Why are so many cardiologists seemingly afraid of caths?

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hoot504

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I work at four different hospitals in a major metro area. In all of them, our cardiologists (several different groups spread across the city) are generally resistant to urgent (non-STEMI) caths.

To illustrate an example of this... Elderly gentleman w/ history of CAD arrives w/ sinus bradycardia and 'upset stomach'. EKG shows lateral depressions and concerning ST segment morphology in the inferior leads. Negative R-sided EKG. No criteria for STEMI. No active chest pain, just some intermittent bradycardia, previously mentioned 'upset stomach' has resolved. High-sensitivity trop comes back significantly elevated. I speak with cardiology (at 10pm). ''This guy should go for urgent cath", I say. "No" is invariably the answer. Every. single.time. "Heparin and admit", they say. Then they dick around with nonsense like Lexiscans and repeat trops for a day or two.

I have seen this scenario play out literally dozens of times. It's rare that the cardiologist says "yeah, you're right, this is really concerning, let's just take him to cath now", even though that is nearly without a doubt the correct next step in almost every instance. This especially puzzles me as I thought caths were the big money-makers for these guys. It seems that there should be no lack of enthusiasm for doing as many urgent and semi-urgent caths as possible.

Don't get me wrong, I will activate the cath lab over a cardiologist's objections all day long if I feel it necessary, but I happen to run into the situation mentioned above far more often. I know this isn't isolated to my practice environment. Any one have any idea what these guys are thinking?

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I work at four different hospitals in a major metro area. In all of them, our cardiologists (several different groups spread across the city) are generally resistant to urgent (non-STEMI) caths.

To illustrate an example of this... Elderly gentleman w/ history of CAD arrives w/ sinus bradycardia and 'upset stomach'. EKG shows lateral depressions and concerning ST segment morphology in the inferior leads. Negative R-sided EKG. No criteria for STEMI. No active chest pain, just some intermittent bradycardia, previously mentioned 'upset stomach' has resolved. High-sensitivity trop comes back significantly elevated. I speak with cardiology (at 10pm). ''This guy should go for urgent cath", I say. "No" is invariably the answer. Every. single.time. "Heparin and admit", they say. Then they dick around with nonsense like Lexiscans and repeat trops for a day or two.

I have seen this scenario play out literally dozens of times. It's rare that the cardiologist says "yeah, you're right, this is really concerning, let's just take him to cath now", even though that is nearly without a doubt the correct next step in almost every instance. This especially puzzles me as I thought caths were the big money-makers for these guys. It seems that there should be no lack of enthusiasm for doing as many urgent and semi-urgent caths as possible.

Don't get me wrong, I will activate the cath lab over a cardiologist's objections all day long if I feel it necessary, but I happen to run into the situation mentioned above far more often. I know this isn't isolated to my practice environment. Any one have any idea what these guys are thinking?
They make as much money from a delayed cath at 10 am on Tuesday as 2 am on a Saturday. Being in bed in pajamas beats working when you're not scheduled to work. It's no different than you getting a call at midnight between two 8am-6pm shifts, saying, "Hey Hoot504, it's Jim here in the ED. Wanna come in and sew up some complex fac lacs and make some RVU money?"

I'm guessing you'd say, "No but I wouldn't mind doing some fac lacs during my shift tomorrow."
 
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Hmm normally we don't have this problem, but since the pandemic started, we've got cardiologists at one of our facilities trying to refuse and and make all kinds of excuses to not cath obvious STEMIs when they are on STEMI call.
 
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To illustrate an example of this... Elderly gentleman w/ history of CAD arrives w/ sinus bradycardia and 'upset stomach'. EKG shows lateral depressions and concerning ST segment morphology in the inferior leads. Negative R-sided EKG. No criteria for STEMI. No active chest pain, just some intermittent bradycardia, previously mentioned 'upset stomach' has resolved. High-sensitivity trop comes back significantly elevated. I speak with cardiology (at 10pm). ''This guy should go for urgent cath",

Why do you think he should go to urgent cath? Chest pain? Cardiogenic shock? Clinical deterioration? New wma that is worsening with hypotension?

even though that is nearly without a doubt the correct next step in almost every instance.

From your post, I am not sure you have the knowledge and expertise to make this claim.

Don't get me wrong, I will activate the cath lab over a cardiologist's objections all day long if I feel it necessary,

Although the EM doc sometimes needs to play this card in the setting of STEMI, I would be careful holding this perspective/attitude. Not only are you likely going to destroy your relationship with your cardiologists, but you are also increasing risks of other providers and maybe patients by activating an emergent system inappropriately.

That said, I too have had to cajole a cardiologist during these COVID times -- but that was for a patient on mechanical ventilation for pulmonary edema due to cardiogenic shock.

