Does the AHA support the heart score?

[BAM!]

Does the American Heart Association officially support the Heart Score? I couldn't seem to find the answer to this. So I called the AHA, and they sent me info on signing up for CPR classes.


The most recent guidelines I could find were from 2014 for NSTEMI management which has some notes about sending chest pain home from the ED. Their rec's are to admit CP with "symptoms consistent with ACS" (even if normal trop and EKG). Or for "possible ACS" you could send them home with stress test withing 72 hours. Or you could get a coronary CT or a myocardial perfusion study before sending them home.

Any more recent guidelines that this? If the AHA doesn't support the new Netherland Heart Score, I'm not sure I should either.

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[migm]

There's clearly a difference in the practice pattern and policies of your hospital, colleagues and ED and what the AHA recommends. I think if you're within the realm of common practice for your hospital, discharging Heart <3 with pt buy in is acceptable even if a bad outcome rarely occurs.

 

[goodoldalky]

As far as I know, the AHA has not updated their guidelines since the heart score was externally validated. So you will not find it in any of the guidelines until they are updated sometime in the next 1-3 years. The data for the heart score is pretty robust, in my area it has become a system-supported standard of evaluation so I have no problem utilizing it.

 

[Instatewaiter]

Does the American Heart Association officially support the Heart Score? I couldn't seem to find the answer to this. So I called the AHA, and they sent me info on signing up for CPR classes.


The most recent guidelines I could find were from 2014 for NSTEMI management which has some notes about sending chest pain home from the ED. Their rec's are to admit CP with "symptoms consistent with ACS" (even if normal trop and EKG). Or for "possible ACS" you could send them home with stress test withing 72 hours. Or you could get a coronary CT or a myocardial perfusion study before sending them home.

Any more recent guidelines that this? If the AHA doesn't support the new Netherland Heart Score, I'm not sure I should either.

The heart score is basically the normal risk stratification that has been done for decades- it just gives it a numerical value now.

Also, if you couldn't take an appropriate chest pain history before, this score isn't going to do anything for you as a lot of it relies on history (1/4 of the score). If the history is classic even without the other risks being negative, they shouldn't be sent home. However, they would have a heart score of 2 which would recommend you send them home...

To my knowledge AHA does not directly recommend HEART score but does recommend risk stratification for those with ACS in the guidelines- so in some ways it means they recommend it.

 

[nlax30]

Reminds me of this episode/podcast: http://blog.ercast.org/amal-mattu-low-risk-chest-pain/

 

[migm]

The heart score is basically the normal risk stratification that has been done for decades- it just gives it a numerical value now.

Also, if you couldn't take an appropriate chest pain history before, this score isn't going to do anything for you as a lot of it relies on history (1/4 of the score). If the history is classic even without the other risks being negative, they shouldn't be sent home. However, they would have a heart score of 2 which would recommend you send them home...

To my knowledge AHA does not directly recommend HEART score but does recommend risk stratification for those with ACS in the guidelines- so in some ways it means they recommend it.

I would send home someone with two negative trops with a classic story and no other risk factors who is no longer having pain, but the EKG really needs to be truly negative, not just what the computer says.

 

[Instatewaiter]

I would send home someone with two negative trops with a classic story and no other risk factors who is no longer having pain, but the EKG really needs to be truly negative, not just what the computer says.

Personally, I think the history should not be underestimated. I don't care if the troponins are negative and the EKG is "normal" if the history is a good one. I also get the benefit of seeing the angiograms...

The HEART score history was based upon what was written in the chart which as we all know is very variable. Despite this, those with a history score of 2 had a 60% likelihood of having an event. That is pretty impressive. Don't poo-poo the history.

 

[WilcoWorld]

Personally, I think the history should not be underestimated. I don't care if the troponins are negative and the EKG is "normal" if the history is a good one. I also get the benefit of seeing the angiograms...

The HEART score history was based upon what was written in the chart which as we all know is very variable. Despite this, those with a history score of 2 had a 60% likelihood of having an event. That is pretty impressive. Don't poo-poo the history.

Yeah, I use the HEART somewhat like PERC. If, I think it's not ACS after I do my H&P I'll apply a HEART score (and let's be honest, in chest pain patients the H&P will include an ECG being shoved under my nose). On the other hand, if I do my H&P and think that it is ACS I don't worry what the HEART score is.

