Epigastric Pain = R/O MI?

[docB]

I was really interested in the first 2 sentences of this article:

1. Treatment of dyspepsia

The first priority, says Mel and Stuart, in any patient with abdominal symptoms is to address any possible life threat, namely acute coronary syndrome (ACS). 30% of ACS patients present with isolated GI complaints, therefore a screening EKG is strongly recommended.

http://www.epmonthly.com/index.php?option=com_content&task=view&id=212&Itemid=28

So here's the question, if you're considering ACS as a cause for epigastric pain is a screening EKG good enough or should you really go all the way with enzymes and a full rule out?

We just had an interesting discussion about working up chest pain in a low risk patient(http://forums.studentdoctor.net/showthread.php?t=515399). This is a discussion about people who might be more risky but are having epigastric pain rather than chest pain. And it's not fair to say you'll work them up if they have risk factors, you've got to say how many risk factors constitute the magic number needed to work them up.

Is a "screening EKG" ever sufficient? If not why are we getting so many of them?

---

Members don't see this ad.

 

[roja]

I'll play.


No, never sufficient.

I do not believe there is EVER a magic number. A thorough history and physical. A good exam. Assessment of follow up, private MD access, and institutional policies. (Ie, do your acs patients get echo's. Mine, generally, don't) Values of the patient.

So, I can't play completely. It depends on all the variable things I will access in my h&p, discussion with private and patient, etc.

Like all things, no absolute, no magic bullet.

 

[lucky_deadman]

I'll play as well.

Last PM had a guy (really healthy in 50's) with epigastic pain for 2-3 weeks. Identical symptoms 3 yrs back w/ clean cath; dx'd with GERD and things well controlled since. Strong family hx for CAD and well controlled dyslipidemia as only risk factors. ED obs'd him for serial trops and stress echo this morning. EKG normal, trops all normal.

I would have bet it was gonna be GERD again. (Responded well to GI Cocktail and not to SL NTG upon initial presentation to ED. Yeah I know this isn't diagnostic, strictly for symptom relief.) This morning's stress echo showed severe wall motion abnormality in LAD distribution.

So to answer your question. No, the screening EKG is not sufficient in most cases if you think ACS could be the cause.

 

[roja]

I had an analogous discussion with a resident regarding 'screening' urine dips for ketones in hyperglycemics.

I think that this is one of those 'get on or off the boat'. If you have a suspicion of ACS/MI, based on a thorough H&P (especially with the atypical or 'equivilant') presentations, then you get the EKG. EKGs are not 'screening' tests.

If we want to use them as such, then we have to redo all the literature on it. (try and think about how you use an HIV test... because if EKG's become screening tests you have to use them in a similar way)

If you don't think someone has ACS/MI, then a negative EKG doesn't make you any safer. (so, your 75 yo with crushing substernal cp radiating to the L arm has a normal ekg, are you done? Your 20 yo with 3 months of nonexertional, reproducable chest wall pain has an 'abnormal' ekg, do you admit?)

You have to know what you are screening for, what the sensitivity, specificity, NPV and PPV are for a test and then decide on if you can use that test to 'screen in' or 'screen out'.

 

[12R34Y]

I had an analogous discussion with a resident regarding 'screening' urine dips for ketones in hyperglycemics.

I think that this is one of those 'get on or off the boat'. If you have a suspicion of ACS/MI, based on a thorough H&P (especially with the atypical or 'equivilant') presentations, then you get the EKG. EKGs are not 'screening' tests.

If we want to use them as such, then we have to redo all the literature on it. (try and think about how you use an HIV test... because if EKG's become screening tests you have to use them in a similar way)

If you don't think someone has ACS/MI, then a negative EKG doesn't make you any safer. (so, your 75 yo with crushing substernal cp radiating to the L arm has a normal ekg, are you done? Your 20 yo with 3 months of nonexertional, reproducable chest wall pain has an 'abnormal' ekg, do you admit?)

You have to know what you are screening for, what the sensitivity, specificity, NPV and PPV are for a test and then decide on if you can use that test to 'screen in' or 'screen out'.

