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I don't know about this


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Recent-ish case had me feeling and thinking the scariest thing ever, Is this really a good idea? 

 

Okay so to set the scene, I work 2 hospitals one that's relatively big cardiac center (my favorite specialty outside of EM) and the other is a big stroke center but is a rural kinda ED. 

We are in the rural ED working night flow and a patient comes in beginning of my 1st night shift that week. It was a 60ish y/o male CC of Chest pains. Same all week 3 PAs 1 in-house MD and 1 call in MD. So I made my plan ECG, CXR, CBC, BMP, troponin, CRP, and go from there. Saw patient was scene last month here with chest pains and was diagnosed with gas so I kept that in mind. Pt appeared relatively well a little anxious, vitals all wnl, and labs were all good. Heart and lung auscultation was unremarkable. Pt was anxious his wife died last year to a heart attack and I sensed he's anxious want to bring reassurance but nothing from what I heard said gas or musculoskeletal pain. He described almost perfectly cardiac chest pains. Talked to the MD agreed to trend troponin if clear cut him loose and move on with the night send him to see his PCP. Troponin clear patient discharged. Note it will be important later to remember troponin was 0.02 first time and 0.02 the second so no change and normal. 

 

Patient returns the very next night around the same time again chest pains. Got same nurse assigned, same RT on standby, same PA and supervising MD. Our plan for second night in a row now was okay this patient probably doesn't need everything repeated this is going to get expensive and probably be unnecessary. We decided ECG, troponin, CMP and then I did another physical assessment. Heart rate when I went in was in the low 100s patient appeared anxious again but exam was completely normal. ECG unremarkable, troponin 0.01 CMP was normal. This time we were like okay this patient isn't acute in nature vitals, exam, labs normal let's have a talk and try to re ensure him that he's okay. Well he seems still anxious so we made a deal we'll refer to outpatient cardiology so you can get there opinion and evaluation and you come back to us it if gets worse before then okay? Good. 

 

2days later I'm on my last shift on night flow same doc different nurse so they started protocol before orders were in so I made sure to put them all in so no blood went to waste. Here he was before me probably tired of seeing me honestly. HR was almost 120 here so I did my assessment anxious as ever but unremarkable exam. Labs CBC, BMP, troponin, CRP, and then we had our ECG done also. Troponin was 0.71 and I stared at it for a second and was like what?? Norm is 0.00-0.04 and here our frequent flyer is with a 0.71 now. Well ECG was good and the CRP was very slightly elevated by like 1 or something like that nothing crazy. Rest vitals normal talked to the same MD and he said patient already has referral to cardiology cut him loose now I was a little more worried about something more acute now ordered pt to be given aspirin and then reordered a troponin as the MD and I decided to do. New Troponin was 0.73 MD was saying let him go if it gets worse he can come back but I was just like I don't know about this. Talked to the call in MD briefly and we agreed so I talked to my MD and decided on holding patient over night here in the ED and repeat Troponin one more time before day crew comes in. Troponin before leaving was 2.46 and patient got admitted and I believe transferred to the heart center.

 

How about that? Anyone else have a frequent flyer that ended up a actually cardiac patient? Needing admission? Also any idea as to what was going on? My guess is NSTEMI but that was my guess that night I don't know what lead up to it. 

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Stable angina that progressed to unstable angina/ACS? 

 

"Also, many patients will already have coronary artery disease. This may be either established coronary artery disease or symptoms they have been experiencing for some time. These patients may have familiarity with the symptoms and may report an increase in episodes of chest pain that takes longer to resolve and an increase in the severity of symptoms. These symptoms indicate unstable angina as the more likely diagnosis, as opposed to stable angina or other causes of chest pain. This is important to note as these differences may indicate impending myocardial infarction and ST-elevation myocardial infarction (STEMI) and should be evaluated expeditiously as the risk of morbidity and mortality are higher in this scenario versus stable angina."

https://www.ncbi.nlm.nih.gov/books/NBK442000/

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1 hour ago, SedRate said:

Stable angina that progressed to unstable angina/ACS? 

 

"Also, many patients will already have coronary artery disease. This may be either established coronary artery disease or symptoms they have been experiencing for some time. These patients may have familiarity with the symptoms and may report an increase in episodes of chest pain that takes longer to resolve and an increase in the severity of symptoms. These symptoms indicate unstable angina as the more likely diagnosis, as opposed to stable angina or other causes of chest pain. This is important to note as these differences may indicate impending myocardial infarction and ST-elevation myocardial infarction (STEMI) and should be evaluated expeditiously as the risk of morbidity and mortality are higher in this scenario versus stable angina."

https://www.ncbi.nlm.nih.gov/books/NBK442000/

Good possiblity, 

Here I was thinking a zebra like

 Takotsubo cardiomyopathy

Lol naw but that seriously is a good idea that could definitely be it. 

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8 hours ago, ChrisPAinED said:

Good possiblity, 

Here I was thinking a zebra like

 Takotsubo cardiomyopathy

Lol naw but that seriously is a good idea that could definitely be it. 

Lol, it's good to have a wide differential. I'm just a simple person who stayed at a Holiday Inn Express. 

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Patient was tachy, so getting a D Dimer to start the PE workup would be a good idea.  I never do a CRP, but I always check a BNP, to eval for heart strain, e.e. from PE.  Consider demand ischemia, but those trops are higher than I would expect if that was the case.  How was the pt's kidney function?

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On 5/4/2024 at 5:27 AM, ohiovolffemtp said:

Patient was tachy, so getting a D Dimer to start the PE workup would be a good idea.  I never do a CRP, but I always check a BNP, to eval for heart strain, e.e. from PE.  Consider demand ischemia, but those trops are higher than I would expect if that was the case.  How was the pt's kidney function?