 

[WilcoWorld]

On a side note, I should really say "H" instead of "H&P" above, because when it comes to ACS the physical exam mainly serves to rule other conditions in. It's not like I've ever palpated the PMI and said, "Oh yeah, this is an MI."

 

[goodoldalky]

You still have to use your brain. We'll never be replaced by computers because you cannot just blindly follow ANY algorithm, including heart. You could have a 44 year old patient with no past medical history (hasn't seen a doc, probably several untreated and undiagnosed health conditions), an atypical story, a positive troponin and significant ST segment depressions, and they'd get a heart score of 3. You sending that home? No.

 

[RustedFox]

You still have to use your brain. We'll never be replaced by computers because you cannot just blindly follow ANY algorithm, including heart. You could have a 44 year old patient with no past medical history (hasn't seen a doc, probably several untreated and undiagnosed health conditions), an atypical story, a positive troponin and significant ST segment depressions, and they'd get a heart score of 3. You sending that home? No.

Happened to me. Guy in his 30s. Nobody is that buttery and DOESN'T have coronary artery disease.

 

[migm]

Personally, I think the history should not be underestimated. I don't care if the troponins are negative and the EKG is "normal" if the history is a good one. I also get the benefit of seeing the angiograms...

The HEART score history was based upon what was written in the chart which as we all know is very variable. Despite this, those with a history score of 2 had a 60% likelihood of having an event. That is pretty impressive. Don't poo-poo the history.

Absolutely, your brain can't turn off. And i'm not sure where you got the 60% number from, those patients didn't have an isolated heart score of 2 from their history and have a ridiculous MACE rate.

 

[Tenk]

An elevated troponin is like the star in Super Mario Brothers, the second you find one you're invincible against a blocked admission.

 

[Arcan57]

So unless the HEART score makes a sizable donation to the AHA I don't see it getting into the guidelines.

 

[BAM!]

An elevated troponin is like the star in Super Mario Brothers, the second you find one you're invincible against a blocked admission.

unless you fall off the dialysis cliff into the lava.

 

[BAM!]

So unless the HEART score makes a sizable donation to the AHA I don't see it getting into the guidelines.

That's a funny thing to say... but is there history of AHA making guidelines based on donations? (aside from medicare "reimbursement-donations" to cardiologists for non-ACS cardiac stent placement)

 

[Arcan57]

That's a funny thing to say... but is there history of AHA making guidelines based on donations? (aside from medicare "reimbursement-donations" to cardiologists for non-ACS cardiac stent placement)

Amiodarone seems a likely candidate.

 

[WilcoWorld]

That's a funny thing to say... but is there history of AHA making guidelines based on donations? (aside from medicare "reimbursement-donations" to cardiologists for non-ACS cardiac stent placement)

What I've witnessed is more along the lines of having people with a lot of pharmaceutical industry sponsorship write the guidelines, rather than outright donations to the AHA.

 

[Tenk]

unless you fall off the dialysis cliff into the lava.

True.

 

[Hamhock]

That's a funny thing to say... but is there history of AHA making guidelines based on donations? (aside from medicare "reimbursement-donations" to cardiologists for non-ACS cardiac stent placement)

Now I will sound like a zealot, but they sure seem excited about tpa and "stroke centers"...except the parts of stroke rehab and non-invasive/non-pharm management.

[I have no data to support this, admittedly.]

HH

 

[Psai]

An elevated troponin is like the star in Super Mario Brothers, the second you find one you're invincible against a blocked admission.

Yeah but you get looked down on for a baby trop in an asymptomatic patient with no indication for the test

 

[Instatewaiter]

Yeah but you get looked down on for a baby trop in an asymptomatic patient with no indication for the test

If I could like this 100 times I would. I feel like before you're allowed to order a troponin, you should have to support why you're ordering it. 55 year old with dyspnea- fine. 60 yo post surgical patient with chest pain- wonderful. 90 year old nursing home resident with a UTI and altered mental status... perhaps not.

 

[TooMuchResearch]

If I could like this 100 times I would. I feel like before you're allowed to order a troponin, you should have to support why you're ordering it. 55 year old with dyspnea- fine. 60 yo post surgical patient with chest pain- wonderful. 90 year old nursing home resident with a UTI and altered mental status... perhaps not.

You can do whatever you want upstairs. Downstairs before there is any history in the old, altered patient, they're getting a trop.

 

[Arcan57]

If I could like this 100 times I would. I feel like before you're allowed to order a troponin, you should have to support why you're ordering it. 55 year old with dyspnea- fine. 60 yo post surgical patient with chest pain- wonderful. 90 year old nursing home resident with a UTI and altered mental status... perhaps not.