HH
 
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Its because the literature shows there is no benefit. That's why they wait, because there is no indication for the immediate cath. If there was, there would be no point in differentiating stemi from nstemi. STEMI has clearly been shown to have improved morbiditiy and mortality from immediate PCI. NSTEMI has not.

There are cases where immediate PCI may be warranted (cardiogenic shock, ongoing severe anginal pain despite medical managment, no true stemi but ecg signs of severe L main / LAD disease like Wellens, dewinters, or isolated STE in AVR), but this is not most NSTEMIs. Most should be medically managed and undergo angiography within 24 hours or so after medical management.
 
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Does anyone know of a concise, clearly worded, evidence based, recent review (or as many of those adjectives as I can get) on when and why to do PCI in NSTEMI patients - specifically on differences between emergent, urgent, early and delayed? Apart from STEMI and other emergent indications (cardgiogenic shock, electrical instability) I would like to have a better idea on how soon my patient needs to go for PCI for when Im talking to cards i.e. 6 hours vs 12 hours vs 24 hours vs 72 hours.

Also from my understanding they are slowly pealing away indications for cath in terms of the evidence not showing a benefit
 
Weird.
My local cardiologists are super-aggro with caths.
Well, until COVID hit.
 
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I wouldn't activate the Cath lab based on the provided information in the OP's post. I really haven't had much of an issue with cards but we've got a pretty good relationship with all of them and they know we don't ever call with bulls**t. When we do call, the pt usually needs a cath and they know it. I haven't noticed an issue during COVID. Hell, I had an NSTEMI today and cards girl was super aggressive...had the guy in the Cath lab within an hour.
 
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Right, and referring to my original post, I didn't activate the cath lab because I understand that there was no strict indication to do so, but let me flesh that case out a little further... What prompted my particular concern in this patient was their HR intermittently but consistently dropping into the mid-40s (no high-grade block, just sinus bradycardia on repeated EKGs). The patient never dropped their pressure or exhibited any clinical deterioration in the ER. Their troponin has tripled since admission. They're undergoing a Lexiscan... really?

Personally speaking I don't have an issue with any of our cardiologists and have only activated against their advice once. I recognize that that is an extremely rare event (or should be). But clinical courses like I just mentioned above simply puzzle me.
 
I understand taking patients to cath between 7a - 7p more frequently than 7p - 7a, but dicking around and doing a lexiscan when the trop goes from 0.5 -> 2 -> 6 seems kind of stupid as the pre-test probability of them having significant CAD is extremely high.

There are probably specific cases to do a lexiscan, but at this point the patient is well admitted and I've got other things to worry about.

I too feel like the indications for emergent cath have very slowly been reduced, but I don't keep uptodate on the specifics as much. I recently recall that cardiac arrest w/ ROSC used to be strong indication to go to cath quickly...but now even that is suspect unless the EKG clearly shows an STEMI.
 
I work at four different hospitals in a major metro area. In all of them, our cardiologists (several different groups spread across the city) are generally resistant to urgent (non-STEMI) caths.

To illustrate an example of this... Elderly gentleman w/ history of CAD arrives w/ sinus bradycardia and 'upset stomach'. EKG shows lateral depressions and concerning ST segment morphology in the inferior leads. Negative R-sided EKG. No criteria for STEMI. No active chest pain, just some intermittent bradycardia, previously mentioned 'upset stomach' has resolved. High-sensitivity trop comes back significantly elevated. I speak with cardiology (at 10pm). ''This guy should go for urgent cath", I say. "No" is invariably the answer. Every. single.time. "Heparin and admit", they say. Then they dick around with nonsense like Lexiscans and repeat trops for a day or two.

I have seen this scenario play out literally dozens of times. It's rare that the cardiologist says "yeah, you're right, this is really concerning, let's just take him to cath now", even though that is nearly without a doubt the correct next step in almost every instance. This especially puzzles me as I thought caths were the big money-makers for these guys. It seems that there should be no lack of enthusiasm for doing as many urgent and semi-urgent caths as possible.

Don't get me wrong, I will activate the cath lab over a cardiologist's objections all day long if I feel it necessary, but I happen to run into the situation mentioned above far more often. I know this isn't isolated to my practice environment. Any one have any idea what these guys are thinking?
Patients with ns
Right, and referring to my original post, I didn't activate the cath lab because I understand that there was no strict indication to do so, but let me flesh that case out a little further... What prompted my particular concern in this patient was their HR intermittently but consistently dropping into the mid-40s (no high-grade block, just sinus bradycardia on repeated EKGs). The patient never dropped their pressure or exhibited any clinical deterioration in the ER. Their troponin has tripled since admission. They're undergoing a Lexiscan... really?

