Cardiology Corner: AHA update on ACS

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Amal M. -

Hey everyone, remember that this discussion focuses on the new AHA update on NSTEMI/unstable angina...this publication did not focus on STEMI.
We'll be covering the new 2013 AHA/ACCF STEMI update in a coming EMRAP. These new STEMI guidelines DO allow use of early prasugrel in patients heading for cath...yes, even in the ED (as an option...not mandatory).
For NSTEMI/UA, guidelines at this time still say "no" to prasugrel prior to cath.

brendan c. -

How about no additional anti-platelet agents for NSTEMI with St elev in Avr
w/ global ST depression? i.e. high index of suspicion for possible CABG.

Amal M. -

I entirely agree with you. Diffuse ST depression with concurrent STE in aVR is predictive of left main coronary artery occlusion, which is likely to need CABG. In those patients, I'd avoid clopidogrel and limit antiplatelet meds to just aspirin.

Sean G., M.D. -

Dear Amal and Mel....I understand Amal's desire to inform us lowly ER docs of the AHA guidelines on low risk chest pain, but have two points to make...
1. They are "Guidelines" not commandments and lets keep that in perspective, if we don't follow them because we are....lets say...sane???? And we get sued the arguement is there that they are "guidelines" and by definition not mandates
2. Why do we, as EM specialists bow to cardiologists guidelines? Why don't we put our big boy pants on and make AAEM or ACEP guidelines that address our particular cohort of low risk chest pain. Correct me if I am wrong but the AHA guidelines are not based on ER studies correct? Don't they base their guidelines on their own patients? That means it is a cohort of pts that has been pre screened by Family Med IM and EM docs and then referred to cards....this is not the same cohort that presents to the ED, so isn't it foolish to try and extrapolate their data to our patients? isn't this like applying orthostatic vitals to everyone and not just young healthy volunteers they were originally based on, or applying the pain scale to all pts as JACHO CMS in their infinite wisdom mandates rather then to the USA pts the pain scale was actually studied on? We all see how useless it is to ask every atient to rate their pain....To me applying these guidelines to all ER CP patients is just as inappropriate, and we need to come up with rational guidelines to apply to our unique cohort of low risk CP. If we follow the AHA guidelines and apply it to our patients we will crush the US economy in a year. Lets be reasonable shall we? Lets all listen to Scot Weingart and be thankful for his head bustin knowledge....

Amal M. -

[Sorry, this is going to be a long reply:]
You are definitely correct that none of these are commandments--nothing I or Weigngart or Mel or EMRAP or ACC/AHA or ACEP or AAEM say is a commandment. If you are the doctor and it's your patient, you can do whatever you think is best. Absolutely anything you want.

Your first point addressed risk management issues. This stuff mostly becomes frustrating for all of us "lowly" ER doctors because of risk mgmt reasons. You brought up lawsuits....if you get sued, you and your defense team will try to justify what you did based on published literature, and the plaintiff team will do the same. In that case, nobody will care about the bankrupt healthcare system or the 43 patients in the waiting room (which I had yesterday) waiting for a bed or anything else. It will just be each side trying to convince a jury based on the eloquence of the experts (often a fairly even match), the size of their CVs (usually even match), and the published literature....that's where we run into problems. It's very difficult to convince a jury that you (defendant) acted appropriately in discharging a patient who is now dead, when you didn't follow national guidelines published by ACC/AHA (endorsed by ACEP, by the way, with authors from ACEP and (yes) references from EM journals), written by nationally-known physicians representing cardiology, general IM, and EM. Difficult...unless you have some good, VALIDATED literature to back you up and indicate why you didn't follow those guidelines. I've seen this play out in too many cases now, and I have not yet seen a defendant emergency physician win a case when it's clear they didn't follow those guidelines because there really is not good, validated literature to back them up. I've been a neutral observer or on the defense in 100% of those cases, and it's very frustrating. The plaintiff experts are often very well-known emergency physicians who simply cite the national guidelines, the endorsement by ACEP, and the lack of validated literature refuting them.