That's an easy fix. Just get the nation to collectively agree on a patient population in which it's ok to miss an acute myocardial infarction

 

[nlax30]

I think the point was not that it's ok to miss an acute MI but why check a lab test for an entity that there's no clinical suspicion or evidence of anyway?

That said, thus far in training I've fully accepted the fact that we have very sensitive assays and they will continued to be ordered on a good number of patients for any number of reasons. Sure I'll see that patient with a trop of 0.1 with a Cr of 4 who missed his dialysis session and came in with a BP of 190. It pays the bills.

 

[Psai]

You can do whatever you want upstairs. Downstairs before there is any history in the old, altered patient, they're getting a trop.

Because this old, altered patient is a good surgical candidate or something I'm assuming. Or maybe they can have a nice fall while on aspirin and a lovely heparin drip

 

[TooMuchResearch]

Because this old, altered patient is a good surgical candidate or something I'm assuming. Or maybe they can have a nice fall while on aspirin and a lovely heparin drip

That's not my concern unless they have a recent polst on the chart stating they don't even want transport.

I don't get to decide in the ED that the altered old person doesn't get a workup if they're alone, can't give history, and the EMR doesn't tell me blatantly to not go looking.

 

[TooMuchResearch]

I think the point was not that it's ok to miss an acute MI but why check a lab test for an entity that there's no clinical suspicion or evidence of anyway?

That said, thus far in training I've fully accepted the fact that we have very sensitive assays and they will continued to be ordered on a good number of patients for any number of reasons. Sure I'll see that patient with a trop of 0.1 with a Cr of 4 who missed his dialysis session and came in with a BP of 190. It pays the bills.

Can an altered person tell you if they have chest pain?

Are you sure the old person has chest pain with their MI?

No.

 

[goodoldalky]

Yeah but you get looked down on for a baby trop in an asymptomatic patient with no indication for the test

Frankly I don't give a chit, we run into this attitude regularly in emergency medicine. Funny thing is no one ever discharges my patients if I call them with an admit like that. They usually stay 4 days and consult 5 specialists after giving me grief saying they can go home.

 

[WilcoWorld]

You can do whatever you want upstairs. Downstairs before there is any history in the old, altered patient, they're getting a trop.

Also, I'm guessing that altered 90 yo was not complaining of dysuria and urgency before we diagnosed the UTI...

 

[Psai]

Frankly I don't give a chit, we run into this attitude regularly in emergency medicine. Funny thing is no one ever discharges my patients if I call them with an admit like that. They usually stay 4 days and consult 5 specialists after giving me grief saying they can go home.

Not sure why you're proud of adding this financial burden to the healthcare system for a baby trop of 0.05. We all know why specialists are called and it's not because you diagnosed an occult mi in the ed

 

[TooMuchResearch]

Not sure why you're proud of adding this financial burden to the healthcare system for a baby trop of 0.05. We all know why specialists are called and it's not because you diagnosed an occult mi in the ed

If you want to put it on yourself as the only person not ordering tests on the altered old person, go ahead. I hope you make it many years without a legitimate lawsuit.

As you're a first year resident who has posted on how they cannot do EM, I don't think you have much place to tell us how to do our jobs.

 

[Psai]

Maybe it's too much to ask someone from the ed to put in thought into their tests instead of looking through all the shotgunning everything on the emr

And the ED is only tiring because I had to pick up the slack

 

[deleted547339]

Maybe it's too much to ask someone from the ed to put in thought into their tests instead of looking through all the shotgunning everything on the emr

And the ED is only tiring because I had to pick up the slack

Coming into a specialty forum and bashing said specialty is generally frowned upon.

Have some insight to realize the upstairs and downstairs docs have very different jobs with different focuses and different stressors. We are sensitive while you are specific.

 

[Instatewaiter]

You can do whatever you want upstairs. Downstairs before there is any history in the old, altered patient, they're getting a trop.

Yeah, so to get AMS from an MI you actually need cerebral hypoperfusion. This means for an MI to be causing that AMS in that nursing home resident, they need to be in cardiogenic shock. Not exactly subtle.