Personally speaking I don't have an issue with any of our cardiologists and have only activated against their advice once. I recognize that that is an extremely rare event (or should be). But clinical courses like I just mentioned above simply puzzle me.
Perhaps we should back up and clarify a basic point you may very well know but others reading this thread may not. There is a large amount of evidence now that PCI only improves outcomes in STEMIs and a few other specific subsets of people. Most NSTEMIs do just as well when managed with medical therapy including antiplatelets, statins, etc and have fewer complications than when managed with PCI plus medical therapy.

Times are changing. Although covid undoubtedly has influenced some decisions to not take people to the Cath lab, the standard of care is slowly changing over time to recognize PCI is not the best management for many people with ACS. STEMI is the clearly outlier subset of ACS that does better with PCI.
 
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Right, and referring to my original post, I didn't activate the cath lab because I understand that there was no strict indication to do so, but let me flesh that case out a little further... What prompted my particular concern in this patient was their HR intermittently but consistently dropping into the mid-40s (no high-grade block, just sinus bradycardia on repeated EKGs). The patient never dropped their pressure or exhibited any clinical deterioration in the ER. Their troponin has tripled since admission. They're undergoing a Lexiscan... really?

Personally speaking I don't have an issue with any of our cardiologists and have only activated against their advice once. I recognize that that is an extremely rare event (or should be). But clinical courses like I just mentioned above simply puzzle me.

Sounds like sick sinus syndrome. Unless they had angina or an EKG showing an inferior or lateral STEMI or hypotension (with ANY EKG changes), I'm not sure I'd push for emergent or even urgent cath since so many times the primary culprits for sick sinus are other things....drugs, age related fibrosis in the SA node, structural dz, etc.. But hey, I DO feel you. We've all had cases where our gestault felt like cath was the right decision and cards pushes back. Luckily, I don't work with any malignant cardiologists anymore, but all you can really do is argue your case and document their decision. I have a handful of cases a year where it's an actual STEMI but does not show criteria on the EKG or it's a LBBB with no previous EKG in the system, etc.. I have all my cardiologists on my iPhone and will transmit the EKG and can get them immediately and I'll run it by them and we'll talk about the case. Most of the time, they will take them to cath. A few times, they don't, but hey...that's all you can do. Document, document, document. For up trending troponin levels, most of our cards guys will cath them so I'm a little surprised yours haven't if they are up trending.
 
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I don't argue with them. Unless STEMI, I just document "Discussed with cardiology, and wants to defer PCI for additional testing", admit the patient and move on.
 
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I work at four different hospitals in a major metro area. In all of them, our cardiologists (several different groups spread across the city) are generally resistant to urgent (non-STEMI) caths.

To illustrate an example of this... Elderly gentleman w/ history of CAD arrives w/ sinus bradycardia and 'upset stomach'. EKG shows lateral depressions and concerning ST segment morphology in the inferior leads. Negative R-sided EKG. No criteria for STEMI. No active chest pain, just some intermittent bradycardia, previously mentioned 'upset stomach' has resolved. High-sensitivity trop comes back significantly elevated. I speak with cardiology (at 10pm). ''This guy should go for urgent cath", I say. "No" is invariably the answer. Every. single.time. "Heparin and admit", they say. Then they dick around with nonsense like Lexiscans and repeat trops for a day or two.

I have seen this scenario play out literally dozens of times. It's rare that the cardiologist says "yeah, you're right, this is really concerning, let's just take him to cath now", even though that is nearly without a doubt the correct next step in almost every instance. This especially puzzles me as I thought caths were the big money-makers for these guys. It seems that there should be no lack of enthusiasm for doing as many urgent and semi-urgent caths as possible.

Don't get me wrong, I will activate the cath lab over a cardiologist's objections all day long if I feel it necessary, but I happen to run into the situation mentioned above far more often. I know this isn't isolated to my practice environment. Any one have any idea what these guys are thinking?


There's no benefit for doing an emergent Cath in an NSTEMI, just look at the data. There's no decrease in mortality, it might actually be less safe. Taking a patient for urgent Cath in unstable angina or NSTEMI is actually more likely to have a poor outcome. You obviously didn't do 3 years of IM + 3 years of cardiology fellowship + 2 years of interventional to make that determination, that "that is nearly without a doubt the correct next step in almost every instance". Do a little more research I'm sure you'll understand why cardiologists are saying start heparin and we will Cath them later (and its not just so they can get a decent nights sleep, although also important, you don't want a sleepy interventionalist doing your catheterization I don't think haha). Look up the GRACE score. Its very useful in this scenario, especially for ED docs.

EDIT: NEJM - study showed no increase in survival for early intervention in NSTEMI

Also check out the TIMACS trial in 2009- showed that for patients with unstable angina or with NSTEMI, early intervention (<24hours) does not result in a decrease in death, MI, or stroke at 6 months compared to delayed intervention (>36h) except in patients who are at high risk with GRACE Score >140. Hence the usefulness of the grace score. Im sure if you called your cardiologist saying their Grace is >140, their decision might change from Cath tonight vs tomorrow.
 