Don't they quote the EKG as being 50% sensitive for ACS? Your point is well taken, and I do agree, but it seems like a fair number of my attendings will get a 12-lead just because..........their point is that it is non-invasive, quick, easy and can only yield something potentially useful, but nothing bad can come from it.


for example, last week I had a 55 y/o guy who had fever, headache, sore throat, some nausea/vomiting and diffuse myalgias. Looked like classic viral something or other.........gave him some vicodin, IVF's, blood sugar (was diabetic), fever came down and was tolerated PO and plan to discharge.

Attending stops by and says "Oh, I added an EKG. He has an old one so I thought it won't hurt due to his history."

Okay, so the guy's history, DM, CAD, CABG, AMI, HTN, Chronic kidney dz etc....compliant on meds, no pain, no soa, no doe, no diaphoresis, no nothing, pressure if fine etc...

So, her thought was that "well............he's got such a terrible history and we might as well look because we have an old one to compare etc..."

what do you think about that?

later

 

[roja]

I think if you ask 10 attendings a question, you will get 12 different answers. Personally, I don't order a test unless it will help me figure out something I need answered, or rule something out. IE: I don't order tests just because. I personally think this is poor medicine, and potentially dangerous- mostly to the attending (by giving false sense of security with inappopriate use of tests) and potentially to patients (order unnecessary tests and you are likely to get a false positive which may or may not end up causing procedures and unnecessary work ups- some of them with complications).

So, in general, I don't order tests 'just because'. But again..... herding cats, all that.

(When I teach my point of view, I try to use examples: ie, if you have a male with abdominal pain, you don't order a pregnancy test, just because. Or if you think someone has gastritis, you don't order a plain film just because it might be an obstruction/perforation, even though you don't think its there. The 'negative' doesn't really rule either of those out.... etc etc. you can insert same for Aortic dissection).

You have to use your h&p and order tests to figure out what to do with your patients.

 

[12R34Y]

I think if you ask 10 attendings a question, you will get 12 different answers. Personally, I don't order a test unless it will help me figure out something I need answered, or rule something out. IE: I don't order tests just because. I personally think this is poor medicine, and potentially dangerous- mostly to the attending (by giving false sense of security with inappopriate use of tests) and potentially to patients (order unnecessary tests and you are likely to get a false positive which may or may not end up causing procedures and unnecessary work ups- some of them with complications).

So, in general, I don't order tests 'just because'. But again..... herding cats, all that.

(When I teach my point of view, I try to use examples: ie, if you have a male with abdominal pain, you don't order a pregnancy test, just because. Or if you think someone has gastritis, you don't order a plain film just because it might be an obstruction/perforation, even though you don't think its there. The 'negative' doesn't really rule either of those out.... etc etc. you can insert same for Aortic dissection).

You have to use your h&p and order tests to figure out what to do with your patients.

I completely and totally agree!

Do you get 12-leads on syncope in the young/healthy patient? 20 y/o that "passed out" for example.

I honestly don't think they're having an AMI, but I'm getting the EKG to look for things like WPW (good but not perfectly sensitive test), long QT etc...

So, while I completely agree I think that getting an EKG (even when you're planning on not doing any more ruling in/out) is okay because it might yield helpful info (sometimes lifesaving).

But, again in that scenario the EKG isn't 100% sensitive as a screening test.

do you think that is wrong?

thanks!

later

 

[roja]

syncope is different. An ekg is indicated in this case. A patient with pneumonia, I don't think is as indicated. (unless you are dealing iwth septic shock and looking for signs of MSOF).

The question is, *why* are you getting an ekg? If you are looking for something specific (wpw, long qt, u waves, etc) then I think its fine.

If you are getting it 'just because', I think you are looking for trouble.

again, this is just my personal take on things.....

 

[12R34Y]

syncope is different. An ekg is indicated in this case. A patient with pneumonia, I don't think is as indicated. (unless you are dealing iwth septic shock and looking for signs of MSOF).

The question is, *why* are you getting an ekg? If you are looking for something specific (wpw, long qt, u waves, etc) then I think its fine.

