Chest pain r/o question

[Makati2008]

I am wondering if anyone still does the three sets of cardiac markers Q4hrs apartX3 for MI rule out anymore? My hospital is saying to admit them and do the Cardiac markers Q8hrs apart which is the more appopriate route.

I am wondering which one is correct because I have seem this done both ways(I have seen the ER doctor's hold a patient to do the three sets and d/c from ER by end of his shift or turn over to colleague and have them d/c)

Thanks for you help

---

Members don't see this ad.

 

[Rendar5]

Both are correct. There are many things in medicine which are a manner of preference and dependent on resources (such as do we have an observation unit? what are our radiologists able to do?). Generally, whatever "standard of care" the hospital you're at establishes is "correct".

At my hospital we do the initial EKG/trop and admit for q4h labs unless they're positive. We send them to different parts of the hospital based on their underlying risk (more extensive testing gets done along with cardiac follow-up for the higher risk patients I believe). We also may do a CT of the coronary arteries to hopefully bypass that route if they're low suspicion without known coronary artery disease.

 

[southerndoc]

We also may do a CT of the coronary arteries to hopefully bypass that route if they're low suspicion without known coronary artery disease.

Any discussion of changing practice in light of the recent pressure to limit radiation exposure?

 

[deleted6669]

we do baseline cardiac enzymes/ekg in the dept then send them to our obs unit(if set #1 neg) where they get repeat ekg and enzymes in 6 hrs. if unchanged( ie still nl) they get a test to risk stratify them based on their hx.
if low risk they get an exercise stress treadmill. folks with higher risk factors get echo or dip/thal.
any positives get a cardiology consult +/- trip to the cath lab.

 

[Arcan57]

CTCA has about the same amount of radiation exposure (5-15 mSv) as a sestamibi scan (13-16 mSv) and far less than a thallium scan. Most institutes are not set up to use stress echoes as a primary means of ruling out ischemia, so the radiation exposure argument is a bit of a straw-man. Now if you want to make a case that the widespread availability of a test with good (but not perfect) sensitivity will be inappropriately applied to a population with essentially no chance of having the disease (see d-dimer). And then argue that the lowering of activation energy would result in more false positives (and more testing in 19 yr olds with atypical symptoms) that then expose the patient to the dangers (and radiation) of a cath. Then yeah, I would buy that.

Edit: just realized that there are probably a decent number of shops that still use EKG treadmill stress tests without nuclear imaging. In which case that obviously would be less radiation then a CTCA (but still a pretty crappy way of ruling out ischemia).

 

[Arcan57]

FWIW, we use the Biosite POC multimarker strategy (0,90 minute CKMB, myoglobin, and troponin). Low-risk patients without evidence of infarction (either by troponin bump or a combination of doubled myoglobin with 50% increase in CKMB) get admitted (usually to hospitalist) for exercise or adenosine thallium scan in the am. We had been getting troponin q8h x 3 prior to the thallium scan, but are switching to an 8h troponin in high-risk patients and no further troponins in low-risk patients.

 

[DogFaceMedic]

we do baseline cardiac enzymes/ekg in the dept then send them to our obs unit(if set #1 neg) where they get repeat ekg and enzymes in 6 hrs. if unchanged( ie still nl) they get a test to risk stratify them based on their hx.
if low risk they get an exercise stress treadmill. folks with higher risk factors get echo or dip/thal.
any positives get a cardiology consult +/- trip to the cath lab.

I do this also. If CP is >8hrs and constant, then one neg trop to r/o ACS. Trop will be elevated if CP >8hrs is due to ischemia/infarction.

 

[southerndoc]

CTCA has about the same amount of radiation exposure (5-15 mSv) as a sestamibi scan (13-16 mSv) and far less than a thallium scan. Most institutes are not set up to use stress echoes as a primary means of ruling out ischemia, so the radiation exposure argument is a bit of a straw-man. Now if you want to make a case that the widespread availability of a test with good (but not perfect) sensitivity will be inappropriately applied to a population with essentially no chance of having the disease (see d-dimer). And then argue that the lowering of activation energy would result in more false positives (and more testing in 19 yr olds with atypical symptoms) that then expose the patient to the dangers (and radiation) of a cath. Then yeah, I would buy that.

Edit: just realized that there are probably a decent number of shops that still use EKG treadmill stress tests without nuclear imaging. In which case that obviously would be less radiation then a CTCA (but still a pretty crappy way of ruling out ischemia).

Cardiac CTA has a lot of variability in radiation exposure (5.7-36.5 mSv in one study). TCM does reduce this somewhat.

