Rowley,
I must confess no knowledge of the Prime waistcoatthing. However, some of
us have been doing a bit of work on a benchtop triple marker test kit,
Troponin I, CK-MB and Myoglobin, in ECG non-diagnostic patients. We did the
test at time 0 and T90 with repeat ECG also. Using this with clinical
decision we sent home half of the patients (vs 17% in control group) with no
bad 30-day outcomes - only one episode of stable angina. Small series -
about 100 patients but looks good. Have developed a protocol, based on this
and on K Mackway-Jones article in recent journal on risk stratification in
chest pain. Hoping to try this out on 1000 patients in near future. Tests
cost £14 and are quantitative. Happy to speak to anyone who's interested
when back from hols in August.
Rocky.
----- Original Message -----
From: "Rowley Cottingham" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, June 28, 2001 6:15 AM
Subject: Re: Chest pain/ funding
> Well, I have given this debate a few days to blow itself out because it
has tapped into a very rich stratum of viewpoint, some
> excellent medicine and some great knockabout slapstick, and I think has
been very productive.
>
> For those who skimmed the whole debate, it fell essentially into three
camps; admit, send home and decide later. In many respects,
> the response related to the seniority of the correspondent; more junior
doctors would have admitted and more senior sent home.
>
> As per usual with my little clinical tales there is a real patient behind
it, disguised a little. However, the patient was seen,
> diagnosed with a first episode of angina and referred to the GP who sent
her up subsequently to the chest pain rapid referral unit.
> However, one of the cardiologists wrote to complain about this and say
that the patient should have been admitted initially. The
> troponin was a red herring, incidentally; a low CK and the lab not
performing the MB fraction should have reminded everyone
> that CK would have been pointless; although it is highly cardiospecific it
is of course quite slow to rise.
>
> As it happens, I think Adrian is right that this is a counsel of
perfection (professor of cardiology/medical negligence lawyer's
> mother notwithstanding) and Simon's excellent comments about the risk
stratification of the patient are absolutely spot-on. She is
> at a low but quantifiable risk of acute myocardial infarction and then of
sudden death. The issue that we are all struggling with is
> that it takes at least 6 hours and ideally an exercise test to make that
decision. The same applies if she attends her GP with these
> symptoms, and this vignette suggests to me that the management of these
patients is changing and evolving rapidly, and we are
> not all perhaps sure how others are managing such patients. It all comes
down to a root issue in the NHS; what degree of risk are
> we as a country prepared to accept for a given level of medical care? It
is the one discussion that our politicians, normally so
> loquacious, are noticeably silent on, and one on which they should give
the lead. In my opinion, this is the role that NICE needs
> most urgently to adopt. In other words, it needs to set us national audit
standards which have been agreed are acceptable. Thus,
> if Mr Jones goes home and drops off his perch, and it turns out that fewer
than 2% of patients at that hospital have done so, it is
> considered bad luck and not bad medicine. At present, we have an uneasy
truce; if the family make enough fuss, they will get
> money. Whatever good that does. If they however shrug their shoulders
nothing happens.
>
> As per usual, I don't quite agree with my cardiologists. They want all
first presentations of chest pain that could be cardiac to be
> admitted. They want all chest pain whether new or not to be referred to
the medical team (I'm not sure the medical SHOs feel so
> keen) and of course they don't want us to thrombolyse anything.
>
> I agree (like Sam Waddy) that we need to look at all first onset chest
pain whether coming to Emergency Units or attending the GP
> to be assessed in a 6 hour system, with exercise test and echo. Just as we
need 8 Consultants in Emergency Medicine per hospital
> we'd need eight cardiologists to deliver such a desirable service
properly.
>
> I don't think that patients with known angina who have an attack that is
classical and resolves completely and spontaneously or
> with GTN should get any further than the Emergency Unit if they pitch up.
I think patients with features suggestive of
> deterioration should also be admitted as a substantial number of these are
at risk of sudden cardiac death within the next year,
> (sorry, can't find the reference) and finally of course I believe
everything barndoor should be thrombolysed instantly.
>
> Clinically, the major problem we have is a poor correlation between
symptoms, signs (usually non-existent, of course) and ECG
> changes. Has anyone tried the new Prime waistcoat thing which allegedly
helps with this dilemma? (Rocky, is your Unit trying
> it?)
>
> Best wishes,
>
>
> Rowley Cottingham
>
> [log in to unmask]
>
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