good story for chest pain with risk factors but...

[realruby2000]

It would be interesting to know what some of you guys do with patients who have multiple risk factors for CAD, or have CAD/DM, and present to your ED with a good story for Chest pain but had a recent stress or myoview that was normal?

better yet, they had a cath and had clean coronaries (or patent grafts/stents in cabg/ptca patients).

I've had these patients more than once and every attending is different.

thanks!

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[beyond all hope]

A good history and physical exam consistent with serious disease is more significant than ancillary data in my book. Stress tests and imaging studies are great but they have limitations. Even caths don't show significant intramural plagues, and the EKG may not change immediately. Believe the patient in front of you and act accordingly.

So, patient trumps data.

That being said, multiple risk factors with negative imaging, a normal/unchanged EKG and a soft story might make me send them home.

 

[deleted87716]

All a recent stress test or cath proves is that they had patent coronaries that day. They could rupture a plaque and thrombose any time after that.

 

[FoughtFyr]

The second to last STEMI I took care of was a 32 yo AAF with a strong family history and a negative SESTIMIBI scan six weeks PTA. Emergent cath for 90% mid LAD lesion.

- H

 

[southerndoc]

We have a policy at my institution: suspected cardiac chest pain in a patient with a negative stress < 3 months ago gets admitted for a catheterization. End of story.

 

[Dr.Evil1]

Depends....
What does the EKG show?
If it is a suspicious story the patient will get at least 2 troponins. What do these show?
If all of that is negative it gives me all the more info to talk to my cardiology colleagues.

Agree that a negative stress does not prevent you from rupturing an intramural plaque and having a STEMI or NSTEMI. It does put you at a very low risk of having unstable angina due to a fixed stenosis though.

 

[The White Coat Investor]

Negative EKG and enzymes and a TOTALLY CLEAN cath within 1-2 years is probably safe to go home from a CAD standpoint, no matter what the story (especially if it was the same story that got him to the cath lab last time.)

 

[Phlegm]

Negative EKG and enzymes and a TOTALLY CLEAN cath within 1-2 years is probably safe to go home from a CAD standpoint, no matter what the story (especially if it was the same story that got him to the cath lab last time.)

There is no warranty that comes with a clean coronary angiogram (aka lumenogram). I have yet to read a cath report that says "totally clean". Until or if a better test becomes available a patient with a "good story" for cardiac chest pain and a few risk factors will continue to be admitted or ruled out in a short stay/ER with the potential for more provocative testing.

 

[The White Coat Investor]

There is no warranty that comes with a clean coronary angiogram (aka lumenogram). I have yet to read a cath report that says "totally clean". Until or if a better test becomes available a patient with a "good story" for cardiac chest pain and a few risk factors will continue to be admitted or ruled out in a short stay/ER with the potential for more provocative testing.

All arteries were 100% patent= "totally clean." Show me the data that suggests a patient with a totally clean cath is at risk for an ACS-related poor outcome within one year. I haven't found it, and there is some data out there to suggest it is a safe approach.

 

[deleted65604]

Speaking broadly, not just about the example given, I just can't sell some of these soft admissions. It's embarassing, and ultimately, I don't think it is the right thing to do. In an academic setting, with residents who really don't have a choice, it may fly. In a private practice setting they are going to hate your guts (not that academic physicians don't care either, it's just they usually aren't getting woken up at 2:30 in the morning for a bull-crap admission). I know that we shouldn't change our standard of care to make the admitting team happy, but admitting every person with chest pain every time they present to the ED is a huge waste of money. Ultimately, we've got to do our part in rationing somewhat our health resources. I believe every individual ER doc has got to decide where their comfort zone lies. No research is going to be able to tell us the right answer in every individual case, when each individual presentation and set of risk factors is so unique. Please, I welcome comments because I haven't quite decided where I'm going to sit on the fence when I'm finished with residency with regard to admitting chest pain.

 

[Phlegm]

All arteries were 100% patent= "totally clean." Show me the data that suggests a patient with a totally clean cath is at risk for an ACS-related poor outcome within one year. I haven't found it, and there is some data out there to suggest it is a safe approach.

I'm not trying to change your approach to risk stratifying patients in the ED. I'm on the other side evaluating them after admission. I would rather admit a 52 yo lady who smokes, has bad lipids and presents with substernal chest pain with radiation to the jaw and diaphoresis and a "totally clean" coronary angiogram 9 months ago than many of the rule-outs I have had to deal with in the past. These patients have the possibility of an interesting diagnosis (variant angina with clean coronary arteries/cardiac syndrome X/paradoxical emboli/vasculitis/cocaine-induced vasospasm etc).

