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
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