 

[Rendar5]

Cardiac CTA has a lot of variability in radiation exposure (5.7-36.5 mSv in one study). TCM does reduce this somewhat.

Our radiologist who specializes in these has some sort of custom set up to really lower the radiation exposure risk. He gets lower doses on his CTA-coronary than we get on our CTA's for r/o PE. (almost makes it worth doing for our PE r/o's too as a triple screen, except for the additional time it takes to drop the HR and get the specific attending to read it) I'll take a look next time, but he's somewhere in the sub-15 range consistently, iirc.

 

[deleted6669]

I do this also. If CP is >8hrs and constant, then one neg trop to r/o ACS. Trop will be elevated if CP >8hrs is due to ischemia/infarction.

I heard greg henry, md lecture about this topic last yr. at an em conference.
apparently one set of enzymes is medicolegal suicide.
the rationale is this:
expert witness(cardiologist)" well, it's likely that the pt had been having stable angina for 7.5 hrs and infarcted 30 min before the enzymes were drawn so they were negative as was the ekg as happens in 10% of MI's. if dr dogfaced medic had followed the standard of care and done a second set mr smith would still be alive today after a successful cathlab procedure instead of dying awaiting(or during) treadmill in the obs unit"....$10 million verdict....apparently this has happened more than once....

 

[southerndoc]

Emedpa has a point. It doesn't matter how many sets of enzymes you check or whether you check them at all. If you miss an MI, it's a liability. You can't justify one set of enzymes in someone who had an MI as much as you can't justify not CT'ing the head of someone with a bleed just because they had no LOC and weren't vomiting. If you miss it, you miss it, and a jury won't care what kind of scientific evidence you have to back up your thought process.

 

[glorfindel]

It doesn't matter how many sets of enzymes you check or whether you check them at all. ...[A]nd a jury won't care what kind of scientific evidence you have to back up your thought process.

Not true -- many physicians sued for malpractice in cases with a bad outcome are fortunate enough to get jurors who do care about the evidence, and who are aware that sometimes bad things happen despite good medical care.

I've never met anyone who ordered a CT for every single patient with a bump to the head. We all use our medical judgment, even if we tend to be more conservative because of a fear of lawsuits.

 

[DogFaceMedic]

Emedpa has a point. It doesn't matter how many sets of enzymes you check or whether you check them at all. If you miss an MI, it's a liability. You can't justify one set of enzymes in someone who had an MI as much as you can't justify not CT'ing the head of someone with a bleed just because they had no LOC and weren't vomiting. If you miss it, you miss it, and a jury won't care what kind of scientific evidence you have to back up your thought process.

Your are right that it is a judgement call. There is solid research to support one enzyme. Still, if someone had a good history, I'd draw a second to cover my retreat. If I get a stupid story that the pt had CP for 3 days, I'm getting one set, and out the door rather than waste time occupying a bed or in my obs unit. Border line 8 hrs and maybe constant CP, multiple risk factors, and a good story, I agree and get multiple sets.

This is much better discussion. I showed disrespect to the sacred cows of psych on Mil Med and my name is being trashed.

 

[southerndoc]

If someone has a good story, those aren't the ones you have to worry about. Not many of us will send home a 60-year-old hypertensive, diabetic, with high cholesterol who comes in with 4 hours of chest pressure relieved with nitroglycerin.

It's the 40-year-old with no risk factors who comes in with 2 days of pleuritic chest pain that will burn you. Nobody is thinking acute coronary syndrome in this patient, and so you send him home. For the most part, your judgement is correct. It's that rare instance where the patient's atypical symptoms were unstable angina or ACS that causes a bad outcome and comes back to bite you.

glorfindel, in your area of the country perhaps that is true. I used to date a medical malpractice attorney (no jokes about sleeping with the enemy please). Physicians can and do lose judgements based on bad outcomes despite good scientific evidence to support their decisions.

 

[deleted109597]

We often lose judgements based on good scientific evidence, or bad. You can be sued for not giving steroids to the spinal cord injury. Now, you can be sued for their VAP after you gave steroids. Pick your poison.
People can have STEMIs the day after a negative cath (and not just from dissected lumens). All we can do is risk stratify and hope.

 

[WilcoWorld]

Having been involved in a lawsuit I will say that one of the worst parts is the way it makes you question your abilities. I think it is as important to be able to review your management and say "even if I loose I know I did the right thing" as it is to win the case. Someone who had a head bonk but had no LOC, no emesis, no neuro findings, no alcohol or anticoagulation, etc, etc who comes back with a subdural would fall into that group for me.

Of course, loosing your shirt would suck, but that's what insurance is for.

