Chest Pain (to D/c or not to D/c)

[southerndoc]

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HEART <4 gets a repeat trop at 90 minutes. If no change, discharge home.

 

[Fox800]

HEART <4 gets a repeat trop at 90 minutes. If no change, discharge home.

High sensitivity? 90 minutes is an odd interval compared to most studies.

 

[ShockIndex]

High sensitivity? 90 minutes is an odd interval compared to most studies.

I agree - accepted for hs-trop; not widely accepted for contemporary sensitivity. Having said that MI is rare in patients with HEART scores <4 and extremely rare for those with a single negative contemporary sensitivity troponin. So, someone doing a 90-min delta could go years without a miss causing a bad outcome. The problem comes if there is a miss and having to explain the decision rule being used - that can get lonely if nobody else in one’s group is doing that short of an interval.

Moreover, I had some problems with Dr. Morgenstern’s commentary in that September 2019 EMRAP on stress tests. First, he tried to make the argument that stenting outside of STEMI has no mortality benefit, therefore stress testing should theoretically have no benefit. Although he didn’t provide a source for his comment that senting doesn’t confer a mortality benefit in NSTEMI, I assume that he was referring to the RITA-3 trial. The problem with this oversimplification is that there are reasons and benefits to PCI aside from placing a stent which accounts for the several studies showing a routine invasive strategy was generally superior to an ischemia-guided or selectively invasive strategy in NSTEMI ACS (mortality NNT 91). For example, there are absolutely patients with ACS who need a cath to identify their 3-vessel disease, but probably don’t need a stent.

Second, Morgenstern cited a bunch of ED observational studies from 8-15 years ago that enrolled ultra-low risk patients and included a variety of stress modalities with no consistent gold standard, and came away with a blanket statement that all stress testing is worthless. I’d like to think that the ball has been moved forward in just the past 5 or 6 years to stressing more moderate risk (HEART Score at least 4) and away from worthless treadmill ECGs. We simply don’t know how the better performing studies like SPECT or CMR perform from the ED in true moderate risk or even those with mild, transient trop elevations.

 

[southerndoc]

High sensitivity? 90 minutes is an odd interval compared to most studies.

No, POC: https://ahajournals.org/doi/full/10.1161/hc3801.096336

Some other studies support it. Think UPenn did some research IIRC that looks at delta troponins. If 90 minute troponin has increased -- even if normal -- they get admitted. i.e. first <0.02, second 0.03. Admitted. Changing troponin.

 

[ShockIndex]

No, POC: https://ahajournals.org/doi/full/10.1161/hc3801.096336

Some other studies support it. Think UPenn did some research IIRC that looks at delta troponins. If 90 minute troponin has increased -- even if normal -- they get admitted. i.e. first <0.02, second 0.03. Admitted. Changing troponin.

Man, you’re dating yourself with that one. What can I say - You’re my boy, Blue! You’re my boy!

I can’t say that I’d be comfortable using that paper, but we are talking about very low risk peeps, so it’s conceivable that you could go a career without a bad outcome.

 

[thegenius]

I agree - accepted for hs-trop; not widely accepted for contemporary sensitivity. Having said that MI is rare in patients with HEART scores <4 and extremely rare for those with a single negative contemporary sensitivity troponin. So, someone doing a 90-min delta could go years without a miss causing a bad outcome. The problem comes if there is a miss and having to explain the decision rule being used - that can get lonely if nobody else in one’s group is doing that short of an interval.

Moreover, I had some problems with Dr. Morgenstern’s commentary in that September 2019 EMRAP on stress tests. First, he tried to make the argument that stenting outside of STEMI has no mortality benefit, therefore stress testing should theoretically have no benefit. Although he didn’t provide a source for his comment that senting doesn’t confer a mortality benefit in NSTEMI, I assume that he was referring to the RITA-3 trial. The problem with this oversimplification is that there are reasons and benefits to PCI aside from placing a stent which accounts for the several studies showing a routine invasive strategy was generally superior to an ischemia-guided or selectively invasive strategy in NSTEMI ACS (mortality NNT 91). For example, there are absolutely patients with ACS who need a cath to identify their 3-vessel disease, but probably don’t need a stent.

