Taj,
Thank you for the detailed reply.
I am most interested in how people are managing "low risk" but not "no risk"
chest pain.
Do I take it, therefore, that you choose 30 years old, all other things
being equal, as a cut off for entry into your chest pain unit?
I have read some info that women less than 40 years old an men less than 30
years old have extremely low rates of troponin positivity, and wonder if
there should be a different age cut off for men and women.
Do you think that a 10% positive trop rate means that you are setting your
thresholds too high? This seems to me to be a substantial +ve rate and I
would be worried that many cases were being missed if I had a 10% +ve
rate....
With regards to CTCA, I too see this becoming more common in the future.
The problems as I see it are that (a) it is promoted as an alternative to
coronary angiography, but we don't currently investigate low risk chest pain
with coronary angiography, so what are we to do in the 30 year old patient
with high coronary artery Ca2+ score who has low risk chest pain to start
with?
What will be the consequences of screening these patients in terms of cost,
radiation dose, complications of false positive CTCAs leading to coronary
angiography and so on.
I guarantee you that we will be performing CTCA in the absence of any good
data in this regard "because we can".
PB
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Taj Hassan
Sent: Thursday, 29 March 2007 4:21 AM
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain
Hi Paul
You ask some really pertinent stuff much of which continues to be
investigated either formally by various groups or informally via continuing
audit work....so the goal posts continue to move a bit. Our unit in Leeds
like a number of others nationally has an 18 bedded CDU as part of the main
ED (maybe larger than some). We have been running about 15 protocols for
about 6 years now, one of which is for 'chest pain - exclude cardiac'. We
admit about 500-600 cases to CDU /yr and have an approx 10% pick up rate
(trop +ve) for referral onto the cardiologists....so we think we have got
more or less the right ball park for the low / moderate end of the
spectrum....it does need good GATEKEEPING though.
So here are a few of the hurdles / questions we have and what we do about
it:
1) Getting onto CDU?
If the patient is over 30 (general rule and not the 'line sniffers') and has
pain which is either typical or atypical but cardiac origin
considered...then they get onto CDU.
We haven't come across anythng better though TIMI and GRACE do help in some
sub stratification when on CDU and might help us around some targeted
treatment on CDU. Some work on this ongoing.
Occasionally we have ended up being caught out with other significant causes
of chest pain ( patients have moved across to the PE protocol or had both,
we have also had a few dissections of thoracic aortas, myocarditis and
cardiomyopathy) ...even though they came with 'innocent looking' chest pain.
We have found overall history is a pretty poor predictor...but autonomic
features are good. This fits in with some work we tried to do in my
Leicester days 10years ago when we were trying to develop an artificial
neural network to select such patients...the computer programme never really
worked (one of my many failed research projects!!)though Baxt and his
colleagues did make it work in the States and published in the Lancet.
So autonomic features are a real big plus...no surprise really but sometimes
forgotten.
2) Once on CDU - what do you treat while you are waiting?
Some people are keen to treat aggressively with aspirin, clopidogrel and
enoxaparin. I must admt i dont think there is evidence for this but with the
TIMI this might be easier. at the moment they all get aspirin and if they
have lots of risk factors etc (ie high TIMI) they get clopi and
enox...though I am not sure about the evidence on this. We hope to tighten
up on this soon.
3) The cardiac marker strategy
We play a bit boring and safe in Leeds...12 hr Trop I (Centaur...this newer
assay is much better I am told by our Chem path people:-))
We have looked at the Biosite NPT triple assay on a number of occasions
(CKMB, Trop and Myoglob) but never been tempted usually because of
cost...(we are very broke in Leeds!!)...setting aside all the advatages of
more rapid turnaround. Fortunately Steve Goodacre has just got a great grant
looking at this issue as a multicentre project...so that will be good!!
In Leeds we are just in the final stages of finishng a project evaluating a
novel biomarker - hFABp..heart type fatty acid binding globulin with over
1000 patients recruited which some pilot work suggests is going to be much
better than Troponins. We are comparing it to trops and have a smaller
subset looking at the 0 and 4hrs (post admission) as well as 12hrs (post
onset of pain)...so we think that could be an interesting way forward.