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Check out the VERDICT trial. There's also a nice meta analysis in the Lancet from 2017ish if I remember right.

Cathing folks isn't a benign procedure as I'm sure you know. If you can delay the procedure safely to the point where the patient has cooled off, had pain/symptoms controlled, and have a well rested crew in the lab, things are going to go smoother.

The indications for early catheterization are easy to find in the literature. GRACE score as mentioned above is helpful.
 
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You obviously didn't do 3 years of IM + 3 years of cardiology fellowship + 2 years of interventional to make that determination, that "that is nearly without a doubt the correct next step in almost every instance".

Point taken. Poorly worded on my part and not meant to sound as hyperbolic as it did.
 
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I don't argue with them. Unless STEMI, I just document "Discussed with cardiology, and wants to defer PCI for additional testing", admit the patient and move on.

This.

If I'm worried it's so close to a STEMI that it needs to go to the lab, I request that the cardiologist review the tracings relative to the clinical context.

If that doesn't happen, I document my clinical concern (appropriately) and the plan of attack by cardiology after the above. Then I move on. Better things to do, other battles to pick.
 
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Personally speaking I don't have an issue with any of our cardiologists and have only activated against their advice once.

Out of curiosity, what was the outcome of this instance where you activated against advice? I've seen my fair share of consults where the consulting team unequivocally "knew" the patient needed an angiogram where, in fact, it was probably the last in a long line of interventions they needed (such as "NSTEMI" in a patient with a Hgb of 4..."but, but, the troponin!"). You tend to remember the ones who call you for that sort of thing as well. Not saying you're one of them, but all it can take is one emergency activation that turned out to be nothing (or could have waited) that can tag you with that reputation.
 
I work at four different hospitals in a major metro area. In all of them, our cardiologists (several different groups spread across the city) are generally resistant to urgent (non-STEMI) caths.

To illustrate an example of this... Elderly gentleman w/ history of CAD arrives w/ sinus bradycardia and 'upset stomach'. EKG shows lateral depressions and concerning ST segment morphology in the inferior leads. Negative R-sided EKG. No criteria for STEMI. No active chest pain, just some intermittent bradycardia, previously mentioned 'upset stomach' has resolved. High-sensitivity trop comes back significantly elevated. I speak with cardiology (at 10pm). ''This guy should go for urgent cath", I say. "No" is invariably the answer. Every. single.time. "Heparin and admit", they say. Then they dick around with nonsense like Lexiscans and repeat trops for a day or two.

I have seen this scenario play out literally dozens of times. It's rare that the cardiologist says "yeah, you're right, this is really concerning, let's just take him to cath now", even though that is nearly without a doubt the correct next step in almost every instance. This especially puzzles me as I thought caths were the big money-makers for these guys. It seems that there should be no lack of enthusiasm for doing as many urgent and semi-urgent caths as possible.

Don't get me wrong, I will activate the cath lab over a cardiologist's objections all day long if I feel it necessary, but I happen to run into the situation mentioned above far more often. I know this isn't isolated to my practice environment. Any one have any idea what these guys are thinking?

So weird how things vary geographically. With all the elective surgeries/procedures being cancelled, all the cardiologists where I'm at are chomping at the bit for more caths (aka, their bottom line).

Its because the literature shows there is no benefit. That's why they wait, because there is no indication for the immediate cath. If there was, there would be no point in differentiating stemi from nstemi. STEMI has clearly been shown to have improved morbiditiy and mortality from immediate PCI. NSTEMI has not.

There are cases where immediate PCI may be warranted (cardiogenic shock, ongoing severe anginal pain despite medical managment, no true stemi but ecg signs of severe L main / LAD disease like Wellens, dewinters, or isolated STE in AVR), but this is not most NSTEMIs. Most should be medically managed and undergo angiography within 24 hours or so after medical management.

lol. Ya all those "exceptions" made up 8/10 chest pain patient's I admitted this week that got a cath the same day, and 7 got stents...albeit it was during the day. Plus, gotta know which cardiologist is gonna roll outa bed at noon the next day and start doing caths at 5-6pm after seeing his clinic patients causing a potential 24hr delay...Why even become a cardiologist if you like to sleep is the real question...
 
I think it's important to not equate "got cath because cath team was in hospital and looking for cases to do" with "patient needed an emergent cath." We've all seen cases where there was an exceedingly high pretest probability that the patient had significant coronary disease; that doesn't necessarily mean it was the wrong thing to wait until the next day to do the intervention. Patients get cathed the same day for "not high-risk" NSTEMI because the cath team happened to be in the hospital during normal working hours, not because they're moving the goalposts on what is and isn't emergent.
 
