I cringe as I listen to this. I doubt I would have been quick enough on my feet, but I'd like think I would have pointed out to the attorney that "STEMI" stands for "ST elevation myocardial infarction," i.e. it is defined by ECG changes. A "STEMI" cannot be diagnosed any way other than on ECG. Although some are suggestive, there are no clinical signs nor symptoms that diagnose a "STEMI," and only a "STEMI" is an indication for emergent heart cath.
I'm sure we have all seen cardiologists take patients to the cath lab that are "not quite STEMI" but worrisome enough to cath them now, rather than in the middle of the night when the patient deteriorates or biomarkers elevate, however, that is specialists preference, not absolute indication.
The attorney didn't seem to understand that the signs and symptoms are suggestive of ACS, but to activate the cath lab for presumed STEMI you need a strongly suggestive ECG as well. In this case, nobody debated the presence of ACS. It was the issue of cath lab activation that was debated.
Agreed. The part that made me "cringe" were his asking damning questions with the phrase "100 percent of the time you would do x" and then "if the ecg machine were broken." It would be very easy to lose your cool when you see someone clearly setting traps for you to step into.
I am certain I would have lost it with this guy...good control Amal. Why does the judge not redirect him more esp with the complexity of his questions the double negatives etc?
A recent JAMA review (http://jama.jamanetwork.com/article.aspx?articleid=2468896) emphasizes the importance of "pain similar to prior ischemia" in predicting ACS. Conversely pain "worse with exertion" was found to be less predictive of ACS than previously reported.
Yes, that's the most recent article on this topic. Interestingly 3 prior articles seemed to dispute the pain similar to prior ischemia and validate the concerns with pain worsening with exertion. Anecdotally, it seems that people in our ED ALWAYS say that their pain is similar, and then tend to rule out. Perhaps we'll never have an exact answer. Thanks for sending the link.
Sorry to distract from a case of high-risk chest pain with a question on low-risk chest pain.
How do you safely apply those symptoms predictive of ACS to otherwise low risk patients? (Specifically, I mean the four you mentioned in this segment or, instead, those from the JAMA Rational Exam article from Christopher B).
Specifically, how do you define the ‘H’ in the HEART score with these factors in mind? The derivation and validation papers for the scores are pretty vague in terms of ‘mostly specific’ vs. ‘mostly nonspecific’ for their definition of ‘suspicious.’
All of this just seems like a moving target, especially with ongoing adoption of ADPs, including at my institution.
Rob, That's a frequent question. The HEART score is an attempt to standardize the evaluation process for patients with low risk chest pain, but as with the majority of decision instruments (including PERC, Wells, NEXUS, etc.) there is still a bit of subjectivity built in. If there were no need for subjectivity and clinical judgment, there might not be a need for trained clinicians! Therefore whether the patient gets 0, 1, or 2 points for the H is really up to you and your gestalt. The more experience you get and more you learn about this stuff, the better.
The 4 major factors I use in this evaluation, based on literature I've discussed on EMRAP before, are the following: 1. is the chest pain (or equivalent symptom) associated with diaphoresis? 2. is the chest pain associated with vomiting? 3. does the chest pain radiate? [this obviously only works if there is chest pain] 4. does the chest pain worsen with exertion (based on patient hx)?
If the patient answers no to all 4, I give them 0 points. If they say yes to one, they get 1 point. If they say yes to 2 or more, I give them 2 points.
That's my personal practice, though unstudied and unvalidated.
It's definitely a moving target, and I anticipate there will continue to be critiques and revisions of the HEART score, and new decision instruments in the future.
Agree with Amal, as a further note, the 'T' of the heart score is troponin, helpful (to some degree) when initially negative, but the scoring system awards the same amount of points for elevated tropoin as elevated age! We still need to use these rules in the context of each specific patient. Finally, the HEART looks at ACS, but we still need to eval for PE, dissection and the other life threatening causes of chest pain. Thx for the comments on this wild case!!
Great points about CP in general and also the TN issue. Regarding TN, if positive we will admit for workup, so in essence we are actually using a "HEAR" score.
