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Nuclear stress is about 90% sensitive for ACS, stress echo is about 80% sensitive. So yeah, stress testing performs rather poorly as a rule out test.
Things "Specialists" Told You Couldn't Happen, That Happened
Started by Birdstrike
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deleted859535
Ding ding ding. My thoughts exactly.
I discuss this as a routine with folks we same-day stress. I make it clear in conversation that "stress tests are not 100% sensitive for heart problems, so if you ever feel you're having chest discomfort you're worried about, you should come back to the ED immediately". The chart says the same.
I feel that it's all a matter of where you draw the line. For some, they're happy with a low-risk HEART and discharge. For me, if there's any concern, it's after a stress test if no recent testing. I find the latter more practically defensible than the former. Just so happens that at some of our facilities, we discharge our own same-day stress tests. In a deposition, I would much rather say, "Yes, Mr. Smith's chest pain was not clearly due to cardiac disease at the time I saw him in the ED; in fact, he was 'low risk.' But even so, because I always consider atypical presentations of dangerous conditions, I obtained a series of EKGs and troponin measurements, which were all unchanged/normal, leading up to a stress test which was normal that same day. I also explained in my note that I considered alternative dangerous conditions, including X, Y, and Z, as well as why I did not feel they applied to Mr. Smith. He denied any concerns at time of discharge. We discussed that stress testing is not "100%" for heart disease, and he was encouraged to return immediately if any concerns. There was no indication for any further testing that day."
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deleted206819
Here's the HEART Pathway presentation. I hope it's useful to others.
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Are you saying that you admit all of those patients? If your spidey sense is tingling, yeah, go ahead and admit these people. Reading your post though sounds like you're taking the 41 yr old marathon runner with no PMH, sort of GERD-like sx that have resolved, a normal EKG and 2 negative trops and you're admitting them. That sounds exceedingly aggressive.
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deleted109597
There is a clinical policy on this now that allows you to use science to help guide you. Of course, like any clinical decision instrument, it's simply a guide, and not a rule.
Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary S... - PubMed - NCBI
Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Non-ST-Elevation Acute Coronary S... - PubMed - NCBI
Just noticed this a few days ago from Ryan Radecki's blog. I skimmed it. Looks great. Now all we need is the AHA to endorse something like this and it should be a fairly rock-solid defense if there is a bad outcome.
Are you sure?
.
"Heart disease in marathon runners: a review.
Noakes TD.
Thirty-six cases of heart attack or sudden death in marathon runners have been reported in the world literature to date. The mean age of the runners was 43.8 yr (range = 18 to 70), the mean years' running was 6.8 yr (range = 0.5 to 29), and the mean best standard 42.2 km marathon time was 3 h 28 min (range = 2 h 33 min to 4 h 28 min). Coronary artery disease was diagnosed either clinically, angiographically, or at autopsy in 27 runners (75%), two of whom also had histological evidence of hypertrophic cardiomyopathy. Seventy-one percent of the runners with coronary artery disease had premonitory symptoms, and most ignored such symptoms and continued to train or race. Fifty percent of all cardiac events occurred either during or within 24 h of competitive running events or long training runs. The marathon running population does not constitute solely persons with excellent cardiovascular health. Marathon runners, especially those with a family history of heart disease and other coronary risk factors, should not consider themselves immune to either sudden death or to coronary heart disease and should seek medical advice immediately if they develop any symptoms suggestive of ischemic heart disease. Physicians should not assume that "physically fit" marathon runners cannot have serious, life-threatening cardiac disease."
"Increased Coronary Artery Plaque Volume Among Male Marathon Runners
by Robert S. Schwartz, MD, et al.
This study found that long-term participation in marathon training/racing is paradoxically associated with increased coronary plaque volume. Abstract Background Long-term marathon running improves many cardiovascular risk factors, and is presumed to protect against coronary artery plaque formation. This hypothesis, that long-term marathon running is protective against coronary atherosclerosis, was tested by quantitatively assessing coronary artery plaque using high resolution coronary computed tomographic angiography (CCTA) in veteran marathon runners compared to sedentary control subjects. Methods Men in the study completed at least one marathon yearly for 25 consecutive years. All study subjects underwent CCTA, 12-lead electrocardiogram, measurement of blood pressure, heart rate, and lipid panel. A sedentary matched group was derived from a contemporaneous CCTA database of asymptomatic healthy individuals. CCTAs were analyzed using validated plaque characterization software. Results Male marathon runners (n = 50) as compared with sedentary male controls (n = 23) had increased total plaque volume (200 vs. 126 mm3, p < 0.01), calcified plaque volume (84 vs. 44 mm3, p < 0.0001), and non-calcified plaque volume (116 vs. 82 mm3, p = 0.04). Lesion area and length, number of lesions per subject, and diameter stenosis did not reach statistical significance. Conclusion: Long-term male marathon runners may have paradoxically increased coronary artery plaque volume."
