Rbbb

[roja]

So, I'm curious,


What would *you* do with this guy?

CC: Someone died in my building this weekend and I am nervous.

48 mild HTN, diet controlled, nl ex tol, etc. nl exam. No CP/SOB/Diaph/dizziness. No exertional cx. Has a PMD to see the next day.

FS 97
EKG: RBBB (no brugada)


He has never had an EKG done before

 

[USCDiver]

So, I'm curious,


What would *you* do with this guy?

CC: Someone died in my building this weekend and I am nervous.

48 mild HTN, diet controlled, nl ex tol, etc. nl exam. No CP/SOB/Diaph/dizziness. No exertional cx. Has a PMD to see the next day.

FS 97
EKG: RBBB (no brugada)


He has never had an EKG done before

CBC, BMP, maybe CXR, touch base with PMD (maybe he's had a previous EKG in office, or at least charted h/o RBBB). Anticipate discharge home with good discharge instructions and PMD followup.

 

[Blue Dog]

I assume the person who died had some sort of cardiac event?

The RBBB is probably nothing; it's rare that you find underlying disease (PE, cardiomyopathy, structural heart disease, etc.) in an asymptomatic patient, unlike LBBB, which definitely needs to be worked up. If you're really paranoid, you can get a CXR and stress him as an outpatient, but you don't have much to support it. A negative stress test on an asymptomatic patient today doesn't guarantee that he won't rupture a plaque and have an MI tomorrow.

Anything more you do at this point is primary care. As in...what's his BMI, smoking status, family history, lipid profile, etc.? If you know all of that, you can do a risk assessment and advise him accordingly. That's probably more appropriately handled by his PCP.

 

[margaritaboy]

Nothing.

 

[NinerNiner999]

A la casa.

 

[kungfufishing]

pan-MRI and then home, or just home and go see PMD tomorrow.

 

[stoic]

1mg ativan and send him home with a copy of his ekg for his pmd. i'll dx it as anxiety and hold off on doing any testing unless his PE or Hx turned something up to suggest otherwise. CXR's and the like are sooo much cheaper in the office. i seem to remember that RBBB can be transient secondary to PAC or SVT (but i can't remembery exactly why), which could fit in the picture with anxiety.

caveat - i'm only an MSII and can't give drugs, dx, or discharge pts in real life. so wtf does it matter what i think anyway


i am curious about the workup asymptomatic RBBB would get in the primary care clinic? i just don't know much about it. i know it can show up in kids with VSD repairs and that it can show up in some other potential serious condition (the name of which escapes me), but i think if it was serious it usually showed up with some other ekg abnormalities as well as a profoundly split s2?

 

[jojo14]

I thought I heard somewhere that 5% of the general population has RBBB. Actually, I think my cardiology attending told me this, but it's all kind of fuzzy in my mind...cardiology was a while ago.

Anyway, has anyone else ever heard this?

 

[FoxyDoc]

I would wonder why in the hell he decided to come to the ED during MY shift!

 

[southerndoc]

The RBBB is probably nothing; it's rare that you find underlying disease (PE, cardiomyopathy, structural heart disease, etc.) in an asymptomatic patient, unlike LBBB, which definitely needs to be worked up. If you're really paranoid, you can get a CXR and stress him as an outpatient, but you don't have much to support it. A negative stress test on an asymptomatic patient today doesn't guarantee that he won't rupture a plaque and have an MI tomorrow.

The patient is not asymptomatic: he is complaining of feeling anxious.

It may not be chest pain or dyspnea, but feeling anxious is a complaint and a symptom of many diseases. I've had patients with PE present with just anxiety, and the only reason it was caught is because a smart nurse asked the patient about family history of PE.

Assumption is the mother of all muckups, so I won't assume the vital signs and the rest of the physical exam are normal until Roja tells me otherwise.

What were his vital signs, exam, etc.?