So, my practice is to be responsible and prudent, but only to the point that I am acting in my patient's best interest. The coronary CT on a 19 year old is a safe medicolegal decision, from an ACS-risk standpoint anyway, but it's really not good for the patient or society.

Anyway, I generally do two sets if I'm concerned enough to do one set. Occasionally, when the stars align (normal ECG, good alternative diagnosis, constant pain for > 8 hours...) and I get a warm fuzzy feeling inside, I'll d/c after one set.

 

[GeneralVeers]

Anyway, I generally do two sets if I'm concerned enough to do one set. Occasionally, when the stars align (normal ECG, good alternative diagnosis, constant pain for > 8 hours...) and I get a warm fuzzy feeling inside, I'll d/c after one set.

I took the "High Risk Emergency Medicine" course last year, and it will scare you to death. The take-home point from that entire course was that everyone with chest pain should be admitted to minimize your risk. Do I admit every 19 year old with chest pain? Absolutely not, but it sure makes me think twice before just discharging them.

 

[dmitrinyr]

Having been involved in a lawsuit I will say that one of the worst parts is the way it makes you question your abilities. I think it is as important to be able to review your management and say "even if I loose I know I did the right thing" as it is to win the case. Someone who had a head bonk but had no LOC, no emesis, no neuro findings, no alcohol or anticoagulation, etc, etc who comes back with a subdural would fall into that group for me.

Of course, loosing your shirt would suck, but that's what insurance is for.

So, my practice is to be responsible and prudent, but only to the point that I am acting in my patient's best interest. The coronary CT on a 19 year old is a safe medicolegal decision, from an ACS-risk standpoint anyway, but it's really not good for the patient or society.

Anyway, I generally do two sets if I'm concerned enough to do one set. Occasionally, when the stars align (normal ECG, good alternative diagnosis, constant pain for > 8 hours...) and I get a warm fuzzy feeling inside, I'll d/c after one set.

How a doctor rules out ACS in a pt with CP is very attending dependent. I've had attendings that have told me that "if you are concerned enough to get 1 set of enzymes, then you should be concerned enough to get the second set if the 1st is negative". I've also had attendings tell me similar approaches as the one above from WilcoWorld. The problem is not our medical training and not our approach. You can do everything right and everything is negative and then the pt can have an MI the next day. The problem is the medicolegal aspect of it. The lawyers can always twist your actions (in the event of a bad outcome) to make it seem like you could've done something else. As WilcoWorld, the worst thing that a lawsuit can do is make you question your own abilities. I've seen attendings in the ED admit almost anything with CP just to cover their as*es. The best thing that we can do is trust our abilities as physicians and our training and do the right thing for the pt. We cannot admit everyone with CP and we cannot CT every pt with a bump on he head with no signs or symptoms of a bleed.

 

[southerndoc]

Some of the things that I've seen that were near misses (patients I've personally seen) really make me wonder what I am missing sometimes.

Case in point: A few weeks ago a 32-year-old presented with bilateral shoulder soreness after using a hydraulic lift to put in a transmission the night before. Normal vital signs. Not writhing in pain. Resting comfortably on the stretcher. Normal exam except some deltoid tenderness. Could easily be considered a shoulder/deltoid strain. I actually wrote his script for discharge and thought "something's just not right." I ordered an EKG and CXR. Both normal. I put his chart back in the discharge bin (for the second time). As the nurse was writing his discharge paperwork, I said "can you send some labs?" D-dimer came back at 2800. CTA showed an ascending dissection with involvement of the subclavian artery. A near miss, but thankfully a near miss and not a total miss.

A colleague of mine had a 20-year-old with palpitations all keyed up for discharge. As they were giving him discharge instructions and about to disconnect him from the monitor, he went into VT and subsequently lost a pulse. Was successfully resuscitated. Had the department not been busy and he would've been discharged 20 minutes earlier, the kid would've died at home from polymorphic VT. (His EKG and electrolytes were normal.)

You never know what's hiding pathology wise, and even the simplest and most benign presentation could be a catastrophe waiting to happen.

 

[gutonc]

Some of the things that I've seen that were near misses (patients I've personally seen) really make me wonder what I am missing sometimes.

Case in point: A few weeks ago a 32-year-old presented with bilateral shoulder soreness after using a hydraulic lift to put in a transmission the night before. Normal vital signs. Not writhing in pain. Resting comfortably on the stretcher. Normal exam except some deltoid tenderness. Could easily be considered a shoulder/deltoid strain. I actually wrote his script for discharge and thought "something's just not right." I ordered an EKG and CXR. Both normal. I put his chart back in the discharge bin (for the second time). As the nurse was writing his discharge paperwork, I said "can you send some labs?" D-dimer came back at 2800. CTA showed an ascending dissection with involvement of the subclavian artery. A near miss, but thankfully a near miss and not a total miss.