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Yep, just because someone does get cath’d doesn’t mean they should have gotten cath’d. Afterall, people get cath’d for chest pain without an MI (nl trops) and there is zero data showing any mortality benefit for that. I guess you could say that if someone has stable angina causing life altering chest pain with exertion all the time, then the cath and stent improve their quality of life. But other than that improvement in quality of life in that specific case, there is no mortality benefit in cathing or stenting patients with chest pain with normal troponins. There is not mortality benefit to stenting coronary lesions when an MI hadn’t occurred. And yet, we stent 60-70% lesions all the time.

All the “benefit” for stenting non-MI CAD is based on composite end points of MACE which includes death, mi, and need for coronary revascularization. If you look at the data, there is no mortality or MI benefit, all the benefit is in the need for future revascularization. Which is silly. Because that means you are revascularizing someone to prevent the need for revascularizing someone.

A heart cath and stent are not a benign procedure. Stents can cause clot aggregation and MIs (we have all seen the person come back right after getting a stent with an MI). The cath itself can cause MIs from coronary injury. There is pseudoaneurism risk from the arterial puncture.
 
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I wish death wasn't always the primary endpoint for a lot of these studies. Sometimes we do things to improve quality of life and it's quite meaningful. Maybe the person can play tennis now and couldn't before because of recurrent angina or SOB.

I don't want an argument out of this, just saying that living with an 80-90% lesion that can clot off at any time can frock with your psyche.
 
Yep, just because someone does get cath’d doesn’t mean they should have gotten cath’d. Afterall, people get cath’d for chest pain without an MI (nl trops) and there is zero data showing any mortality benefit for that. I guess you could say that if someone has stable angina causing life altering chest pain with exertion all the time, then the cath and stent improve their quality of life. But other than that improvement in quality of life in that specific case, there is no mortality benefit in cathing or stenting patients with chest pain with normal troponins. There is not mortality benefit to stenting coronary lesions when an MI hadn’t occurred. And yet, we stent 60-70% lesions all the time.

All the “benefit” for stenting non-MI CAD is based on composite end points of MACE which includes death, mi, and need for coronary revascularization. If you look at the data, there is no mortality or MI benefit, all the benefit is in the need for future revascularization. Which is silly. Because that means you are revascularizing someone to prevent the need for revascularizing someone.

A heart cath and stent are not a benign procedure. Stents can cause clot aggregation and MIs (we have all seen the person come back right after getting a stent with an MI). The cath itself can cause MIs from coronary injury. There is pseudoaneurism risk from the arterial puncture.

Which really makes you wonder, if no MI basically equals no benefit from stent, is there really any benefit to admitting high HEART score patients with CP but no MI. Yes they have a higher risk than a low HEART score, but does admission and further work up actually decrease that risk. Are we going to get to the point someday where no MI = no admission?
 
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If it's standard practice, that's fine with me.
Which really makes you wonder, if no MI basically equals no benefit from stent, is there really any benefit to admitting high HEART score patients with CP but no MI. Yes they have a higher risk than a low HEART score, but does admission and further work up actually decrease that risk. Are we going to get to the point someday where no MI = no admission?

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Its because the literature shows there is no benefit. That's why they wait, because there is no indication for the immediate cath. If there was, there would be no point in differentiating stemi from nstemi. STEMI has clearly been shown to have improved morbiditiy and mortality from immediate PCI. NSTEMI has not.

There are cases where immediate PCI may be warranted (cardiogenic shock, ongoing severe anginal pain despite medical managment, no true stemi but ecg signs of severe L main / LAD disease like Wellens, dewinters, or isolated STE in AVR), but this is not most NSTEMIs. Most should be medically managed and undergo angiography within 24 hours or so after medical management.

This. Its nice to have EM colleagues who actually know how to triage MIs. Having to have the same discussion with people like the OP over and over gets old after a while.
 
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I guess I don't understand the point of activating the cath lab against cardiologist recommendation. Why wouldn't they just cancel it immediately being as they would be the one doing the procedure.
 
I guess I don't understand the point of activating the cath lab against cardiologist recommendation. Why wouldn't they just cancel it immediately being as they would be the one doing the procedure.

For legal / pompous reasons.

In case you have to get in front of the lawyers.
 
There is increasing evidence to support the thought that many NSTEMIs really should not be having emergent catheterization as it doesn't improve their mortality. Soon we may no longer even admit patients for risk stratification testing as it may not benefit them.

The ISCHEMIA Trial (NEJM 2020) recently showed that in patients with moderate to severe ischemia proven on stress testing, there was no evidence that initial invasive strategy as compared to initial conservative strategy reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years.

Maron D.J et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. NEJM 2020.
 
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There is increasing evidence to support the thought that many NSTEMIs really should not be having emergent catheterization as it doesn't improve their mortality. Soon we may no longer even admit patients for risk stratification testing as it may not benefit them.