 

[docB]

I don’t disagree with anything people have said and I do send RBBBs home. However, just to make everyone sleep a little less soundly, I had this guy a few years ago who made me think. 60 yo diabetic M on vacation has GERD symptoms. Now I know what you’re thinking, 60 yo DM male with epigastric pain. Treat like chest pain. No brainer. But this guy was just classic GERD. Hx of GERD. Burning in epigast, not pain or pressure. No radiation. No SOB, N/V or diaphoresis. Burning gets better with milk and bland foods and worse with spicy foods and ETOH. Sour burps with burning in throat. Worse at night. Improved with GI cocktail. Just classic GERD. I talked to the guy forever and I decided that this was really just GERD. So I explained my thinking to the guy and his wife and got an EKG. I had decided that if the EKG was normal I’d dc him with GI stuff. EKG shows RBBB. Hmmmm. So I go back and tell them that the EKG is abnormal. I offered them a cards work up or they could still decide to go with the GI stuff. The wife decided to stay for the work up (the husband who was the patient was overruled). Needless to say the troponin was 4 and he wound up going to cath the next day. I actually went and hugged the wife and told her that she had made the right call. Sometimes it’s just scary.

 

[stoic]

Assumption is the mother of all muckups, so I won't assume the vital signs and the rest of the physical exam are normal until Roja tells me otherwise.

What were his vital signs, exam, etc.?

"48 mild HTN, diet controlled, nl ex tol, etc. nl exam. No CP/SOB/Diaph/dizziness. No exertional cx. Has a PMD to see the next day."


it dawns on me cases like this are rarely posted unless something interesting turns up...

so what made this guy come in? was he anxious about something happening to him cardiac-wise? did something happen (other than the guy in his building dying) that peaked his anxiety level enough that he came in?

if he was anxious specifically about something happening to his heart and then you turned up the RBBB, from a CYA stand point i suppose you pretty much have to do a cardiac workup.

and of course a quick pubmed search pulls up at least a couple case reports that provide some interesting reading...

Roja, was that RBBB masking an event elsewhere?

but i still have to say that had i not hit pubmed i'd still be trying to convince the attending that this guy was just nervous and that there is no real reason to work him up... but that's my inexperience talking. and if he were seen in clinic with the exact same presentation, i feel comfortable that 99.9% of the time that there would be no urgency about the case or in getting him to a cardiologist.

 

[DrQuinn]

I don’t disagree with anything people have said and I do send RBBBs home. However, just to make everyone sleep a little less soundly, I had this guy a few years ago who made me think. 60 yo diabetic M on vacation has GERD symptoms. Now I know what you’re thinking, 60 yo DM male with epigastric pain. Treat like chest pain. No brainer. But this guy was just classic GERD. Hx of GERD. Burning in epigast, not pain or pressure. No radiation. No SOB, N/V or diaphoresis. Burning gets better with milk and bland foods and worse with spicy foods and ETOH. Sour burps with burning in throat. Worse at night. Improved with GI cocktail. Just classic GERD. I talked to the guy forever and I decided that this was really just GERD. So I explained my thinking to the guy and his wife and got an EKG. I had decided that if the EKG was normal I’d dc him with GI stuff. EKG shows RBBB. Hmmmm. So I go back and tell them that the EKG is abnormal. I offered them a cards work up or they could still decide to go with the GI stuff. The wife decided to stay for the work up (the husband who was the patient was overruled). Needless to say the troponin was 4 and he wound up going to cath the next day. I actually went and hugged the wife and told her that she had made the right call. Sometimes it’s just scary.

Dood don't be postin that sorta stuff! i actually had a good second day shift as an attending, now you gotta go post this and i'm gonna lose more sleep than I already have....

j/k. interesting case, though. is your practice now to do an EKG/enzymes on all your high risk factors and the "vague symptoms of MI?" I've basically been beat down to death by my residency to do that... so the following would all get EKG/enzymes upon initial orders:

older ladies with vague symptoms (n/v/abd pain, fatigue, weakness, diaphoresis, anxiety)
known CAD with above
known DM with above
older schizophrenics/mentally challenged with above

One thing I've learned, though, doing my residency in FL, is that people get extra sick on their vacation. Sounds like vegas is the same.

