Please correct me if I'm wrong but I learned in residency that elevated troponins are associated with increased mortality so I often get the trop not because I'm looking for ACS per se but as a risk stratification tool. But that info could be totally outdated.
TNs do provide risk stratification but in the non acute MI setting, it's unclear what the time frame for the prognosis is. For example, if you have a patient with acute heart failure who is NOT having an AMI, a positive TN will predict a worse prognosis...over the next 6-12 mos. But I don't think we really care so much about that; and we certainly aren't going to do anything differently with that information.
If the TN is positive, you are also stuck keeping the patient for a few hours to repeat the TN and guarantee that it is not acutely rising (i.e. not an AMI). But you probably could have done that with a good hx; remember that this discussion focused on the non AMI patient to start with.
With respect to furosemide dosing, I'd say you should at least mention the NEJM article from March 2011 (N Engl J Med 2011; 364:797-805): "Diuretic strategies in patients with acute decompensated heart failure." They compared the traditional dosing you advocate with 2.5 times that given IV, and although it didn't result in a change in the primary outcome of patient assessment of symptoms at 72 hours, it did show favorable outcomes with regard to several prespecified secondary measures including relief from dyspnea, change in weight, and net fluid loss. The paper concluded that treatment with furosemide at a daily dose of 2.5 x the previous oral dose is a reasonable initial strategy for most patients (and no worse renal function outcomes either.) David Glaser, Denver
Another thing I'll add is a critique of your point that one of the reasons not to d/c people from the ED is because hospitals might be penalized if a patient comes back and gets readmitted. This really has nothing to do with the care of the ED patient. If we d/c them after ED care (or even after ED care with an observation-level stay), they have not been admitted; hence, if they return and get admitted, that would be their first admission and not a readmission--no penalty there.
Finally, the decision to send a patient home is really not ours alone. Patients get to weigh in. Patients should be advised of their risk of an adverse outcome (with the majority of that meaning the patient has to come back), as well as your recommendations, but in the end, many whom you might lean toward keeping will assume the risk of going home. Let's not forget the role of shared decision making here. It's very similar to using a PSI when contemplating sending a patient with CAP home.
Wan T. et al in a paper “Strategy’s to modify Heart Failure Readmission “ claimed that a comprehensive intervention involving the health care team and patients reduced by half Readmission to hospital of patients with heart failure . This involved salt restriction medication adherence support education around signs of heart failure recurrences psychosocial support and rapid communicatiin channels . Health Serv Res Manag Epidemiology Jan 2017 . MegaTechnological is the insertion of a Heart Sensor Monitor in the Pulmonary Artery with signals to a Central Centre for quick recognition of rise in pulmonary artery pressure and fast remedial treatment The CardioSense Monitor FDA approved 2016..
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Dallas Holladay, DO - August 3, 2018 8:35 AM
Please correct me if I'm wrong but I learned in residency that elevated troponins are associated with increased mortality so I often get the trop not because I'm looking for ACS per se but as a risk stratification tool. But that info could be totally outdated.
Amal M., M.D. - August 4, 2018 10:50 AM
TNs do provide risk stratification but in the non acute MI setting, it's unclear what the time frame for the prognosis is.
For example, if you have a patient with acute heart failure who is NOT having an AMI, a positive TN will predict a worse prognosis...over the next 6-12 mos. But I don't think we really care so much about that; and we certainly aren't going to do anything differently with that information.
If the TN is positive, you are also stuck keeping the patient for a few hours to repeat the TN and guarantee that it is not acutely rising (i.e. not an AMI). But you probably could have done that with a good hx; remember that this discussion focused on the non AMI patient to start with.
I hope that helps.
Amal
David G., M.D. - August 16, 2018 1:48 PM
With respect to furosemide dosing, I'd say you should at least mention the NEJM article from March 2011 (N Engl J Med 2011; 364:797-805): "Diuretic strategies in patients with acute decompensated heart failure." They compared the traditional dosing you advocate with 2.5 times that given IV, and although it didn't result in a change in the primary outcome of patient assessment of symptoms at 72 hours, it did show favorable outcomes with regard to several prespecified secondary measures including relief from dyspnea, change in weight, and net fluid loss. The paper concluded that treatment with furosemide at a daily dose of 2.5 x the previous oral dose is a reasonable initial strategy for most patients (and no worse renal function outcomes either.) David Glaser, Denver
David G., M.D. - August 21, 2018 10:48 AM
Another thing I'll add is a critique of your point that one of the reasons not to d/c people from the ED is because hospitals might be penalized if a patient comes back and gets readmitted. This really has nothing to do with the care of the ED patient. If we d/c them after ED care (or even after ED care with an observation-level stay), they have not been admitted; hence, if they return and get admitted, that would be their first admission and not a readmission--no penalty there.
Finally, the decision to send a patient home is really not ours alone. Patients get to weigh in. Patients should be advised of their risk of an adverse outcome (with the majority of that meaning the patient has to come back), as well as your recommendations, but in the end, many whom you might lean toward keeping will assume the risk of going home. Let's not forget the role of shared decision making here. It's very similar to using a PSI when contemplating sending a patient with CAP home.
Ian L., Dr - August 26, 2018 9:32 PM
Wan T. et al in a paper “Strategy’s to modify Heart Failure Readmission “ claimed that a comprehensive intervention involving the health care team and patients reduced by half Readmission to hospital of patients with heart failure .
This involved salt restriction medication adherence support education around signs of heart failure recurrences psychosocial support and rapid communicatiin channels .
Health Serv Res Manag Epidemiology Jan 2017 .
MegaTechnological is the insertion of a Heart Sensor Monitor in the Pulmonary Artery with signals to a Central Centre for quick recognition of rise in pulmonary artery pressure and fast remedial treatment
The CardioSense Monitor FDA approved 2016..