The ISCHEMIA Trial (NEJM 2020) recently showed that in patients with moderate to severe ischemia proven on stress testing, there was no evidence that initial invasive strategy as compared to initial conservative strategy reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years.

Maron D.J et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. NEJM 2020.

I bet that will take 10 years to percolate through the Cardiology circles with behavior change. It's hard to change old habits.
 
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Check out the VERDICT trial. There's also a nice meta analysis in the Lancet from 2017ish if I remember right.

Cathing folks isn't a benign procedure as I'm sure you know. If you can delay the procedure safely to the point where the patient has cooled off, had pain/symptoms controlled, and have a well rested crew in the lab, things are going to go smoother.

The indications for early catheterization are easy to find in the literature. GRACE score as mentioned above is helpful.

I hate the use of the term "cooled off." Let's let the splenic rupture bleed out, ahem, I mean cool off...

I agree that emergent cath isn't necessary in NSTEMI's. Data has shown that.
 
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There is increasing evidence to support the thought that many NSTEMIs really should not be having emergent catheterization as it doesn't improve their mortality. Soon we may no longer even admit patients for risk stratification testing as it may not benefit them.

The ISCHEMIA Trial (NEJM 2020) recently showed that in patients with moderate to severe ischemia proven on stress testing, there was no evidence that initial invasive strategy as compared to initial conservative strategy reduced the risk of ischemic cardiovascular events or death from any cause over a median of 3.2 years.

Maron D.J et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. NEJM 2020.

correct, bc cathing and stenting really doesnt make sense unless the patient is having an MI or its a quality of life issue. I totally agree with what someone said above, that if you get a cath and stent and now can go and be physically active again, that’s an important endpoint. Unfortunately that’s not why many of the patients get caths, at least not the ones we see. We really don’t see stable angina patients who get pain on exertion and no pain at rest. We see random chest pains that last one or two minutes and go away, often nonexertional. They have a few min of of chest pain at rest, we call it possible acs or unstable angina, maybe they get some equivocal stress test, and then undergo Cath and find a 60% lesion and someone stents it.
 
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This. Its nice to have EM colleagues who actually know how to triage MIs. Having to have the same discussion with people like the OP over and over gets old after a while.

Trust me, it goes both ways in terms of not accepting the literature. We have had ED docs peer reviewed by cardiology for not calling interventional for an nstemi. It makes no sense. The literature shows no urgent need for a cath, why do I need to call them in the middle of the night to ask them if the patient needs a cath? They say no literally every time anyways.
 
Trust me, it goes both ways in terms of not accepting the literature. We have had ED docs peer reviewed by cardiology for not calling interventional for an nstemi. It makes no sense. The literature shows no urgent need for a cath, why do I need to call them in the middle of the night to ask them if the patient needs a cath? They say no literally every time anyways.

agree thats pretty lame if it truly was for a nstemi without any high risk features. some may want a heads up for logistical issues, or they may have unfortunately been burned in the past so rather triage the MIs themselves (eg missed STEMIs, missed CHB etc)
 
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And then there is the opposite:
My only "seems like near classic ACS" of the day was cholecystitis.
correct, bc cathing and stenting really doesnt make sense unless the patient is having an MI or its a quality of life issue. I totally agree with what someone said above, that if you get a cath and stent and now can go and be physically active again, that’s an important endpoint. Unfortunately that’s not why many of the patients get caths, at least not the ones we see. We really don’t see stable angina patients who get pain on exertion and no pain at rest. We see random chest pains that last one or two minutes and go away, often nonexertional. They have a few min of of chest pain at rest, we call it possible acs or unstable angina, maybe they get some equivocal stress test, and then undergo Cath and find a 60% lesion and someone stents it.

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I don't argue with them. Unless STEMI, I just document "Discussed with cardiology, and wants to defer PCI for additional testing", admit the patient and move on.
I mean as you shouldn’t. I feel like some people are over stepping their areas of expertise as ED docs. Outside of indications for emergent cath I feel I’m mostly always going to defer to the experts.
 
OP, based on what you stated, I would actually have been much more aggressive about getting the cardiologist to come in, as the patient you saw almost undoubtedly has an OMI (occlusion MI). STEMI criteria is incredibly non sensitive for acute occlusion MI. It misses 25-30% of patients with acute occlusions on cath. Those 25-30% of patients have worse outcomes than their STEMI counterparts. The literature for counting boxes is pretty weak. The data on thrombolytics in STEMI was based on pre-cath era medicine in patients with an unspecified amount of ST elevation, there was no "STEMI criteria" in most of these trials that demonstrated mortality benefit. With isolated lateral depressions and abnormal appearance of ST segments in inferior leads, along with bradycardia and elevated troponin, this is clearly a patient that needs to go to the cath lab now. There is nothing magical about 1mm STE vs 0.9mm.
 