Man...why are those dudes always lifting something?

Had a similar case on the CCU service a couple of years ago. 40-ish dude, HVAC contractor working on construction in our hospital. Lifting an AC compressor which he dropped (not on himself). Picked it back up with some help and installed it. Had b/l anterior and posterior chest pain about 30 minutes later. They were done working for the day anyway (swing shift so this is ~10pm) so figured he'd stop in the ED on the way home to get checked out. Odd, non-diagnostic EKG but all labs nml so they sent him to the scanner. CT shows small descending thoracic aortic dissection. Gets admitted to CCU and CT surg called. By the time they get there ~1h later he's intubated, on 3 pressors and barely hanging on. 2 hours after that, he's dead on the table in the OR. Fortunately his work buddies called his wife when they took him to the ED so she and his kid actually made it there before he got intubated.

 

[turtle md]

WOW, the above 2 posts are scary! So far, none of my muscle strains have died of dissections, but...

Scan everyone? Admit everyone? ???

 

[Arcan57]

Always listen to the little voice in the back of your head, and admit (scan, perform functional testing on) everyone you're even vaguely concerned about. Won't keep you from getting sued or your patients having bad outcomes, but it is conducive to sleeping well.

 

[Lumberg]

Chest pain doesn't go home.

 

[deleted65604]

One of my colleagues saw a 20 year old kid with presenting complaint of sudden onset of chest tightness. He also had some really vague URI symptoms. D-dimer was positive, leading to a CTA that showed a big aortic aneurysm in his chest (but no dissection. They repeated the contrast bolus to better evaluate the aorta and saw a dissection on the first scan. He got helicoptered out and got surgery and did fine. No family history of aneurysms or connective tissue disease. Didn't look marfanoid. No risk factors for aneurysms... sleep tight.

 

[GeneralVeers]

One of my colleagues saw a 20 year old kid with presenting complaint of sudden onset of chest tightness. He also had some really vague URI symptoms. D-dimer was positive, leading to a CTA that showed a big aortic aneurysm in his chest (but no dissection. They repeated the contrast bolus to better evaluate the aorta and saw a dissection on the first scan. He got helicoptered out and got surgery and did fine. No family history of aneurysms or connective tissue disease. Didn't look marfanoid. No risk factors for aneurysms... sleep tight.

Was CXR normal? Chest pain is just scary. If I admitted every 18-28 year old female with pleuritic chest pain, our hospital would be overflowing out into the parking lot, not to mention I'd be out of a job.

 

[glorfindel]

GeneralVeers says:

Chest pain is just scary. If I admitted every 18-28 year old female with pleuritic chest pain, our hospital would be overflowing out into the parking lot, not to mention I'd be out of a job.

One way to understand why chest pain is so scary is to contrast the ex ante (prospective) view with the ex post (retrospective) view of how an ER doc should handle a young person with chest pain:

Prospectively, as GeneralVeers notes, there is an expectation that the ER physician won't spend scarce resources on patients who are extremely unlikely to have serious pathology. It's why he'll get fired if he admits every young female with pleuritic pain, or if he gets a contrast CT on all of them.

Retrospectively, however, there's an expectation that we simply won't tolerate any misses of serious chest pathology. If the young woman turns out to be dissecting and dies or ends up in the unit for a month, the ER doc might get sued for failing to diagnose it.

Southerndoc says:

Normal exam except some deltoid tenderness. Could easily be considered a shoulder/deltoid strain. I actually wrote his script for discharge and thought "something's just not right." I ordered an EKG and CXR. Both normal. I put his chart back in the discharge bin (for the second time).

I wonder what might have happened if southerndoc had stopped right there. He's already "wasted" resources if it turns out to really be a shoulder strain, 'cause that doesn't need an EKG or a CXR. Clinically, ex ante, he's already done too much. But what if the pt had gone home, died of a dissection, and his widow had sued. The pts lawyer, ex post, is going to say, "look, you must have been concerned that this was more than a strain, because you ordered a chest xray. Why didn't you also order a dimer and a CT chest?" And the jury, looking back retrospectively, might say, "yeah, that doc knew something was wrong but didn't do enough to figure it out."

Yeah, I'd agree that chest pain is scary.

