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Cardiology Corner - New ACS Guidelines

Rob Orman, MD and Amal Mattu, MD FAAEM
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23:19
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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06:28

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EM:RAP 2015 May Written Summary 1 MB - PDF

It's not a STEMI, but bad things can still happen

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scott g. -

what is the consensus on the super high sensitivity troponin that come back. 03 with an okay story

Sean G., M.D. -

question on the on going pain thing. I too as some EMRAP commentators have expressed am and always have been frustrated with this. Number 1 the "squirrely" chest pain often never gets below a "0.5/10" and I feel I have to intubate them to tell the cards they are "pain free"....but thats not really the issue here. What is for me is how do they get pain free? Is it acceptable that they are pain free after 8mg of morphine? I dont like giving opioids in CP work ups because I feel like they may mask the real issue. It seems in my experience no amount of opiod short of deep sedating doses relieves the CP of a true massive MI but the smaller ones, like Inf, or the nstemi's or the "high risk" acs ones u describe...i could easily see some mod opioid making them pain free...so whats the deal? Does it count if there pain relief was likely thru an analgesic as opposed to rest 02 and nitrates and my disarmingly suave bed side manner?

Amal M., M.D. -

Scott,
I'm assuming the 0.03 is a slight bump in TN but not clearly positive? For those values, I get a repeat and look for the 20% rise. If there's no significant rise, I think about the multitude of non-ACS related causes of TN bumps.

Sean,
Remember that these guidelines are only intended for the true ACS patients, not really for the squirrely CP patients. So if you have low enough concern that you are giving morphine to chill them out, I'm not worried about cath lab activation (CLA). But if it's a patient that you are truly worried about, e.g. positive first TN, and/or clearly ischemic ECG, the kind of patient that you are starting your NTG drip, then those are the type of patients in whom this applies. For those patients, if they ongoing pain and ischemia on ECG, you should think about CLA. On a related note, I can't imagine that a patient with intractable ischemia will have a normal looking ECG, so the ECG might help considerably.

I agree with you about opioids masking ischemic CP, so I wouldn't use them unless I had a strong feeling it wasn't true ACS. By the way, there has been evidence in the past that morphine was associated with worse outcome, and now evidence that morphine inhibits the beneficial effects of some antiplatelet meds....another reason to avoid morphine when you are truly concerned about ACS.

Chesney F. -

Dr. Mattu et al (and other really smart people),

I hope you can settle a matter between my cardiologist colleagues and myself. In regards to the Sgarbossa criteria, does it apply to LBBBs that are artifically paced (i.e. have a pacemaker)? I have seen reference to positive Sgarbossa in the setting of "ventricularly paced rhythm" but it is not explicit if this ventricular pacing is organic or induced by an implaced pacemaker. My current shop does not subscribe to academic journals which would allow me to access the original articles.

Thank you.

CF

PS. Dr. Mattu, the UMD Low Risk Chest Pain documentation and patient-friendly shared-decision-making document that was published recently on EMRAP was outstanding. Thank you for the contribution.

Amal M., M.D. -

Thanks Chesney.
Pacemakers are generally placed in the RV and therefore induce a LBBB type of pattern, so this appearance is typical of patients with pacers. The Sgarbossa criteria have been shown to be pretty good at predicting AMI in patients with pacers, although there's not a TON of literature on this (pacemaker MIs are just not that common so it's tough to get large enough studies to get into the guidelines). Because of the lack of large, multiple studies, this stuff doesn't get into the guidelines and so cardiologists don't know about this unless they are reading the ECG literature...which they rarely do. Email me and I'll send you some articles.
Amal
amalmattu@comcast.net

Ian L., Dr -

Not giving opioids in severe pain with the sympathetic vasoconstriction and who knows what goes on with the cerebral vessels seems craziness .
There is fentany and morphine can be titrated to reduce the pain to " humane " levels .

Amal M., M.D. -

I certainly agree that pain should always be treated humanely.

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