Jason09 Posted October 14, 2011 Share Posted October 14, 2011 So I know there will be a lot of variable opinions but just wanted to see how everyone approaches epi/upper abd pain in low risk cardiac patients regarding cardiac view point. This means do you get EKGs, enzymes, both, one, none, or other studies. Just wanting to see how I compare. Thanks in advance. Link to comment Share on other sites More sharing options...
Moderator ventana Posted October 14, 2011 Moderator Share Posted October 14, 2011 define low risk? Vagal nerve stimulation does cause nausea epigastric pain and cannot rule out on history alone. Additionally GI cocktail as no benefit. Certainly at least one enzyme and EKG on a very low risk patient. Link to comment Share on other sites More sharing options...
pawag Posted October 14, 2011 Share Posted October 14, 2011 If low risk meaning no risk factors and they are over 40 and not clearly a GI cause then an EKG at least. +/- enzymes depending on how long this has been going on for. I agree GI cocktail not real helpful. Honestly I will say if these pt's are older, no RF's and no clear cause of it being GI related I keep'em for a r/o. Link to comment Share on other sites More sharing options...
HopefulPA Posted October 14, 2011 Share Posted October 14, 2011 Most of the Attendings I work with want at min a ECG and one trop. Link to comment Share on other sites More sharing options...
andersenpa Posted October 15, 2011 Share Posted October 15, 2011 Most of the Attendings I work with want at min a ECG and one trop. agree w/ ^^^^^^^^ Link to comment Share on other sites More sharing options...
Contrarian Posted October 15, 2011 Share Posted October 15, 2011 "Low risk" to ME means 17-25yr old non cocaine using, pleuritic pain aggravated with position change absent any valvular issues. Otherwise, ECG and enzymes as a min... Why... because they are cheaper and easier than trying to salvage infarcted cardiac tissue and lawsuits. YMMV Contrarian Link to comment Share on other sites More sharing options...
Jason09 Posted October 15, 2011 Author Share Posted October 15, 2011 So it's pretty much a consensus. Basically I was thinking along the same lines. Thanks for the responses Link to comment Share on other sites More sharing options...
medic25 Posted October 16, 2011 Share Posted October 16, 2011 Remember to be cautious about sending one set of enzymes and then discharging the patient. Many would argue that if you have enough concern about ACS to send a set of enzymes, then you should likely complete the ROMI workup with serial enzymes/EKG's and a stress test. If you really do not think that the pain is cardiac in origin, it seems that it would be easier to defend not getting any enzymes (with a valid documentation of why you did not think the pain was cardiac) than it is to defend sending one set and discharging home. If the patient has a poor outcome, it is tough to argue that you did not believe the patient had a cardiac issue if you've sent one set of enzymes. Link to comment Share on other sites More sharing options...
medic25 Posted October 16, 2011 Share Posted October 16, 2011 Remember to be cautious about sending one set of enzymes and then discharging the patient. Many would argue that if you have enough concern about ACS to send a set of enzymes, then you should likely complete the ROMI workup with serial enzymes/EKG's and a stress test. If you really do not think that the pain is cardiac in origin, it seems that it would be easier to defend not getting any enzymes (with a valid documentation of why you did not think the pain was cardiac) than it is to defend sending one set and discharging home. If the patient has a poor outcome, it is tough to argue that you did not believe the patient had a cardiac issue if you've sent one set of enzymes. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted October 16, 2011 Share Posted October 16, 2011 Remember to be cautious about sending one set of enzymes and then discharging the patient. Many would argue that if you have enough concern about ACS to send a set of enzymes, then you should likely complete the ROMI workup with serial enzymes/EKG's and a stress test. If you really do not think that the pain is cardiac in origin, it seems that it would be easier to defend not getting any enzymes (with a valid documentation of why you did not think the pain was cardiac) than it is to defend sending one set and discharging home. If the patient has a poor outcome, it is tough to argue that you did not believe the patient had a cardiac issue if you've sent one set of enzymes. Very true! Link to comment Share on other sites More sharing options...
CAdamsPAC Posted October 16, 2011 Share Posted October 16, 2011 Remember to be cautious about sending one set of enzymes and then discharging the patient. Many would argue that if you have enough concern about ACS to send a set of enzymes, then you should likely complete the ROMI workup with serial enzymes/EKG's and a stress test. If you really do not think that the pain is cardiac in origin, it seems that it would be easier to defend not getting any enzymes (with a valid documentation of why you did not think the pain was cardiac) than it is to defend sending one set and discharging home. If the patient has a poor outcome, it is tough to argue that you did not believe the patient had a cardiac issue if you've sent one set of enzymes. Very true! Link to comment Share on other sites More sharing options...
Joelseff Posted October 16, 2011 Share Posted October 16, 2011 In an outpt GI setting I would get an EKG and if there are changes or I am really feeling cardiac vs GI, then I call 911 to get them to the ER. It would be impratical for me to get a trop level as it would take days to get back. Now, if they present with epigastric pain for a consult, I would do an EGD with a UBT then treat accordingly (if the EGD is c/w erosive gastropathy I start a PPI if H. pylori is positive-seems to be an outbreak in Oakland recently- I start triple therapy or if its recalcitrant I start sequential therapy. I usually get them from PCP after all the more serious i.e. cardiac stuff has been ruled out. BUT... You were probably asking more from an urgent care/ER perspective though so EKG and Trop would be my move too :D Link to comment Share on other sites More sharing options...
