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Low Risk Chest Pain: A Rational Approach

Ashley Shreves, MD, Scott Weingart, MD, and David Newman, MD
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EM:RAP November 2012 Written Summary 2 MB - PDF

What to do, What to do? Risk stratification strategies are on the table in this segment on the treatment of patients with low risk chest pain.

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Ryan T. -

When you discuss the "two troponin" rule-out, how far apart are the troponins? Do they have to be 8 hours? Any data on 6 hours, or even 4, or 2?

EMCrit -

The shownotes for this episode can be found here: EMCrit Chest Pain Show Notes.

Matthew Oliver -

AMAZING stuff! Great discussion and review of the literature. And nice closing with Mel. Thanks guys.
Now all we have to do is get the cardiologists on board!

Mike -

Great episode. I have the same question as Ryan T. about two troponin rule out.

Geoffrey C., M.D. -

I also have the same question. What exactly does 2 sets of enzymes mean? Please clarify the length of time between sets. Thanks!! Great stuff!!


2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker: The ADAPT Trial. Than M, Cullen L, Aldous S, et al
J Am Coll Cardiol. 2012;59:2091-2098

Jeffrey H. -

Thanks for the great discussion. I have one question. You modify the triple composite endpoint saying the 'urgent revascularization' isn't a meaningful patient oriented endpoint (because it is not a surrogate for death or MI). When you say "urgent revascularization" are you only referring to NSTEMI? wouldn't patient returning for STEMI also fall into the category of "urgent revascularization?" If yes, isn't there evidence that urgent revascularization of STEMI does prevent death/MI?

Cortney S. -

Great segment...right up until Weingart's summary! What happened? The whole episode seemed to be explaining how stress testing very low risk patients with normal ECGs and negative biomarkers is not good for our patients because it actually increases mortality...but then, somehow the summary still included ensuring a 72hr outpatient stress test is done. Seriously? I will also add that at my hospital in BC, Canada, the only way you can get a 72-hr stress test is by keeping the patient as an inpatient, so that is simply not an option. What about sending the extremely low risk patient to see their PCP to discuss lowering cholesterol, hypertension, quitting smoking, exercising, eating healthy and maybe taking a daily ASA?

EMCrit -

Cortney, You are so right! Here is what it comes down to. On a podcast like EM:RAP or EMCrit, I cannot recommend things that will definitively get people sued. This was Amal's problem with the whole ball of wax; he doesn't disagree, it is just not safe practice in the US until the AHA repeals its policy or ACEP releases its own. I can lay out the evidence on how ridiculous this all is, but I can't tell you to practice in a way that may get you fired. As I mentioned if you can get your whole ED group on board with the way things should be and right it into policy, then you are set.

Jeffrey H. -

Scott, can you respond to my question above? Thanks

EMCrit -

Jeff, You lost me. The three of us feel that a patient-oriented outcome would be Death or STEMI/STEMI equivalent. So revasucularization for a STEMI is part of the STEMI portion. Let me know if I am misunderstanding.

Jeffrey H. -

Sorry if I misunderstood. I wasn't clear to me how exactly the
previous literature defined 'urgent revascularizarion' (if stemi was included in this endpoint or if it was placed in the 'mi/death' endpoint).

Sean G., M.D. -

Thanks Scott, I couldn't understand what Amal was getting at in that earlier seemed insane to me given how many pts I see with low risk CP. I have actually been following the concepts u outlined for most of my career. I think I tend to practice based on common sense and actually understanding your patient and having a feel for what is legit and what is fantasy. rather then what some "guidelines" say, they are after all "guidelines" not commandments. I see your point that Amal was just echoing the guidelines. I wish he had made a comment on how insane they were. Could it be these cardiology colleges are basing some of their guidelines on that which would be most profitable for cardiologists? I never bought into the pharm/cards requirement that we give Amiodarone to everyone we catch before they die either. I love your concept of getting the ED group and cardiologists on board. Our cardiologists have not been following these guidelines anyhow, but to protect ourselves your suggestion is solid. I also tend to document and discuss my feelings with my patients, helping them understand that I am trying to do right by them with my dispo. Most pts seem to get it. If I find someone who clearly isn't buying into it, I just admit them for cardiology consult. Excellent piece. Now could you please inject some common sense into Jim Ducharme's sense of the probability of narcotic addiction vs true chronic pain in ED pts seeking oxycodone at 2 am?????

