I had a conversation with a few of the residents about the management of low risk chest pain in the Emergency Department. The issues which always seem to come up are:
- If the first troponin is normal, can I send them home?
- I don’t think this is cardiac, let’s just get one troponin and then send ’em home.
- Okay fine, let’s just do two sets and then send ’em home.
The patients which are obviously cardiac and obviously not cardiac are easy, but what about those ones in which there’s some question?
There’s a great review in Circulation from 2010 which discusses the management of low risk patients (click the link to get the article) and it’s not all about cardiac risk factors.
If you’re not into reading, then here are two short videos I made summarizing it. Let me know what you think and then we’ll discuss it in the context of our patients during a shift.
Note: I’ve switched from uploading the video files which stream from the site (very slowly) to embedded YouTube videos (which stream much more quickly). This has the downside of breaking the podcast version. I don’t think anyone will mind because I’m pretty sure no one has downloaded it yet.
my peripheral brain 
I have never realized how an assessment of cardiac risk factors is not as helpful in identifying ACS in the acute ED setting. My assumption is that you would still asking some of these questions to assess if they have had cardiac risk factors in the past, as this event could be the cumulative moment from all of those risk factors. It is interesting that the statistics suggest otherwise. Thanks for the Video, Dr. Patwari!
Oh, I would still ask those questions. Obviously someone who smokes, has high blood pressure, early cardiac disease in their family, high cholesterol and diabetes is at greater (lifetime) risk than someone who doesn’t. The point is that you can’t say that if someone has NONE of those features – that this isn’t cardiac. It is not helpful in that regard.
Can you comment when to draw cardiac enzymes 2 hours apart (what I’ve seen in the ED) versus 8 hours apart (what I saw on my Internal Medicine clerkship)?
Each place will do it differently. We do a 6-hour rule-out in our ED Chest Pain unit. I would go with whatever your particular institution deemed was long enough, though I think 6-hours is the shortest I’ve seen. The 2-hour (delta-trop) method I don’t believe was proven anywhere, but may work in with our increased sensitivity troponins.
Good things to think about here, especially your take that “just because they DON’T have a “posistive X” doesn’t mean that they are not having ACS. Something I’ll have to work on personally, as I know I have been guilty of this myself a few times.
Perhaps its just the hospitals i’ve been through, but i’ve yet to see much in the way of stress testing done in an ER setting, seems to be typically done following admission. Are there any specific situations or criteria you feel that this sort of testing would be more helpful in an ED setting (compared to admitting the patient and leaving it to the inpatient team?). Otherwise very informative video again.
The first video was very helpful in learning about how to differentiate life threatening chest pain from not. The Duke Treadmill score/test seems a little tedious to be done in the ED, no? Regardless, re-learning about the tests/scans is very helpful in being able to describe these to patients. Often times patients don’t know the names of tests, but can describe them, so this will help in knowing what tests/scans they are talking about.