exactly the type of pt you should be worried about if they even give you the slightest history that makes you suspect ACS.

My 2 cents.

 

[deleted547339]

I've discharged these patients with a single trop before, but never if I'm worried about cardiac ischemia. If they have a viral syndrome, it's not crazy to get a single trop to eval for myocarditis. If they have 2d of dyspnea, it's reasonable to get just one. I always document trop is unchanged from previous, feel this is much more likely related to renal dz than ACS. Have discussed and offered admission for further workup vs. discharge with the patient and the patient would prefer outpatient followup.

 

[Birdstrike]

If you're not worried enough about a cardiac cause to act on an abnormal result, you shouldn't order the test to begin with. In general, don't order a test not worth,

1-Following up on the result of, or

2-Acting on, if abnormal.


That being said, if you have a documented baseline over time of a chronically slightly elevated level, then the abnormal is essentially "normal." Without any specific symptoms, treat as such.

 

[Arcan57]

If you're not worried enough about a cardiac cause to act on an abnormal result, you shouldn't order the test to begin with. In general, don't order a test not worth,

1-Following up on the result of, or

2-Acting on, if abnormal.


That being said, if you have a documented baseline over time of a chronically slightly elevated level, then the abnormal is essentially "normal."

Just be sure that you're not looking at a visit for an NSTEMI. Sort of like how the CXR is unchanged from prior but they were diagnosed with acute pneumonia on the prior CXR

 

[Birdstrike]

Just be sure that you're not looking at a visit for an NSTEMI. Sort of like how the CXR is unchanged from prior but they were diagnosed with acute pneumonia on the prior CXR

True. That's why I said, "baseline over time." Just one previous elevated level, could be up not because it's their normal, but because it was abnormal two separate times. NSTEMI then and NSTEMI now, like you said. That's brings us full circle to the point others have made, that these are all-around tough patients to judge, in general.

 

[BAM!]

I agree -- I don't order a trop if I'm not worried about ACS. But sometimes a triage nurse, provider at triage, or a PA will order one. Then there is some explaining / "shared decision making" / more work to do. I agree with all the above posts and do the same. Thanks for the replies.

 

[Raryn]

I've been called for admission before for a trop elevation... when the trop was not just at baseline but the lowest it had ever been for that patient. *shrug*

 

[VentJockey]

Ok, as an internist this is one of my pet peeves. First of all, if ACS isn't in your differential, don't order the trops. This happens in the ED at my shop all the time, and I don't get it. I personally like to order labs in response to a specific clinical question, not just because it tickles my fancy. But whatever, now you have a positive troponin. If you are a stand up guy you will order another one 4 hours later and do an EKG and then discharge them. If you are a weasle who wants to dump liability onto someone else, you will consult medicine and I will write in my consult "out of context troponin." And I will be done with it. Or maybe I'll send the patient for an MPS to cover my ass. If the patient is really having a lucky day, they'll end up with a stent for an asymptomatic lesion and come back to you in two months with a life threatening bleed from their dual anti platelet therapy all because you kicked the bee hive and ordered a trop when it was not needed or wanted. Y'all need to be less trigger happy with the trops. Unnecessary testing carries downstream morbidity and mortaility.

 

[GeneralVeers]

Ok, as an internist this is one of my pet peeves. First of all, if ACS isn't in your differential, don't order the trops. This happens in the ED at my shop all the time, and I don't get it. I personally like to order labs in response to a specific clinical question, not just because it tickles my fancy. But whatever, now you have a positive troponin. If you are a stand up guy you will order another one 4 hours later and do an EKG and then discharge them. If you are a weasle who wants to dump liability onto someone else, you will consult medicine and I will write in my consult "out of context troponin." And I will be done with it. Or maybe I'll send the patient for an MPS to cover my ass. If the patient is really having a lucky day, they'll end up with a stent for an asymptomatic lesion and come back to you in two months with a life threatening bleed from their dual anti platelet therapy all because you kicked the bee hive and ordered a trop when it was not needed or wanted. Y'all need to be less trigger happy with the trops. Unnecessary testing carries downstream morbidity and mortaility.

Actually admitting the suspected ACS patient with negative troponin isn't being a "weasel". There are a couple of reasons for doing so, and I rarely send a 4 hour one.

1. Two negative troponins at 4 hours does not rule out ACS. Current ACEP guidelines are at least 8 hours after the start of chest pain to rule out ACS.

2. My ED is busy and packed. If I kept every patient for two sets of troponins 4 hours apart, the nurses would tie me to the gurney and rip my arms and legs off as a sacrificial offering to the God of Patient Flow. Seriously, IM people don't get it that we have to move people through, and can't just sit on people for hours repeating testing, or doing huge workups. In my view if they need stay longer than 3-4 hours they should get admitted upstairs for obs.

 

[VentJockey]

Well I have seen on multiple patients who come for things like knee pain, or a gout flair, or even once a med refill with no cheif complaint at all get trops drawn (I asked why they checked the trop, and the ER doc got indignant and said its because they are on "a bunch of cardiac meds". It isn't all ER docs who do this, it is specific bad actors and I really dislike them. Sorry if I sounded angry, but unindicated trops open a huge can of worms for everyone and get my blood pressure substantially elevated.

Oh my favorite one was the recent 21 year old male with urethritis who I got called on a positive troponin. Because an STD in a 21 year old is as good a reason as any to check a troponin.....

