I agree with the enzymes. If I'm contemplating discharge, I won't send a "screening set". The lawyers would crucify you with this in court.
I was always taught this in residency but I haven't seen a court transcript where it happened. That's not to say they don't exist but I have seen transcripts where no enzymes were sent. Juries are fairly simple people and I think the take home message they will get is that there was an easily available blood test which wasn't done and therefore the patient died.
Look at it another way. Even with the aggressive rate that we admit patients for chest pain rule outs we still miss I think something like 1-4% of ACS. Those probably aren't patients that got admitted for two troponins and then stressed. They are the ones like this guy that you couldn't even imagine had ACS. They had tooth pain, or musculoskeletal shoulder pain, or an earache, or pleuritic chest pain for 3 days. I've seen all of those. So, the question is how much of that did we miss and could we catch some of them by saying to ourselves, "OK, I don't believe this is ACS but before he goes I'm going to send a troponin to try and capture some of that 1% I'm missing"
In terms of standard of care I think it is debatable. Certainly if you polled many community physicians in my area you would find them checking a troponin on this guy. What does the academic literature say about the practice? Here is an example:
J Emerg Med. 2004 May;26(4):401-6.
Outcome of low-risk patients discharged home after a normal cardiac troponin I.
Smith SW, Tibbles CD, Apple FS, Zimmerman M.
Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis,
Minnesota 55415, USA.
Patients with symptoms suggestive of, but at low risk for, acute coronary syndrome (ACS), who have a negative electrocardiogram (EKG) and a single normal troponin I at 6-9 h after symptom onset are frequently discharged from our Emergency Department (ED). We sought to determine their rate of adverse cardiac events at 30 days (ACE-30), defined as cardiac death or myocardial infarction (MI), by chart review, telephone interview, or county death records. Of 663 patients, data were available for 588 (89%). Mean age was 48 years; 59% were male. There were 390 patients (66%) who complained of chest pain. Previous coronary artery disease (CAD) was reported in 145 patients (25%). Two patients (0.34%) had ACE-30, both with non-ST elevation MI. There were no cases of cardiac death. None of the patients died in Hennepin County within 30 days. At our institution, low-risk patients with symptoms suggestive of ACS who aredischarged home after a normal cTnI drawn 6-9 h after symptom onset have a very low incidence of cardiac events at 30 days.
PMID: 15093844
So, a couple of thoughts
1. At least at this very well respected residency program it appears that sending low risk patients with a single negative troponin 9 hours after their pain is very common. If you practice in Minnesota an article like this might be used to establish standard of care in your community.
2. They are more aggressive than I am. I don't know that 25% of the low risk chest pain I send home has previously known coronary disease.
3. If you do decide to do it there is at least some evidence in the literature that it is a safe practice.
This case becomes more difficult if you change it to one hour of pain or intermittant pain.
I still haven't heard some of the other fairly long standing private practice docs like docb and spyder weigh in on how they practice.
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