How do you handle chest pain?

[beyond all hope]

I'm curious because our hospital is extremely unorthodox in a number of ways.

At the recent ACEP conference many authors suggested we need to admit ALL chest pain, because there is still at least a 1% bad outcome for anyone regardless of risk factors. Many people also site that the standard of care for any chest pain is stress, scan, cath or admit.

Our attendings are extremely conservative. We usually admit all chest pains, and rule them out in the ER. Very few (probably <5%) rule in.

What do you do?

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[dread]

Yup, even the best ER is still sending 1-2% of positive MI patients home. This is fairly significant considering that there is a 25-35% decrease in mortality for those post-MI patients admitted into hospitals. If you increase your sensitivity though, you end up with a ton more of unneccessary admits. Our ER will actually rule out those patients with really weak stories of CP within the ER in 24 hrs (a CP center in the ER). They occasionally consult with cardiology to see what they want to do in the morning when they aren't sure and the enzymes are negative too (eg see if they want to stress or cath them); the cards fellows actually call down to the ER every morning and ask for these patients (CPEP patients). They still end up missing some, but I think that this way is more cost effective then admitting to medicine floors for rule outs because when you admit to a medicine floor, you have to transport patients and the medicine team and nurses have to get paid as well. Hospital beds are more expensive then ER beds. Our ER is also part of a study looking at EKG-gated CT scans with IV contrast as a way to evaluate chest pain. I think that this is the wave of the future. Imagine being able to evaluate the amount of coronary artery disease your patient has without having to do a diagnostic cath; while ruling out things like PE, aortic dissection, and seeing any musculoskeletal abnormalities as well. One of my attending radiologists even goes so far as to suggest that one day we will just scan everyone who comes into the ER for any reason. If they could decrease the radiation exposure and continue improving computer assisted analysis, I think that this will become a reality in our career lifetimes. One thing that I never understood is why ER's don't draw a lipid panel on all of their CP patients too. Even though your triglyceride counts will be off since they aren't fasting, patient's LDL and HDL should still be valid. This can prevent some patients with hyperlipidemic disorders who are young and otherwise healthy from being sent home prematurely.

 

[Sessamoid]

One thing that I never understood is why ER's don't draw a lipid panel on all of their CP patients too.

For a couple reasons:

Lipid panels don't affect the emergent management of chest pain.

More importantly, if we order a test, we're responsible for getting the result, followup with the patient, and making sure they get appropriately treated for any abnormal findings. That's not something that EDs are designed to do. That's why we have primary care doctors.

 

[imagin916]

[ One thing that I never understood is why ER's don't draw a lipid panel on all of their CP patients too. [/B][/QUOTE]

We do in my ER

 

[Sessamoid]

I'm sorry, but this talk of admitting all chest pain patients is simply insane and completely unaffordable for this country. Let's be realistic. I saw not four hours ago, a 30 year old female whose chief complaint was chest pain. She had zero risk factors, the pain was associated with paresthesias of the fingers, had a stone cold normal ekg, and her symptoms completely resolved with a small dose of benzodiazepines. Somebody's trying to tell me that this patient should have been admitted? That I should have ordered a lipid panel on her? What about the homeless woman who comes in complaining of chest pain just to get a warm place to sleep?

It would be nice if we could never miss and MI, or never miss anything, but the costs associated with trying to do that are astronomical, even for a country that spends more than twice the average for healthcare per capita compared to the other industrialized western nations.

The liberal use of CT scanning has certainly made it easier to miss a lot less, but we're never going to be perfect. I do think that CT will be more and more prevalent as time and technology goes onward. I do think that one day it will supplant angiography for most diagnostic cases, and it'll enable us to decrease or miss rate further.

 

[dredd]

Actually, your case of CP is exactly the type that I think would benefit from a lipid panel before sending the patient home. Benzo's could decrease CP in a true MI patient, just like how nitro's decrease CP in non-MI patients or 10% of MI's have reproducible CP on palpation and maalox can relieve CP in MI patients as well. There was actually a malpractice case a few years ago involving an ER doc who discharged a 40 year old male with no known risk factors at the time other then a father who had his first MI in the 50's because he thought that the pt's story was a very weak story and the patient had no other discernable risk factors (the ER doc neglected the FH). Plus, the ER doc noted in his record that the patient had reproducible CP on exam, and his CP history sounded very musculoskeletal in nature. The patient ended up dying from a subsequent MI the next day, and ER doc lost the case because other ER doc's testified against him citing the data that I cited above. My point is that the ER doc could have avoided the discharge altogether had he drawn a non-fasting lipid panel, which would have revealed the patient to have undiagnosed, untreated hyperlipidemia. I don't think lipid panels cost very much to order, I think that they are probably around the price of chest x-ray and they are probably higher yield in these young patients who never see a PCP and come to ER complaining of CP. Anyways, that's just my 2 cents. On the flip side, I've been on medicine teams when the ER has admitted 30 some year old women with history of panic disorders for r/o MI when they tell me in the history that they have been stressed lately; so I'm not saying that I don't appreciate your d/c of that patient.

