Chest Pain

[Jason09]

Let's talk chest pain. Obviously there are clear admits and clear go homes. I want to talk about grey area CPs. How about the 30's or early 40's with no risk factors or maybe a family history of CAD. Do you get serial enzymes in the ED? 1 set? Obs unit? Admit? We unfortunately don't have a obs unit where we can send these patients so they are either worked up in the ED and sent home or admitted. Does your thinking change with constant, unchanging chest pain that may or may not be reproducible >1 day? Just want to see what everyones take is on this. Thanks.

[rev ronin]

Do you use TIMI risk score in your risk stratification?

[CAAdmission]

Once you start down a pathway where you are considering cardiac ischemia, you will get eaten alive some day if you do not follow it through. That is to say, based on your history and physical if you do not intend to do something along the lines of 3 EKG/enzymes sets, don't even bother doing the first one...

[nebero]

Discharging low risk pts with one set of enzymes and EKG is very common practice in my Ed. I always struggle with this same issue. Experienced folks chime in.

[ventana]

Duration makes a big difference in the one set and dc. If constant symptoms for a number of hours days and no EKG changes and neg labs my er is dc them.

[fuma102]

Im more likely to discharge if the patient has reasonable follow up and two negative trops and has a normal ekg. If the pain has been constant for the last 6 hours and has one negative trop and normal ekg.

 

More likely to admit if a compelling story- im tending now to admit anyone diaphoretic, which may or may not seem silly. Morbidly obese 30 year olds with new CP i tend to take more seriously especially if they have poor follow up. I had an obese guy about 35 on DM & HTN meds and on statins who had a weak story (CP x a few days no n/v/radiation of pain) with a trop of 8.

 

If its a weak story but they look like theyre due for a cath, i tend to admit.

 

Im always willing to discharge with 2 neg trops and 2 normal ekgs provided they can get into an office within a week. If theyre diaphoretic at any time or have stents the only conversation is over AMAing. Otherwise i agree with ventana and nebero.

[True Anomaly]

This is from EMRAP April 2011, talking with Amal Mattu about low-risk chest pain patients:

 

II.Who are the “missed” 2%?• The 2% miss rate for MIs really means patients in whom we’ve missed unstable angina

• These typically are patients with:

1. Fewer risk factors

2. Less typical presentations

3. More likely to be women

4. Less concerning or less abnormal EKGs

5. Tend to be younger

• Despite being younger & more likely to be healthy overall, they have a much higher risk of mortality

 Baseline mortality for patients admitted with ACS or MI is 8-*10%

 In the ACS patients who are sent home, their risk of morality is 25-*35%

III. The “low risk” patient according to Amal:

• Everyone is a continuum of risk

• According to the guidelines, there is no clear delineation of who is low risk

• Low risk may be a patient with all of the below:

 The absence of pressure, radiation to arm, nausea or diaphoresis

 No cardiac risk factors

 A completely normal EKG

 A good, likely alternative explanation for their chest pain

• There is no clear age cut-*off; MIs have been reported in patients as young as the late teens

IV. The Basics of a Work-*Up:

• History

 The HPI is the most important aspect of chest pain & trumps all else

 Coronary risk factors are good at predicting underlying disease & long term risk but tell you nothing about the immediate risk of the ED patient in front of you

 If the pain is truly momentary (i.e. 1 sec) then they are lower risk

 If the pain is truly constant & unchanged for a prolonged period (i.e. 24 hours) then they are lower risk

 Be extremely careful in pinning down the patient on the duration of pain; “constant” for 24 hours may really mean waxing & waning for 24 hours & thus indicative of ACS

 

He also advocates the need for provocative testing for those who rule out for MI with negative troponins (remember that troponins don't rule out cardiac ischemia- only MI), and to admit/obs these people. Scott Weingart, in the April 2012 EMRAP, however recommended to send those patients HOME who rule out for MI, as those who return with non-STEMI and those without non-STEMI in the long run have about the same 5-10 year outcomes. There is of course a lot of gray area with a statement like that, but it was still surprising to hear.

[True Anomaly]

Do you use TIMI risk score in your risk stratification?

 

At our main hospital, TIMI ≥ 3 gets placed in the "telemetry observation" category where they are seen by a cardiologist on the telemetry floor. TIMI < 3, they are placed in our ED Observation unit, and we can consult cardiology if we so choose.

[EMEDPA]

we have an ed obs unit where pa's do treadmills. we tend to do folks >35 yrs of age there after 2 sets of neg ekg's/ enzymes unless they have a really good story and/or risk factors(htn/dm/smoker/dad died at 30 of MI, etc).

if you get one set of enzymes the medicolegal burden is then placed upon you to get a 2nd.

also always remember perc for PE's, especially for young women.

[EMEDPA]

we have an ed obs unit where pa's do treadmills. we tend to do folks >35 yrs of age there after 2 sets of neg ekg's/ enzymes unless they have a really good story and/or risk factors(htn/dm/smoker/dad died at 30 of MI, etc).

if you get one set of enzymes the medicolegal burden is then placed upon you to get a 2nd.

also always remember perc for PE's, especially for young women.

[EMEDPA]

we have an ed obs unit where pa's do treadmills. we tend to do folks >35 yrs of age there after 2 sets of neg ekg's/ enzymes unless they have a really good story and/or risk factors(htn/dm/smoker/dad died at 30 of MI, etc).

if you get one set of enzymes the medicolegal burden is then placed upon you to get a 2nd.

also always remember perc for PE's, especially for young women.