unstable angina?

[DancingFajitas]

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Quick scenerio question:
Say you have a patient that presents to the ED c/o CP that occured at rest, lasted 20 min or so with SOB. So you do an EKG which is normal, then check troponins. My question is, do you need 3 sets of normal troponins to r/o anything bad? And also, since this pt had unstable angina, would you admit them to at least Obs overnight and possibly cath later?

 

[Depakote]

Haven't done medicine yet, but my understanding was it takes serial troponins over 24 to r/o MI in the presence of a normal EKG. Unstable angina = admission. I would assume they'd be getting a cath, if not for a stent, at least diagnostic purposes to identify the occlusion.

 

[Scaredshizzles]

Quick scenerio question:
Say you have a patient that presents to the ED c/o CP that occured at rest, lasted 20 min or so with SOB. So you do an EKG which is normal, then check troponins. My question is, do you need 3 sets of normal troponins to r/o anything bad? And also, since this pt had unstable angina, would you admit them to at least Obs overnight and possibly cath later?

Yea, would get cathed at most places if available. (And I assume it is available at pretty much every teaching hospital you could be at.) As far as 3 sets of troponin, the timing is more important than number...If the patient didn't present until 12 hours after it occurred, 2 sets would be more than enough.....You get them every few hours so that you can manage the patient accordingly asap if you notice the enzymes rising. But in reality if the troponin does not rise at all within 16 hours of CP, it is not an MI. (the reason why it is not 100% sensitive is because you allow some degree of a tiny rise on the basis that test results can vary slightly based on measurement error...but sometimes that tiny rise is a legit rise.)

 

[SoCuteMD]

I would obs/admit the patient and have them stressed.

 

[Depakote]

I would obs/admit the patient and have them stressed.

I thought you didn't put unstable angina pts on a treadmill (or other means of stress test).

 

[Scaredshizzles]

I thought you didn't put unstable angina pts on a treadmill (or other means of stress test).

If you really think it is unstable angina you would not...On the other hand, a 35 yo woman complains of some chest pain but has no RFs (not morbidly obese, no DM, no htn, etc.), you would probably stress and not cath.

 

[SoCuteMD]

I thought you didn't put unstable angina pts on a treadmill (or other means of stress test).

If you had admitted overnight and had negative enzymes, I think you'd stress them. If they had positive enzymes, off to the cath lab.

 

[jdh71]

Yea, would get cathed at most places if available. (And I assume it is available at pretty much every teaching hospital you could be at.) As far as 3 sets of troponin, the timing is more important than number...If the patient didn't present until 12 hours after it occurred, 2 sets would be more than enough.....You get them every few hours so that you can manage the patient accordingly asap if you notice the enzymes rising. But in reality if the troponin does not rise at all within 16 hours of CP, it is not an MI. (the reason why it is not 100% sensitive is because you allow some degree of a tiny rise on the basis that test results can vary slightly based on measurement error...but sometimes that tiny rise is a legit rise.)

this ^^ 👍

To the OP:

Timing on chest pain is important!

If you're like most in your veteran population, you roll in Sunday night, after watching all of your weekend sports with a history of chest pain beginning sometime thursday night, but you wanted to wait out the weekend, ordered trops and they are high, this patient had an MI . . . heh

Timing is the often the most important factor when it come to cardiac chest pain. You NEED to know when it started prior to presentation in ED, and how long it lasted. Now for the other issues involved in with unstable angina, you need to have a reason to suspect it. If this were a 20 y/o female with CP at rest, you won't call this unstable angina.

Now lets merely beg the question and assume, per the given scenario that this is unstable angina, this patient gets admitted to the cardio floor, not obs, and gets a cath. Stressing unstable angina, if you've called it "unstable angina" is bad form. Remember once you've committed to a dx, there are consequences.

CAVEAT: If this is a frequent flier CP guy, with KNOWN cardiac dz by previous cath . . . he may or may not get a new cath. Repeat caths tend to occur based not on any sort of great guidelines, but are attending specific

 

[Depakote]

If you had admitted overnight and had negative enzymes, I think you'd stress them. If they had positive enzymes, off to the cath lab.

I see. Thanks for the clarification.

 

[jdh71]

If you really think it is unstable angina you would not...On the other hand, a 35 yo woman complains of some chest pain but has no RFs (not morbidly obese, no DM, no htn, etc.), you would probably stress and not cath.

you should check out stress tests and young women on up-to-date . . . the false positives in this population tends to make the test somewhat unhelpful unless it's negative . . . so in a 35 y/o female (and I saw one MI this year in a beautiful young lady with familial hypercholesterol) unless you have strong clinic suspicion for cardiac pain, you would rule them out and send them home with an alternative dx.

 

[Scaredshizzles]

you should check out stress tests and young women on up-to-date . . . the false positives in this population tends to make the test somewhat unhelpful unless it's negative . . . so in a 35 y/o female (and I saw one MI this year in a beautiful young lady with familial hypercholesterol) unless you have strong clinic suspicion for cardiac pain, you would rule them out and send them home with an alternative dx.

Yea, you don't necessarily need any fancy test at all if you don't suspect the diagnosis, although a lot of places will get a 2d echo anyway just because you have the patient there for a few hours under observation...

I have not read about the increase in false positives in young women, do you know more for the reason behind that? Obviously in any population where the prevalence of something is low, false positives go up, so I'm sure they would be somewhat higher in this kind of population....But if they are singling out young women, I wonder if there is some sort of physiological difference that makes them more prone to prolonged ST depressions when exerted. Usually generalized ST depressions are less likely to be called positive in comparison to those following some coronary territory.

 

[werd]

Quick scenerio question:
Say you have a patient that presents to the ED c/o CP that occured at rest, lasted 20 min or so with SOB. So you do an EKG which is normal, then check troponins. My question is, do you need 3 sets of normal troponins to r/o anything bad? And also, since this pt had unstable angina, would you admit them to at least Obs overnight and possibly cath later?[/QUOTE

The answer depends on both your attending and the details of the history. unstable angina earns admission, but it's a subjective diagnosis. tons of people come to the ED with chest pain that's non-cardiac. typically, this is how it goes... do a troponin rule out, which requires troponins q4hrs until the patient is 8 hours out from chest pain. a negative TnI 8 hours after chest pain rules out an acute coronary syndrome unless UA is very strongly suspected. a TnI bump gets admitted for NSTEMI. patients with chest pain and negative EKG/TnI who are at risk for CAD get stressed in the next few days.
something to remember is that if a patient has chest pain for a half hour but no troponin bump 8 hours later, the pain wasn't coming from their heart. if the pain were from cardiac ischemia, it would have caused a trop bump.

the ddx for chest pain is huge... someone with cp/sob could have a panic attack, or PNA, or a pneumothorax, or pericarditis, or anemia. cp/nausea could be peptic ulcer, or esophagitis, etc.
my experience in the ED tells me that about 1/5 patient's presenting with chest pain will have an MI, another 2/5 at most will have something worth diagnosing, and the rest will just have, well, nothing to diagnose.

 

[doogoshly]

i thought unstable angina was treated like a possible MI and you have basically r/o MI by cardiac enzymes x3 and walking/dobutamine stress. if cardiac enzymes are positive, cath lab. if not, sayonara.