Q

 

[roja]

"48 mild HTN, diet controlled, nl ex tol, etc. nl exam. No CP/SOB/Diaph/dizziness. No exertional cx. Has a PMD to see the next day."


it dawns on me cases like this are rarely posted unless something interesting turns up...

so what made this guy come in? was he anxious about something happening to him cardiac-wise? did something happen (other than the guy in his building dying) that peaked his anxiety level enough that he came in?

if he was anxious specifically about something happening to his heart and then you turned up the RBBB, from a CYA stand point i suppose you pretty much have to do a cardiac workup.

and of course a quick pubmed search pulls up at least a couple case reports that provide some interesting reading...

Roja, was that RBBB masking an event elsewhere?

but i still have to say that had i not hit pubmed i'd still be trying to convince the attending that this guy was just nervous and that there is no real reason to work him up... but that's my inexperience talking. and if he were seen in clinic with the exact same presentation, i feel comfortable that 99.9% of the time that there would be no urgency about the case or in getting him to a cardiologist.

I am a firm believer that CYA medicine is crappy medicine.

He had nothing and I sent him out with nothing. Reassurance and he was seeing his pmd in the morning.

 

[roja]

I don’t disagree with anything people have said and I do send RBBBs home. However, just to make everyone sleep a little less soundly, I had this guy a few years ago who made me think. 60 yo diabetic M on vacation has GERD symptoms. Now I know what you’re thinking, 60 yo DM male with epigastric pain. Treat like chest pain. No brainer. But this guy was just classic GERD. Hx of GERD. Burning in epigast, not pain or pressure. No radiation. No SOB, N/V or diaphoresis. Burning gets better with milk and bland foods and worse with spicy foods and ETOH. Sour burps with burning in throat. Worse at night. Improved with GI cocktail. Just classic GERD. I talked to the guy forever and I decided that this was really just GERD. So I explained my thinking to the guy and his wife and got an EKG. I had decided that if the EKG was normal I’d dc him with GI stuff. EKG shows RBBB. Hmmmm. So I go back and tell them that the EKG is abnormal. I offered them a cards work up or they could still decide to go with the GI stuff. The wife decided to stay for the work up (the husband who was the patient was overruled). Needless to say the troponin was 4 and he wound up going to cath the next day. I actually went and hugged the wife and told her that she had made the right call. Sometimes it’s just scary.

I was signed out a lady (who we called Ms Sunshine because she had such a sunny disposition ) 72 HTN classic GERD improved with gicocktail. Nonspecific T wave changes. Astute resident worked her up for cardiac and she had a troponin of 10.

 

[Apollyon]

I am a firm believer that CYA medicine is crappy medicine.

There's a difference between CYA and being conservative.

Things not looked for are rarely found - or, put another way, "the eye does not see what the mind does not know".

I'm not saying to become a mindless automaton, but, sometimes, "cookbook medicine" will save you.

 

[roja]

Note: I said CYA. Not conservative. obviously NOT the same thing.
Not practicing CYA doesn't mean that you dont' entertain a solid differential or that you are 'blind' to possibilities.


As an aside, I posed the question because there is very little information on what to do with incidental/asymptomatic patients found to have a RBBB. (online, tintinalli, etc.)

 

[southerndoc]

I don’t disagree with anything people have said and I do send RBBBs home. However, just to make everyone sleep a little less soundly, I had this guy a few years ago who made me think. 60 yo diabetic M on vacation has GERD symptoms. Now I know what you’re thinking, 60 yo DM male with epigastric pain. Treat like chest pain. No brainer. But this guy was just classic GERD. Hx of GERD. Burning in epigast, not pain or pressure. No radiation. No SOB, N/V or diaphoresis. Burning gets better with milk and bland foods and worse with spicy foods and ETOH. Sour burps with burning in throat. Worse at night. Improved with GI cocktail. Just classic GERD. I talked to the guy forever and I decided that this was really just GERD. So I explained my thinking to the guy and his wife and got an EKG. I had decided that if the EKG was normal I’d dc him with GI stuff. EKG shows RBBB. Hmmmm. So I go back and tell them that the EKG is abnormal. I offered them a cards work up or they could still decide to go with the GI stuff. The wife decided to stay for the work up (the husband who was the patient was overruled). Needless to say the troponin was 4 and he wound up going to cath the next day. I actually went and hugged the wife and told her that she had made the right call. Sometimes it’s just scary.