I agree that everyone needs to find their own comfort level. But 100% patency on a coronary angiogram does not mean the abscence of clinically significant coronary artery disease. This is well documented in autopsy series and with IVUS data. Coronary angiography is low resolution and has intrinsic limitations in that it is a lumenogram. It also does not rule out the potential for variant angina and very bad ACS outcome, paradoxical embolus in the future, the development of vasculitis, etc. You will get no warranty from the cardiologist.

If you're comfortable with your post cath outcome data then great, you won't be missing very many instances of myocardial ischemia. Personally, I would order the EKG, get some troponins, give the nitro etc. and then decide what needs to be done based on the present evaluation and response to treatment rather than on a previous "totally clean" coronary angiogram.

 

[Jeff698]

I believe every individual ER doc has got to decide where their comfort zone lies. No research is going to be able to tell us the right answer in every individual case, when each individual presentation and set of risk factors is so unique.

This is the money quote of this discussion. You're dead on. There is no good answer.

Dr. Hoffman on EM Abstracts talks about a national missed MI rate of between 2 and 5% twenty years ago. Now that we are super aggressive about admiting ACS patients (with good reason, it's the cause of the largest payout in EM malpractice suits) we've dramatically changed the miss rate.....

to around 2%.

No matter what we do, we're going to miss some MIs and let them go home. If we are careful and do our best, the only ones we'll likely miss are the ones that were un-catchable. The only alternative is to admit everyone with any symptom between their neck and their waist. As you've pointed out, this isn't an acceptable option.

Take care,
Jeff

 

[NinerNiner999]

BTW - there is no data to support disharge following a single set of cardiac markers. The best data I could find suggests that two sets at least two hours apart and negative is minimal to exclude active ACS. When you guys do decide to discharge these chest pain patients, how long do you wait before doing so?

I have also worked at a place where the cardiologists on call would stress low-risk patients prior to their discharge home from the ED. We would not beta-block them and they required one negative set of markers prior to stress testing...

 

[southerndoc]

BTW - there is no data to support disharge following a single set of cardiac markers. The best data I could find suggests that two sets at least two hours apart and negative is minimal to exclude active ACS. When you guys do decide to discharge these chest pain patients, how long do you wait before doing so?

Although not published in a prestigious journal, one of our community hospitals has some limited data on using single troponins in patients with chest pain at least 3.5 hours in duration:

Zarich, et al. Value of a single troponin T at the time of presentation as compared to serial CK-MB determinations in patients with suspected myocardial ischemia. Clin Chim Acta, 326(1-2):185-192.

Department of Medicine, Division of Cardiology, Bridgeport Hospital, Yale University School of Medicine, New Haven, CT, USA. [email protected]

BACKGROUND: Prior studies with cardiac markers have focused predominantly on subjects presenting to the emergency department with chest pain or unstable angina, and have relied on serial markers for the diagnosis of acute myocardial infarction. We evaluated the diagnostic utility of a single cardiac troponin T (cTnT) determination at the time of presentation as compared to serial creatine kinase (CK) MB determinations in a broad spectrum of patients with suspected myocardial ischemia. METHODS: A total of 267 consecutive patients presenting to the emergency department with suspected myocardial ischemia had a single, blinded cTnT determination drawn at the time of presentation to the emergency department in addition to routine serial electrocardiographic and CK-MB determinations. RESULTS: The specificity (93.7% vs. 87.1%; p<0.05) and positive predictive value (80.0% vs. 69.4%; p<0.05) of a single cTnT determination were superior to that of serial CK-MB determinations without compromising sensitivity. Forty-six percent of patients with confirmed myocardial infarction and an abnormal cTnT at presentation had a normal initial CK-MB determination. Conversely, 20% of patients without acute coronary syndromes had an abnormal CK-MB determination in the setting of a normal cTnT. The initial cTnT was abnormal in all patients with confirmed myocardial infarction and a symptom duration of at least 3.5 h. CONCLUSIONS: In a heterogeneous population of patients with suspected myocardial ischemia, the initial cTnT determination drawn at the time of presentation is a powerful diagnostic tool that, when used in context with symptom duration, allows for more rapid and accurate triage of patients than serial CK-MB determinations.

We are currently evaluating myeloperoxydase as a screening tool. The study is underway, but won't be completed for quite some time.

 

[bulgethetwine]

All arteries were 100% patent= "totally clean." Show me the data that suggests a patient with a totally clean cath is at risk for an ACS-related poor outcome within one year. I haven't found it, and there is some data out there to suggest it is a safe approach.

One year is a little beyond my comfort level, but I have no more data to support my approach, either. I saw a person 3 months post have a STEMI not related to cocaine (which is the other population still at risk, at least theoretically, no matter what/when their last cath showed although in this case if spasm is the underlying etiology, it's not like we can do much in terms of optimal medical therapy, etc. anyway)