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What Does Low Risk Chest Pain Really Mean?

Rob Orman, MD and Mike Weinstock, MD
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19:56
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Nurses Edition Commentary

Mizuho Spangler, DO, Lisa Chavez, RN, and Kathy Garvin, RN
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02:02

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EM:RAP 2016 March Written Summary 858 KB - PDF

This study narrows in on how we can identify define low risk with chest pain. Normal EKG, normal vitals, negative troponins- very low risk for major adverse event in the next few days.

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Pierre M., M.D. -

Why why why would anyone ever admit someone with a low risk story, normal ECG, normal vitals and normal markers? What's wrong with the USA?

Anand S. -

You mention: A study by James found that patients admitted to the hospital had an incidence of iatrogenic death of 1 in 160.
I don't think this study said that. If the 160 NNH figure comes from the 0.6% mortality rates (the lowest estimate), I think was referring to mortality as a percentage of the adverse events.
ie you'd need to know the percentage of admissions who experience adverse events before multiplying this by 0.6% to get the percentage of patients admitted who died as a result of iatrogenic means.
Do you agree?

Rob O -

Hi Anand, Mike's reply below...

Mike W. -

You are correct! You are correct that this is actually not iatrogenic deaths, but cited in the study as preventable adverse events which contributed to the death of hospitalized patients. This is a tough calculation and I choose the lowest of all the studies cited. The percentage of lethal adverse events was 0.6% with the top 2 being hospital acquired infections and acute renal failure. That is where the number of 1 death in 160 hospitalized patients came from... thx for the clarification!

Mike J., M.D. -

The problem as I see it is this sense that there is an acceptable miss rate of 0. By striving for this low rate, we expose patients to harm. This is rarely addressed (the current discussion excepted). The continued efforts to improve our diagnostics are important, but are continuing to drive the sense that a 0 miss rate is possible, and even desirable. This is not the case. By trying to achieve this degree of perfection we will expose patients to the unavoidable harms of overdiagnosis, overtesting and the resultant excessive management of false positives. Stop the madness...

Tracy G. -

From Mike Weinstock:

Thanks Mike, by admitting half of our chest pain patients, we are exposing patients to significant risks, not only from hospital complications such as infections, sundowners, DVTs but also the risk of overtesting... not to mention costs to the health care system and costs to the patient such as lost work and time with family. Thx for your comments!

M

Jonathan J., M.D. -

What Troponin did your study use? Was it a HS troponin? thanks

Mike W. -

Use not HS trop. Was trop i done either as POC or lab

GHS, MD -

Confused about the exclusion of patient diagnosed with NSTEMI - I understand that they did not meet the criteria of CRACE, but discharging them home without intervention increases long-term mortality. References included in article point to the non-emergent strategy for these patients, but seems to selectively ignore the importance on long-term morbidity and mortality with early invasive strategy likely before discharge from hospital (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)31276-4/abstract).

The numbers are still extremely low and iatrogenic harm would still be greater, but wonder about the choice for exclusion of these patients.

Mike W. -

Hi GHS, Our study did not look at treatment for nSTEMI, and did not say these patients were fine, just that they could have their evaluation safely continued as an outpatient (in an expedited fashion). The nSTEMI evidence goes back and forth and before this Lancet article, the common thought was that intervention for nSTEMI was equivocal or harmful (for STEMI it is definitely helpful). Still, extrapolating out the Lancet numbers with the 7266 patients we studied and the 28 positive troponins who did not have a CRACE outcome (we are in the midst of a second study looking to see if these trop elevations really were from ischemia) and the marginal benefit from the Lancet study - it would make the number of patients we had to avoid one CRACE pretty astronomical, but definitely food for thought and a great discussion point - Thx for sending this article and for your comments!!

Ian L., Dr -

How many adult males aged 50 with Chest Pain Diaphoresis Pain down left arm Short of breath with nausea and vomiting have normal serial EKGs and normal serial Troponins.
More how many like this are in normal health .

Mike W. -

Good question - I don't know that we have a good answer for this and I would CERTAINLY be concerned about this presentation... but... what is the risk AFTER the ecgs, trops and vitals are normal? The study suggests it is pretty darn low! The study does not change the concern or the initial work up, just the disposition after testing returns normal - thx for the comment, Ian!

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Spring Forward Into PE Full episode audio for MD edition 236:48 min - 330 MB - M4AEM:RAP 2016 March Aussie Edition Australian 38:52 min - 53 MB - MP3EM:RAP 2016 Mars Résumé en Francais Français 52:06 min - 72 MB - MP3EM:RAP 2016 March Canadian Edition Canadian 33:43 min - 46 MB - MP3EM:RAP 2016 March German Edition Deutsche 101:18 min - 139 MB - MP3EMRAP 2016 Marzo Resumen Español Español 87:22 min - 120 MB - MP3EM:RAP 2016 March Written Summary 858 KB - PDFEM:RAP 2016 March Board Review Answers 187 KB - PDFEM:RAP 2016 March Board Review Questions 169 KB - PDFEMRAP 2016 March MP3 Files 302 MB - ZIP

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