Cardiology Corner- The 2 Hour CP Protocol

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Richard S. -

I may be the only stupid one out this lecture as well as many others, we are admonished to be familiar with the "guidelines" or the "ACEP guidelines". Uhhhhh...where can we find those guidelines? No, I'm not a premed, and I even went to an on-shore medical school and residency. Obviously I've tried the usual searches--I'm getting all kinds of info related to guidelines, some long sundry policy statements, missives from the past, commentaries, etc. but I am just not finding "guidelines". In brief, my friends, WHERE CAN WE FIND GUIDELINES?

Amal M. -

No problem. I don't know how to post PDFs on this reply, so I can only provide the references here regarding the "guidelines" that we refer to; which are also the guidelines that get pulled into risk mgmt discussions and depositions.
1. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients with Non-ST-Segment Elevation Acute Coronary Syndromes. Annals of Emerg Med 2006;48:270-301. [this is the last time ACEP did a clinical policy related to this]
The next 2 are a bit more recent and more often cited:
2. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction....Circulation 2007;116;e148-3304. [it's in print also, but I only have the reference for this online version]
3. Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain: A Scientific Statement From the American Heart Association. Circulation 2010;122:1756-1776.

I hope that helps.

tom w. -

Send the PDF to me and I will post it to this segment.

steve r. -

At our small community hospital we routinely discharge ED CP patients after 1 or 2 negative troponins (usually have 6 hour troponin after onset of pain) and serial EKG's for return next morning to have stress echo. Patients return to ER next am and we obtain repeat troponin and EKG, as well as MD re-eval prior to stress echo . Many of these patient have known CAD, take ASA, had more than one episode of CP,etc; yet they are "felt" to be safe to go home and return in AM. Are we setting ourselves up for medico-legal issues since they don't have TIMI score of 0??

Amal M. -

I think your practice is well-within the standard of care based on the current guidelines, which suggest that if you believe someone is low risk for ACS, rule them out for infarction (current generation TN done 6 hours after Sx's ended), demonstrate unremarkable serial ECGs, and get outpatient provocative stress within 72 hours to rule out ACS. I wish we had similar access to 24-hour stress echo. Obviously these patients should have a HPI and ECG that is consistent with low risk. Sounds like you guys are following the current guidelines already. See the 2010 AHA article noted above for details.

The TIMI 0 we discussed applies to the Accelerated Diagnostic Protocols. These ADPs state that if TIMI 0 + 2 negative TNs, you can discharge WITHOUT needing a provocative test. This is the newer concept we are hoping more literature will support.

Hope this clarifies.

Andy M. B. -

according to the discussion by dr Newman that Unstable Angina pts are actually not benefitting from PCI and that the real benefit is seen in the STEMI patients. And the NSTEMI pts benefit a little, yet the timing can be immediate or delayed. This may make sense anatomically if NSTEMI are just misread ekgs that are actually stemi or stemi equivalent or a resolved stemi. The Stemi is indicative of coronary occlusion that needs intervention. Therefore the unstable angina concept should be thrown out.
I also cant stand the TIMI scores because they are trying to show risk of a patient and are also subjective. And as ER physicans we all know that pre existing risk is useless when looking at a specific case of Chest pain. Risk factors do not change risk of your patient having acute occlusion, or the pts who will benefit from pci. Also the subjective portion of TIIMI is exactly the thing we are looking to get rid of when we look to a clinical decision rule, in that we are trying to objectify a pts data. Therefore looking at "angina in 24 hours" is maddening, as this is subjective as this is exactly what you are trying to figure out!.
Bottom line is...hopefully one day we can run ekg and troponin at time zero and then again at 2 hrs and then dc pts knowing that the risk is less than 2% which should be acceptable miss rate for a 30 day mortality.

Constantino D. -

About the ACP pre test likelihood of CAD by gender, age, and animal pain or not anginal pain will have to have 3 components 1) retrosternal 2) trigger by activity or emotional stress 3) relieved by rest if only 2 is atypical angina if one or none non anginal pain , depending again on age and gender and angina or not place the patient into a low probability of CAD 0 to 10%; intermediate probability 10 to 90%; and high probability 90% . Their recommendation is to do nathing for the low probability the intermediate are the ones that need workup and provocative testing and the high need cardio ?

Constantino D. -

Anginal pain not animal pain sorry

Amal M. -

If I understand your note correctly: the ADP studies are really just addressing the safety of discharging these very low risk patients without further workup. They are not addressing or making recommendations regarding how to manage intermediate or high risk patients. With those patients, I suggest you just continue with whatever your 'usual' practice is, until there are good studies that address those patients and indicate we need to do something different. I hope that answers your question. Thanks.

Constantino D. -

ACP american collage of physicians the internal medicine they do have recommendations in what to do with the intermediate and high probability patients on both MKSAP 15 old and the new one MKSAP 16 just out in July 2012 thanks

David H., M.D. (@BritFltDoc) -

In the original ASPECT trial in the Lancet the ADP missed 3 MACE. In the J AM Coll Cardiology the ADP missed 1 MACE. Are these 2 different data sets, or the same data set? Mel states that they are "really the same data set" so if they are the same, then what happened to the 2 patient's that had a MACE in the original ASPECT trial ? Can anyone help ?

Amal M. -

The data sets were "essentially" but not "exactly" the same. JACC study (AKA the ADAPT study) only involved 2 of the 14 sites used in ASPECT, and incorporated some patients post-ASPECT.

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