young patient with chest pain

[rohit76]

Is it recommended to order cardiacs and d-dimer routinely on young patients with chest pain?
If first set of cardiacs are negative, are we supposed to repeat it even on young patient or just d/c them?

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[Hercules]

Is it recommended to order cardiacs and d-dimer routinely on young patients with chest pain?
If first set of cardiacs are negative, are we supposed to repeat it even on young patient or just d/c them?

For a patient under 40 with no cocaine use and no cardiac risk factors I get an EKG and CXR no enzymes. There is literature to back this up but I don't know the reference off the top of my head. As a side note, this is the only time cardiac risk factors have much utility in the ED for us.

I definitely would not get a d-dimer on every yound person with chest pain as your false positive rates could be painful. I like the Carolinas PERC rule out on eligible patients when looking to rule out PE on a very low risk patient.

 

[Schnoffle]

Here's a thread that covered this topic
http://forums.studentdoctor.net/showthread.php?t=303647

Our ED basically does an EKG, enzymes, and CXR it seems on every patient who comes in with chest pain. Of course, being from WV, we're the cardiovascular hell hole of the world.

 

[bartleby]

The treatment for undifferentiated chest pain in the ED is to start by taking a history. You are asking for the answer before you have even come up with a question. Indiscrminate ordering of tests in general, but especially in the ED is a recipe for disaster. If you order an EKG on a 25 who has a presentation consistent with pectoralis strain and the person has lateral T wave inversions, what are you going to do about it? The more tests you order, the more false positives you will have to chase, and if you order them in people who didn't need the test in the first place, you're totally wasting your time.

Furthermore, you should not be routinely ordering cardiac enzymes in everyone with chest pain, especially in the young. If you think that a low risk patient has non-cardiac chest pain by history and exam, that is as good as you're going to get..you should not order enzymes on them "just to be sure". The sensitivity of cardiac enzymes is abysmal if you order them 2 hours after the start of the patient's pain, so the result is meaningless anyway.

As far the D-Dimer goes, you should research "Well's Criteria for PE", which helps you risk stratify patients and identify the low risk population in whom the D Dimer is helpful. In high risk populations, you should not order the D Dimer and go straight to VQ or CTA. Conversely, if someone has normal vitals and you think that they are much more likely to have another cause for their pain, you shouldn't even order the D Dimer. In this popoulation, various literature states that their likelihood of having a PE is south of 2%, which is the same, if not better than the negative predictive value of a D Dimer in the low risk population. Your clinical judgement is free and doesn't have nearly as many false positives as a D Dimer.

If first set of cardiacs are negative, are we supposed to repeat it even on young patient or just d/c them?

 

[GeneralVeers]

The official ACEP position on cardiac enzymes states that one set of enzymes is insufficient to rule out heart attack.

This is why I get mad when they automatically order enzymes on young or low-risk patients. If they are negative and you discharge, and that patient has any kind of cardiac event in the next year, you're screwed.

"Doctor Smith, you had reason enough to believe that your patient, who is a volunteer at a charity to help disabled puppies, was at significant enough risk of heart attack to order one set of enzymes, yet you sent him home? Are you familiar with the guidelines set forth BY YOUR OWN professional organization as to the use of cardiac enzymes?"

 

[leviathan]

The official ACEP position on cardiac enzymes states that one set of enzymes is insufficient to rule out heart attack.

This is why I get mad when they automatically order enzymes on young or low-risk patients. If they are negative and you discharge, and that patient has any kind of cardiac event in the next year, you're screwed.

"Doctor Smith, you had reason enough to believe that your patient, who is a volunteer at a charity to help disabled puppies, was at significant enough risk of heart attack to order one set of enzymes, yet you sent him home? Are you familiar with the guidelines set forth BY YOUR OWN professional organization as to the use of cardiac enzymes?"

Wouldn't they also be able to say that someone was "at significant enough risk of heart attack to order an ECG, yet you didn't order 2 sets of cardiac enzymes?"

I hope they can't.

