SSmith-DRAFT— CP, Nl Trop- Send Pt Home? (1-29.1-2023)-ME_TO_DO

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Comment by KEN GRAUER, MD (1/29/2023):

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ECG-1 (top) — ECG 2 (bottom) — Note difference in heart rate! Like a stress test!

I still need to make a Figure with both ECGs together !!!

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Figure-1: The initial ECG in today's case. (To improve visualization — I've digitized the original ECG using PMcardio).

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SSmith DRAFT as of 12-14.1-2022:

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5198955

A 60-something male complained of episodes of chest pain.

The troponins were "negative."  High sensitivity Abbott Artchitect at time zero was 4 ng/L and at 2 hours was 5 ng/L.  URL for this assay is 34 ng/L in men.   Thus, Acute MI was ruled out, and it was ruled out with VERY low troponins.

We can discharge the patient, right?

I had not seen the ECG at this point, but the residents had not seen any ischemia.  I said, "Well, how long are the episodes of chest pain?"

They did not know the answer, so I went with the med student to ask.  The patient stated that no episode, including today's, had lasted longer than 15 minutes.

He also confirmed that he had had chest pain at the time of the ECG recording.

He mentioned that his chest pain was worse when he rolled to the side, and when taking a breath.  But it was not at all tender to my exam.

I said to the residents that you have not ruled out unstable angina if troponins are negative but the chest pain was only brief.  Brief ischemia with pain might not lead to troponin elevation.

For such patients, it can be useful to use "Risk Scores" such as HEART or EDACS.  I prefer EDACS for many reasons:

1. Age is in 5 year increments.  With HEART score, age of 46 = 64, and that is absurd.

2. The "E" and "T" in HEART score: if the ECG is ischemic, or the Troponin is elevated, then the patient needs admission regardless of the remainder of the score.

3. That leaves "H" and "R".  We know from many studies that risk factors are only important in young people. And the EDACS derivation confirmed this. Which is why EDACS does not take risk factors into account for patients over age 50.

4. That leaves "H".  "H" is very subjective, and this is great for someone who knows the chest pain literature and has a lot of experience.  But what about for those with less knowledge?  EDACS has such factors as "Reproducible" "Radiation" "Worse with inspiration" and "diaphoresis".

5.  Finally, EDACS is completely independent of the ECG and Troponin.  If either are "positive," the patient needs further evaluation.

So when I teach use of the risk scores, I prefer EDACS.

This patient EDACS score was 19.  A score of 15 or below in the presence of a non-ischemic ECG and 2 (4th or 5th generation) troponins below the 99th percentile confers a ＜1% risk of 30-day adverse events.  High sensitivity troponins that are very low result in a 99.7% NPV!

But this patient's score is 19.  With very low troponins, his risk is probably less than 1%.

But that is ONLY if the ECG is non-ischemic.

So I went to look for the ECG:

There is ST depression in V3-V5.

Here is the subsequent ECG recorded when the patient was pain free:

The ST depression is resolved, all but proving that the ST depression during pain was ischemic STD