----- Original Message -----
From: "Sam Waddy"
> I agree that SOME of these patients will indeed be their first
> presentation of "stable" angina, but some of them it will be unstable
> angina...thinking about the biology of this there is no way we can tell
> on a single episode whether her stable atheroma has now reached a
> critically narrow stage or whether she had a small plaque rupture this
> morning and formed a clot which she then lysed...if it is the latter
> then she is at extremely high risk of having an infarct later on today
> or in the near future. The only way of ensuring this woman has an
> exercise test to assess that risk is to admit her. Also you need to do
> at least a 6 hour troponin if not a 12 if you do one at all otherwise it
> will be a falsely reassuring test.
> Sam Waddy
Your approach is overly defensive (don't go into general practice!). Her
symptoms were clearly exertion related and relieved by rest - she does not
give a history of instability e.g. rest pain or pain on minimal exertion,
and this may have been her first strenuous exertion for months! I wouldn't
even do troponins as she had pain only for 10-15 minutes with complete
resolution thereafter. Let's not lose our ability to make clinical diagnoses
just because someone has invented a new test!
As in much of my practice, this approach could be viewed as utilitarian (the
greatest good for the greatest number) i.e. this may not be optimal
management for each individual patient but is appropriate for the service as
a whole, or put another way, I don't believe we should clog up our hospitals
further "just to be on the safe side". I should emphasize however that I
don't like to see juniors concerning themselves unduly about "rationing" -
that's my job - but I honestly believe my approach with this particular
patient is reasonably sound medicine, whether or not she collapses in the
car park afterwards!