Good discussion, I've been out several years and still am not sure what to do with these people. I have seen MIs in 20-30 year olds although I realize those are the exceptions the tolerance for missing an MI is 0.0% unfortunately.
If I think the story is junk and they have no RF I don't even give them a cardiac w/u. I don't want someone to come back and say well you had enough suspicion to get one set of enzymes? If the onset is greater than 6 hours and they have some RF (smoking, over 40 etc) I'll just get one set, but multiple EKGs in the ER and close outpt f/u.
The majority of CPers I see come in less than 6-8 hours after pain and I get two sets of enzymes with the 2nd one being greater than 8 hours after CP onset.
I have in the past done 2hr delta and the data seems good, but I don't think it has reached the level of being acceptable and don't do it anymore. Francis Fesmire, Erlanger and Judd Hollander have some good articles on the low risk CP RO. Seems like cardiac CT might be useful. Ironic how we get "too many CTs" but the answer to discovering pathology often times is to CT. Sigh.