Related to other questions that often arise about the HEART score, is it possible for a patient to have a significantly positive TN due to ACS and yet still have a HEART score of only 2 and therefore be discharged? Theoretically, yes. However, in discussing this issue with the main researchers in Holland (Barbra Backus) and and US (Simon Mahler), they had indicated that this simply hasn't happened amongst the thousands of patients they've studied (though I'd still defer to them to give exact info).
So what's the point of including a TN in the score? Personally I like using the TN as part of the score for patients being admitted (since none of our TN-positive patients are going home). The data indicates that if the HEART score is 4-6, the 30-day risk of adverse event is 15-20%, and if the score is > 6 it's 50%. So for HEART scores of 4-6, I push for telemetry admission but if the HEART score is > 6, I push for CCU/ICU. So the HEART score (including the T) can be useful for patients being admitted also.
With respect : Steve Smith MD in podcast 146 EM Critic would activate the Cath lab for NSTEMI if there is Hemodynamic Instability .Pain Persisting for more than 20 minutes despite Nitrates Dose and Asprin and to that add Electric trouble : Tell the cardiologist :Get in .
Futher Predatoty Litigation and the cost are a big problem. Unless a Doctor or other Health Professional commits a Malicious Error the Health Professional ought be Anonymous .The Psychological costs are too high . The Case is argued and Just Compensation is given not based on the spin skills of expert witnesses or lawyers . Anonymity unless there is Malice and Just Compensation .
Jeff S - June 13, 2016 12:45 PM
I cringe as I listen to this. I doubt I would have been quick enough on my feet, but I'd like think I would have pointed out to the attorney that "STEMI" stands for "ST elevation myocardial infarction," i.e. it is defined by ECG changes. A "STEMI" cannot be diagnosed any way other than on ECG. Although some are suggestive, there are no clinical signs nor symptoms that diagnose a "STEMI," and only a "STEMI" is an indication for emergent heart cath.
I'm sure we have all seen cardiologists take patients to the cath lab that are "not quite STEMI" but worrisome enough to cath them now, rather than in the middle of the night when the patient deteriorates or biomarkers elevate, however, that is specialists preference, not absolute indication.
Mike W. - June 14, 2016 5:35 AM
You are right Jeff, thx for sharing this!
Amal M. - June 14, 2016 9:52 AM
Jeff,
The attorney didn't seem to understand that the signs and symptoms are suggestive of ACS, but to activate the cath lab for presumed STEMI you need a strongly suggestive ECG as well. In this case, nobody debated the presence of ACS. It was the issue of cath lab activation that was debated.
Amal
Jeff S - June 14, 2016 12:51 PM
Agreed. The part that made me "cringe" were his asking damning questions with the phrase "100 percent of the time you would do x" and then "if the ecg machine were broken."
It would be very easy to lose your cool when you see someone clearly setting traps for you to step into.
Sudhir P. - June 18, 2016 4:41 PM
I am certain I would have lost it with this guy...good control Amal. Why does the judge not redirect him more esp with the complexity of his questions the double negatives etc?
Amal M. - June 18, 2016 6:48 PM
This all took place at the deposition, not in court; therefore no judge present.
Christopher B. - June 24, 2016 8:05 AM
On the topic of symptoms predictive of ACS...
A recent JAMA review (http://jama.jamanetwork.com/article.aspx?articleid=2468896) emphasizes the importance of "pain similar to prior ischemia" in predicting ACS. Conversely pain "worse with exertion" was found to be less predictive of ACS than previously reported.
Amal M. - June 24, 2016 8:17 AM
Yes, that's the most recent article on this topic. Interestingly 3 prior articles seemed to dispute the pain similar to prior ischemia and validate the concerns with pain worsening with exertion. Anecdotally, it seems that people in our ED ALWAYS say that their pain is similar, and then tend to rule out. Perhaps we'll never have an exact answer. Thanks for sending the link.
Robert T. - July 5, 2016 6:58 PM
Dr. Mattu,
Sorry to distract from a case of high-risk chest pain with a question on low-risk chest pain.
How do you safely apply those symptoms predictive of ACS to otherwise low risk patients? (Specifically, I mean the four you mentioned in this segment or, instead, those from the JAMA Rational Exam article from Christopher B).