 

[Sessamoid]

It's been my limited experience that cardiac chest pain in young people doesn't hide from you. One 30 year old female with an MI I diagnosed gave me a history that could have been taken out of a textbook. Acute onset of crushing substernal chest pain, worsened by exertion, assoc with dyspnea, nausea, vomiting, profuse diaphoresis, and big tombstones on her EKG. It seems the younger you are the more likely your symptoms will be obvious.

I'd admit a 40 year old male with a family history of early MI. I'm not sure I'd do so in a musculoskeletal-sounding pain with no risk factors without the family history (assuming the EKG was normal of course). That case is at least as much a lesson that you can get sued for anything (including nothing), and whether you win or lose depends more on the patients severity of outcome and the plaintiff's pitiability than whether or not anything was done incorrectly.

 

[docB]

I keep hearing figures about defensive medicine only adding ~3% to health care costs overall. I'd say that's crap. It's much bigger. The reason is that ultraconservative, defensive approaches have become standard of care and don't show up on the radar of "defensive medicine." Every shift I have to hold my nose and admit people with weak stories or manipulative behavoir because it's always in the back of my mind that they're just itching to get my house.

 

[ERMudPhud]

Originally posted by dredd
Actually, your case of CP is exactly the type that I think would benefit from a lipid panel before sending the patient home... ...My point is that the ER doc could have avoided the discharge altogether had he drawn a non-fasting lipid panel, which would have revealed the patient to have undiagnosed, untreated hyperlipidemia.

This is exactly the sort of thing that seems simple but really isn't. Keep in mind we are trying to find someway to catch that last 1% of MI's that have poor stories for ischemia, normal ekg's, and normal enzymes. You need a study showing that addition of a lipid panel allows you to catch that last 1% of MI's that we are missing. You will never see such a study for several reasons. 1) What LDL cutoff do you need to set as your criteria for admission 180? 220? 260? 2) How many lipid panels would you have to send and how many patients with bogus sounding stories would you have to admit to catch that last 1%? 3) Would some more ridiculous strategy like admitting every chest pain over age 21 do just as good a job of catching that last 1% without being any less specific than the lipid panel strategy? 4) How do you factor in the patients visit to the MacDonalds in the hospital lobby prior to coming to the ED? The fact is that just adding another lab-especially one as non-specific as a lipid panel is unlikely to catch us that last 1% of missed MI's.

On another note there are several reasons not send a lipid panel in the ED. 1.) It shouldn't and probably couldn't change your decision to admit or discharge the patient (see above) 2.) assuming you will admit the patient then a fasting level drawn from the floor in the AM is both cheaper and more clinically relevant.

 

[Sessamoid]

If you really wanted to catch ALL of that last 1%, then you'd also have to admit everybody who complains of:

1) shortness of breath
2) malaise
3) weakness
4) dizziness
5) nausea and vomiting
6) arm pain
7) abdominal pain
and many, MANY, MORE!

As we all know, you don't have to be in training long before you see MI presenting as every one of the above complaints.

 

[ayndim]

I'm only a lowly premed student, who should be studying but this is so much more fun. In December I went to the ER with cp. I feel like an idiot now but then it seemed serious. My neighbor had just had a c-section and asked to pick up her daughter from school. Well the school is a 5 minute walk and it was a nice day (over 70, I am in Phoenix) I gathered up my kids (all 3) and pushed the stroller up there. By the time I got back, I was gasping for breath, my arm hurt and it felt like someone had kicked me in the chest. I also have high triglycerides that don't respond to diet (do well with tricor but am nursing a baby) and my mom died from a MI. Thankfully, I convinced my husband I didn't need an ambulance. Hospital is about 5 mins away. I thought for sure I was having a heart attack. Turns out I had a respritory infection. I felt like an idiot. It isn't a large hospital and I had 2 of my kids there. One in Sept. 2003 and I volunteer there. Funny I didn't even have a runny nose or cough. It hit the next day though and I was sick for about a week. Not sure why my arm hurt. Maybe from pushing a double stroller.