D dimer good I forgot about that one lol 

And BNP was done urgent care the day before day 1 of that week started 

 

Kidney function seemed okay because now that I think about it a tox, UA, and a creatine was checked in urgent care also. 

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1st visit - Why no pro-BNP right away? It doesn't matter if one was done at a UC the other day; the pt is in the ED now (and should be checked for any interval changes given age, complaint and HPI putting stress cardiomyopathy on DDx). I can understand not utilizing dimer on this visit (if you can justify it with a bunch of pertinent negatives in the HPI/PE).

2nd visit - The pt is a bounceback with an identical complaint; d-dimer is a must at this point. Trops x3; shared decision-making regarding admit depending on rslts of complete eval.

3rd visit - What's the rationale for ED observation for a significant increase in Trop on this visit? Slam dunk admission; don't need to hold the pt to trend Trops before deciding to admit.

Other questions:

- How is CRP changing your management? If you suspect myocarditis/pericarditis, you'd typically expect a bump in Trops/EKG changes etc.

- Persisting tachycardia with anxiety; any thoughts on TSH/T4 during his ED visits?

- What was his HEART score?

- Why only BMP? This may be shop-specific, but I've seen a decent number of pts who complain of chest pain but have biliary pathology occurring. CMP all day, every day for these pts.

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4 hours ago, Apollo1 said:

1st visit - Why no pro-BNP right away? It doesn't matter if one was done at a UC the other day; the pt is in the ED now (and should be checked for any interval changes given age, complaint and HPI putting stress cardiomyopathy on DDx). I can understand not utilizing dimer on this visit (if you can justify it with a bunch of pertinent negatives in the HPI/PE).

2nd visit - The pt is a bounceback with an identical complaint; d-dimer is a must at this point. Trops x3; shared decision-making regarding admit depending on rslts of complete eval.

3rd visit - What's the rationale for ED observation for a significant increase in Trop on this visit? Slam dunk admission; don't need to hold the pt to trend Trops before deciding to admit.

Other questions:

- How is CRP changing your management? If you suspect myocarditis/pericarditis, you'd typically expect a bump in Trops/EKG changes etc.

- Persisting tachycardia with anxiety; any thoughts on TSH/T4 during his ED visits?

- What was his HEART score?

- Why only BMP? This may be shop-specific, but I've seen a decent number of pts who complain of chest pain but have biliary pathology occurring. CMP all day, every day for these pts.

1) At least for us BNPs aren't standard AMI protocol for us so we tend to just do the troponin to start or if they have cardiac history we may order it also, they had several other presentations also like again mentioning a month ago they had chest pains and had a full workup done and a handful of times before that. 

2) D-dimer was done day 1 as I replied to any other comment I forgot to include that but it was done and normal. 

3) Normally yes any acute elevation would be a slam dunk admission but this is not a cardiac center so we call the cardiology team there and they made the point patient was discharged a little tachycardic last time they appeared to be anxious still. Persistent tachycardia even do to anxiety if it last long enough may elevate the troponin slightly. Well 0.71 is not slightly so we asked them for recommendations and that was to trend it (risk of lab error was also one thing to consider) mostly to determine if it was still increasing to determine suspicion for something like an AMI. 

 

Bonus questions: 

CRP is just a general inflammation marker and is just standard protocol 

 

Thyroid panel was also covered in urgent care and yes it can acutely change but in a rural hospital that doesn't see a whole lot of variety it's harder to order extras if the MD doesn't think it's necessary. 

 

Heart score is a 1 initially only because of age. 

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  • 4 weeks later...

"He described almost perfectly cardiac chest pains. Talked to the MD agreed to trend troponin if clear cut him loose and move on" - medmal attorneys literally scoping out new BMWs right now.

Also, I agree with others that CRP has little value.

End of the day, if this same doc told you to send this guy home 3 times, he does not care about your license or his. People who return to the ED with risk factors and a story deserve broader workups and admission until they've proven to be slugs. You did the right thing getting the second opinion.

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On 5/7/2024 at 12:00 PM, Apollo1 said:

 

- Why only BMP? This may be shop-specific, but I've seen a decent number of pts who complain of chest pain but have biliary pathology occurring. CMP all day, every day for these pts.

agree. all of my chest pains get a lipase as pancreatitis is a good mimic for cardiac disease. 

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12 hours ago, narcan said:

"He described almost perfectly cardiac chest pains. Talked to the MD agreed to trend troponin if clear cut him loose and move on" - medmal attorneys literally scoping out new BMWs right now.

Also, I agree with others that CRP has little value.

End of the day, if this same doc told you to send this guy home 3 times, he does not care about your license or his. People who return to the ED with risk factors and a story deserve broader workups and admission until they've proven to be slugs. You did the right thing getting the second opinion.

agree. 

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something to remember....normal trops does not mean it isn't cardiac. If your spidey sense( and the heart score) is bothering you, they need admission or a set urgent f/u for further testing like stress tests, etc. Stable angina can become unstable or crescendo angina fairly quickly, just like TIAs proceeding a CVA. I worked in an ED obs unit as part of one of my trauma ctr jobs. To get there, pts needed 2 nl ekgs and 2 nl trops 3 hrs apart as well as the standard cardiac workup. Many of those folks failed their treadmill stess tests and I sent them on to emergent cath, despite "negative" cardiac workups 24 hrs earlier. . If they are diabetic smokers with bad family history, high cholesterol, high bmi, and exertional chest pain, it IS cardiac disease until a cath says it isn't. 

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