Second, Morgenstern cited a bunch of ED observational studies from 8-15 years ago that enrolled ultra-low risk patients and included a variety of stress modalities with no consistent gold standard, and came away with a blanket statement that all stress testing is worthless. I’d like to think that the ball has been moved forward in just the past 5 or 6 years to stressing more moderate risk (HEART Score at least 4) and away from worthless treadmill ECGs. We simply don’t know how the better performing studies like SPECT or CMR perform from the ED in true moderate risk or even those with mild, transient trop elevations.

I read or listened to those articles and commentary as well. I just don't know enough about stress testing to give an opinion. Nor will I ever spend the time to read all relevant studies about efficacy of stress tests (and I'm sure there are dozens and dozens). It seems a little odd to say that stress tests are useless for everybody, but I'm not sure that is exactly what he is saying. Anyway....even if he is.....we as Emergency Docs are not going to influence Cardiology outpatient offices and if Cardiology is still going to order stress tests decades into the future then....there ya go. We don't have to order them in the Emergency Department.

I used to order them, maybe 4-5 times a year while they were in the ED. Haven't done it in over a year and I plan on continuing that anyway.

Remember...that Kaiser data I posted above? The N = 29,000 and their percent mortality and AMI over the next 30 days was 0.6%. This is out of everybody, low medium and high HEART scores. Death or AMI after 30 days is extremely low.

But another way of looking at this is as follows: I see probably 3 patients a shift with isolated chest pain. That is approximately 540 a year (3 * 15 * 12). So I'm sending 3 home every year to have a heart attack or die within the next 30 days! *gulp*

Actually probably the real question to be asked is will outpatient stress testing measurably change that 0.6%? What if it goes to 0.3%? That isn't much of a change.

 

[TooMuchResearch]

I think that would be reported as a 50% reduction though

I read or listened to those articles and commentary as well. I just don't know enough about stress testing to give an opinion. Nor will I ever spend the time to read all relevant studies about efficacy of stress tests (and I'm sure there are dozens and dozens). It seems a little odd to say that stress tests are useless for everybody, but I'm not sure that is exactly what he is saying. Anyway....even if he is.....we as Emergency Docs are not going to influence Cardiology outpatient offices and if Cardiology is still going to order stress tests decades into the future then....there ya go. We don't have to order them in the Emergency Department.

I used to order them, maybe 4-5 times a year while they were in the ED. Haven't done it in over a year and I plan on continuing that anyway.

Remember...that Kaiser data I posted above? The N = 29,000 and their percent mortality and AMI over the next 30 days was 0.6%. This is out of everybody, low medium and high HEART scores. Death or AMI after 30 days is extremely low.

But another way of looking at this is as follows: I see probably 3 patients a shift with isolated chest pain. That is approximately 540 a year (3 * 15 * 12). So I'm sending 3 home every year to have a heart attack or die within the next 30 days! *gulp*

Actually probably the real question to be asked is will outpatient stress testing measurably change that 0.6%? What if it goes to 0.3%? That isn't much of a change.

 

[SamtheWise]

But another way of looking at this is as follows: I see probably 3 patients a shift with isolated chest pain. That is approximately 540 a year (3 * 15 * 12). So I'm sending 3 home every year to have a heart attack or die within the next 30 days! *gulp*

But another way of looking at it is that theres a 0.6^540 (1.591018e-120)% chance that you're sending EVERY SINGLE ONE home to have an AMI or die within the next 30 days. Now that's a risk I can't live with.

But all joking aside, there are greater risks of an elderly patient with a negative non-arterially phased contrasted CT a/p (sensitivity of 93% in this population) going home and having missed mesenteric ischemia than 0.6%, and how many of those do you see a shift? But we don't calculate a 'B3LLY' score and admit them for a mesenteric stress test the next morning, and this disease process carries a higher risk of M&M than AMI.