I think the definitions of USA given on the list are all pretty valid (in
that they are in widespread use). However, (as I think I have said before)
from an A+E perspective are we INITIALLY really looking at putting people
into risk categories as much asdiagnoses, and then investigating/treating
according to risk. The risk category idea fits well with what people have
said already.
We would suggest 3 categories following initial assessment
AMI (ECG criteria)
High risk - features suggestive that this person should be admitted and
sorted out
e.g. LVF,
significant deterioration in anginal symptoms (bit wooly as almost all IHD
patients are in the ED because of some change)
New (or not known to be old) ECG changes
Low/Moderate - features that suggest that the person may be suitable to go
home after ED assessment.
USA as a definition may be best left as an exit diagnosis from the ED, or
even just abandoned to the cardiologists.As has already been mentioned on
the list new definitions of AMI may soon incorporate patients with small
Trop rises, previously diagnosed as USA.
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: Dunn Matthew Dr. ACCIDENT & EMERGENCY - SwarkHosp-TR
<[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, July 12, 2001 8:50 AM
Subject: Re: Chest pain/ funding
> > -----Original Message-----
> > From: Rowley Cottingham [mailto:[log in to unmask]]
>
> > Unstable angina is cardiac chest pain that
> > lasts for more than 20 minutes at rest or
> > is associated with pulmonary oedema, hypotension and/or tachycardia
> > has ECG changes, particularly ST segment depression in more
> > than two leads or
> > occurs after recent MI or cardiac surgery (within 14 days) or
> > has an elevated serum troponin level.
>
> Not sure if I agree 100% with your definition. My understanding is that
> unstable angina is rest pain; increasing severity or frequency of stable
> angina or new onset angina with frequent or severe attacks.
> Presence of ECG changes or pulmonary oedema (or possible HS 3/4) is
> predictive of severe stenosis; but is not needed for the diagnosis
(clearly
> frank cardiogenic shock is different). (The difference being that patients
> without these changes are likely- but not certain- to settle with medical
> treatment; whereas those with changes are likely to require angioplasty
etc.
> Not so much of an issue in centres where trial of medical therapy is first
> line treatment.)
> The 'increasing frequency or severity with negative ECG and troponins'
group
> are different from our viewpoint as they are suitable for outpatient
follow
> up. Nevertheless, the have a significant 1 year mortality (based on pretty
> poor evidence, but I haven't done a proper search and am prepared to be
> corrected), and are important to subchronic physicians.
> New treatments, new investigations. Maybe we should change the terminology
> as what we have is a poor predictor of need for treatment and prognosis
> (especially if you classify everything from increased frequency of attacks
> to cardiogenic shock as 'unstable angina'. Different people define the
term
> differently, so we may have to be more precise as to whether we mean rest
> pain; increasing pain with 'ischaemic' ECG; pain with elevated troponins
> etc; or alternatively 'reversible ischaemia with blah de blah findings'
kind
> of thing.
>
> md
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