"Myocardial Injury and Ventricular Dysfunction Related to Training Levels Among Nonelite Participants in the Boston Marathon
Tomas G. Neilan et al
13 Nov 2006Circulation. 2006;114:2325–2333
Abstract
Background— Multiple studies have individually documented cardiac dysfunction and biochemical evidence of cardiac injury after endurance sports; however, convincing associations between the two are lacking. We aimed to determine the associations between the observed transient cardiac dysfunction and biochemical evidence of cardiac injury in amateur participants in endurance sports and to elicit the risk factors for the observed injury and dysfunction.
Methods and Results— We screened 60 nonelite participants, before and after the 2004 and 2005 Boston Marathons, with echocardiography and serum biomarkers. Echocardiography included conventional measures as well as tissue Doppler–derived strain and strain rate imaging. Biomarkers included cardiac troponin T (cTnT) and N-terminal pro-brain natriuretic peptide (NT-proBNP). All subjects completed the race. Echocardiographic abnormalities after the race included altered diastolic filling, increased pulmonary pressures and right ventricular dimensions, and decreased right ventricular systolic function. At baseline, all had unmeasurable troponin. After the race, >60% of participants had increased cTnT >99th percentile of normal (>0.01 ng/mL), whereas 40% had a cTnT level at or above the decision limit for acute myocardial necrosis (≥0.03 ng/mL). After the race, NT-proBNP concentrations increased from 63 (interquartile range [IQR] 21 to 81) pg/mL to 131 (IQR 82 to 193) pg/mL (P<0.001). The increase in biomarkers correlated with post-race diastolic dysfunction, increased pulmonary pressures, and right ventricular dysfunction (right ventricular mid strain, r=−0.70, P<0.001) and inversely with training mileage (r=−0.71, P<0.001). Compared with athletes training >45 miles/wk, athletes who trained ≤35 miles/wk demonstrated increased pulmonary pressures, right ventricular dysfunction (mid strain 16±5% versus 25±4%, P<0.001), myocyte injury (cTnT 0.09 versus <0.01 ng/mL, P<0.001), and stress (NT-proBNP 182 versus 106 pg/mL, P<0.001).
Conclusions— Completion of a marathon is associated with correlative biochemical and echocardiographic evidence of cardiac dysfunction and injury, and this risk is increased in those participants with less training."
"Risk Stratification For Coronary Artery Disease In Marathon Runners
Raimund Erbel et al
European Cardiology - Volume 4 Issue 1;2008:4(1):23-26
Coronary Atherosclerosis in Marathon Runners
...We found no association of CAC burden with any of the exercise-related variables such as numbers of marathon completed, training mileage and frequency or years of regular marathon running. Hence, currently it is unclear whether frequent exhaustive exercise such as marathon running has direct pro-atherosclerotic effects. This is unlikely given the substantial evidence on the benefits of regular physical activity on coronary atherosclerosis, but no epidemiological studies have so far examined individuals engaged in such prodigious amounts of exercise. It is possible that the observed mismatch between a low risk factor burden and a high CAC score may be explained by a higher risk factor exposure earlier in life in marathon runners, and supports the limitations of conventional risk-stratification algorithms in master athletes. Alternatively, repetitive bouts of exhaustive exercise with the associated oxidant and inflammatory cytokine bursts may have contributed to the development of coronary atherosclerosis. The CAC burden is an independent predictor for myocardial damage and seems to contain prognostic information in marathon runners like in other asymptomatic cohorts (see below).39,31 The implication of our findings is that the true CV risk in marathon runners may be underestimated if it is assessed based on established risk factors alone."
" N Engl J Med. 1979 Jul 12;301(2):86-9.
Autopsy-proved coronary atherosclerosis in marathon runners.
TD, Opie LH, Rose AG, Kleynhans PH, Schepers NJ, Dowdeswell R."
"Eur Heart J. Aug;29(15):1903-10.
Running: the risk of coronary events : Prevalence and prognostic relevance of coronary atherosclerosis in marathon runners.
CONCLUSION:
Conventional cardiovascular risk stratification underestimates the CAC burden in presumably healthy marathon runners. As CAC burden and frequent marathon running seem to correlate with subclinical myocardial damage, an increased awareness of a potentially higher than anticipated coronary risk is warranted."