Specifically, how do you define the ‘H’ in the HEART score with these factors in mind? The derivation and validation papers for the scores are pretty vague in terms of ‘mostly specific’ vs. ‘mostly nonspecific’ for their definition of ‘suspicious.’
All of this just seems like a moving target, especially with ongoing adoption of ADPs, including at my institution.
Thank you,
Rob (Resident) from Michigan
Amal M. - July 6, 2016 6:28 AM
Rob,
That's a frequent question. The HEART score is an attempt to standardize the evaluation process for patients with low risk chest pain, but as with the majority of decision instruments (including PERC, Wells, NEXUS, etc.) there is still a bit of subjectivity built in. If there were no need for subjectivity and clinical judgment, there might not be a need for trained clinicians! Therefore whether the patient gets 0, 1, or 2 points for the H is really up to you and your gestalt. The more experience you get and more you learn about this stuff, the better.
The 4 major factors I use in this evaluation, based on literature I've discussed on EMRAP before, are the following:
1. is the chest pain (or equivalent symptom) associated with diaphoresis?
2. is the chest pain associated with vomiting?
3. does the chest pain radiate? [this obviously only works if there is chest pain]
4. does the chest pain worsen with exertion (based on patient hx)?
If the patient answers no to all 4, I give them 0 points. If they say yes to one, they get 1 point. If they say yes to 2 or more, I give them 2 points.
That's my personal practice, though unstudied and unvalidated.
It's definitely a moving target, and I anticipate there will continue to be critiques and revisions of the HEART score, and new decision instruments in the future.
Mike W. - July 6, 2016 6:41 AM
Agree with Amal, as a further note, the 'T' of the heart score is troponin, helpful (to some degree) when initially negative, but the scoring system awards the same amount of points for elevated tropoin as elevated age! We still need to use these rules in the context of each specific patient. Finally, the HEART looks at ACS, but we still need to eval for PE, dissection and the other life threatening causes of chest pain. Thx for the comments on this wild case!!
Amal M. - July 6, 2016 6:58 AM
Great points about CP in general and also the TN issue.
Regarding TN, if positive we will admit for workup, so in essence we are actually using a "HEAR" score.
Related to other questions that often arise about the HEART score, is it possible for a patient to have a significantly positive TN due to ACS and yet still have a HEART score of only 2 and therefore be discharged? Theoretically, yes. However, in discussing this issue with the main researchers in Holland (Barbra Backus) and and US (Simon Mahler), they had indicated that this simply hasn't happened amongst the thousands of patients they've studied (though I'd still defer to them to give exact info).
So what's the point of including a TN in the score?
Personally I like using the TN as part of the score for patients being admitted (since none of our TN-positive patients are going home). The data indicates that if the HEART score is 4-6, the 30-day risk of adverse event is 15-20%, and if the score is > 6 it's 50%. So for HEART scores of 4-6, I push for telemetry admission but if the HEART score is > 6, I push for CCU/ICU. So the HEART score (including the T) can be useful for patients being admitted also.
Ian L. - September 16, 2016 2:01 AM
With respect : Steve Smith MD in podcast 146 EM Critic would activate the Cath lab for NSTEMI if there is Hemodynamic Instability .Pain Persisting for more than 20 minutes despite Nitrates Dose and Asprin and to that add Electric trouble : Tell the cardiologist :Get in .
Amal M. - September 16, 2016 10:34 AM
Agree with that, and that's in the NSTE-ACS guidelines. This patient had no hemodynamic or electrical instability.
Ian L. - September 16, 2016 2:13 AM
Futher Predatoty Litigation and the cost are a big problem.
Unless a Doctor or other Health Professional commits a Malicious Error the Health Professional ought be Anonymous .The Psychological costs are too high .
The Case is argued and Just Compensation is given not based on the spin skills of expert witnesses or lawyers .
Anonymity unless there is Malice and Just Compensation .
Mike W. - September 16, 2016 6:18 AM
Wouldn't it be nice to have an objective set of physicians determine if there was malpractice... instead of a jury (of our peers)?!