How do you guys deal with the feeling of "missing something"?

[GeneralVeers]

Heart score < 3 I discharge. I make sure to document this in the chart and I think it's defensible. Unfortunately my patients population is too poorly educate to actively participate in shared decision making.

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[Zebra Hunter]

Re: one troponin.

It's about statistics and shared decision making. The HEART score is based off one troponin and the timing of that troponin isn't factored in. If you have a patient with a HEART score of 3 or less, that persons 30 day risk of MI/death is 2%. If you get a second troponin, that risk goes under 1%. Now obviously, this is only for low risk CP (defined by a HEART of 3 or less). People with an abnormal ECG, lots of risk factors, great story, etc... for those people the risk with one troponin, or even more, is greater and therefore generally an observation for provocative testing is recommended.

Here's what I do:

HEART > 3: Observation. If the patient doesn't want to, I explain the higher risk, develop an outpatient followup plan, make sure they take an aspirin a day, and tell them they can come back if they change their mind. And I have them leave AMA. Our hospital policy recommends obs for HEART > 3, so them leaving is technically always AMA based on hospital standard of care.
HEART < 3: I use shared decision making. I explain the risk (2%) based on the single trop. I explain that risk is lower (under 1%) with a second negative trop and recommend a 2 hr delta troponin, but if the patient is totally cool with 2% and doesn't want to stay (personally, I wouldn't stay), they go home with outpt followup at this point with good return precautions. If the patient stays for the delta trop and if there is any rise, they get observation. If unchanged and normal, they go home.

Nitpicking but the bolded is inaccurate. It is ~2% risk of MI/Death/PCI/CABG with the majority being PCI or CABG. Being that I don’t care whether a patient I d/c’d later had a PCI or CABG despite lack of AMI, the MACE that I care about is already below 1% with a single troponin.

 

[gamerEMdoc]

Nitpicking but the bolded is inaccurate. It is ~2% risk of MI/Death/PCI/CABG with the majority being PCI or CABG. Being that I don’t care whether a patient I d/c’d later had a PCI or CABG despite lack of AMI, the MACE that I care about is already below 1% with a single troponin.

Excellent point.

When you take the PCI out of the equation for MACE and only look at patient oriented outcomes, you could make the case for never admitting any chest pain regardless of risk that rules out with two troponins based on the Weingart article from NEJM, the rate of a patient oriented bad outcome was ridiculously low, and was almost always iatrogenic from staying in the hospital. I always wanted to see that repeated with a single troponin, even if its just in lower risk people.