clarification on anginal equivalent?

[Painter1]

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older diabetic patient presents with SOB, sob began last night but much worse this morning, had some "chest discomfort" earlier that resolved. cxr reveals no chf.

her ekg reveals signfiicant t wave inversions in the lateral leads consistent with ischemia. (no s1q3t3, no new right bundle and no new anterior or inferior lead t wave inversions to think of a large PE).

can you refer to her present sob as a possible "anginal equivalent"?

in a discussion about the patient with the cardiologist, when i mentioned possible angingal equivalent, the dude went ape ****, stating "she had chest discomfort earlier" so that means she can mount chest pain, therefore her present sob can't be an anginal equivalent".

any thoughts?

 

[docB]

Anginal equivalent is kind of a garbage term that can be applied to pretty much any symptom you'd care to list. That said it doesn't mean that it's not real. It sounds like the cardio was trying to explain away the symptoms similar to the fabeled "troponin leak." When it comes down to it an elderly diabetic female is exactly the patient that can burn you by presenting atypically.I don't think that the fact that the patient had chest pain previously would sway me. The pain could have been GI or any number of other things (specifically all the things that admitting docs bring up when they don't want to admit the patient) and now the SOB is the real anginal equivalent.

 

[Jeff698]

One of the most common chief complaints in patients with documented MI (other than chest pain) is dyspnea.

Also on the list is syncope, dizzyness, nausea and abdominal pain (usually epigastric).

There were a couple of nice studies on this in the last couple of years.

Take care,
Jeff

 

[Mighty Mouse]

At ACEP, Mattu gave a lecture on pitfalls of ACS. His moral of the story....chest pain + diaphoresis, chest pain + sob, or chest pain + nausea = admit for provacative testing or cath.

I think the cardiologist does raise an interesting point about her ability to mount a pain response, but in the end, I would consider the dyspnea to be an ongoing cardiac issue until you can prove otherwise....which is something than cannot be definitively done out of the emergency department, even with serial trops in my opinion.

 

[Radiohead]

Most Cardiologists really don't get excited about "atypical" CP or anginal equivalents, unless they have positive enzymes or obviously ischemic EKG findings. In private practice, I would usually admit that to the hospitalist and they can rule her out and arrange further testing...unless they already have a private Cardiologist, then I give them the right of first refusal.