 

[southerndoc]

I wonder what might have happened if southerndoc had stopped right there. He's already "wasted" resources if it turns out to really be a shoulder strain, 'cause that doesn't need an EKG or a CXR. Clinically, ex ante, he's already done too much. But what if the pt had gone home, died of a dissection, and his widow had sued. The pts lawyer, ex post, is going to say, "look, you must have been concerned that this was more than a strain, because you ordered a chest xray. Why didn't you also order a dimer and a CT chest?" And the jury, looking back retrospectively, might say, "yeah, that doc knew something was wrong but didn't do enough to figure it out."

Yeah, I'd agree that chest pain is scary.

I was getting some teasing from the nurses for ordering it (but of course looked like a shining star when the final diagnosis was made). I mention this story because I wonder what I've sent home that ended up having serious pathology. You can't work everyone up, and nor should you. Working every person up will unnecessarily increase healthcare expenditures, and even worse, will expose patients to unnecessary radiation. Thankfully my inner voice kept telling me that something was going on with this guy. Unfortunately, I probably won't have that inner voice with every patient I see.

 

[WilcoWorld]

I was thinking about this thread when the wuss in me sent a 2nd troponin on a 34 year old with a normal ECG, because the 1st troponin (which was negative) was sent only 4 hours after his onset of pain... and something just didn't sit right.

It came back 10 times above our lab's cut-off.

 

[deleted6669]

I was thinking about this thread when the wuss in me sent a 2nd troponin on a 34 year old with a normal ECG, because the 1st troponin (which was negative) was sent only 4 hours after his onset of pain... and something just didn't sit right.

It came back 10 times above our lab's cut-off.

GOOD JOB!
you saved his life...and your career....

 

[Jeff698]

I was thinking about this thread when the wuss in me sent a 2nd troponin on a 34 year old with a normal ECG, because the 1st troponin (which was negative) was sent only 4 hours after his onset of pain... and something just didn't sit right.

It came back 10 times above our lab's cut-off.

That's not the wuss in you, that's the part of you that understands the limitations of negative markers. One set at less than 8-10 hours doesn't mean much at all.

Take care,
Jeff

 

[enfuegoEP]

Thankfully my inner voice kept telling me that something was going on with this guy. Unfortunately, I probably won't have that inner voice with every patient I see.

I was thinking about this thread when the wuss in me sent a 2nd troponin on a 34 year old with a normal ECG.

The "inner voice" and "wuss" in all of us is actually much more sophisticated than we think. Malcolm Gladwell's book "Blink" gives a interesting and detailed explanation of why we don't put down the chart and d/c the patient southerndoc is talking about, or why we send off that d-dimer or second set of enzymes in a patient we're taught should be OK to send home. The book takes an interesting look at those decisions we make when our "inner voice" or "gut feeling" tells us something isn't right. It's a worthwhile read for EP's who have to make critical decisions multiple times in a shift with inadequate information under pressure. Listen to that inner voice...IMO it will save the patient and you.

 

[deleted109597]

Chest pain with normal EKG. CTA ruled out PE on visit 1. Came back a week later.
Trop 4.34, MB 16. In a 32 year old female without a family history.
I'll have to see how it turned out when I go back in tomorrow.

 

[Rendar5]

The "inner voice" and "wuss" in all of us is actually much more sophisticated than we think. Malcolm Gladwell's book "Blink" gives a interesting and detailed explanation of why we don't put down the chart and d/c the patient southerndoc is talking about, or why we send off that d-dimer or second set of enzymes in a patient we're taught should be OK to send home. The book takes an interesting look at those decisions we make when our "inner voice" or "gut feeling" tells us something isn't right. It's a worthwhile read for EP's who have to make critical decisions multiple times in a shift with inadequate information under pressure. Listen to that inner voice...IMO it will save the patient and you.

I'll have to check it out. I wonder if this is something that we get from our training?

 

[deleted109597]

Beats me if the inner voice is trained (ie, you see a million, but this one doesn't act the same way, etc) or what.
However, the 32 year old ended up having a dissection in her LAD. And her verterbral.

 

[Arcan57]

I think there is some training of that "spidey-sense". I vividly remember the first patient I saw as a second year with a cc of sore throat. Saw dozens and dozens of sorethroats as an intern, and none of them were sick. This guy isn't in respiratory distress, voice is a little hoarse, no meningismus, and the throat's a little red. And I walk out of the room convinced he was sick, but I didn't quite know why. After the CT came back with an RPA, I realized that the dude had been sitting in the sniffing position during the initial H&P. None of the other sorethroats had been doing that, and it tripped a warning.

Incidently, I think this is why a some of EPs (myself included) get twitchy around kids. We don't see as many peds patients as adults, and thus slightly atypical presentations tend to send that alarm jangling. This can either lead to occasional unnecessary transfers (because we follow our gut) or disastrous misses (because we get used to the alarm and start ignoring it).