To Stress Test or Not?

[OptimusPrime]

83yo female visiting from europe is bib neice to the ED w/ several concerns:

1)The patient has had worsening fatigue on exertion over past couple of weeks/1month

2)Over past week patient's BP has been high SBP 180-200 measured on automatic home BP cuff

3)Questionable AMS over last several days

Rest of story: Patient is visiting for 1month, denies prior history of chest pain, SOB, PND, orthopnea, LE edema. No fevers/chills, ROS pretty much negative.

PMHx: Dyslipidemia & DVT/PE(diagnosed 1year ago and treated w/ 6months of coumadin), no prior history of CAD, HTN, DM.

Meds: daily aspirin and fibronate, no history of prior cardiac med use

Social: denies Tobacco, ETOH and IVDA

Exam: Afebrile, vitals wnl, SBP always remained 100-125 in the ED
Normal Exam

Labs: CBC, BMP, COAGS all w/in normal limits, BUN is slightly elevated at 26, Cr normal (0.9), U/A is dirty concerning for UTI

Serial Troponins & ECGs are negative, BNP & ESR normal.

CXR and CT Head all show no significant pathology. CT Angio rules out PE and other lung pathology.

Patient states she feels fine and would like to go home. Not a trick question, I just want your honest opinion. Do you think this patient warrants further workup for possible CAD with a stress test (dob or adenosine)?

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[dragonfly99]

do a urine cx before giving abx, then treat for a UTI if the UA looked dirty and was not contaminated. The confusion and the dirty urine suggest a UTI to me.
Make sure the blood pressure is being treated. Do you feel confident the BP readings that were high were accurate?

I don't see a reason to rush to stress here here. I don't see an emergent reason to stress her. Would have her f/u in clinic or when she goes home to Europe, return to ER if has chest pain, SOB, arm pain, etc.

 

[dragonfly99]

What do you mean the ECG was negative? What did it show. Any LVH? Was there any suggestion of heart block, sick sinus syndrome, etc. that could explain the fatigue?

 

[cardsfellow2007]

You could check an echo.

 

[OptimusPrime]

she was treated for UTI. the ECG was showed normal sinus rhythem at 78bpm. no heart block, did not meet criteria for LVH.

the reason why i posted the question was this was a 2am admit and me and the ED doc had some tense moments because i did not feel she needed to be admitted for stress test to evaluate possible CAD in this 83yo patient.

the echo the following day showed normal EF, 70%, no regional wall motion abnormality, no valvular pathology, mild diastolic dysfunction.

my attending also felt that this was a legit admit, i disagree. i realize that since she is visiting from europe her follow up would have to wait a few weeks until she goes back and checks with her pmd over there but based on what we had and all the normal initial workup i did not feel it was indicated to admit her on 2am on a saturday for a stress test on monday.

i'm not too sure about the history of elevated bp at home either since she has never had SBP higher than 130 over the past three days inpatient. i think the automatic bp cuff at her home probably over-read her bp.

anyways, i just wanted to see if there was a guideline somewhere stating that this particular patient warranted a stress test-- again keep in mind no prior history of CAD/DM or HTN. Never complained of chest pain or SOB. No history of PND/Orthopnea/Edema. Negative CXR/Trops/BNP. Normal serial ECGs. all we had was an elderly female w/ history of dyslipidemia and DVT/PE bib weird history of fatigue on exertion (which could be explained by dehydration and malaise from her uti).

feel free to share your two cents.

OP

 

[cardsfellow2007]

she was treated for UTI. the ECG was showed normal sinus rhythem at 78bpm. no heart block, did not meet criteria for LVH.

the reason why i posted the question was this was a 2am admit and me and the ED doc had some tense moments because i did not feel she needed to be admitted for stress test to evaluate possible CAD in this 83yo patient.

the echo the following day showed normal EF, 70%, no regional wall motion abnormality, no valvular pathology, mild diastolic dysfunction.

my attending also felt that this was a legit admit, i disagree. i realize that since she is visiting from europe her follow up would have to wait a few weeks until she goes back and checks with her pmd over there but based on what we had and all the normal initial workup i did not feel it was indicated to admit her on 2am on a saturday for a stress test on monday.

i'm not too sure about the history of elevated bp at home either since she has never had SBP higher than 130 over the past three days inpatient. i think the automatic bp cuff at her home probably over-read her bp.

anyways, i just wanted to see if there was a guideline somewhere stating that this particular patient warranted a stress test-- again keep in mind no prior history of CAD/DM or HTN. Never complained of chest pain or SOB. No history of PND/Orthopnea/Edema. Negative CXR/Trops/BNP. Normal serial ECGs. all we had was an elderly female w/ history of dyslipidemia and DVT/PE bib weird history of fatigue on exertion (which could be explained by dehydration and malaise from her uti).

feel free to share your two cents.