So that troponin of 0.04 you guys are consulting me for that was ordered for no reason, does nothing but increase costs. We're not cathing that guy anyway. So do what you want, but expect me to actively make fun of you

That's an easy fix. Just get the nation to collectively agree on a patient population in which it's ok to miss an acute myocardial infarction

Yup, saving lives. One troponin of 0.035 at a time. You aren't missing an acute MI in a patient who has no clinical suspicion of an MI. That means that troponin is a false positive and representative of demand. Those patients aren't discharged immediately because there is something going on (whether it be sepsis, stroke or whatever)... but it isn't primary cardiac. So that troponin isn't doing much, perhaps outside of risk stratification which can be done more precisely in other ways.

 

[Instatewaiter]

That's not my concern unless they have a recent polst on the chart stating they don't even want transport.

I don't get to decide in the ED that the altered old person doesn't get a workup if they're alone, can't give history, and the EMR doesn't tell me blatantly to not go looking.

I understand that you can't unilaterally decide not to go full tilt for an altered patient but I don't understand the leap in logic to let's go search for an MI where there is no clinical suspicion because he could be having chest pain that he can't tell me about

 

[migm]

We search for a lot of things that the patient can't tell me about but that may be the cause of their ams or contributing to it. Just pain in general can cause AMS in the elderly. At the other spectrum, In pediatric patients, the only symptom of an intuss can be AMS in certain presentations. It's not my job to miss an NSTEMI. I have to catch it, ie check for it . If the level is indeterminate, then a lot of what happens next is driven by the discomfort of the hospitalist, the repeat troponin and the other clinical conditions. There is no such thing as a "false positive" troponin unless you're saying the lab screwed up the biochemistries. It's positive or its negative, and then you use your brain to decide what's happening next to decide where this is coming from.

 

[DrDrummer]

There is no such thing as a "false positive" troponin unless you're saying the lab screwed up the biochemistries. It's positive or its negative, and then you use your brain to decide what's happening next to decide where this is coming from.

This. I constantly hear people saying that these "troponin leaks" are somehow clinically meaningless outside the narrow context of ACS. It's not like the myocardial cells are poorly-fit pipes that are now leaking. It is representative of dying or stressed myocardium and a prognostic marker associated with increased mortality in a whole spectrum of disease. If people are upset about the over diagnosis of NSTEMI now, just wait until the FDA approves high-sensitivity assays and hospitals start deploying those.

 

[WilcoWorld]

If the positive troponin is so obviously not from ACS, then how come the Hospitalists and Cardiologists don't simply write a note in the medical record saying that no further testing is warranted? Because they don't ant to get sued any more than we do.

 

[nlax30]

If the positive troponin is so obviously not from ACS, then how come the Hospitalists and Cardiologists don't simply write a note in the medical record saying that no further testing is warranted? Because they don't ant to get sued any more than we do.

Actually that is sort of what I end up saying in a good number of those type of consults. Certainly in those cases where there's no clinical suspicion of ACS with some other issue that's certainly compatible with a minor troponin elevation whether it be HTN, sepsis, rhabdo, renal failure, etc...

Obviously it's all about liability shifting and the ER shifts it to the hospitalists or primary who for the most part aren't going to accept it so then shift it to us.

It is what it is and a reality in our current medico-legal environment.

Like I said I've gotten over the angst of these type of consults and accepted the fact that these will "pay the bills" so to speak, and I will ultimately have to share in whatever liability comes with seeing these cases. Sometimes that may mean getting that echo or stress test on some questionable history as if I'm going to accept some liability then that's going to mean some element of further work-up. You might be surprised though how often we do nothing though.

Really my issue with the ER isn't about this. For now this particular thing isn't going to change.

My main issue, at least at my shop, is the lack of communication of the ED with the patient ("Oh I'm sorry Ms Smith, they never told you you were going to be admitted? Awesome, well don't yell at me") or the complete lack of review of any sort of medical records even though the patient was just here with SOB, got a full cardiac w/up which was negative and ultimately though it was purely pulmonary disease yet the primary sends home with no Pulm eval yet they show back up 2 days later to the ED with of course CHF which we need to see again.... Those are really the only sort of times I really get frustrated with the ED as it's completely from a lack of effort.


I know there are different priorities, concerns and constraints down in the ED. It's a tough job that I couldn't do. I try to help out as well and make their job easier with getting people out, whether it's by getting them upstairs easier or "cleared" earlier to go home with f/up, but I also expect the same consideration over aspects that they can control in the ED.... (telling the patient they're being admitted, a quick/basic look at the EMR for relevant cardiac history or recent w/up, asking the patient who their cardiologist is before I spend 20min reviewing records only to find out they see another group)

 

[WilcoWorld]

I also expect the same consideration over aspects that they can control in the ED.... (telling the patient they're being admitted, a quick/basic look at the EMR for relevant cardiac history or recent w/up, asking the patient who their cardiologist is before I spend 20min reviewing records only to find out they see another group)

This is entirely reasonable. I expect this of myself and my trainees.

