sickle cell and MI

[unchartedem]

I had a patient yesterday who was a sickler and was there for non-pleuritic non mus-skl chest pain. No fever or sob. Not her usual pain crisis site and she wasn't even there for crisis just for the chest pain. She was only 19 yrs old. Would you do a cardiac workup based on the sickle hx? Ive seen case reports regarding missed MI in sicklers. Her pain had resolved. I did an ekg and CXR. Should I have done more?

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[cofcemt]

At least here in SC, sicklers with CP get a CXR, EKG, Trop; especially if the CP is different than usual.

 

[danzman]

At least here in SC, sicklers with CP get a CXR, EKG, Trop; especially if the CP is different than usual.

So do they just get one set of enzymes, or do you keep em for three?

 

[cofcemt]

From what I've seen it depends on the attending. Most do at least 2 sets, many do 3.

 

[Rendar5]

No trop.
If you're working up chest pain in a young sickler, you're looking for Acute Chest Syndrome, not Acute Coronary Syndrome. Same acronym, different disease.

 

[danzman]

No trop.
If you're working up chest pain in a young sickler, you're looking for Acute Chest Syndrome, not Acute Coronary Syndrome. Same acronym, different disease.

I think the op, and certainly myself are talking about an MI

I was always told that menstruating women don't have MIs (thanks a lot Conrad Fischer) until I saw a 26yr AAF have one. She was a type 1 dm, + cocaine, and looked like she was 50, had a stemi and got cathed. I have seen different attendings approach young women with cp differently and have not yet come to a consensus as how to deal with them if they have a comorbidity. Where I'm at, we have a very large SS population and I have seen them get a single poc troponin if their pain is different. I always felt that if you only do one enzyme you kinda tied yourself do getting serial ones. I have yet to see any reason for this which is why I asked about it above.

 

[Rendar5]

I think the op, and certainly myself are talking about an MI

I was always told that menstruating women don't have MIs (thanks a lot Conrad Fischer) until I saw a 26yr AAF have one. She was a type 1 dm, + cocaine, and looked like she was 50, had a stemi and got cathed. I have seen different attendings approach young women with cp differently and have not yet come to a consensus as how to deal with them if they have a comorbidity. Where I'm at, we have a very large SS population and I have seen them get a single poc troponin if their pain is different. I always felt that if you only do one enzyme you kinda tied yourself do getting serial ones. I have yet to see any reason for this which is why I asked about it above.

I certainly realize what you are referring to, but again, the initial situation described is not going to make me look toward MI. Trop is really unnecessary in this population. To get one would be overly cautious. Sickle Cell Disease is not a huge MI risk factor, and there is a much much much more likely and common cause of the chest pain. Now, obviously if the sickler in question had done cocaine or had a very anginal-sounding story, they warrant a troponin, and if they had a myocarditis or pericarditis sounding story, they warrant a troponin. Other situations that would warrant it woudl be a sickler with a known history of acute chest who says the pain is different from acute chest they had in the past. or someone with EKG changes.

The initial situation is very much different than the one you just described. Certainly type I DM and cocaine are very large risk factors when it comes to acute MI. This population warrants a trop regardless of the EKG, imo. I have had a 19yo man with a heart attack before related to cocaine.

 

[Arcan57]

Except in rare cases, troponin is not part of the work-up of patients with sickle cell disease and chest pain.

 

[xaelia]

EKG, no troponin unless an exceptional case of typical anginal symptoms with other specific risk factors as above.

 

[cofcemt]

Other situations that would warrant it would be a sickler with a known history of acute chest who says the pain is different from acute chest they had in the past.

This is what I was talking about. It doesn't happen very often though.

 

[97t]

what about well appearing sicklers with fever or history of fever......worry about bacteremia or not?

 

[southerndoc]

I almost always check troponins in sickle cell patients with chest pain. I still look for acute chest syndrome, but I also check a troponin. I've caught 3 MI's that way. Normal EKG or EKG's with non-specific T changes that had troponins >1. One had a troponin of 15 and had an occluded RCA with a normal EKG.

 

[gutonc]

I was always told that menstruating women don't have MIs (thanks a lot Conrad Fischer) until I saw a 26yr AAF have one.

That's the difference between learning how to pass the tests and learning how to be a doctor. If would be nice if they involved the same things but in general they don't.

 

[J-Rad]

Since the patient in the OP is really a pediatric patient as far as CP (I sort of think of people up to the early 20s as pediatric for this complaint) and I have the pain of seeing a lot of pediatric CP, this piqued my interest. Don't have a lot to add, but a history of congenital cardiac surgery that would put the coronaries at risk (i.e. they had to move them, like transposition repair or a Ross) should push you to think more cardiac (yes I know any history of cardiac surgery will push you in that direction, but there are higher risks to the coronaries with some procedures than others).
Less obvious would be a history of Kawasaki disease which also puts their coronaries at risk for the remainder of their lives.

I almost always check troponins in sickle cell patients with chest pain. I still look for acute chest syndrome, but I also check a troponin. I've caught 3 MI's that way. Normal EKG or EKG's with non-specific T changes that had troponins >1. One had a troponin of 15 and had an occluded RCA with a normal EKG.

Would you mind sharing what the ages and other risk factors were? Interesting cases no matter what, but I'm curious.