"How Can You Tell?"
He was a middle-aged smoker, half a foot taller than the average male, and quite slender. Like many Texans, he had a penchant for spicy food and the reflux esophagitis to go with it. He'd been admitted a few months previously for an extensive chest pain workup which failed to detect any problems with his heart, but which did provide him with the diagnosis of a small hiatal hernia. And yet his father had died of a heart attack at a similar age, so he worried, as would most of us.He was taking his proton pump inhibitor as prescribed, and he watched his diet as reasonably as any of us living in Tex-Mex heaven could be expected to do. But from time to time, he would still get chest pains, and each time he agonized whether to return to the ER for another $10,000+ workup. When he does finally decide to come to the ER, here is our dilemma:
- A normal ECG does not rule out a heart attack
- The first set of normal cardiac enzymes does not rule out a heart attack
- A GI cocktail, even if successful in relieving his pain, does not rule out a heart attack
- Epigastric pain described as "indigestion" does not rule out a heart attack, and in fact is a relatively common presentation for MI
- Epigastric tenderness does not rule out a heart attack
- The absence of shortness of breath or diaphoresis does not rule out a heart attack
- Tall slender individuals might have Marfan's Syndrome or spontaneous pneumothoraces, and yet a normal chest X-ray does not rule out dissecting aneurysm or pneumothorax. So he gets a CT scan too.
Should he get a heart cath? If his arteries were totally normal perhaps that would save him some money over time, but if he had any subtle coronary disease at all, he would still probably be need to be admitted each time he presented to the ER. Maybe CT angiography would be a reasonable alternative, although patients with his risk profile would still give ME heartburn if I sent any of them home.
It's a tough question with no easy answers. Of course quitting smoking, avoiding spicy food, and maybe a fundoplication procedure might help. Then again, they might not.
Labels: chest pain, ER, patients
posted by scalpel at 4:13 PM
17 Comments:
How about this idea? Give him a stress test, severe enough that it causes angina. Then he will know what "real" angina feels like and so will be able to distinguish it from heartburn (provided it is sufficiently characteristically different enough for him).
He shouldn't have a CT angio - he has a high pre-test probability of having CAD and the CT may not be able to differentiate whether he has significant stenoses or not.
An exercise myocardial perfusion test may be better to r/o ischemia.
(if you have reliable "unclear medicine" docs).
But, I vote for having the cath to definitively r/o significant CAD.
While it does not r/o future ACS events, it can give him some reassurance that his current sx are not due to his heart if there are no sig stenoses.
I'd up his PPI dose, tell him to lay off the Tex-Mex and stop the cigs.
If he can't do that, then he should designate me as beneficiary on his life insurance policy :)
BTW, go see Aggravated Doc Surg's recent post on fundoplication.
CardioNP
How about the guy/girl that comes with a similar story and risk profile, but instead likes to get the morphine (or dilaudid) for the pain? There is finally no choice but to have them admitted and get the angio to see whether you have to worry the next time they come in.
Then once they are established that they are "seekers" then they start going to another ER where they are oblivious to the previous work up -- and of course the patient won't volunteer it. In my urban area a patient can do the rounds at about 15 hospitals within a 40 mile radius.
Of course may of these are "self pay - no pay" patients or draining medicaid.
BTW, for this guy. I vote to get the cath once for this guy, then let him do his own risk tolerance estimate and decision on subsequent visits.
Um. A heart cath, even if done, doesn't rule out coronary artery disease/events...the plaque can be building up behind the arteries which could lead to a spontaneous clot to form from a rupture of the artery. These people with "normal coronary angiograms" can still experience coronary events.
In other words, only clinical judgment, it seems, can tell you whether you think someone should be admitted or not. These politicians that advocate that patients not be allowed to sue ER docs for using sound clinical judgment need to be elected like yesterday.
"How about this idea? Give him a stress test, severe enough that it causes angina."
