She is at risk of myocardial damage and from an ED perspective needs a ROMI
(rule out myocardial damage strategy). This could be either
1. Serial CKMB's (preferably with continuous ST segment monitoring)
2. Trop T / I at AT LEAST 12 hours. (If the Trop I you describe was taken at
first patient contact you may as well flip a coin).
Anything else then you will miss patients with prognostically significant
myocardial damage. The risk of your patient (your description is of a
low/moderate risk patient) having myocardial damage in our (and the Goldman
series) is about 10% - pretty high to send home without a ROMI.
If the ROMI screen is negative then the question is "does this patient have
ischaemic heart disease?". This should be addressed but can be done via a
good GP service +/- a parid chest pain access clinic (depending on local
circumstances).
There will be hopefully be a workshop on ED chest pain assessment at the
Faculty meeting in November.
Missed AMI is the most expensive source of litigation against Emergency
Physicians in the US.
You should also entertain alternative diagnoses based upon any other hx you
turn up (which you may not have given us)
Simon
NB Am I the only person who saw Rowley on Chopper Coppers?? (Rowley came
across very well)
Simon Carley
SpR in Emergency Medicine
Manchester Royal Infirmary
England
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Evidence based Emergency Medicine
http://www.bestbets.org
----- Original Message -----
From: Rowley Cottingham <[log in to unmask]>
To: <[log in to unmask]>
Sent: Friday, June 15, 2001 7:25 AM
Subject: Chest pain
> A 63 year old woman attends you at the Emergency Unit. She gives a good
history of tight chest pain. This came on while she was out for a walk, and
when she
> stopped because of the pain it settled about 10 minutes later. It is now
an hour later. You ascertain that she has smoked 20 cigarettes a day for 30
years and that
> she had a cholecystectomy 15 years ago. She was previously well, and feels
quite well now. She has never had chest pain before, either on exercise or
at rest.
>
> Examination reveals a quiet midsystolic murmur without click, a blood
pressure of 153/88 and pulse of 78. Her ECG is unremarkable. In particular,
there is no ST
> segment elevation nor t-wave inversion. She has a few scattered wheezes at
both bases. Her biochemical profile is normal: in particular her troponin-I
is 0.1, her
> CK is 56 and the lab have not performed a CK-MB.
>
> You make a diagnosis of a angina pectoris. What is your management now?
>
> Best wishes,
>
>
> Rowley Cottingham
>
> [log in to unmask]
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