EMCrit -

Sean-thanks! I am not even going to wade into the morass of opioid pain control.

Sean G., M.D. -

ahhhh Thats too bad, though I can't say I blame you! I appreciate you bustin knowledge into my head, always one of my favorite portions of this excellent program.

Michael G. -

I just document like Newman suggests. Risk discussion had with patient and patient wants to go home. Hopefully that will cover me in the eventual bad outcome. Its bound to happen someday, just by the shear numbers of chest pain we all see. Someone will go home and have a STEMI or arrythmia. But irrationally practicing out of fear is crazy.

The bigger question is, how far apart for the 2 troponins, and do we even need 2 troponins if the pain occurred 4 or 6 hours before the first set was drawn. We dont have an Obs Unit where I work, and with turnaround times being tracked, serial enzymes are discouraged, and its encouraged to just obs people on the floor. But when that happens, they stay for 2 days, and many get cathed even with negative enzymes. Im really torn what to do, I hate bringing low risk chest pain in, but admin doesnt want us holding people for 6 hrs doing rule outs.

One other thing, why is it that ACEP won't put out a policy on this? The data is clear on this. Yet we are practicing based on an AHA guideline that makes no sense because its the standard of care. We define the standard of care in our specialty, right? If we are truly causing harm by admitting low risk chest pain, and obviously adding huge cost to the healthcare system, shouldnt we be looking to set a new standard of care? Yet it seems more likely that we'll be pushed into more testing (coronary ct) than less, doesnt it?

EMCrit -

My personal 2 set rule-out is 2 troponins and 2 Ck-MBs looking at the delta for both. You can do this at the 2 hour mark, we stretch this to a four hour rule out. I believe this was in the last ACEP chest pain guidelines.

Jack G. -

Great discussion. I think this reinforces what a lot of us are already doing.

2 questions ...

The ACEP clinical policy mentions 90 min delta markers and the wording is confusing.

"A negative myoglobin in conjunction with a negative CK-MB mass, or negative Troponin§ when measured at baseline and 90 minutes in patients presenting less than 8 hours after symptom onset."

Is it only referring to multi markers (myo / MB AND troponin) or is troponin only a reasonable option?

I'm spearheading a hospital policy for D/C without stress test plan for our low risk patients (kind of like ADP). We're already essentially doing this, but without a formal policy to back us up. Has anybody else gone through this process at their shop? Any suggestions?

Teresa P., M.D. -

My administration is getting on board with helping facilitate at least the AHA guidelines (whether right or wrong) which for some of my more conservative docs should allow a bit better flow by not taking up tele beds with very low risk patients. But same conservative docs feel like 2 negative sets of enzymes in TIMI score 0 patients and stress test scheduled in 24 hours is still too risky. Trying to find others who are doing anything similar. ideas?

Masafumi T. -

I have two questions. The numbers, David Newman showed in his ACEP 2013 lecture, NNB:250 for low risk & >40 and NNB:100 for intermediate are so impressive. However, how did he calculate them? Based on HEART score validation study(Int J Cardiol 2013), which is more sensitive than TIMI & GRACE, missed death & MI was 1% in low risk group. 0.4% seems to be too small based on existing prediction rules. What does ” low risk” specifically stand for ?

EMCrit -

David leaves out the need for cath as part of the composite--appropriately, because it is crap. I would go still further and leave out missed NSTEMI. Only death and STEMI-equivalents truly matter.

Masafumi T. -

Thanks, Dr. Weingart. I'm really appreciated. Just missed death & MI was 1% in HEART study, but gathering many studies, it will be 0.4%. Is it correct? As a whole, I agree with you. But, I still have some points I can't follow you. It's about prognosis. He quoted the article in NEJM 2000, and observed mortality for AMI was nearly identical between hospitalized & not hospitalized. However, although not significant, observed mortality tended to be higher in not hospitalized patients with UAP. Of course, stents can't alter their prognosis if trops are negative, but how about medical treatment ? If it effects, there was room to improve the prognosis if they were hospitalized.

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Episode 134 Full episode audio for MD edition 239:14 min - 99 MB - M4AEM:RAP November 2012 Written Summary 2 MB - PDF