Someone without heart disease shouldn't have angina even with maximum exercise. Fatigue, yes. Angina, no.
"An exercise myocardial perfusion test may be better to r/o ischemia."
He had one of those 6 months ago, and it was normal. I think a cath would be helpful, but I wonder if the negative stress test a few months prior might make the CT angio more useful.
my expert opinion :) says heart cath. And asprin. :) hehehe
Disclaimer: "expert" means I shadowed for three months in the cath lab in high school.
Disclaimer disclaimer: I'm just kidding. Sometimes it doesn't come across in writing :)
Persantine-thallium stress test perhaps?
here's your problem....YOU can't cath him. So you've got the get the cardiologists on board, which isn't always the easiest to do. You get him admitted, he gets stressed, it's negative.
What he needs is a good cardiologist, who will look over his stuff and go, all right, enough is enough...we need to find this out once and for all.
OR he needs to stop coming to the ER for the same symptoms over and over again.
Middle aged male smoker with a family history of heart disease? I don't know what you do in Texas, but if that guy had been in NYC he would have been cath'd faster than you could say Brooklyn Bridge.
I don't see what's causing the dilemma? In all his visits to the ER, did anyone even check his lipid profile? This guy needs a good primary care doctor, not more ER visits.
all this talk about stress tests - the guy needs a cath already! like probably the majority of caths are done for lesser indications.
and how do you know that his primary care doc isn't treating his cholesterol, giving him aspirin, and advising smoking cessation / lifestyle / dietary changes???
it is not uncommon at all for someone w/typical risk factors to have clean-looking nuclear stress images & bad coronary disease on angiography.
the patient should be admitted to the service of a sensible pcp and cardiology consult obtained who will not mess around with another stress test. docwhisperer's got it right- in NYC this would've happened very early on.
A small point-I was taught in my pulm.fellowship that a plain cxr would very likely r/o all but the very smallest pneumo. ( if you could see lung markings out to the lateral third) and if you really want to you could get an expiratory cxr to increase the sensitivity ever further.
Agreed, but even the smallest pneumos can cause chest pain, and such a diagnosis would have saved the patient from undergoing other perhaps more invasive tests. In the ER, expiratory chest x-rays are a waste of time imo unless there is a post-procedure concern like after a central line or thoracentesis.
CT scan is much more sensitive
Hi Scalpel - I am sorry this is off topic but do you have any idea why Trenchy's blog says it is suspended? Just thought since you are an ER doc that you might know. Thanks!
His employer made him shut it down, like what happened to Butterfly.
Thank you Scalpel.
Can they really do that? I guess so. What is going on here though? Is there some kind of corporation phobia? Due to our litigious society - no one taking any chances? (I just put something up last night about our litigious society) It just seems wrong!
I guess just don't let your co-workers know what you are doing or completely out yourself and then write like you know everyone is reading it. (I don't mean you specifically - but collectively) And if you really need to vent maintain a blog so secretively that you don't even tell yourself. :)
I will have serious Trench Doc withdrawal! He was so funny! I loved his red velvet cake, his Throckmorton salad bar test(all time funniest comment ever)and his post on his going through a Target store with his ED headlamp still on his head with the light turned on. Not only will I never view a salad bar or a red velvet cake the same way - ever again, but the same goes for McNuggets - prize winning or not. :)
I was also looking forward to Mr June. :)
Sigh! I feel like a favorite show has been wrongfully canceled. Sigh..
He said something recently about maybe traveling across country.
Trenchy - Thanks for the laughs! This girl wishes you and your family well in whatever you do. :)
Scalpel - hope you don't mind if I put all that there. I am figuring that he will still be checking out you ED docs, etc. :)
P.S. Too bad he didn't do what Fat Doctor did and open a private one.
I'll miss his blog too. He was funny as heck. Maybe I'll post an "Ode to Trenchy" this weekend.
Yes - do it! That's a great idea Scalpel! :)
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