OP

The crux of the argument lies on if you think this is "possible ACS" versus "noncardiac diagnosis."

http://www.acc.org/qualityandscience/clinical/guidelines/exercise/exercise_clean.pdf

http://content.onlinejacc.org/cgi/reprint/50/7/e1.pdf

 

[dragonfly99]

optimusprime,
the other thing to remember is that the #1 thing that ER docs are sued for (apparently...I just learned this) is failure to diagnose acute coronary syndrome. This is why they often want cards to admit things that are probably not cardiac, or not really emergent enough to need admission and rapid workups. They have to cover their a--. At least this wasn't a completely bogus admit...I mean she had a complaint, was not drug seeking, was old and actually a little sick. Don't you have a general IM service that can admit patients like this, then consult cards in the a.m. if necessary?

 

[Myostatin]

I agree with you that the pt doesn't need an inpatient stress given an alternative explanation for symptoms, her normal ekg and negative troponins in the context of several days of symptoms. If she were reliable and had close followup I would be fine with an outpatient stress if symptoms persisted after treatment of the (presumed) UTI - the fact that she's foreign and likely will not have access to followup prior to return to her country complicates things, and I can see why the ER would lean towards admitting - if you were sure you could ensure close followup I think discharge from the ER would've been fine.

 

[BatmanMD]

optimusprime,
the other thing to remember is that the #1 thing that ER docs are sued for

I work as an ED attending and this is absolutely correct. Missing someone who has ACS is a huge concern for everyone who works in the ED. Pretty much anyone who has Chest pain/SOB/weakness and is old with cardiac risk factors will at least get trops sent on them. The story with the 80 y.o. lady is very common. More men than females get true "chest pain" with their MIs. That said, I would have just sent troponins, admitted to medicine and just checked repeat trops. Get her up and walking around, see how she feels. That'll help with the need for a stress test.

We all hate admitting cardiac pts. Eventually you see someone complaining of chest pain, and if their over 50, dispo is done at that point. They get admitted. They could be a healthy marathon runner, but medico-legally, if you don't admit for a stress, you're setting yourself up for a lawsuit. I hate it because, it means we're not practicing medicine at this point.

Most of what we do in the ED is to avoid getting sued. We know things will be normal, but we have to "rule them out" so we don't get that certified letter( this includes CTs, xrays,..) . TIMI scores, and other multiple scoring designs have been tried to be used, but have not been verified.

I love what I do, but this is by far (along with the drug seekers) that biggest pain in the ass about it.

 

[OptimusPrime]

to answer the earlier question i was the poor medicine teaching resident the ED called at 2:30am to admit this patient.

i respect what most of you have contributed to this thread but my issue is not if the stress test should be done inpatient or as outpatient but that I don't think this lady bought herself a stress test with this story.


83yo female who has a PMD but no history of CAD, HTN or DM. came in complaining of some degree of confusion per her niece and generalized fatigue (which the ED doc explained to me as DOE). This could have easily been explained by her UTI.

she had never had chest pain. no history of HF symptoms, clear CXR, normal BNP. ruled out for ACS with serial troponins and EKGs by the time i got there, feeling fine and the niece was mainly concerned about a repeat PE but they already did the bloody CT angio and ruled that out.

patient is feeling fine after being rehydrated by one liter of NS and was asking if she can eat and go home.

we keep throwing the kitchen sink at everybody and wonder why the cost of health care is through the roof. i feel your pain Batman but its just sad that we hardly ever practice medicine the way we were taught to back in med school.

fyi her 2d echo was fine and she had a normal stress test. sorry to sound a bit bitter but at this rate we should start arguing about the sensitivity of some of these stress test methods in the elderly and just send anyone over the age of 60 w/ a semi good story for a coronary ct angio or plain old cath just to put all doubt to rest (which i don't mind since some day i hope to be the punk IC in the cath lab yelling NEXT!!! ;-)