Discharging CP patients

[nebero]

What do you em guys think about discharging CP patients from the Ed after 2 sets of ekg and cardiac enzymes 6 hours apart

[medic25]

I've seen some people do it, but you might want to do a lit search to see what the most current recommendations are. At our facility we do 3 sets of EKG/enzymes every 3 hours, then a stress test +/- nuclear imaging before discharge.

[nebero]

One particular doc I work with seems to do this a lot and I wanted to see how common practice this is.

[CAdamsPAC]

I've seen it done with documented cards f/u including stress test on the chart.

Are we talking about a community versus teaching hospital?

[nebero]

Community hospital.

[CAdamsPAC]

Community hospital.

 

I think my post would fly and be good to go in that setting.

[EMEDPA]

My facility has a pa run obs unit for chest pain, tia's, cellulitis, etc

after the 2 ekg's and 2 sets of enzymes six hrs apart the pa's do a treadmill. if nl we d/c home, if + we admit to cards.

I have probably done 100 treadmills at this point with maybe 15 positives, some really spectacular like a 45 yr old lady with onset of substernal cp and an 18 sec run of vtach with a pulse. ten yrs ago we would have sent those 15 folks home some a chest pain/obs unit definitely adds a measure of safety. we also admit folks there we(er folks) need to be admitted but our consultants refuse like the post op tonsillectomy bleed we almost had to crich 15 min after she would have been discharged home due to projectile arterial bleeding at the surgical site and an unstable airway...saved that ent's bacon for sure....

[True Anomaly]

We also have an obs unit- one connected to the ED run by us which focuses on lower-acuity chest pain patients, and one run by the cardiologists who are higher risk (the cutoff is a TIMI score of 3 or higher). In the ED, we do repeat EKG's along with 2 "biosites" that measure CK-MB/Myo/Troponin 90 minutes apart- if neg, then decision is made.

 

Assuming of course that you're considering the chest pain to be cardiac, then it's important to remember that the enzymes only rule out INFARCTION, not ISCHEMIA- at some point a provocative test is needed, hence either observation for stress test or outpt f/u for stress if they have a known cardiologist.

[kargiver]

Its all about risk tolerance...

 

There are several approaches now showing up in the literature, one being the 6 hour R/O and D/C. The ONLY acceptable approach using this testing strategy is having some sort of stress test within 72 hours of D/C (and as CAdamsPAC states - document it). Also, the patient must be LOW RISK in the first place in order to use this testing strategy and be within the currently accepted AHA standard of care. You can also use a 3 enzyme test model (0,4,8, 0,3,6, 0,6,12) for R/O ACS. Rememeber, all this "rules out" in CP parlence is that the person is not having an active NSTEMI event. It does not rule out any other disease pathology. Also, this approach does not hold water for anyone who has a "subclinical" stenosis in the first place.

 

We evaluate these people all the time in our Obs unit. I see about 100 a month (when I am staffing the obs unit). They are all stratified based on risk and all either get a same day stress test, a next day stress test, a cards C/S while in the ER/Obs unit, or follow-up is arranged for a stress test within 72 hours. Anything else is outside the current "standard of care" and opens you up to liability.

 

G

[ATCLATEMTB]

Interesting question, I completed my thesis on this last fall (2011) regarding this very question. It seems everyone has their own level of risk they are comfortable with.

 

To toss some wood in the fire of discussion, I ran across a seemingly well done however small study out of the Asia-Pacific countries. They tested a two hour workup and discharge, with fairly decent outcomes. I'm confident with further validation and adoption of highly-sensitive troponin assays this could be a possibility for low risk CP patients in the future.

 

Than M, Cullen L, Reid CM, et al. A 2-h diagnostic protocol to assess patients with chest pain symptoms in the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet. Mar 26 2011;377(9771):1077-1084.

[kargiver]

Agreed, there are a couple of studies out there looking at the delta trop over a couple of hours... but it isn't quite the standard. Yet.

 

I think that this is where the field will ultimately go though - chest pain with two hour trops - if negative, and no other significant risk factors or pathology, O/P stress. The question will be - what is the acceptable risk level such that what percentage of patients will we be allowed to miss with cardiac events that we might otherwise pick up with "longer testing timeframes?" 2%? 1%?

 

G

[EMEDPA]

re: ultrasensitive trops:

I heard an excellent mel herbert lecture at acep this yr regarding these. the feeling was that they were TOO SENSITIVE( ie too many false positives).

one of the take away points for the lecture was"the road to hell is paved with d-dimers, bnp's, and ultrasensitive troponins...."

[CAdamsPAC]

re: ultrasensitive trops:

I heard an excellent mel herbert lecture at acep this yr regarding these. the feeling was that they were TOO SENSITIVE( ie too many false positives).

one of the take away points for the lecture was"the road to hell is paved with d-dimers, bnp's, and ultrasensitive troponins...."

 

 

It's been my experience the sphincter tone ofyour ED attending is the true gauge for level of comfort in D/C'ing CP pts from the ED! Just another old guy observation. ;-)