 

[shoal007]

This is entirely reasonable. I expect this of myself and my trainees.

a good % of patients dont know their doctors name. so this doesnt always work. depending on your system, it may take 20+ minutes finding and reviewing records. by the time you do this, you've backed up the waiting room. i need to dispo 2pph. i get 30 minutes total per pt (h&p + orders + reassessment + review of results + dispo activity). Add in an hour code, multiple transfer acceptance calls, calls from labs, procedures and charting, youre pretty much screwed.

However, still no excuse not to be complete and no excuse not to tell patients whats going on before consults or admission team sees them. it does happen sometimes even to the most diligent and i apologize when it does happen, its not ideal care.

Sent from my XT1635-01 using Tapatalk

 

[WilcoWorld]

a good % of patients dont know their doctors name. so this doesnt always work. depending on your system, it may take 20+ minutes finding and reviewing records. by the time you do this, you've backed up the waiting room. i need to dispo 2pph. i get 30 minutes total per pt (h&p + orders + reassessment + review of results + dispo activity). Add in an hour code, multiple transfer acceptance calls, calls from labs, procedures and charting, youre pretty much screwed.

However, still no excuse not to be complete and no excuse not to tell patients whats going on before consults or admission team sees them. it does happen sometimes even to the most diligent and i apologize when it does happen, its not ideal care.

Sent from my XT1635-01 using Tapatalk

Agreed. If Dr. Suarez cathed the patient last month, then followed them up in clinic a week ago, you should read that note and incorporate it into your decision making. If the patent got a Cards consult 4 hospitalizations and 64 progress notes ago, and you fail to call that group's interventionist when that same patient comes in with a STEMI...well, these things happen.

 

[nlax30]

a good % of patients dont know their doctors name. so this doesnt always work. depending on your system, it may take 20+ minutes finding and reviewing records. by the time you do this, you've backed up the waiting room. i need to dispo 2pph. i get 30 minutes total per pt (h&p + orders + reassessment + review of results + dispo activity). Add in an hour code, multiple transfer acceptance calls, calls from labs, procedures and charting, youre pretty much screwed.

However, still no excuse not to be complete and no excuse not to tell patients whats going on before consults or admission team sees them. it does happen sometimes even to the most diligent and i apologize when it does happen, its not ideal care.

Sent from my XT1635-01 using Tapatalk

Yea I'm not expecting a full/comprehensive review of medical records or a million phone calls to find out who that 85yr demented patient's cardiologist is who has no clue.

I'm talking about the obvious oriented patient who can very clearly tell me who exactly there doc is after being told by the ED "we don't know" when it's obvious they didn't ask.

Our EMR, while crappy as it is, is pretty easy to view the last consult/cath/stress and when you pull the patient, if they were very recently there already has some of the prior notes in the list so in those cases it's just purely out of laziness. I'm not expecting you to dig through the EMR archives to find the unlabeled note from 1997 showing that they had negative cath then.

 

[Instatewaiter]

If the positive troponin is so obviously not from ACS, then how come the Hospitalists and Cardiologists don't simply write a note in the medical record saying that no further testing is warranted? Because they don't ant to get sued any more than we do.

I cannot tell you how many times I have written a note which specifically says not to check another troponin.

There is no such thing as a "false positive" troponin unless you're saying the lab screwed up the biochemistries. It's positive or its negative, and then you use your brain to decide what's happening next to decide where this is coming from.

When you are checking a troponin, you are doing so to find those with a true plaque rupture not to risk stratify people and hopefully not for brainless, shotgun medicine. If the troponin is positive and there is no heart attack, that is a false positive- a positive result which is not from a heart attack. That you do not understand this, explains why there is a disconnect between the ER and the rest of the hospital, why there are so many needless troponins ordered, and why I said people should have to defend why they want to order a troponin.

 

[Instatewaiter]

This. I constantly hear people saying that these "troponin leaks" are somehow clinically meaningless outside the narrow context of ACS. It's not like the myocardial cells are poorly-fit pipes that are now leaking. It is representative of dying or stressed myocardium and a prognostic marker associated with increased mortality in a whole spectrum of disease. If people are upset about the over diagnosis of NSTEMI now, just wait until the FDA approves high-sensitivity assays and hospitals start deploying those.