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Sometimes I wish we had cardiologists here to weigh in on this stuff.

OP, post the EKG. Curious to see what it looks like. Make it HIPPA compliant.
 
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There's no benefit for doing an emergent Cath in an NSTEMI, just look at the data. There's no decrease in mortality, it might actually be less safe. Taking a patient for urgent Cath in unstable angina or NSTEMI is actually more likely to have a poor outcome. You obviously didn't do 3 years of IM + 3 years of cardiology fellowship + 2 years of interventional to make that determination, that "that is nearly without a doubt the correct next step in almost every instance". Do a little more research I'm sure you'll understand why cardiologists are saying start heparin and we will Cath them later (and its not just so they can get a decent nights sleep, although also important, you don't want a sleepy interventionalist doing your catheterization I don't think haha). Look up the GRACE score. Its very useful in this scenario, especially for ED docs.

EDIT: NEJM - study showed no increase in survival for early intervention in NSTEMI

Also check out the TIMACS trial in 2009- showed that for patients with unstable angina or with NSTEMI, early intervention (<24hours) does not result in a decrease in death, MI, or stroke at 6 months compared to delayed intervention (>36h) except in patients who are at high risk with GRACE Score >140. Hence the usefulness of the grace score. Im sure if you called your cardiologist saying their Grace is >140, their decision might change from Cath tonight vs tomorrow.
I would be very careful interpreting these results and extrapolating them to NSTEMI patients in front of you. This patient would likely have been excluded from this trial due to significant bradycardia. Other patients that are excluded are those with refractor angina, any hemodynamic instability, BP over 180 systolic or 120 diastolic, evidence of heart failure, has an indication for PCI, weight > 120kgs. Not to mention that their idea of "early" intervention was 24-48 hrs which introduces survivorship bias. At 24 hrs, most of the damage has already been done to the myocardium. So of course there was no increase in survival in that group, because they removed anyone that would likely benefit from PCI.
 
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I would be very careful interpreting these results and extrapolating them to NSTEMI patients in front of you. This patient would likely have been excluded from this trial due to significant bradycardia. Other patients that are excluded are those with refractor angina, any hemodynamic instability, BP over 180 systolic or 120 diastolic, evidence of heart failure, has an indication for PCI, weight > 120kgs. Not to mention that their idea of "early" intervention was 24-48 hrs which introduces survivorship bias. At 24 hrs, most of the damage has already been done to the myocardium. So of course there was no increase in survival in that group, because they removed anyone that would likely benefit from PCI.

OP stated sinus Brady but also didn't say how bradycardic, so how do you know its significant bradycardia?
 
Because OP stated the HR was in the 40s on a f/u post.
 
I would be very careful interpreting these results and extrapolating them to NSTEMI patients in front of you. This patient would likely have been excluded from this trial due to significant bradycardia. Other patients that are excluded are those with refractor angina, any hemodynamic instability, BP over 180 systolic or 120 diastolic, evidence of heart failure, has an indication for PCI, weight > 120kgs. Not to mention that their idea of "early" intervention was 24-48 hrs which introduces survivorship bias. At 24 hrs, most of the damage has already been done to the myocardium. So of course there was no increase in survival in that group, because they removed anyone that would likely benefit from PCI.

Actually the exclusion criteria for the TIMACS trial was 1) Age <21 yrs 2) Not suitable for revasculariation 3) comorbid condition with life expectance <6 months. The trial was a multi-center blinded parallel - group randomized controlled trial and had >3000 patients with about half randomized to early intervention and half to delayed intervention so im not sure where you are getting that this study can't be extrapolated.

Additionally thats the entire point of using the grace score if you look at what's included in the score itself patients who are higher risk aka with cardiogenic shock, have heart failure on presentation, or elderly would fall into the high grace score category and would go for early catheterization.
 
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Sorry for the confusion, but I was talking about ICTUS.
 
As for TIMACS, it has similar issues to timing of cath. Avg time to cath was 14hrs following randomization. I would not call 14 hrs early intervention, as the damage is already done by that point.
 
Sorry for the confusion, but I was talking about ICTUS.

I see but even with the ICTUS trial exclusions, they make sense because either those people are obviously going to need an urgent cath or they can't have an urgent cath because of another factor and thus can't be randomized. The exclusion criteria (Exclusion criteria were an age younger than 18 years or older than 80 years, myocardial infarction with ST-segment elevation in the past 48 hours, an indication for primary percutaneous coronary intervention or fibrinolytic therapy, hemodynamic instability or overt congestive heart failure, the use of oral anticoagulant drugs in the past 7 days, fibrinolytic treatment within the past 96 hours, percutaneous coronary intervention within the past 14 days, a contraindication to treatment with percutaneous coronary intervention or glycoprotein IIb/IIIa inhibitors, recent trauma or risk of bleeding, hypertension despite treatment (i.e., systolic pressure >180 mm Hg or diastolic pressure >100 mm Hg), weight greater than 120 kg, or inability to give informed consent.) I mean its obvious amongst those who needs an emergent cath and those that can't be cathed right away. Here we're talking about those borderline unstable angina and NSTEMI patients where the answer isn't obvious.
 