If you are getting it 'just because', I think you are looking for trouble.

again, this is just my personal take on things.....

We totally agree. good topic.

later

 

[deleted65604]

I think if you ask 10 attendings a question, you will get 12 different answers. Personally, I don't order a test unless it will help me figure out something I need answered, or rule something out. IE: I don't order tests just because. I personally think this is poor medicine, and potentially dangerous- mostly to the attending (by giving false sense of security with inappopriate use of tests) and potentially to patients (order unnecessary tests and you are likely to get a false positive which may or may not end up causing procedures and unnecessary work ups- some of them with complications). "

My attending added an EKG on a 40 yo guy with renal transplant, weakness and subjective fevers, while we waited for labs to check for white count and urine results. She did it more to look at the intervals to screen for electrolyte abnormality. it showed funny st segment "bumps". We hemmed and hawed and asked him if he had chest pain. we ended up calling cardiology, who took him to the cath lab. On the table he was telling them he didn't need the procedure. the last thing he said before they performed the cath was , "Are you mother F'rs sure i need this?" Clean coronaries. whoops. Better safe than sorry I guess.

 

[leviathan]

The 'negative' doesn't really rule either of those out.... etc etc. you can insert same for Aortic dissection).

You have to use your h&p and order tests to figure out what to do with your patients.

I'm guessing that would really look bad in court and the lawyers could take you to town.

E.g. abdo pain and you get an ECG...turns out it is a non-STEMI but you d/c the patient.

Now it looks like you thought the patient was having an ACS, you started SOME investigations into it, but did not do a full workup. The lawyer will probe you on the standard of care for evaluating possible ACS, and ask why you did not follow that standard if you thought the patient was having one. How would you respond?

 

[roja]

I'm not sure I understand your question. Can you clarify a little more? or maybe the context of my response is not clear?

(and btw, lawyers can say/do anything. defensive medicine =bad medicine)

 

[leviathan]

I'm not sure I understand your question. Can you clarify a little more? or maybe the context of my response is not clear?

(and btw, lawyers can say/do anything. defensive medicine =bad medicine)

Let's say you d/c someone with abdominal pain, who you ran an ECG on "just because", and it was negative. After the fact, if he actually was having a NSTEMI, couldn't the lawyers make a good case against you that you didn't follow the correct standard of care to ruling out an ACS, and thus were negligent? (Ie., you didn't run enzymes, do stress testing, etc)

 

[roja]

Ah. Got it. Sorry. (I have been in the midst of looking for housing and traveling and I am alittle brain fried).

1. A lawyer (in the US) can say *anything*. (see case about assault on a head injured patient who got a DRE).

2. Your case is hard to answer because they are never this simple. Does the patient have risk factors? what are the modifiers to the pain? (exertional?associations?exercise tolerance?SOB?) What is the family history? Is there drug use? Other diseases? Medicines?

However, you are raising a very important point. You need to know the sensitivity and specificity of your test that you are using. EKG's are terrible at this. In the right patient, an EKG that is normal doesn't mean anything (ie a pt with DM, HTN, high cholesterol with substernal, crushing, exertional cp that radiates to the left arm and is relieved some with rest) doesn't 'rule out' an MI.

A 22 year old, nondrug user, triathalete with no FH and no complaints who has ST elevations doesn't mean that there is CAD.


So, pick your test accordingly and know its strength and weakness.

 

[docB]

bump

 

[QuikClot]

An EKG and enzymes are separate issues. EKGs are pretty sensitive for acute MI. Get a clean EKG to guide our rx while you're waiting for the enzymes.

I sympathize with those who do not want to order a test "just because." The "because," however, does not have to be a clear dx. That's the IM way -- chasing the truth. In EM, the equation of whether to do a test is more complex, because time is limited and you are focused on identifying acute life threats.

Is it quick? (Yes.) Is it cheap? (Yes.) Is it safe? (Yes, and compare to those INSANE CT scans in low-probability PE -- killing some kidneys, causing some cancers -- for a snowball's chance in hell of a better outcome than you'd get with a D-dimer.) Is it productive of information that can affect the balance of your decisions, even if it doesn't decide anything by itself? (Yes.)