We've all had this kind of cases. I had a 42-year-old diabetic female who presented with a similar presentation, except she had a normal EKG. Sent her to the chest pain center. First troponin was negative. The second came back at 32. (She had developed T-wave changes during a repeat EKG when the second troponin was drawn.) Needless to say, she went to the cath lab and bought 2 stents.

 

[southerndoc]

He had nothing and I sent him out with nothing. Reassurance and he was seeing his pmd in the morning.

To be continued during the M&M presentation? Just kidding!

 

[southerndoc]

"48 mild HTN, diet controlled, nl ex tol, etc. nl exam. No CP/SOB/Diaph/dizziness. No exertional cx. Has a PMD to see the next day."

Sorry, I missed that. Although normal exam doesn't always include normal vitals. (Most people differentiate the two.)

At any rate...

 

[Apollyon]

Note: I said CYA. Not conservative. obviously NOT the same thing.
Not practicing CYA doesn't mean that you dont' entertain a solid differential or that you are 'blind' to possibilities.

My point is that, sometimes, it is NOT obviously not the same thing - sometimes, the paths cross (like the "stabilizing" or "diagnostic" treatment of EMTALA also being definitive and therapeutic). That's all.

 

[12R34Y]

A cardiologist who read 12-leads with me and another student last year during an elective for 2 hours straight every night for 4 weeks told me this once.

What is the electrical conduction system of the heart?

Answer: heart muscle. You can't seperate them out. They're specialized conductive heart tissue.

What if you have someone with a BBB? (right or left)?

Answer: It means they have dead heart muscle. It is abnormal.

He's probably had some sort of cardiac event in the past and has since resolved and a weeee little bit of septum got dead on him. now he has a right bundle.

Not a "no-risk" patient for sure.

Of course there are weird congenital heart blocks and bla blah, but in a 48 y/o with HTN. that cardiologist would have said he has dead heart muscle.

later

 

[beyond all hope]

I've found a huge difference between the two.

Often you'll find the smarter docs with less experience can think of a lot of bad things that could go wrong, so they order a crapload of tests and admit. Maybe not the best clinical docs, but at least I think these docs have the patient's best interest in mind.

CYA medicine is often practiced by lazy docs, often very experienced and previously sued, who will simply aim the biggest gun test at a certain cheif complaint thinking nothing will be missed. E.g. CP -> enzymes/admit. AP -> CTAP, 'belly labs'. HA -> HCT, as rote.

Important to note that even the big gun tests aren't perfect, and aren't even very good unless you aim them right. Enzymes won't catch most PEs, dissections, etc. CTAP's not very good for biliary disease. HCT can't diagnose pseudotumor or temporal arteritis.

BTW, I think Roja did the right thing. I would have sent him home with a copy of the EKG for his PMD and strict return instructions (CP/SOB, etc).

 

[docB]

Dood don't be postin that sorta stuff! i actually had a good second day shift as an attending, now you gotta go post this and i'm gonna lose more sleep than I already have....

j/k. interesting case, though. is your practice now to do an EKG/enzymes on all your high risk factors and the "vague symptoms of MI?" I've basically been beat down to death by my residency to do that... so the following would all get EKG/enzymes upon initial orders:

older ladies with vague symptoms (n/v/abd pain, fatigue, weakness, diaphoresis, anxiety)
known CAD with above
known DM with above
older schizophrenics/mentally challenged with above

One thing I've learned, though, doing my residency in FL, is that people get extra sick on their vacation. Sounds like vegas is the same.

Q

Yeah but I also know a lot of docs that firmly believe that if you are worried enough to get one set of enzymes you have to commit to the full wu. I've also been told that no matter what the time course is one set is like flipping a coin. It's tough to get these people to go along with an admit for a wu and a stress all the time.

 

[stoic]

Yeah but I also know a lot of docs that firmly believe that if you are worried enough to get one set of enzymes you have to commit to the full wu. I've also been told that no matter what the time course is one set is like flipping a coin. It's tough to get these people to go along with an admit for a wu and a stress all the time.

so i'm curious what percantage of your patients who are unlikely to have cardiac etiology get the second set of enzymes drawn? this isn't something i've run into out here in the boonies; you've got to look like a cardiac player to get the second set if the first (and ekg) are negative.

and how much of that depends your ability to find evidence for a non-cardiac pathology? does it go back to those who commonly have atypical presentations of cardiac problems (older women, DM, etc)?