"Nat Clin Pract Cardiovasc Med. 2007 Jul;4(7):396-401.
On the paradox of exercise: coronary atherosclerosis in an apparently healthy marathon runner.
Möhlenkamp S1, Böse D, Mahabadi AA, Heusch G, Erbel R.
Author information
Abstract
BACKGROUND:
An asymptomatic and apparently healthy 64-year-old marathon runner underwent comprehensive cardiovascular risk assessment as part of a prospective study on calcified coronary plaque burden in master marathon runners. His profile suggested a low 10-year cardiovascular risk.
INVESTIGATIONS:
Conventional risk-factor assessment, coronary artery calcium quantification, bicycle stress test, echocardiography, coronary angiography, intravascular ultrasonography, including virtual histology, and intracoronary Doppler ultrasonography.
DIAGNOSIS:
Severe coronary atherosclerosis of the left anterior descending, mid left circumflex, and left main arteries.
MANAGEMENT:
Stenting of the left anterior descending artery, CABG surgery, and intensive risk-factor modification. The patient was also advised against participating in future marathon competitions."
"Preventing Sudden Cardiac Death during Marathons with Pre-Race Aspirin
Arthur J. Siegel1,2
ABSTRACT
Objectives: Prevention of sudden cardiac death is the number one clinical priority in sports cardiology. While the overall cardiovascular risk of long distance running is acknowledged as low, the frequency of cardiac arrests and sudden death has increased in middle-aged males during marathons since the year 2000. An evidence-based strategy for protecting susceptible runners from these acute cardiac events during races is considered based on identification of the underlying cause. Method: Review of articles in Pub Med on adverse cardiac events during marathons. Findings: Recent epidemiological studies have identified an increasing frequency of cardiac arrest in middle-aged males during marathons since the year 2000 with atherosclerotic heart disease as the main cause of sudden cardiac death. Same-aged asymptomatic middle-aged male physician-runners showed a post-race polymorphonuclear leukocytosis with sequential increases in interleukin-6 and C-reactive protein as a likely consequence of rhabdomyolysis after “hitting the wall”. Increased fibrinogen, von Willebrand factor and D-dimer with in vivo platelet activation indicated a concurrent hemostatic imbalance with pro-coagulant effects. Cardiac troponins I and T and NT-pro-B-type natriuretic peptide were elevated after races as additionally predictive of acute cardiac events in asymptomatic persons. Conclusions: High short-term risk for acute cardiac events in asymptomatic middle-aged male runners is shown by stratification of validated biomarkers, which may render non-obstructive coronary atherosclerotic plaques vulnerable to rupture during marathons. Pre-race aspirin usage is prudent to reduce these events mediated by atherothrombosis based on conclusive evidence for prevention of first acute myocardial infarctions in same-aged healthy male physicians. Prospective studies are needed to determine the efficacy of pre-race low-dose aspirin for curtailing the increasing frequency of race-related cardiac arrest and sudden death in susceptible runners."
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Interesting articles, they don't seem to refute my sentiment though.
I can't access the full article, however: "The marathon running population does not constitute solely persons with excellent cardiovascular health. Marathon runners, especially those with a family history of heart disease and other coronary risk factors, should not consider themselves immune to either sudden death or to coronary heart disease "
I'm still not worried about my no-risk factors 41M that we were talking about.
I read this entire paper. It quotes several other studies, all of which say that marathon runners are at a LOWER risk of cardiac death than non-runners, and only those in the hardest training groups saw their mortality benefit drop to that of the average non-runner due to the increased plaque phenomenon. Translation: marathon runners are at worst, of average cardiac health, and most likely of improved cardiac health than the average person.
Every single person in this study had an elevated troponin, which I said I was in favor of checking x2. If it's negative go home.
This study was limited to patients >= 50 yrs old. It goes on to discuss how coronary artery calcium is increased in some of these marathon runners, but does not provide any mortality correlations. Referencing one of the papers above, it seems that even in the patients with increased CAC burden, the downside is outweighed by the benefit of increased CV health from all the running.
"Regular marathon running has a beneficial effect on the cardiovascular risk factor profile but the extent of calcified coronary plaque is underestimated from that risk factor profile"
We've touched on this issue twice already.
This is a single case study about a 64 year old runner. I'm not really sure what to do with this.
This paper just says that middle aged males are at increased risk of having a heart attack during a marathon. Color me shocked.
I can't access the full article, however: "The marathon running population does not constitute solely persons with excellent cardiovascular health. Marathon runners, especially those with a family history of heart disease and other coronary risk factors, should not consider themselves immune to either sudden death or to coronary heart disease "
I'm still not worried about my no-risk factors 41M that we were talking about.