 

[mikecwru]

The treatment for undifferentiated chest pain in the ED is to start by taking a history. You are asking for the answer before you have even come up with a question. Indiscrminate ordering of tests in general, but especially in the ED is a recipe for disaster. If you order an EKG on a 25 who has a presentation consistent with pectoralis strain and the person has lateral T wave inversions, what are you going to do about it? The more tests you order, the more false positives you will have to chase, and if you order them in people who didn't need the test in the first place, you're totally wasting your time.
.

This is philosophically true, but not practically true. EKGs get ordered by triage nurses, long before we can act all Osler-like and take a grand history. Even if you're ED is pushing a Domino's "we'll see you in 30 minutes," you'll be hard pressed to meet a door-to-EKG time of 10 minutes if you wait for physician history. But as far as testing overall, I agree with your sentiment.

 

[southerndoc]

Wouldn't they also be able to say that someone was "at significant enough risk of heart attack to order an ECG, yet you didn't order 2 sets of cardiac enzymes?"

I hope they can't.

There are other things to look for on an EKG besides cardiac ischemia... arrhythmia, pericarditis, etc.

 

[leviathan]

There are other things to look for on an EKG besides cardiac ischemia... arrhythmia, pericarditis, etc.

Good point.

 

[kungfufishing]

This is philosophically true, but not practically true. EKGs get ordered by triage nurses, long before we can act all Osler-like and take a grand history. Even if you're ED is pushing a Domino's "we'll see you in 30 minutes," you'll be hard pressed to meet a door-to-EKG time of 10 minutes if you wait for physician history. But as far as testing overall, I agree with your sentiment.

How did you know I had been compared so frequently to Osler?


Seriously speaking, I agree with ordering as few tests as possible from triage or in general for that matter. Sometimes it is nice to have labs ordered before I see the patient but much of the time they are not what I really want, superfluous, or incomplete, leading us right back to square one.

I tend to evaluate younger patients primarily for nonischemic problems with the ECG, enzymes only if their story is great and I generally expect an admission OR their symptoms have been present long enough that a single set would be meaningful.

 

[txterp98]

A cardiologist where I work made me think pretty hard about how I stratify young patients with chest pain. In essence, I've become more conservative with them and tend to admit them more often. Here are the bullet points I got from my conversation:

1) Juries tend to hang you out to dry more if you miss ACS on a young patient. Mess up on an elderly person...that'll suck and open up your checkbook. Mess up on a younger person who has/had their whole life ahead of them (especially if it's the primary breadwinner of a family)...that'll suck and be ready to open up your checkbook for a whole lot more.

2) Whether you have one negative set of enzymes or two negative sets of enzyme timed a few hours apart, if you send home a patient who later has a bad cardiac outcome, neither case is going to help you that much. You may argue that two negative sets helped you risk stratify the patient. The counter argument is that you risk-stratified incorrectly...i.e., they weren't really low-risk to begin with and the chest pain being experienced in the ER was actually unstable angina.

3) If you have a bad outcome regarding a patient you sent home, your group will likely try to settle as opposed to let it actually go to court. To reiterate, bad outcomes in young people with chest pain tend to pull at juries' heartstrings. Unfortunately, as I preach to the choir, we are not actually being judged by a jury of our peers. As much as we can argue about the literature, standards of care, and the process of risk stratification, the jury is not made up of prudent emergency physicians.

Don't get me wrong, I hate ordering enzymes on people in their early 30's, especially if they don't have any solid cardiac risk factors. That being said, understand that the stakes really are higher with these people.

Just food for thought. I thought it was interesting and felt it was worth sharing.

 

[rohit76]

Is there any data on young patients with chest pain ( Retrospectively unstable angina) sent home and later on diagnosed to have MI?

There must be some way we can stratify these patients as Internist,Hospitalist will have problems with these admissions.