 

[Apollyon]

so i'm curious what percantage of your patients who are unlikely to have cardiac etiology get the second set of enzymes drawn? this isn't something i've run into out here in the boonies; you've got to look like a cardiac player to get the second set if the first (and ekg) are negative.

and how much of that depends your ability to find evidence for a non-cardiac pathology? does it go back to those who commonly have atypical presentations of cardiac problems (older women, DM, etc)?

In the Meador/Slovis book "A Little Book of Emergency Medicine Rules", one rule is "atypical chest pain IS typical chest pain". As I said above, things not looked for are rarely found.

Another rule is you can't get too many EKGs on a cards player. Since MI (or dissection) is the worst-case scenario (PE that massive would not be so vague), you have to consider it, and, as you will learn with more clinical experience, the first set of markers is a point in space - you need at least a second (if the first is negative) set to compare, to draw a line between them.

Four groups will ALWAYS screw you - ALWAYS - the very young, the very old, the very drunk, and the very crazy. You'll do a more-thorough workup on these folks, lest ye get burned.

An acceptable miss rate for MI (or ectopic) is 0%, but man - and machine - will miss between 2% and 6% - now think about that - anywhere from one in 50 to one patient in 16. Then again, if you are judicious and sober and logical in your thinking, you could be that doc that is the "reasonable man".

A lot of it is (ugh - I hesitate to use the word - so OVERused) 'gestalt'. Some patients will, at first exam, be negative, but something about them clicks in your mind to go a little further. Your gut will help you. It's a lot easier to admit a patient than to send them home. As the old folks in EM will tell you, sending home a chest painer is doing a stress test on yourself.

Here is an abstract from the May Annals of EM showing that outpatient stress tests - up to 3 days - can be done on patients with negative markers and EKGs. What is not clear is how long after (if 3 days is optimal, or you can go longer) you have to do the provocative testing.

 

[stoic]

i love you guys. i swear i've learned more in the EM forum than most of my classmates could believe. stuff from this forum has saved me when getting pimped on more than on occasion. i've also learned so much about working up common EM problems that now when i actually get to go participate in their care, i've got a real jump on the how and why of it all.

thanks for continuing to indulge me. it continues to amaze that this particular forum has perhaps more cohesiveness than any other on the site. i remember when quinn was a beautiful female med student (and i was a high schooler). now he's an attending and i'm an MSII.

anyway, i know i chime in a lot of these discussions and i've always really appriciated how you all let me do so instead of blowing me off as a student.


dave

 

[DrQuinn]

Yeah but I also know a lot of docs that firmly believe that if you are worried enough to get one set of enzymes you have to commit to the full wu. I've also been told that no matter what the time course is one set is like flipping a coin. It's tough to get these people to go along with an admit for a wu and a stress all the time.

I've heard that, too... but have also talked to cardiologists and hospitalists who say if their symtpoms are constant and have been going on for "quite some time," then one set will work.

Q

 

[docB]

I've heard that, too... but have also talked to cardiologists and hospitalists who say if their symtpoms are constant and have been going on for "quite some time," then one set will work.

Q

I hear the same thing all the time too. However I am very cognizant of the fact that the cards and IMs who are saying this are also essentially saying "I don't want to deal with it. Sent it home." I file those opinions along with the ones I've heard about the ever popular "troponin leak."

 

[Jeff698]

I've heard that, too... but have also talked to cardiologists and hospitalists who say if their symtpoms are constant and have been going on for "quite some time," then one set will work.

OK, so I'm lazy (actually, just bone-tired), but what does the liturature say about prolonged, constant chest pain (say, greater than 12 hours) with a single negative ECG and single negative set of markers, regardless of story quality? What's the risk of ACS?

Take care,
Jeff

 

[basementbeastie]

OK, so I'm lazy (actually, just bone-tired), but what does the liturature say about prolonged, constant chest pain (say, greater than 12 hours) with a single negative ECG and single negative set of markers, regardless of story quality? What's the risk of ACS?