I see but even with the ICTUS trial exclusions, they make sense because either those people are obviously going to need an urgent cath or they can't have an urgent cath because of another factor and thus can't be randomized. The exclusion criteria (Exclusion criteria were an age younger than 18 years or older than 80 years, myocardial infarction with ST-segment elevation in the past 48 hours, an indication for primary percutaneous coronary intervention or fibrinolytic therapy, hemodynamic instability or overt congestive heart failure, the use of oral anticoagulant drugs in the past 7 days, fibrinolytic treatment within the past 96 hours, percutaneous coronary intervention within the past 14 days, a contraindication to treatment with percutaneous coronary intervention or glycoprotein IIb/IIIa inhibitors, recent trauma or risk of bleeding, hypertension despite treatment (i.e., systolic pressure >180 mm Hg or diastolic pressure >100 mm Hg), weight greater than 120 kg, or inability to give informed consent.) I mean its obvious amongst those who needs an emergent cath and those that can't be cashed. Here we're talking about those borderline unstable angina and NSTEMI patients where the answer isn't obvious.
I'm not questioning the exclusion criteria, I'm stating the OPs patient would not have been among those randomized given marked bradycardia which likely would have had him excluded under hemodynamic instability, so it is important to know when not to extrapolate study results to patients in front of you. Regardless, I don't think anyone would expect mortality benefit on a PCI done 24h after randomization. That's a study that was set up to have a negative primary outcome.
 
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I'm not questioning the exclusion criteria, I'm stating the OPs patient would not have been among those randomized given marked bradycardia which likely would have had him excluded under hemodynamic instability, so it is important to know when not to extrapolate study results to patients in front of you. Regardless, I don't think anyone would expect mortality benefit on a PCI done 24h after randomization. That's a study that was set up to have a negative primary outcome.

Not to be argumentative, but I guess agree to disagree. I think both studies are very influential and I actually don't know many cardiologists at my program that cath an NSTEMI within <12 hours unless with elevated GRACE >140. And as far as the sinus brady goes my husband is an athlete and his resting HR is typically 45-55. Would that mean if he has some nausea and a normal ECG he should undergo an urgent cath without a stress test? I hope not!
 
Not to be argumentative, but I guess agree to disagree. I think both studies are very influential and I actually don't know many cardiologists at my program that cath an NSTEMI within <12 hours unless with elevated GRACE >140. And as far as the sinus brady goes my husband is an athlete and his resting HR is typically 45-55. Would that mean if he has some nausea and a normal ECG he should undergo an urgent cath without a stress test? I hope not!
I have actually yet to meet a cardiologist that doesn't cath some NSTEMIs immediately due to concerning ECGs that don't quite meet criteria. EKG evidence of acute coronary occlusion is on a spectrum, not a yes or no. There is quite a bit of recent literature regarding subtle STEMIs (ST elevation MIs that don't meet criteria, as well as ECG patterns that indicate acute occlusion w/o overt ST elevation meeting critieria). You should review some of Dr. Stephen Smith's literature on subtle STEMIs.

I'm glad your husband has a low resting HR, however, something tells me OPs patient was not an athlete and probably did not have a resting HR in the 40s.
 
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Sometimes I wish we had cardiologists here to weigh in on this stuff.

OP, post the EKG. Curious to see what it looks like. Make it HIPPA compliant.

Present. I feel like previous posts are nitpicking the few times that a patient presents with a high-risk/unstable NSTEMI should go to the cath lab early, then extrapolating those experiences to every NSTEMI that comes through the door because they "might" become high risk. Truth be told, short of calling a STEMI alert and activating the cath lab accordingly, unless some rogue cardiologist wants to discharge the patient home, I'm not quite sure what the vested interest is in the work-up beyond getting them admitted.

EDIT: I apologize for the string of edits...phone spazzed while I was typing and I didn't want to lose whole post.
 
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Present. I feel like previous posts are nitpicking the few times that a patient presents with a high-risk/unstable NSTEMI should go to the cath lab early, then extrapolating those experiences to every NSTEMI that comes through the door because they "might" become high risk. Truth be told, short of calling a STEMI alert and activating the cath lab accordingly, unless some rogue cardiologist wants to discharge the patient home, I'm not quite sure what the vested interest is in the work-up beyond getting them admitted.

EDIT: I apologize for the string of edits...phone spazzed while I was typing and I didn't want to lose whole post.

The vested interest is caring in what happens to our patients.
 
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