So after several years and a bunch of cases of trying to convince people of what you describe as guidelines vs. sanity, only to see the defense consistently lose/settle, I've recently focused more on trying to get word out about what the guidelines say, because I think many emerg physicians don't really know what they say (after all, they are not published in our journals, yet the CLEAR expectation is that we know about them). The Cardiology Corner EMRAPs are an attempt to get word out about what the cardiol literature, including the ACC/AHA guidelines, say. Do you need to follow those guidelines 100%? No, of course not. But I DO think you need to know about them and you need to address them in your decision making, in your discussion with the patient, and in your documentation. And hopefully as VALIDATED literature comes out indicating that the guidelines are wrong or inappropriate in some settings, we can use that in our defense cases.
[I keep emphasizing "validated" because there have been a bunch of studies over the years indicating who doesn't need a workup, but attempts to validate them have often failed...e.g. Vancouver chest pain rule.]

For comparison, consider the ACLS guidelines. Since 2000, I and others have been lecturing about why the ACLS guidelines are wrong on some points, and in the past decade there are countless articles (validated) saying that the ACLS guidelines are wrong on those points. With that literature, I feel comfortable NOT following the ACLS guidelines and many others don't follow them either....and when occasional lawsuits have sprung up for deviating from those guidelines, we've been very successful at winning because we've got good literature to back us up. But not yet for ACS guidelines, so be very careful.

I agree with Weingart's arguments against the guidelines from a practice standpoint, but from a risk mgmt standpoint, podcasts and blogs are no match for published guidelines in front of a jury. NO MATCH. I've discussed this with him and David Newman, and Newman said he is going to work towards putting all the stuff in writing. Once that comes out, it's going to be extremely helpful in turning the tide in ACS risk mgmt. away from those guidelines.

In terms of bankrupting the system, I honestly don't think stress testing based on these guidelines is bankrupting the system. After all, most of the "low-risk-for-ACS" patients don't even get the < 72hr stress tests. I DO think that a far bigger financial problem is that too many "practically-no-risk-for-ACS" patients are getting worked-up with labs, TNs, obs units, CTs, etc. These are often patients that should have been sent home right from the start without ANY further workup after Hx, PE, EKG, and maybe CXR. In fact, consider the patients enrolled in some of the coronary CT studies or the Accelerated Diagnostic Protocol (2 TNs 2 hours apart) studies....these are TIMI 0 patients with normal EKGs and practically no risk factors.....why are so many of those patients being worked up in the first place?? The risk management problem here is that once you start the workup, you've fallen into the trap of needing to decide whether or not to follow the guidelines. Better to not start the workup in the first place for many of those patients.

One final risk mgmt point...I'm convinced that excellent documentation is far more defensible than half-as__d workups and would avert many lawsuits and even obviate the need to head down these guideline-based algorithms in the first place. Good documentation is free and saves tons of money in the long run because it results in fewer workups and fewer lawsuits. The problem is that it's not sexy to talk about or do.

In the end, it's up to you to take everything you read, hear, and experience, and take into account your threshold for risk, wrap it up into your own personal practice style and follow that. Hopefully the guideline discussions are adding some more information for consideration. That's all they are intended to do. They are not intended to "command."


Sean G., M.D. -

Dear Amal,
Thank u for your informative reply. I greatly appreciate your effort.
Allow me to retort...I would like you to envision that little avatar of me with a Samuel L Jackson Pulp Fiction ridiculous jerri curl wig on and a 45 magnum in my right hand as u read this.....