Our cardiologists have done some great work which shows some very signficant
'major cardiac events' (MACE) at 6 month using the trop strtaegy...so there
are some interesting thngs there to emerge.
On a wider scale...there are you probably know lots of other more non
specfic biomarkers being evaluated ...myeloperoxidase, CRP etc. The
Americans it seems use 6 as standard....though God knows how they interpret
it....probably all go for angio (depending on if they have their insurance
HMO/ credit card!!)
Am sure this is a very big area for continuing work
4) What happens if the marker is negative?
In the 'bad old days' before a more standardised approach to chest pain
evaluation was accepted as much safer and cheaper ( confirmed by a variety
of US studies) we used to send home about 5% of patients with ACS from ED.
With a marker strategy it gets you down to 2% or so and supposedly with ETT
prior to discharge down to about 1%...again SG has done great work in this
area.
We have continued to go for ETT at 7 days or so via Chest Pain clinic..
Am not really sure about how good ETT really is in terms of cost
effectiveness...but ESCAPE hopefully will answer some of that....we are
pretty happy with our approach on this we think...
Peering into the crystal ball...in the next 5 years I think we will be
evaluating the role of 64 slice CT or the llike (?better EBT or next
generation cardiac MRI or something else fancy!!)and defining these
patients' coronary arteries....now that really will be providing definitive
answers!!
Sorry to go on...but haven't contributed for a little while...so thought
this would be a good way to re-start
:-)
Hope some of that is of interest
Best wishes
Taj
----- Original Message ----
From: Dr Paul Bailey <[log in to unmask]>
To: [log in to unmask]
Sent: Wednesday, March 28, 2007 10:25:23 AM
Subject: Re: Assessment of possibly ischaemic chest pain
Thanks Tim,
Although unfortunately there is not a lot of detail on the site as they are
yet to report their findings.
They do, however, report a 1.8% 'adverse incident' rate in discharged
patients. I wonder how an 'adverse incident' is defined because that's a
pretty substantial rate in my opinion.
PB
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Coats Tim - Professor of
Emergency Medicine
Sent: Wednesday, 28 March 2007 4:25 PM
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain
The Sheffield protocol has been studied in the ESCAPE Trial. The
protocol is on the website at http://www.chestpain.group.shef.ac.uk/
Tim Coats.
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Dr Paul Bailey
Sent: 28 March 2007 09:21
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain
Thanks Matt,
Do you have a reference or is anyone on this list from Sheffield?
I'm really after some specifics.
Eg
Timing of troponin testing
Whether anyone is using rapid rule out with myoglobin / CK at 2 hours
(or
whenever)
Whether anyone has a good tool for deciding who is so low risk that they
don't require testing at all. As an example of this, is there a lower
age limit below which you say it's just not worth it. And before anyone
says no I'm assuming that you don't do late troponin testing / stress
ECGs on 9 year olds with chest pain. Or, perhaps you do. My department
sees a lot of people with atypical pain in their twenties and thirties
who have no good alternate diagnosis. A lot of my colleagues keep these
patients in for late
(12h) troponin testing.
Rates of stress ECG positivity
Whether stress ECG needs to be done contemporaneously with the
admission, or whether it can be done in the few days following
presentation.
Whether stress ECG is the right test, or should it be stress echo, or
some sort of myocardial perfusion scan.
What sort of rates of true positives are achieved from stress ECGs
Ie the nuts and bolts of all of this.
These patients don't make up a huge %age of our work. But, when they
are held for late troponin testing they do take up a huge %age of ED
monitor time as they don't get admitted to CCU (I assume this is the
same in most locations).
I've looked at our rates of late troponin positivity and it's about
1:250 for those with an initial negative troponin who are not considered
high risk enough to be sent to the Cardiologists...... That's 995
people waiting for up to 13.5 hours (lab takes 1.5 hours to get us a
troponin result) for 5 patients found.
PB
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Dunn Matthew Dr. (RJC)
A & E - SwarkHosp-TR
Sent: Wednesday, 28 March 2007 4:11 PM
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain
Work from Sheffield on this. Put patient in assessment area; check
troponins; exercise ECG; allow clinical judgement.
Matt Dunn
Warwick
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