I read this entire paper. It quotes several other studies, all of which say that marathon runners are at a LOWER risk of cardiac death than non-runners, and only those in the hardest training groups saw their mortality benefit drop to that of the average non-runner due to the increased plaque phenomenon. Translation: marathon runners are at worst, of average cardiac health, and most likely of improved cardiac health than the average person.
Every single person in this study had an elevated troponin, which I said I was in favor of checking x2. If it's negative go home.
This study was limited to patients >= 50 yrs old. It goes on to discuss how coronary artery calcium is increased in some of these marathon runners, but does not provide any mortality correlations. Referencing one of the papers above, it seems that even in the patients with increased CAC burden, the downside is outweighed by the benefit of increased CV health from all the running.
"Regular marathon running has a beneficial effect on the cardiovascular risk factor profile but the extent of calcified coronary plaque is underestimated from that risk factor profile"
We've touched on this issue twice already.
This is a single case study about a 64 year old runner. I'm not really sure what to do with this.
This paper just says that middle aged males are at increased risk of having a heart attack during a marathon. Color me shocked.
None of those studies with varied descriptions of various types of CV disease in marathon runners prove or disprove anything. A total of 30-something worldwide reports in that first one? Suggests a signal worth looking into but certainly not something that’s going to make me significantly alter my treatment of this particular population behind the risk stratification tools I have now.
Correlation does not equal causation.
That report of that 64yr guy is worrisome to me as it seems as if he had NO symptoms, had good exercise tolerance And only happened to find incidental CAD as part of that study. He got revascularized with no hard data that we improved his long term morbidity or mortality.
Correlation does not equal causation.
That report of that 64yr guy is worrisome to me as it seems as if he had NO symptoms, had good exercise tolerance And only happened to find incidental CAD as part of that study. He got revascularized with no hard data that we improved his long term morbidity or mortality.
We are a terrible lot. We should be supporting each other instead picking apart papers that talk about a case report of a 64 yr guy who runs marathons and died of an MI.
Doh!
Doh!
I don't take away from these papers that "marathon runners are at higher heart risk," at all. That's not my point. The take home from these papers, for me, is the fact that someone "runs marathons" doesn't mean "their heart must be okay, because they ran a marathon" but only that they've essentially passed the equivalent of a stress test. That's all. But they're no less likely to have plaque than any other schlub, before he decides to get off the couch and start running, then builds up to a marathon. That's what I take home from someone telling me "But I ran a marathon, so my heart has to be okay, right?"
My answer is, "Maybe. Probably. But not certainly." We've all seen people that had an MI and, you look back, and they just passed a stress test.
@BoardingDoc
Where in the above HEART pathway scoring is the amount of exercise a person does?
Anyone else?
Where in the above HEART pathway scoring is the amount of exercise a person does?
Anyone else?
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It's nowhere. The marathon runner comment was only included in there because it happened to be in the example you used previously. I don't care that he's a marathon runner. I care that he's 41, with a not great story for MI and no PMH.
My comment was that all comers (runners or otherwise) with the presentation I described are going to be going home because their HEART score is a 1 at best. (1 pt for hx, 0 for EKG, age, risk factors, trop per my example).
If he goes home and dies, yes, that's tragic. But I'm also not going to admit every patient with a HEART of 1 for a cath and I was simply asking if you were saying that you would.
This is getting absurd man.
On my second refused admission in a patient with moderate HEART score of the day. Both “just wanted to get checked out” and are leaving despite my explanation/warning that they are at serio risk for bad things.
“So my labs are normal doc?”
“Yessss, however...”
“So my labs are normal doc?”
“Yessss, however...”
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It's "getting absurd" because the amount a patient exercises is in the HEART score and I totally missed that obvious fact?
Or because it's not in the decision rule, and it's absurd for me to expect those using it to think about why it's not?
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I can't make a blanket "always would/always wouldn't" statement based on a two line hypothetical patient on the internet. I'm simply advocating for a very conservative approach to atypical, potentially cardiac symptoms, in patients there's no other certain diagnosis, since it's a high risk diagnosis, during a time when there's outside pressure against admitting. I don't think that's controversial. At the same time, I don't advocate over-reliance on decision rules that have a disclaimer that "clinical gestalt" outweighs them, when my clinical gestalt is that decision rules always have their own problems. That's just my personal bias on decision rules. I've yet to see one as good as whatever the gold standard is. I think we generally agree and are going back and forth over minutia. If you're generally more conservative that whoever's doing the admitting, then you're probably fine.
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