Take care,
Jeff

one thing to consider: i do not trust the history given by my patients....i listen with many grains of salt....constant chest pain is acknowledged to attempt to give symptoms more credence ("doc i have been in constant pain for DAYS!) as far as i have been taught and have read -> even with "constant" pain multiple sets of cardiac enzymes are needed to rule out an acute infarction.

 

[augmel]

I know that it is a little different in the ER, but I still think that if a patient's pre-test probability of having a condition is so low that a positive test still leaves you in the 50% probabality range, then you shouldn't do the test. You are as likely to cause harm to patients by overdiagnosing as you are by underdiagnosing. A 48 year old with no sx but anxiety spurred by a recent death and mild hypertension as the only risk factor has a very low pre-test probability for MI. Therefore, I wouldn't do an ECG. Send him to his PMD for proper risk factor assessment and w/u. Of course, I sympathize and realize the lawyers probably won't see it this way.

Overordering troponins for instance "cause I saw this one dude with foot pain who had a huge MI" means maybe you won't get burned on that but we are all gonna get burned by someone. Ordering more tests isn't the answer. It just means 100 guys with foot pain and troponins of 0.15 will fill up hospital beds, a couple will get PEs cause they sat around and someone forgot to order SCDs, a couple more will get renal failure cause of a medication mishap, etc. etc. I'm obviously overstating things here, but you get the idea. Thanks for listening to my rant.

 

[basementbeastie]

I know that it is a little different in the ER, but I still think that if a patient's pre-test probability of having a condition is so low that a positive test still leaves you in the 50% probabality range, then you shouldn't do the test. You are as likely to cause harm to patients by overdiagnosing as you are by underdiagnosing. A 48 year old with no sx but anxiety spurred by a recent death and mild hypertension as the only risk factor has a very low pre-test probability for MI. Therefore, I wouldn't do an ECG. Send him to his PMD for proper risk factor assessment and w/u. Of course, I sympathize and realize the lawyers probably won't see it this way.

Overordering troponins for instance "cause I saw this one dude with foot pain who had a huge MI" means maybe you won't get burned on that but we are all gonna get burned by someone. Ordering more tests isn't the answer. It just means 100 guys with foot pain and troponins of 0.15 will fill up hospital beds, a couple will get PEs cause they sat around and someone forgot to order SCDs, a couple more will get renal failure cause of a medication mishap, etc. etc. I'm obviously overstating things here, but you get the idea. Thanks for listening to my rant.

you are correct to state that one should not order cardiac enzymes if you do not feel that ACS is a possibility. the question about length of chest pain symptoms and how many sets of enzymes is relavant IF you are diagnostically evaluating for ACS. otherwise, do NOT order enzymes....

 

[southerndoc]

Oddly enough, I had a guy tonight who came in for an allergic reaction. For some odd reason the nurses took it upon themselves to get an EKG. Asymptomatic RBBB. Immediately I thought of this thread.

 

[mikecwru]

OK, so I'm lazy (actually, just bone-tired), but what does the liturature say about prolonged, constant chest pain (say, greater than 12 hours) with a single negative ECG and single negative set of markers, regardless of story quality? What's the risk of ACS?

Take care,
Jeff

The literature will not back you up on this decision, although it logically makes sense. If you're doing markers, you need to get another set. Most miss rates for MI will be around 2%, the one study that I remember that tried to rely on peoples' estimation of CP time had higher misses. Now, there was some work by a guy at the Cleveland Clinic using a combination of troponin and myeloperoxidase, I believe, which he suggested would be like a D-dimer for low risk chest pain and could safely "rule out" certain people with CP.


mike

 

[Apollyon]

Now, there was some work by a guy at the Cleveland Clinic using a combination of troponin and myeloperoxidase, I believe, which he suggested would be like a D-dimer for low risk chest pain and could safely "rule out" certain people with CP.

In the current issue of Academic EM, there's a paper out of Carolinas that looked at 5 "novel" markers, including myeloperoxidase, and it said that they didn't work - weren't specific or sensitive enough.