I don't need a troponin to tell me the 92 year old nursing home resident who presents altered has an almost 100% 6 month mortality... That 75 year old with diffusely metastatic cancer and platelets of 15 is screwed with or without a positive troponin. When I come down to the ER for a troponin of 0.04 and I have to step over a puddle of the patient's blood, I should never have gotten that consult.

As above, I'm not faulting anyone for sending a troponin in any reasonable circumstance. It is those ridiculous ones where there was a zero percent chance that not only did the person have a heart attack but it is someone we would never cath.

 

[goodoldalky]

If the troponin is positive and there is no plaque rupture, that is a false positive- a positive result which is not from a heart attack. That you do not understand this, explains why there is a disconnect between the ER and the rest of the hospital, why there are so many needless troponins ordered, and why I said people should have to defend why they want to order a troponin.

Troponins are frequently positive without an acute plaque rupture thrombosis. They are assays for myocardial injury, not "heart attacks". Surely, you've seen a troponin positive at 2 and 4 and 10 for patients with myocarditis, massive pulmonary embolism, myopericarditis, etc. You may have been involved in cases where troponin assays are elevated in patients with acute allograft rejection after cardiac transplant, if you work in a transplant center. I can go on, but the point is these are not "false positives". They are positive.

 

[Janders]

I should only order a troponin if I think the patient has acute plaque rupture? Huh.

Just today, I had a nice demented woman who was acutely weak, tired, delirious x 2 days. Mild dementia at baseline, rather functional. Initial vitals normal. EKG without any appreciable ischemia. Physical exam not exciting.

I got a CBC, BMP, cath urine, chest X-ray along with the EKG.

WBC 16k, urine was pus. Ceftriaxone, admit.

Oh wait I also got a trop that came back at 0.8. Huh. Go back, bother the family more "well she did c/o nausea 2 days ago, but she never threw up".

Now maybe I shouldn't have gotten that troponin; hell maybe I shouldn't have gotten that CBC and urine and should have consulted palliative care on arrival...

I fully agree that a lot of these troponins of 0.04 are NOT "nstemi" and are due to impaired renal clearance, rapid fib, sepsis, or sometimes due to chronic elevation. I generally put precisely that in MY note, as one step in the process that hopefully can avoid these patients NOT getting a stress / cath unless it is truly indicated. But I don't know when I order said troponin if the result is going to be 1.4, 0.04, or <0.01. Thats the whole point of ordering it. And if I order a troponin in a patient with septic shock, and it results at 0.10... well I surely am not calling cards to emergently see the patient in the ED! There is not reason to bother consultants with stupid things. But I can still order the blood work

 

[Instatewaiter]

Troponins are frequently positive without an acute plaque rupture thrombosis. They are assays for myocardial injury, not "heart attacks". Surely, you've seen a troponin positive at 2 and 4 and 10 for patients with myocarditis, massive pulmonary embolism, myopericarditis, etc. You may have been involved in cases where troponin assays are elevated in patients with acute allograft rejection after cardiac transplant, if you work in a transplant center. I can go on, but the point is these are not "false positives". They are positive.

So while troponin leaks come from a variety of things, in the ED, these are not the things you're looking for.

Let's be honest, you all are not sending that troponin to find myopericarditis. Are you looking for rejection in that 90 year old without a heart transplant? Give me a break. You're looking for an MI and then when you find a positive troponin in someone who shouldn't have ever had a troponin drawn in the first place you pass the buck on to someone else.

 

[Instatewaiter]

I should only order a troponin if I think the patient has acute plaque rupture? Huh.

Just today, I had a nice demented woman who was acutely weak, tired, delirious x 2 days. Mild dementia at baseline, rather functional. Initial vitals normal. EKG without any appreciable ischemia. Physical exam not exciting. WBC 16k, urine was pus. Ceftriaxone, admit.

Oh wait I also got a trop that came back at 0.8. Huh. Go back, bother the family more "well she did c/o nausea 2 days ago, but she never threw up".

So is the moral of the story that you should blindly order troponins or that you should actually talk to the patient and their family?

Similarly we should probably order CT scans of the chest on everyone in case they happen to have pneumonia. That way when it is positive we can go back to the patient and ask if they've had fevers and sputum production.