I sure am glad not all ERs admit all cp.

 

[edmadison]

Originally posted by imagin916
[ One thing that I never understood is why ER's don't draw a lipid panel on all of their CP patients too.

We do in my ER [/B][/QUOTE]

Here's one reason. The hospital is paid by diagnosis (DRG). Any test that is ordered that is not necessary for the treatment of the patient in the acute setting will just come out of the hospitals overhead.

Ed

 

[DrQuinn]

The LDL in the acute setting can be worthless. If someone is having an ACS, the LDL can be falsely LOWERED. And as ERMudPhud stated, what if they just had a super-sized #3? So what's the point? I know when I did my CCU rotation we always ordered the lipid profile, but I think (in my whole 8 months of experience) that getting a lipid profile on the 200000000000 patients we see a week with chest pain would give me about 000000000000 change in management.

Q, DO
(back from Austria)

 

[Sessamoid]

Originally posted by QuinnNSU
And as ERMudPhud stated, what if they just had a super-sized #3?

Mcdonald's bites. If you're in LA, make it a "double double, animal style." [In 'N Out Burger]

 

[DrQuinn]

Originally posted by Sessamoid
Mcdonald's bites. If you're in LA, make it a "double double, animal style." [In 'N Out Burger]

Mmm In N' Out burger... by far the best fast food hamburger on the planet! I had one in Vegas once...

I'm still trying to find the best burger 'round the Tampa/ST. Pete area... any ideas? Checkers is decent but I"m not too fond of their bread.

Q, DO

 

[Sessamoid]

Originally posted by QuinnNSU
I'm still trying to find the best burger 'round the Tampa/ST. Pete area... any ideas? Checkers is decent but I"m not too fond of their bread.

Q, DO

I never did find a fast food burger I was happy with in Tampa Bay. I didn't really even find a great restaurant burger. In N' Out simply kicks copious ass on every other fast food burger chain.

 

[Febrifuge]

Originally posted by ERMudPhud
How do you factor in the patients visit to the MacDonalds in the hospital lobby prior to coming to the ED?

Just in case anyone thinks this is a joke, I know of at least one hospital in my city (with a good rep for heart care, too) which has a McDonald's inside. Ohh, the interesting discussion they had, when the hospital built it...

 

[Sessamoid]

Originally posted by Febrifuge
Just in case anyone thinks this is a joke, I know of at least one hospital in my city (with a good rep for heart care, too) which has a McDonald's inside. Ohh, the interesting discussion they had, when the hospital built it...

Parkland Hospital, UT Southwestern's main teaching hospital, has had a McDonald's in it for at least 10 years. Not sure if it's still there.

 

[juddson]

I find this discussion interesting. This is an area I am considering. I know it will be painful, but PLEASE could somebody list the common abbreviations and thier meaning for us premeds. I'm getting lost before I even begin. CP (ok, I got that one), FH, ACS, etc.

Judd

 

[DrQuinn]

FH = Family History (people whose parents had heart problems are more likely to have them as well)
ACS = Acute Coronary Syndrome (what everyone likes to call a big ol' heart attack)
DM = Diabetes Mellitus
ACEP = American College of Emergency Physicians
LDL = Low Density Lipoprotein (L ousy cholesterol)
HDL = High Density Lipoprotein (H appy cholesterol)
ED = Emergency Department, (or erectile dysfunction).

Q, DO

 

[Apollyon]

Originally posted by QuinnNSU

ED = Emergency Department, (or erectile dysfunction).

Or, "ectodermal dysplasia" - when Bob Dole began shilling for Viagra and talking about "ED", these folks that are part of a support group for ectodermal dysplasia sufferers got really mad that Bob had "ripped off" their abbreviation, that they had worked so hard to associate with.

 

[ERMudPhud]

Originally posted by Febrifuge
Just in case anyone thinks this is a joke, I know of at least one hospital in my city (with a good rep for heart care, too) which has a McDonald's inside. Ohh, the interesting discussion they had, when the hospital built it...

My old hospital used to have one too but they replaced it with the new CCU or cath lab (I can't remember which). The best part about the MacDonalds was its diagnostic utillity while evaluating belly pain. If they came in with a supersize fries it probably wasn't anything serious in their belly. I also got a supposedly quadraplegic malingerer to walk by leaving a pack of fries on the mayo stand in the room.

 

[Sessamoid]

Originally posted by ERMudPhud
I also got a supposedly quadraplegic malingerer to walk by leaving a pack of fries on the mayo stand in the room.

Mmmm, fries with mayo. The best way to eat them (and the original Belgian way).