BS Chest Pain Admits

[The White Coat Investor]

I'm a PGYII EM resident. Sometimes it seems to me that my attendings want to admit every chest pain patient over 40 for a rule/out, unless we can find a pneumonia, PE, or PTX that we can clearly blame their chest pain on. It is quite clear to me that most of these are bulll****tt admits, but the literature that is frequently cited to me includes all the bizarre ways that MIs present. (most without chest pain at all it seems at times.) To make it worse, one out of every 10-15 of these bs admits I put in turns out to rule in, making it even more difficult to send anyone home. My friends in IM give me a hard time about these soft rule/outs, and I agree with them most of the time. Does anyone know of any good literature out there that can be used by a good Emergency Physician to do a better job differentiating the bs from real disease? (Don't lecture me on risk factors, the classic presentation of ACS etc, I've got the basics down.) On a related note, how long is "a clean cath" "good for?" That is to say, if my patient had a clean cath 5 years ago, is it possible he has significant coronary disease now? What about 2 years ago, or 6 months ago?

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[Bobblehead]

Unfortunately the best way is to not fight the power. Everyone is worried about liability. Yours is not the final signature on the discharge papers and the more you see the more afraid you become of missing that one that's going to come back to bite you in the ass in the form of a lawsuit. It's an easy admission, rule out, stress test, discharge by 5 the next day. Most likely it's bogus but in the current litiginous climate that's just something that'll have be sucked up.

The best solution may be to have a small amount of holding beds where 12 hour rule outs can be placed without admitting them formally and having them stressed from that holding unit.

 

[jdaasbo]

ER attendings have no disincentives to admit, but they have every incentive to admit. Liability and fear of litigation dictates a lot of what they do. I have had many ER attendings at mine and other institutions freely admit to admitting patients (not just for chest pain) without any criteria for admission because, in their words, "it isn't loosing your house over." That I find quite sad.

 

[Seaglass]

On a related note, how long is "a clean cath" "good for?"

If 100% clean I've heard that it is good for up to 2 years. If anything less than 100% I've heard that it's good for 0 years, ie you can't put any stock in it. Current research tends to suggest that small plaques are the ones that rupture and all cath is looking for are large stentable lesions. Same for a stress test (even more worthless).

 

[PimplePopperMD]

If 100% clean I've heard that it is good for up to 2 years. If anything less than 100% I've heard that it's good for 0 years, ie you can't put any stock in it. Current research tends to suggest that small plaques are the ones that rupture and all cath is looking for are large stentable lesions. Same for a stress test (even more worthless).

A "clean cath", or nonobstructive cath, is good for only the time that the cath is done.

What does that mean?

If someone comes into your emergency department after having had a cath 2 weeks ago, but now has sscp, diaphoresis, risk factors, etc etc, would you not stress this guy?

The small plaques rupture. Unless you get an endovascular ultrasound, you cannot say that his coronaries are "normal". You CAN say that the lumens are normal, which may not mean all that much.

There is NO amount of time that the cath is good for. The bottom line is that you have to be a good clinician, and use all the data at your disposal to make an informed decision.

 

[Seaglass]

It's more like a clean cath is reassuring in a category 4 patient, but of course you go with the history and exam first.

 

[DrQuinn]

A "clean cath", or nonobstructive cath, is good for only the time that the cath is done.

What does that mean?

If someone comes into your emergency department after having had a cath 2 weeks ago, but now has sscp, diaphoresis, risk factors, etc etc, would you not stress this guy?

The small plaques rupture. Unless you get an endovascular ultrasound, you cannot say that his coronaries are "normal". You CAN say that the lumens are normal, which may not mean all that much.

There is NO amount of time that the cath is good for. The bottom line is that you have to be a good clinician, and use all the data at your disposal to make an informed decision.

Disagree. This is a great article:

Am J Cardiol. 1997 Oct 15;80(8):1086-7. Related Articles, Links


Repeat coronary angiography in patients with chest pain and previously normal coronary angiogram.

Pitts WR, Lange RA, Cigarroa JE, Hillis LD.

Department of Internal Medicine, University of Texas Southwestern Medical Center, and Parkland Memorial Hospital, Dallas 75235, USA.

Patients with chest pain and normal coronary angiograms have excellent long-term survival and are unlikely over the ensuing years to develop clinically significant atherosclerotic coronary artery disease. Specifically, of the 17 subjects with a previously normal coronary angiogram who had repeat angiography an average of almost 9 years later, 15 showed no appearance of coronary artery disease and 2 developed single-vessel coronary artery disease, 1 of whom had a myocardial infarction.

PMID: 9352985 [PubMed - indexed for MEDLINE]



As long as the patient can have good follow up (they have a cardiologist who I talk to, or a good PCP), I will send these patients out.

Q

 

[Seaglass]

Quinn, please, a study of 17 patients is hardly a study at all and nothing I would hang my hat on.

 

[PimplePopperMD]

I don't care if the cath was two days ago, two months ago, or two years ago. What's more important than a good history and physical?

You then synthesize all of your data, including the NONOBSTRUCTIVE cath, and make your best clinical judgement.