 

[bartleby]

I had a 75 y/o lady who looked 60 and swore up and down that her epigastric pain went away with a GI cocktail. She had cholangitis. Beware the therapeutic trial as a tool for ruling out life-threatening illness.

72 HTN classic GERD improved with gicocktail. Nonspecific T wave changes. Astute resident worked her up for cardiac and she had a troponin of 10.

 

[southerndoc]

I've never looked at it, but what is the literature about using two sets of markers, drawn 4 hours apart, to rule out MI?

 

[mikecwru]

I've never looked at it, but what is the literature about using two sets of markers, drawn 4 hours apart, to rule out MI?

Our observation unit does an 8 hr rule out time 0, 4 hrs, 8 hrs. For cocaine chest pain low risk we do 6 hr rule outs. I haven't seen anything to suggest using less.

mike

 

[mikecwru]

In the current issue of Academic EM, there's a paper out of Carolinas that looked at 5 "novel" markers, including myeloperoxidase, and it said that they didn't work - weren't specific or sensitive enough.

I didn't see this article. The way the guy presented it, combining troponin and the myeloperoxidase, you would have a very good sensitivity but a piss-poor specificity.... so it would be much akin to the d-dimer for low risk PE.

Granted, this was preliminary data from the Cleveland Clinic ED observation unit, and I don't think he published it yet.

Do you guys do resting sestamibis? Those seem to have decent lit as backup. Good for low risk CP rule outs if you image the chest within 2 hrs of active chest pain. I've used that a few times. From what I've seen, it's as good as the marker rule out, but does not have a good sensitivity for CAD, so you would have to sestamibi and then do an outpatient stress.

mike

 

[southerndoc]

Our observation unit does an 8 hr rule out time 0, 4 hrs, 8 hrs. For cocaine chest pain low risk we do 6 hr rule outs. I haven't seen anything to suggest using less.

mike

We also do the same thing (3 sets, 4 hours apart), but was curious what the literature is about drawing two sets: a set at 0 hours and then a repeat set at 4 hours. Our cardiologists seem to think it's ok, but I haven't seen the literature.

 

[Apollyon]

Do you guys do resting sestamibis? Those seem to have decent lit as backup. Good for low risk CP rule outs if you image the chest within 2 hrs of active chest pain. I've used that a few times. From what I've seen, it's as good as the marker rule out, but does not have a good sensitivity for CAD, so you would have to sestamibi and then do an outpatient stress.

No - and, for the paper in Academic EM, the authors quote the obs unit chief at Duke as "personal communication".

Haven't worked the chest pain unit yet at my new job, so I don't know here.

 

[po' boy]

Regarding chest pain, atypical is now typical.

If his anxiety manifested itself in any way with symptoms of chest discomfort/SOB, I think I would have gotten at least a set of 2-hour delta enzymes and an exercise treadmill test (not a MIBI). I would want one functional test before sending a 48 year old man with "anxiety" and cardiac risk factors.

Just my .02-

Sorry, I missed that. Although normal exam doesn't always include normal vitals. (Most people differentiate the two.)

At any rate...

 

[Apollyon]

Regarding chest pain, atypical is now typical.

That's what I said in the post that is first on this page (2), post #26.

 

[stoic]

Regarding chest pain, atypical is now typical.

If his anxiety manifested itself in any way with symptoms of chest discomfort/SOB, I think I would have gotten at least a set of 2-hour delta enzymes and an exercise treadmill test (not a MIBI). I would want one functional test before sending a 48 year old man with "anxiety" and cardiac risk factors.

Just my .02-

but this patient didn't present with chest pain/SOB or anything else pointing to cardiac origin. his cc was anxiety because someone in his building died. he got an EKG which uncovered a RBBB.

if he'd been having cp or sob or exertional sx, yea, surely roja would have worked him up as a cardiac r/o regardless of what the ekg said.

with no cardiac sx and no ekg abnormalities other than a RBBB, this guy is free to go home and take some ambien or whatever to get him through the night and to his pmd tomorrow.

 

[roja]

Thank you for that vote of confidence.

Obviously, if he had a single, even remote cardiac-like compliant I would have had to work him up.

Thankfully, his only complaint was fear.