What would you do with this patient?

[WilcoWorld]

This case is over & done with, so I'm not seeking medical advice - I'd just like some perspective from any Cards fellows/attendings.

38 yo diabetic male with hypercholesterolemia and a father who had CAD, but not until his 50's presents to the ED with a good chest pain story and gets a dobutamine stress echo after initially negative trops and ECG. During the stress he develops squeezing chest pain (described with a clenched fist) associated with nausea which resolves after about 20 minutes. The stress test was negative for wall motion abnormality or ST changes, but somehow a troponin gets sent after the stress test and it comes back 30 times the 99th percentile value for our assay. It is resent 2 hours later in hopes that the initial value was a "lab error" and it comes back 30% higher.

What would you do with this patient?

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[nstemi]

sounds like he just failed his stress test.

 

[KRichards62]

This case is over & done with, so I'm not seeking medical advice - I'd just like some perspective from any Cards fellows/attendings.

38 yo diabetic male with hypercholesterolemia and a father who had CAD, but not until his 50's presents to the ED with a good chest pain story and gets a dobutamine stress echo after initially negative trops and ECG. During the stress he develops squeezing chest pain (described with a clenched fist) associated with nausea which resolves after about 20 minutes. The stress test was negative for wall motion abnormality or ST changes, but somehow a troponin gets sent after the stress test and it comes back 30 times the 99th percentile value for our assay. It is resent 2 hours later in hopes that the initial value was a "lab error" and it comes back 30% higher.

What would you do with this patient?

What was the time frame between initial presentation and dobutamine stress echo? Sounds like an event occurred between the two times, as troponin usually takes 4-6 hours to become detectable in the blood. Was CK-MB sent?

Although the patient has risk factors, he's still relatively young to have significant CAD. Transient coronary artery spasm is a thought...I've seen it cause surprisingly high elevations in troponin (although this is usually a diagnosis of exclusion). Regardless, I think this guy has earned himself a cath.

 

[Dabigatran]

By definition this patient fits the Diagnosis of NSTEMI in addition to his high risk profile (DM most likely insulin dependent ,HLD and family history of CAD)
So based on this he warrants left heart cath to know his coronary anatomy +\- Revascularization if necessary , of course after starting him on ASA ,B-Blocker and Statin ,the cath need to be done as soon as possible.

Can you please tell us what happen to the patient ?

 

[WilcoWorld]

Thanks for the input.

There were no CKMB's sent, but the elevated troponin was sent approximately 4 hours after the DSE-associated chest pain episode.

I'll post follow-up when I have that information.

 

[Angioplasty]

1) With his story of anginal chest pain and risk factors, I would take him for cath.

2) 38 years old, typical angina pectoris- the pretest probability of CAD is Intermediate. (ACC/AHA stress test guidelines). There is nothing wrong in choosing the path of stress echo. However I dont understand the approach of Dobutamine Echo instead of the Exercise Echo.
Now dobutamine echo can be falsely negative in subendocardial ischemia, delay in acquisition of images at the peak heart rate, false interpretation. Any way with the available information I would say the test is clinically positive. That will buy him an angiogram.

3) I would also like to know the BP at presentation and during DOb echo. Also does he have LVH?

4) We dont know yet what we have to do with the information of post dobutamine stress POSITIVE TROPONIN.

Anyway further recommendations will be based on the coronary angiogram results.

I would put my money on a mid-LAD lesion or a diffuse disease. Please post the results of angiogram and further follow up.

 

[dragonfly99]

Needs a cath ASAP.
I hope he got it while inpatient.
I think he should have had a couple of sets of negative myoglobin plus trops (+/- CK-MB...our ER hates them but I was residency trained using them and I like them) 4 hrs apart at least before getting a stress test.

If the patient can exercise, he/she should get an exercise stress test, not pharmacologic. Was he unable to exercise?

Family history is very powerful/important in CAD. Also, diabetes is a big bad risk factor. I think I would have been a bit nervous about stressing this guy, and also would have been loathe to believe the stress test results had they come back negative/normal. I'm pretty noninvasive, but would have been tempted to send this guy straight for diagnostic cath...diagnostic cath isn't actually very dangerous and in somebody like this I think your pretest probability is pretty high. Technically it was not wrong to stress him first, though.

 

[Trifling Jester]

Not sure why he'd have such a high troponin after a negative DSE... any renal issues? what was his admission BP? was anything else going on with him medically at that time, like sepsis? Did he get beta blockers in the ED prior to the DSE and not reach his target heart rate, or did they stop infusion prematurely due to his chest pain? (in which case it really wouldn't be negative IMO...)

-The Trifling Jester

 

[WilcoWorld]

The patient had normal renal function, he was never severely hypertensive and the patient was not septic.The troponins trended down over the rest of the night, and a cardiac CT showed some mild to moderate calcifications (sorry, but I can't recall the specifics). The patient got discharged on aspirin. No cath was performed.

I think the real clinical question here is what is the significance of a troponinemia after a stress test? Is there Cardiology literature on this? I would really like to be enlightened.

Thanks,
WW

 

[k96tw01]

wow.

Not one but two incorrect tests to order

1) should have been an exercise stress test... DSE induced possibilities in this situation could have included balanced ischemia from epicardial disease or subendocardial ischemia in the setting of LVH+dobut, dynamic outflow tract obstruction, hypertensive urgency/emergency w/ LV strain/troponin release, etc. Hence the reason that DSE should only be out of necessity when unable to exercise

2)followed up with a CT cors... in a diabetic with that disease having associated higher propensity to small vessel and distal epicardial disease

....good story with those RF's... could make an easy case just to go straight to cath and if not that then definitely an exercise stress +/- imaging

 

[WilcoWorld]

The plan also struck me as, err, "unconventional". That's why I posted the question.

Thanks,
WW