Tests that meet these criteria include the 12-lead, blood glucose, the CBC, a rapid strep, RUQ ultrasound, and basic electrolytes. It's good, rational medicine to have a low threshold for ordering them just as it's good, rational medicine to demand the data drag you kicking and screaming to the CT scanner.

 

[docB]

An EKG and enzymes are separate issues. EKGs are pretty sensitive for acute MI. Get a clean EKG to guide our rx while you're waiting for the enzymes.

I sympathize with those who do not want to order a test "just because." The "because," however, does not have to be a clear dx. That's the IM way -- chasing the truth. In EM, the equation of whether to do a test is more complex, because time is limited and you are focused on identifying acute life threats.

Is it quick? (Yes.) Is it cheap? (Yes.) Is it safe? (Yes, and compare to those INSANE CT scans in low-probability PE -- killing some kidneys, causing some cancers -- for a snowball's chance in hell of a better outcome than you'd get with a D-dimer.) Is it productive of information that can affect the balance of your decisions, even if it doesn't decide anything by itself? (Yes.)

Tests that meet these criteria include the 12-lead, blood glucose, the CBC, a rapid strep, RUQ ultrasound, and basic electrolytes. It's good, rational medicine to have a low threshold for ordering them just as it's good, rational medicine to demand the data drag you kicking and screaming to the CT scanner.

But the question here is about what the "screening" EKG will cause you to do that you might not have otherwise and is it reasonable to get the EKG without enzymes. Does a non-diagnostic EKG mean we have to admit someone who got a "screening" EKG? If you got the EKG it's evident in the chart that you were thinking about ACS so should you have done the whole rule out process (whatever that is at your place)? Screening tests usually result in additional work up when positive, e.g. + guiac leads to a colonoscopy. But does every epigastric pain need an EKG, enzymes and an admission for rule out?

 

[roja]

EKG is not that great for acute MI. Its not BAD but its not awesome. IE people can be having an MI and have a normal EKG. they can have UA and have a normal EKG. they can have ACS and have a normal EKG.

An EKG is definately NOT a screening test. Neither is a CBC. Or basic electrolytes. blood glucose and rapid streps are diagnostic tests in the ED. (ie we aren't screening for diabetes, we are looking for DKA, etc).

You have to use ones pretest probablility with these tests. If its not changing anything, you shouldn't order it.

 

[QuikClot]

If you got the EKG it's evident in the chart that you were thinking about ACS so should you have done the whole rule out process (whatever that is at your place)? Screening tests usually result in additional work up when positive, e.g. + guiac leads to a colonoscopy. But does every epigastric pain need an EKG, enzymes and an admission for rule out?

I can't comment on that reasoning (EKG requires enzymes requires admission) from a legal perspective. From a medical perspective, if you have a low-risk pt. with a clean EKG, there is no reason you have to continue down the path. If it's not clean, or course, you have to go farther, so I wouldn't slap an EKG on someone on whom I had no suspicions at all.

Roja: docB used the term "screening." I wouldn't use that term. Nor is the EKG usually "diagnostic." But between those two things lie a lot of useful information in pushing things up and down on the differential.

In history taking, we recognize this. Most of our questions are not "screening" (asked only for demographic reasons) but neither do most of them produce a pathognomonic answer ("diagnostic.") But we still ask those questions, because they produce useful data that ultimately leads to a better decision.

As I say, it may be legally necessary to either exhaustively rule out a problem or to pretend it never occurred to your mind. Many smart and experienced people seem to believe that it is, and I don't know better. But from the point of rational medical decision making, I would argue, the gray area is where we should be most of the time.

 

[docB]

I would argue, the gray area is where we should be most of the time.

I agree. It is where we are most of the time. And I certainly agree that getting the quick, cheap, non-invasive, info laden EKG should be a no brainer. But, speaking of no brains, the lawyers have forced us to a point where we have to debate not just how much defensive medicine we have to practice but how much liability we incur from doing such an easy test.