flighterdoc said:
Except, the FP didn't get a baseline EKG or enzymes, didn't advise the pt to go to the ED if it happens again, and it seems didn't do anything but ORDER a stress EKG
Actually, we weren't there so we don't know exactly what her discharge instructions were. That's one reason its always dangerous to second guess patient management from a distance.
flighterdoc said:
in the US if a pt presented like that to a PCP, I think that they'd get labs (baseline enzymes, even post event), an EKG, and strict orders to go to the ED via 911 if it happened again.
You think so? Try polling your FP colleagues on what they do with suspected angina in the clinic. I see patients all the time who say, "Yeah I've been having chest pain, I saw my doc about it and he scheduled a stress test for next week. I'm having pain again so he told me to come in to the ED"
As long as we are fixated on ordering outpatient enzymes for a transient episode of chest pain which happened >24 hours ago and assuming you believe in evidenced based medicine. Show me an article that advocates use of troponins in the
outpatient work up of angina.
flighterdoc said:
Aside from being the appropriate tx, imagine what would happen if while waiting for a scheduled stress EKG or their lipids, the pt had an MI and died. This isn't even a CYA ordering of tests, it's simply the appropriate tx.
How exactly is having a set of enzymes cooking overnight in the lab going to keep your patient from dying in the next 24 hours. Tests aren't tx. Remember this is likely a little FP clinic not an academic center. They put their labs in a little mailbox, the courrier picks them up, and the results come back the next day. Even with a negative troponin this could still be unstable angina and they could have an MI the second they left your office.
The appropriate treatment is an aspirin a day (that might keep them from having an MI), schedule some sort of stress test as soon as possible, and instructions to go the ED if the pain came back.
Assuming this is cardiac ischemia is having an MI and dying is the most likely means of death? No. If they have an MI they will most likely go to the hospital and get treated for it. The persistant pain of an MI is hard to ignore and doesn't usually kill you quick. The big fear is the off chance that the 10 minutes of pain yesterday was actually an MI and that you have a post MI arrythmia(most common in the few days after an MI) that kills you quick. Having enzymes sitting in the lab won't prevent that either. These are the rare cases in which the PCP and patient is screwed but you can't prevent that short of admitting everyone who had CP within the last week to Tele until they've completed their workup. That doesn't happen here much less in Canada. Even on Tele sometime the vFib kills them.
flighterdoc said:
Now, based on the hx (relieved with ASA and antacids in 10 min) it's probably either a stress reaction or mild angina, but it's better to be safe. After all, it's someones Mom.
Every patient is someones mom, dad, child, or friend.
What I described is pretty much what happened to my Mom (CRF= high cholesterol, HBP, ex-smoker) and after her outpatient cardiac work up was negative she was subsequently diagnosed with biliary colic.
What's a "stress reaction" and why not add reflux, esophageal spasm, or biliary colic to the differential?