You don't have to re-cath everybody; certainly, there is a large role for the various "stress-tests". But to send someone home with crushing substernal chest pain, that YOU BELIEVE could be coronary, is in my opinion foolhardy. Now, if you believe that it is NOT coronary, that's a different issue. Perhaps the 27 yo who was cathed for cocaine chest pain last week is a different beast than the 64 yo who was cathed last week and now has a "different" chest pain....

You have to individualize your therapy, and indeed your disposition, based on the specific h&p you get. I don't think you'll disagree with that...

 

[Seaglass]

I don't think you'll disagree with that...

No, I don't think any of us do. I know for me it's more like when I have a soft admit (good story but multiple neg workups, convincing exam) and the medicine resident says "But they had a clean cath 6 months ago!" it would be nice to have something research-wise available to back you up when you tell them you don't give a rip about the cath (or negative stress, or lack of risk factors, etc.)

 

[Stormreaver]

The bane of the cardiology service: the BS chest pains. I haven't seen any good data on how long a "clean cath" is good for, but I agree that if there are no lesions seen whatsoever, it should be fairly convincing. If it is merely nonobstructive, you could lay more stock in the H&P, but remember that an unstable plaque is more likely to cause EKG changes as well (this is more expert opinion than EBM). In most cases, the ER attending WILL call for an admit and the cardiology service WILL NOT turn them down. As an IM resident, I do my 10-minute workup, put them in the chest pain unit and go back to sleep, knowing that my cards rotation will soon be over...

I know, I've fought these admits, and will continue to do so, more for form's sake than anything.

 

[MustafaMond]

It would be nice to have something research-wise available to back you up when you tell them you don't give a rip about the cath (or negative stress, or lack of risk factors, etc.)

I hope they develop computers that can triage pt's w/ CP, so that docs like you stop running up health care costs.

This is the same poster who is anti-blood cultures for pneumonia because of "cost issues".
Tell me seaglass, how many dollars do you throw down the $hitter every time you admit a crappy CP.

I hope Quinn is the ED doc at my hospital instead of you. He obviously posseses the powers of judgement that you lack.
Seaglass you are so ignorant, and the fact you "don't give a rip" about a clean cath reflects a lot about your judgement (poor).

{imagines how many extremely $hitty admits you must make every week}
All I can say is "WOW!" .
I hope you never work in my hospital.

 

[Seaglass]

There are different standards of care for EM and IM. There is currently a zero-tolerance policy in the legal world for missed MI, and currently even the best centers are sending home 1-5% of MI patients from the ED. So in a patient with a convincing story a clean cath is not going to change my management and it shouldn't change yours either.

As for working in the same hospital - feeling's mutual.

 

[DrDre']

Em docs don't always want to admit these CPs. In fact, most of the time, they feel exactly like you do about them.


Sending home a CP in this zero tolerance legal climate is like not ordering an HCG on a young woman with ABD px who absolutely claims there is no chance of pregnancy.

You shouldn't be upset with the ER, you should be upset with the legal climate that drives us in these ways.

As to computers to interpret these findings... Obviously if cardiologists can miss an MI, how is a computer going to do better? There are so many cases of atypical and silent MIs out there. Experience has a place in medicine that science can not replace.

Do you want computers taking away your job, Mustafa? It would be easier to design programs that determine how to do med checks. Up this, lower that, d/c this. Sounds like out patient IM is now out of business!

 

[Winged Scapula]

I hope they develop computers that can triage pt's w/ CP, so that docs like you stop running up health care costs.

This is the same poster who is anti-blood cultures for pneumonia because of "cost issues".
Tell me seaglass, how many dollars do you throw down the $hitter every time you admit a crappy CP.

I hope Quinn is the ED doc at my hospital instead of you. He obviously posseses the powers of judgement that you lack.
Seaglass you are so ignorant, and the fact you "don't give a rip" about a clean cath reflects a lot about your judgement (poor).

{imagines how many extremely $hitty admits you must make every week}
All I can say is "WOW!" .
I hope you never work in my hospital.

MustafaMond - you have been warned repeatedly about the abusive tone your posts frequently take. Please refrain from continuing to do so, as my tolerance for banning your account is very low at this moment.

 

[DrQuinn]

Quinn, please, a study of 17 patients is hardly a study at all and nothing I would hang my hat on.

I've spoken with a lot of interventional cardiologists at my institution and they basically agree with me and that article. Tintinalli's says that if a cath has been absolutely clean within the past two years, its ok to send them home for follow up. I've posted this to my EM attendings and the Cards attendings and have met up with no resistance. So that is my policy now.

Q

 

[Seaglass]

I don't have a problem with the fact that you, or cardiologists, or Tintinalli believe that people with a clean cath can go home, I have a problem with using a study with an N of 17 to hang my hat on.

 

[chameleonknight]

This is an interesting thread.

What symptoms would make an EM doc "nervous" about sending a CP pt home, even if he/she was 80% certain that ACS was not involved? And to cover the liability factor, couldn't you tell a pt that he/she is "at risk" for ACS in the future, thus cushioning against missed diagnosis?

 

[Seaglass]

A classic story with negative tests.

, couldn't you tell a pt that he/she is "at risk" for ACS in the future, thus cushioning against missed diagnosis?

No.

Lawyer: "So you thought he had risk factors for ACS, and he was reporting syptoms of ACS, and you sent him home? Please explain that doctor."