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Cardiology Corner - Cardiac Imaging

Rob Orman, MD and Amal Mattu, MD FAAEM
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN

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EM:RAP 2016 October Written Summary 754 KB - PDF

Coronary CT gets a lot of attention in this guideline, but is it worthy?

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Jonathan G. -

Where I work, the docs have very different approaches to managing low risk chest pain patients. Those that have been in practice for >10 yrs lean towards stress testing. Those of us a bit newer feel comfortable using the decision tools like the HEART score to guide our management.
My more seasoned colleagues argue that we are unable protect ourselves medicolegally when societies as cardio and rads are setting forth guidelines such as these.
What can I say to sway them?

Jonathan G. -

And to further complicate the issue for us, members of ACEP and AAEM were on the committee. They cite ACEP as a sponsor.
Not to be a conspiracy theorist but the ER specialist who co-chaired the writing panel, Dr W. Frank Peacock, published a book in 2009 entitled "Short Stay Management of Chest Pain".
The other 2 ER members on the committee, Dr Judd Hollander and Dr. Louis Graff authored chapters in this book.
The book becomes largely obsolete if we are to move away for observation unit stays and look to discharge people even sooner.

Amal M., M.D. -

Regarding your questions/comments, I would have been one of your "older" colleagues up until 2-3 years ago when we finally started to have good, prospective externally validated studies showing that is is safe to follow a rapid rule out protocol and discharge patients for outpatient followup and further risk stratification. There's SO much literature now on these rapid rule out protocols that there is definite defensibility.

I agree that it's important to know about the guidelines, but they are just evidence-based suggestions...not mandates. If you have good evidence to deter from the guidelines, it is certainly defensible to not follow them as long as you follow alternative good evidence.

Ross B. -

I listened to the Oct section on Cardiac imaging with Dr. Mattu and thought it was excellent. He seemed to suggest that pts with elevated trops and abnormal EKG should go to cath and not have any stress testing done because the stress tests aren't as useful. I understand that stress testing is not definitive testing, however, it's also my understanding from listening to other podcasts (SMART EM by Dr. Newman) that there isn't data that supports interventional PCI strategies for pts without STEMI (that is seems that STEMI is really the group where benefit has been shown and NSTEMI pts or pts with unstable angina may have more harm than benefit). Add this to the interesting article recently noting that during a major cardiology conference the death rate from ACS went down, I wonder how much good we are really doing for our patients and how much harm we are causing. I understand the utility to perform a cath to r/o triple vessel dz and determine if CABG is indicated, but I wonder if we are doing too many caths...thoughts?

Amal M., M.D. -

I agree that too many caths are done, especially elective and semi-elective. I would suggest that the best literature criticizing caths for patients without STEMI relates to those elective and semi-elective caths.

Related to caths for non-STEMI patients (i.e. patients with MI but not STEMI), as I see the literature there is better outcome, at least in terms of quality of life, with urgent cath (urgent = within 24-48 hours). But I think there's probably better literature ahead which will parse out which NSTEMIs are best treated with urgent cath vs. which ones are appropriately treated conservatively.

Ian L., Dr -

HEART SCORE 3 : Greater than 3 Risk Factors for cardiovascular disease 45-65 say 55 .
Madness not to do comprehensive follow up .
Also of 100,000 patients presenting with chest pain what is the spread of the HEART score and how many have Major adverse events both without any intervention and with comprehensive intervention.
HEART score :Great prompt not be all and end all for getting to negligible risk .

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Say Hello to BRUE Full episode audio for MD edition 217:39 min - 303 MB - M4AEM:RAP 2016 October German Edition Deutsche 115:41 min - 159 MB - MP3EM:RAP 2016 October Canadian Edition Canadian 10:10 min - 14 MB - MP3EMRAP 2016 October Résumé en Francais Français 35:33 min - 49 MB - MP3EM:RAP 2016 October Aussie Edition Australian 31:48 min - 44 MB - MP3EM:RAP 2016 October Spanish Edition Español 94:36 min - 130 MB - MP3EM:RAP 2016 October Board Review Answers 187 KB - PDFEM:RAP 2016 October Board Review Questions 292 KB - PDFEM:RAP 2016 October MP3s 257 MB - ZIPEM:RAP 2016 October Written Summary 754 KB - PDF