A couple of questions. I know these are nationally published guidelines, and as you say they are endorsed by ACEP and referred to in EM journals. What is the SOURCE of these guidelines. Did the AHA study a group of pts presenting to the ED for CP assign certain ones to low risk and do a double blinded study on outcomes of pts who received the protocol guidelines and compare them with those who didn't and conclude a statistically significant decrease in M and M when following the guidelines as opposed to not? Clearly I suspect they did not, so what is the actual source of their guidelines? I suspect it is another case of a bunch of docs getting together and saying....Hmmmm this sounds like a good idea....and if that is the case why does ACEP endorse them? I'll bet AAEM does not, as a student of McNamara I am an AAEM member but not ACEP and my personal opinion is that ACEP does not always represent the solo ED docs needs that well.
second I would greatly appreciate if you and Mel included in cardiology corner a few minutes describing the "No risk" cp pt who presents to the ED. I have listened to all these sections over the years and I know you have mentioned in at least one, these people exist and you wouldn't even go down that pathway, perhaps an EKG and d/c, yet when you listen to the lectures I can't seem to find anyone who would be "no risk" based on the content of these lectures. I don't recall the month, but one lecture you blew away some long held myths about CP pts and warned us that we had to consider ever younger pts as possibly having ACS even teenagers, and they didn't have to be diabetics, and we couldn't be reassured by a female being in her years of menses that it offered no protection against ACS, and on and on. Im not being smart, but honestly from listening to your lectures the only person I can see who is a "no risk" cp would be a non diabetic teenager who was struck in the sternum with a baseball and tells me it hurts "right here" where the bruise is. Perhaps you could clarify what you would consider "no risk" with some historical and demographic features. I do think the guidelines are insane and I'll explain that by the statistics from my rural ED. We see 30,000 pts a year probably 3,000 are CP pts and probably 1500 of those would meet the low risk CP category. That amounts to slightly better then 4 a day or 28 a week. We have two cardiologists in town with Tucson being 70 miles away for the next cardiologist. Each of our cardiologists would have to find the time to stress test 14 ED pts a week in addition to their own workload either as inpt or out pt....This is simply not feasible, and even when I do Weingart's protocol, as I have been doing something fairly similar for years I end up having at least 2 pts a week that I feel need stress in 72 hours and my cards are not always stressing EVEN THESE. I see them back in the ED a few months later and they tell me the cards just did an ekg and sent them home. I don't think its feasible for our guys to stress 28 pts a week from the ED and since a 3rd of them have no insurance they couldn't afford to. One of the problems I run into is that in cardiology corner you mention that a "good story" is enough to make someone low risk. Unfortunately when I began practice in the "pre web" error a good story was the exception. I almost never heard of "an elephant on my chest" Now I am sure thanks to wikipedia and webmd a good story is the rule. It is the most common cp I see to have "pressure on my chest" "someone sitting on me" and "SOB sweats and nausea" as well as the "pain goes to my jaw and down my left arm"(apparently they have yet to update wikipedia that Dr Matu has pointed out radiation to the right arm is more concerning) but give them a few years....its coming I'm sure. So again I'm not trying to be smart, but this is the dilemma. I think some clarification on what a "no risk" cp is ,the ones we can put to rest in the ED(not 6 feet under) would be real helpful. I know all about lawsuits. I worked in Philly and have been sued 9 times. 6 were dropped pretty quickly three went to court and I won them all including the one where Jerry Hoffman was the expert against me. I find that jurors understand the dilemma we ED docs face a lot more then most people give them credit for. They also tend to listen to the doctors and decide who is being truthful and who is twisting the truth to benefit their client. I have never had to twist the truth. I have found that jurors don't expect us to be Gods, and what they generally look for is falseness in the witnesses. I appreciate u informing us of these risks. I still believe the guidelines are impractical and though I have been sued a lot I have seen a ton of low risk CP, have NOT followed those guidelines on the vast majority and have never been sued for doing that. I'm sure I will receive that certified letter tomorrow for having typed that....

Amal M. -

1. Your proposed avatar has me afraid. Samuel L. Jackson with a 45 magnum?
2. I hear your anger and frustration. Sounds like you need to get involved with the AAEM Practice Guidelines Committee. They are always looking for more community physicians to get involved, and it's better to be part of the solution than to be angry or frustrated. 'You want change? Be the change' [-Morgan Freeman]. Or how about 'better to light a candle than to curse the darkness.'
3. Our job is not to rule in or rule out, but to risk stratify. There is no simple rule that gives you 0% or 100%. People need to accept that we'll miss some cases of ACS, but the issue is whether your evaluation and thought process was reasonable and supported by literature during the risk stratification. I still think HPI + good interpretation of ECG is the best form of risk stratification we've got in the ED, and very defensible if documented well. Here's a bit more info on utility of various aspects of HPI: [registration is free]
4. It sounds like what you are doing with your patients in your setting is working just fine.

Sean G., M.D. -

thanks Im really not that frustrated, I carry a "bad mother f*****" wallet in my pocket because Pulp Fiction is my favorite movie, with Mr Jackson's character "Jules" my favorite. I also found his "allow me to retort" a very ironic statement in the setting of that scene....I would appreciate if u and Mel could spend a few moments on cardiology corner telling us a typical pt who u would consider "no risk" cp, the kind you said you see, maybe do an EKG and dc to follow up with primary care. that would be very helpful, because obviously we can not follow the AHA guidelines on everyone who presents to the ED with CP.. Thanks much, I have learned an incredible amount from you....and Mel....well, he's a very funny guy.

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