TWI - what to do?

[winterallsummer]

I am a new PA hoping to gain some perspective on this common clinical scenario I am encountering. A pt presents with CP but is low risk. They get serial trops and EKG ordered. Trops are all negative and pt feels fine or has minimal persistent CP. But then either all or perhaps the 2nd EKG comes out with a single or sometimes two (but usually just one) TWI. There is no prior EKG to compare to. Is it appropriate to admit these PTs or send home with cardiology f/u? Thanks a bunch for any insight.

[ventana]

T-wave inversion on electrocardiogram is related to the risk of acute coronary syndrome in the general population.

Bakhoya VN1, Kurl S, Laukkanen JA.

Author information

 

Abstract

BACKGROUND:

T-wave inversion (TWI) is a frequently encountered electrocardiographic (ECG) finding during routine medical examination of asymptomatic individuals, and of patients with various clinical conditions. However, the role of isolated TWI in the prediction of acute coronary syndrome (ACS) in the community has not been extensively studied. We investigated the relationship between TWI in routine ECG and the risk for ACS in the general population.

METHODS:

This study is based on a random sample of 1997 men aged 42-60 years in Eastern Finland. Electrocardiograms recorded at rest were classified using the Minnesota codes. The association between isolated TWI and ACS was determined using a multivariable adjusted Cox proportional hazard model.

RESULTS:

Negative T-waves were present in 3.6% of the participants. During an average follow-up of 20 years, a total of 493 ACS events were registered. After adjusting for age, TWI was associated with a 3.10-fold (95% confidence interval (CI) 2.21-4.32) risk for ACS. After additional adjustment for previously known coronary risk factors, TWI remained statistically significant in predicting ACS (relative risk 2.23; 95% CI 1.57-3.15). Negative T-waves was one of the strongest risk markers for ACS compared with other ECG-based variables such as left ventricular hypertrophy, previous Q-wave and prolonged QRS duration.

CONCLUSION:

TWI has a strong and independent predictive value for ACS in the general population.

KEYWORDS:

Electrocardiography; acute coronary syndrome; population study

[Boatswain2PA]

Symptomatic + the most minor EKG change = admit every time. 

 

Symptomatic + absolutely no EKG or lab change = admit for obs most of the time.

 

What is the acceptable miss rate for ACS/MI?  Zero, that's why I admit pretty near all of them (unless I can clearly describe why this is chest wall pain).

[EMEDPA]

this is where serial enzymes and a stress test really help in the setting oif an ed obs unit.

[winterallsummer]

Actually I AM working in the observation unit.  Sometimes the TWI was actually on the 1st EKG and another time it was on the 3rd and final EKG, etc.  So far I have been admitting all of these patients and so far any older EKGs were normal or more likely not avaliable.  In some cases the pt has multiple co-morbidities and it's easy to know admitting them is appropriate.  Another instance, for example, was a relatively young guy with only RF being HTN.  He had CP that was light but persistent, and on his 3rd EKG he had TWI.  In reviewing his prior EKGs there actually was a lot of artificact and he had no older EKGs so it was impossible to tell if these were brand new or not.  I picked him up halfway to his 3rd set of trop/EKG (all trops were negative) and I did admit him because of this (he had a lingering pain also).  Just curious if the fact that TWIs are sometimes a normal variant is ever a factor if the pt is otherwise totally fine, or if it is appropriate to just admit any new TWI seen in the observation unit for CP.  If he had not had TWI I am not sure he would be appropriate to admit.  

[EMEDPA]

if they have 3 nl sets of enzymes, no pain, a nl stress and the only finding is an isolated t wave inversion they can probably go home.

[winterallsummer]

Yep the stress would be great BUT if the only way to get a stress is d/c to get one out pt or admit them and order it for the morning (at which point it's up to the hospitalist what to do).

[EMEDPA]

Yep the stress would be great BUT if the only way to get a stress is d/c to get one out pt or admit them and order it for the morning (at which point it's up to the hospitalist what to do).

gotcha. we do ours through our obs unit. the PAs do them after 2 nl sets of enzymes.

[akdEM]

I'm a new PA too, so I don't have a lot of experience to go on... but it seems to me that there's a big difference between a TWI that shows up on the 2nd or 3rd EKG and a TWI that was there the whole time. If it just showed up, I'd probably be way more inclined to pursue the admission. If it was there the whole time and it's literally the only thing pointing to ACS (negative enzymes, exam isn't too concerning), then I would at least entertain the idea of discharge with close follow up.

[gbrothers98]

I am a new PA hoping to gain some perspective on this common clinical scenario I am encountering. A pt presents with CP but is low risk. They get serial trops and EKG ordered. Trops are all negative and pt feels fine or has minimal persistent CP. But then either all or perhaps the 2nd EKG comes out with a single or sometimes two (but usually just one) TWI. There is no prior EKG to compare to. Is it appropriate to admit these PTs or send home with cardiology f/u? Thanks a bunch for any insight.

A few things.

Define low risk?

One risk factor, 2?

Risk factors are just that, they are not guarantees someone will or will not have disease.

While there may be TWI, is there a pattern or is it isolated?

You mention persistent pain. I dont rank persistent pain as low risk. With the right story, that is unstable angina.

I think we all have to remember that while the troponins are negative, all that means is that there has not been enough damage to elevate those biomarkers. The patient can still have ischemia.

What is the story? Short lived, sharp nonradiating pain at rest is different than dull ache raking leaves with associated SOB and went away with sitting down.

Got to put all those elements together but the one that I weigh heavily is the history. EKGs and enzymes only get you so far. I have many anecdotal cases where EKGs were nonspecific, enzymes negative multiple times but I transferred for stress test based upon history and pt went to cath right after, a handful where they went to CABG right from cath. 

Many of their stories were low risk if they were frameworked within risk factors, EKG findings and biomarkers.

But all of them also told me they were having angina with their histories until proven otherwise.

If there is a good story for ischemia, they need provocative testing.

Young patients with chest pain need a urine tox screen too. Define young? I would say anyone under 50.

Good luck.

G Brothers PA-C

[EMEDPA]

Young patients with chest pain need a urine tox screen too. Define young? I would say anyone under 50.

Good luck.

G Brothers PA-C

I have recently seen a string of guys in their 50s and 60s with bad pmh using cocaine and/or meth....one with a SAH, another with a stemi, several with unstable angina.

[winterallsummer]

Low risk for me would be 1-2 RFs that are controlled. For example, 45 yo male with HTN controlled on one bp med. Depending on the second RF I may or may not define that as still low risk, but generally I consider just one RF and no hx of CP to be low risk - maybe if pt had controlled HTN and low hdl but nothing else then that's also low risk to me. Young is under 45-50.

 

The other problem is PTs presenting with lasting cp, however it is somewhat ambiguous, eg reproducible if they move but not to palp, sharp pain, no accompanying sx. Of course persistent CP alone defines UA but things are not so simple in real life.

 

I too believe a good h and p and risk stratification are most important and next is the EKG. My problem is when their h and p is not concerning, trops are negative and pt looks and feels great but either came in with TWI or develops a TWI - and maybe has had no CP since getting to my unit or even the ED. I worry that I may be thwarting the purpose of obs medicine by being too conservative, but for now I am admitting them unless I have an old EKG and an attending or cards is comfortable with them leaving. But perhaps this is defeating the purpose of obs is my point.