 

[NinerNiner999]

We pick up a positive troponin and you are able to sarcastically "blame" us? Did you ever find out why that troponin was positive in a 21 year old? Cocaine and hookers (to explain the STD)? Come on - this is 2015 - probably the peak of the medical Roman empire and all aspects of what we do are judged. Throughput time, inpatient/obs length of stay, No-miss liability, and declining admission volumes are only going to become bigger problems for both of our fields. Somewhere in the mix, good medicine should prevail, but as long as you work in a hospital today (or should I say a medical factory) your job expectations are far beyond practicing "medicine." Welcome to 2015 hospital medicine.

 

[winkleweizen]

I'll never apologize for ordering a troponin. Believe it or not, people with elevated trips have a higher mortality rate than those who don't.

 

[deleted547339]

Well I have seen on multiple patients who come for things like knee pain, or a gout flair, or even once a med refill with no cheif complaint at all get trops drawn (I asked why they checked the trop, and the ER doc got indignant and said its because they are on "a bunch of cardiac meds". It isn't all ER docs who do this, it is specific bad actors and I really dislike them. Sorry if I sounded angry, but unindicated trops open a huge can of worms for everyone and get my blood pressure substantially elevated.

Oh my favorite one was the recent 21 year old male with urethritis who I got called on a positive troponin. Because an STD in a 21 year old is as good a reason as any to check a troponin.....

Be careful....these are probably the same attendings who would treat your asymptomatic hypertension with IV antihypertensives, lol.

 

[VentJockey]

We pick up a positive troponin and you are able to sarcastically "blame" us? Did you ever find out why that troponin was positive in a 21 year old? Cocaine and hookers (to explain the STD)?

Yes, I blame the guy who ordered the trop. Blame him for what precisely? For creating liability for me, while doing nothing to benefit the patient. I didn't do anything to work up an out of context troponin in a guy who obviously didn't have CAD. There is such a thing as pretest probability, and in someone with a pretest probability as low as his (asymptomatic, young, physically fit, no family history of CAD) a positive troponin alters the post test probability from something like 1 in 1,000,000,000 to 1 in 999,999,999. With a post test probability like that, he's more likely to break his neck on the treadmill for the stress test than he is to benefit from that further workup. Look, the guy came in because his dick was burning and there was a mucupurulent discharge. I totally blame the guy who ordered the trop on that one. He needs zithromax, ceftriaxone and a stern lecture about condom use. He does not need a contrast load and CT coronaries.

 

[VentJockey]

I'll never apologize for ordering a troponin. Believe it or not, people with elevated trips have a higher mortality rate than those who don't.

So, last time I checked there was no medical literature to support the practice of estimating life expectancy with random troponins. Life insurance companies, for example, do not require recent troponins before they will issue a policy. It is not a helpful lab if it is not accompanied by the appropriate clinical context. It does however lead to downstream testing and procedures that probably hurt patients more than it helps them because it starts the ball rolling and everyone tries to cover their ass. I'm not saying don't order troponins. I'm saying order troponins in response to a specific and reasonable clinical question in a patient with a pretest probability of cardiac disease such that a positive result of the troponin will change management of the patient.

 

[ERDude]

Well I have seen on multiple patients who come for things like knee pain, or a gout flair, or even once a med refill with no cheif complaint at all get trops drawn (I asked why they checked the trop, and the ER doc got indignant and said its because they are on "a bunch of cardiac meds". It isn't all ER docs who do this, it is specific bad actors and I really dislike them. Sorry if I sounded angry, but unindicated trops open a huge can of worms for everyone and get my blood pressure substantially elevated.

Oh my favorite one was the recent 21 year old male with urethritis who I got called on a positive troponin. Because an STD in a 21 year old is as good a reason as any to check a troponin.....

Your experiences are truly remarkable (especially given you are a resident and thus have very limited experience). I can't say I order trops on the types of patients described above, but to have seen multiple cases of positive trops (assuming no reason for baseline elevation) in patients with CC of knee pain, gout, med refill and 21 y/o M with urethritis is certainly case-report worthy. The significant majority of trops I send in patients with cardiac risk factors presenting with chest pain come back negative (and I would guess I see more chest pain patients in 2-4 weeks than you've seen in your entire training). You should try and publish - sounds like that guy with urethritis also had myocarditis?

 

[Hamhock]

You should try and publish - sounds like that guy with urethritis also had myocarditis?

Or endocarditis? ECHO?

HH

 

[WilcoWorld]

If the patients are as low risk as you describe (1 in 999,999,999) then what liability are you worried about? Your liability exposure is probably higher when driving to work.

 

[Birdstrike]

If the patients are as low risk as you describe (1 in 999,999,999) then what liability are you worried about? Your liability exposure is probably higher when driving to work.

I'd love to work with that guy: "That's it. I've pinpointed the exact amount of risk. It is exactly 1 in 999,999,999. No more, and no less."
Lol

 

[shookwell]

Some recent papers I've come across addressing cardiac markers in patients with renal disease:

http://www.ncbi.nlm.nih.gov/pubmed/25111593

http://www.ncbi.nlm.nih.gov/pubmed/25403922


If the clinical picture does not suggest coronary occlusion and there are no other reasons to order trops then don't order them. If you get a trop and it's some indeterminate level, I usually do another one 2 hours later and if it's similar I attribute it to the kidney disease (I don't have any data to support this but it makes sense to me).