Joelseff Posted October 16, 2011 Share Posted October 16, 2011 In an outpt GI setting I would get an EKG and if there are changes or I am really feeling cardiac vs GI, then I call 911 to get them to the ER. It would be impratical for me to get a trop level as it would take days to get back. Now, if they present with epigastric pain for a consult, I would do an EGD with a UBT then treat accordingly (if the EGD is c/w erosive gastropathy I start a PPI if H. pylori is positive-seems to be an outbreak in Oakland recently- I start triple therapy or if its recalcitrant I start sequential therapy. I usually get them from PCP after all the more serious i.e. cardiac stuff has been ruled out. BUT... You were probably asking more from an urgent care/ER perspective though so EKG and Trop would be my move too :D Link to comment Share on other sites More sharing options...
andersenpa Posted October 16, 2011 Share Posted October 16, 2011 Remember to be cautious about sending one set of enzymes and then discharging the patient. Many would argue that if you have enough concern about ACS to send a set of enzymes, then you should likely complete the ROMI workup with serial enzymes/EKG's and a stress test. If you really do not think that the pain is cardiac in origin, it seems that it would be easier to defend not getting any enzymes (with a valid documentation of why you did not think the pain was cardiac) than it is to defend sending one set and discharging home. If the patient has a poor outcome, it is tough to argue that you did not believe the patient had a cardiac issue if you've sent one set of enzymes. It depends on the pretest probability, which in this case is low. People are discharged from EDs with one set of neg enzymes all the time. The sensitivity of troponin is high. A low probability pt with nondetectable trops is a safe discharge. The one case you could make is if you had ANY equivocal finding (nonspecific ecg changes) or concerns for adequacy of f/u with pcp.... Link to comment Share on other sites More sharing options...
andersenpa Posted October 16, 2011 Share Posted October 16, 2011 Remember to be cautious about sending one set of enzymes and then discharging the patient. Many would argue that if you have enough concern about ACS to send a set of enzymes, then you should likely complete the ROMI workup with serial enzymes/EKG's and a stress test. If you really do not think that the pain is cardiac in origin, it seems that it would be easier to defend not getting any enzymes (with a valid documentation of why you did not think the pain was cardiac) than it is to defend sending one set and discharging home. If the patient has a poor outcome, it is tough to argue that you did not believe the patient had a cardiac issue if you've sent one set of enzymes. It depends on the pretest probability, which in this case is low. People are discharged from EDs with one set of neg enzymes all the time. The sensitivity of troponin is high. A low probability pt with nondetectable trops is a safe discharge. The one case you could make is if you had ANY equivocal finding (nonspecific ecg changes) or concerns for adequacy of f/u with pcp.... Link to comment Share on other sites More sharing options...
pawag Posted October 16, 2011 Share Posted October 16, 2011 It depends on the pretest probability, which in this case is low. People are discharged from EDs with one set of neg enzymes all the time. The sensitivity of troponin is high. A low probability pt with nondetectable trops is a safe discharge. The one case you could make is if you had ANY equivocal finding (nonspecific ecg changes) or concerns for adequacy of f/u with pcp.... Agreed. Keep timing of symptom onset in mind as well if you're using a single set. Link to comment Share on other sites More sharing options...
pawag Posted October 16, 2011 Share Posted October 16, 2011 It depends on the pretest probability, which in this case is low. People are discharged from EDs with one set of neg enzymes all the time. The sensitivity of troponin is high. A low probability pt with nondetectable trops is a safe discharge. The one case you could make is if you had ANY equivocal finding (nonspecific ecg changes) or concerns for adequacy of f/u with pcp.... Agreed. Keep timing of symptom onset in mind as well if you're using a single set. Link to comment Share on other sites More sharing options...
medic25 Posted October 17, 2011 Share Posted October 17, 2011 I agree that people are discharged home with one set of enzymes all the time, but that doesn't make it ideal management. All a negative troponin shows is that there is not active myocardial necrosis; it still doesn't rule out that the pain is cardiac in origin. The current AHA guidelines for low probability ACS patients recommend serial biomarkers and EKG's, followed by noninvasive testing (e.g. exercise stress). They do offer the caveat that a low risk patient (using a stratified score such as TIMI) under 40 can be discharged after serial enzymes if outpatient testing can be arranged within 72 hours. If I've got a low (but not zero) index of suspicion for CAD as a cause of chest pain, I will usually suggest to the patient that they stay in our ED's Chest Pain Center to be formally ruled out. Link to comment Share on other sites More sharing options...
medic25 Posted October 17, 2011 Share Posted October 17, 2011 I agree that people are discharged home with one set of enzymes all the time, but that doesn't make it ideal management. All a negative troponin shows is that there is not active myocardial necrosis; it still doesn't rule out that the pain is cardiac in origin. The current AHA guidelines for low probability ACS patients recommend serial biomarkers and EKG's, followed by noninvasive testing (e.g. exercise stress). They do offer the caveat that a low risk patient (using a stratified score such as TIMI) under 40 can be discharged after serial enzymes if outpatient testing can be arranged within 72 hours. If I've got a low (but not zero) index of suspicion for CAD as a cause of chest pain, I will usually suggest to the patient that they stay in our ED's Chest Pain Center to be formally ruled out. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 17, 2011 Moderator Share Posted October 17, 2011 also remember that cardiac chest pain improves 15% of the time in pain later proven to be cardiac.....my gi cocktail preference is only give them to young( like <35 yr old) pts with obvious dyspepsia. they should not be used as a diagnostic tool. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted October 17, 2011 Moderator Share Posted October 17, 2011 also remember that cardiac chest pain improves 15% of the time in pain later proven to be cardiac.....my gi cocktail preference is only give them to young( like <35 yr old) pts with obvious dyspepsia. they should not be used as a diagnostic tool. Link to comment Share on other sites More sharing options...
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