Thanks Rowley,
I think we have all seen STEMIs in patients in their twenties.  I know I
certainly have.  It is my experience that they usually present with florid
ECG changes and you are in no danger of sending them home.

That's not the group I'm talking about.  

It's more the 'atypical' (for want of a better term) chest pain that *could*
be ischaemic in the patient with a normal or softly abnormal ECG.

Surely, in the end, it gets down to risk and reward - not unlike the SAH /
LP etc conversation we all had last year that Tim made a great contribution
to.

Saying that you have seen an AMI in a 21 year old are you implying that you
send all 21 year olds with chest pain and no diagnosable cause through a
late troponin protocol?

I'm interested to know what everyone is doing to these low risk patients.

FYI cocaine has historically not been a big factor in Western Australia, but
it is certainly on the rise.

In answer to your question of where have all the MIs gone?  I have a
personal theory that they have all gone to the cath lab many months pre
infarct.  Totally unsupported by anything other than a gut feeling.

PB
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Rowley Cottingham
Sent: Wednesday, 28 March 2007 5:05 PM
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain

I have seen an acute MI in a previously well 21 year old. We are seeing a
substantial and increasing number of young patients with 'classic' features
that are often cocaine related. Many of these turn out to have normal
coronary angiograms.

Our workup depends on the initial suspicion of the chest pain and our
protocol depends on risk stratification. As Charles points out, it is
impossible to depend on a troponin before 8 hours after onset of pain, and
preferably at 12 hours and so we use our clinical decision unit (a small
bedded area where the clock has stopped) for those we stratify as low risk
as a holding area. Despite that we turn up about 1 positive troponin a month
(memo to self; that needs auditing) that then gets transferred to
cardiology. Our weakness is that we do not have access to same day treadmill
testing, and we use the rapid access chest pain clinic for referral of those
who are troponin negative but moderate (or indeed high) risk. In this way we
retain these patients within the purview of emergency medicine. As a
specialty (in the UK) we need to move to the Australasian model of emergency
medicine with smooth seamless handoff to acute medicine. We have gone a long
way along that path in Brighton and we continue to develop it
enthusiastically.

Incidentally, where have all the MIs gone? We are suddenly seeing very small
numbers presenting.

Rowley.

-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Dr Paul Bailey
Sent: 28 March 2007 09:23
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain


Good point Charles,
I had forgotten that the UK 4 hour rule would impact upon this.

I presume that EPs in the UK are involved in the "inpatient" side of things,
or do the cardiologists get to look after all sorts of crappy chest pain
patients in your system?

PB
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Scott, Charles
Sent: Wednesday, 28 March 2007 4:15 PM
To: [log in to unmask]
Subject: Re: Assessment of possibly ischaemic chest pain

How do you do all that within 4 hours?  Can't be done.  Therefore this
system is not part of UK Emergency Medicine so what can EM itself do?

-----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: 28 March 2007 09:11
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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