 

[WilcoWorld]

This article is sort of what you're looking for:
http://linkinghub.elsevier.com/retrieve/pii/S0196064404002902

Slightly off-topic vent/rant: Last night I had a 74 year old woman come in for high blood pressure/CP. Her initial BP was about 220/110, and she reported that when the BP was noted she had what was admittedly atypical chest pain (sharp & non-exertional) followed by an hour of generalized fatigue - both resolved prior to arrival. Her EKG showed LVH and enzymes were negative, but there was no way I was sending her home. Both cardiology and medicine residents balked at the admission, so I kept her in the ED 'till the AM so their attendings could see the patient. I kept thinking, "Seriously? Have these residents never heard of how ACS in elderly women presents?" Arrrg.

 

[elwademd]

This article is sort of what you're looking for:
http://linkinghub.elsevier.com/retrieve/pii/S0196064404002902

Slightly off-topic vent/rant: Last night I had a 74 year old woman come in for high blood pressure/CP. Her initial BP was about 220/110, and she reported that when the BP was noted she had what was admittedly atypical chest pain (sharp & non-exertional) followed by an hour of generalized fatigue - both resolved prior to arrival. Her EKG showed LVH and enzymes were negative, but there was no way I was sending her home. Both cardiology and medicine residents balked at the admission, so I kept her in the ED 'till the AM so their attendings could see the patient. I kept thinking, "Seriously? Have these residents never heard of how ACS in elderly women presents?" Arrrg.

well, if its acs its unstable angina, stemi, or non-stemi. you said the ekg only had lvh. so, not a stemi. enzymes negative, not a nstemi either. if you're saying that her one episode of atypical chest pain is unstable angina, i suppose you have an argument... so, then you really have to ask about prior episodes of chest pain, any prior work up to make her a "slam dunk" admit. of course you could have said she had hypertensive urgency/emergency depending on other lab work and symptoms.

of course in the end, that sounds like my grandma's admission for pulmonary embolus around this time last year! so, i would have taken the admit, but for different reasons.

 

[elwademd]

A cardiologist where I work made me think pretty hard about how I stratify young patients with chest pain. In essence, I've become more conservative with them and tend to admit them more often. Here are the bullet points I got from my conversation:

1) Juries tend to hang you out to dry more if you miss ACS on a young patient. Mess up on an elderly person...that'll suck and open up your checkbook. Mess up on a younger person who has/had their whole life ahead of them (especially if it's the primary breadwinner of a family)...that'll suck and be ready to open up your checkbook for a whole lot more.

2) Whether you have one negative set of enzymes or two negative sets of enzyme timed a few hours apart, if you send home a patient who later has a bad cardiac outcome, neither case is going to help you that much. You may argue that two negative sets helped you risk stratify the patient. The counter argument is that you risk-stratified incorrectly...i.e., they weren't really low-risk to begin with and the chest pain being experienced in the ER was actually unstable angina.

3) If you have a bad outcome regarding a patient you sent home, your group will likely try to settle as opposed to let it actually go to court. To reiterate, bad outcomes in young people with chest pain tend to pull at juries' heartstrings. Unfortunately, as I preach to the choir, we are not actually being judged by a jury of our peers. As much as we can argue about the literature, standards of care, and the process of risk stratification, the jury is not made up of prudent emergency physicians.

Don't get me wrong, I hate ordering enzymes on people in their early 30's, especially if they don't have any solid cardiac risk factors. That being said, understand that the stakes really are higher with these people.

Just food for thought. I thought it was interesting and felt it was worth sharing.

Is there any data on young patients with chest pain ( Retrospectively unstable angina) sent home and later on diagnosed to have MI?

There must be some way we can stratify these patients as Internist,Hospitalist will have problems with these admissions.

is that not the timi risk score/stratification?!

a young person not using cocaine without history of hypertension or family history of sudden cardiac death/early death from mi sounds like a low risk patient... which means they can get a non invasive stress test as an outpatient... but a lot do it inpatient, though it really doesn't need to be done that way.

http://www.ncbi.nlm.nih.gov/pubmed/10938172
http://jama.ama-assn.org/cgi/content/full/284/7/835