EM:RAP 2018 August

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

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.