Does the AHA support the heart score?

[Janders]

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.

I appreciate your insulting and demeaning tone, colleague.

I would re-characterize as follows: the moral of the story is the patient was capable of, literally, one answer (the name of the street they lived on).
The family, despite me sitting in the room and politely speaking with them, and asking many open ended questions, was unable to provide any meaningful specific history or symptoms aside from generalized weakness and increased waxing-and-waning confusion.

With a significantly positive troponin, and new family members showing up, and repeated pointed questioning someone eventually recalled a period of nausea days ago.

So perhaps I'm the worst historian ever to practice medicine, or perhaps ordering a troponin in an acutely weak/debilitated elderly person MAY be appropriate in some clinical circumstances, even if I don't plan to stat-transfer them to cath.

I think the analogy to getting a CT of the chest for pneumonia, and then asking about sputum production is, of course, ridiculous. A more valid analogy might be that I got a chest xray on this precise patient, despite no reported productive cough, precisely because the history was obviously lacking and the a priori rate of possible pneumonia to explain this presentation was reasonably high.

Instatewaiter, you are listed as a fellow? Might I guess you're getting burnt out by a training culture where you and your fellow cardiologists are consulted on every troponin >0.01 regardless of the cause or comorbidities? I would very much understand that. I'm out in the community where I rarely call cardiology for a minimal troponin bump-- and if I do, its usually a patient who appears to be in that moderate risk / possible unstable angina-angina zone and we together decide the next best move for them. I surely never call about someone with sepsis, or renal dysfunction, or dehydration with a minimally elevated troponin and normal EKG.

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[deleted547339]

I appreciate your insulting and demeaning tone, colleague.

I would re-characterize as follows: the moral of the story is the patient was capable of, literally, one answer (the name of the street they lived on).
The family, despite me sitting in the room and politely speaking with them, and asking many open ended questions, was unable to provide any meaningful specific history or symptoms aside from generalized weakness and increased waxing-and-waning confusion.

With a significantly positive troponin, and new family members showing up, and repeated pointed questioning someone eventually recalled a period of nausea days ago.

So perhaps I'm the worst historian ever to practice medicine, or perhaps ordering a troponin in an acutely weak/debilitated elderly person MAY be appropriate in some clinical circumstances, even if I don't plan to stat-transfer them to cath.

I think the analogy to getting a CT of the chest for pneumonia, and then asking about sputum production is, of course, ridiculous. A more valid analogy might be that I got a chest xray on this precise patient, despite no reported productive cough, precisely because the history was obviously lacking and the a priori rate of possible pneumonia to explain this presentation was reasonably high.

Instatewaiter, you are listed as a fellow? Might I guess you're getting burnt out by a training culture where you and your fellow cardiologists are consulted on every troponin >0.01 regardless of the cause or comorbidities? I would very much understand that. I'm out in the community where I rarely call cardiology for a minimal troponin bump-- and if I do, its usually a patient who appears to be in that moderate risk / possible unstable angina-angina zone and we together decide the next best move for them. I surely never call about someone with sepsis, or renal dysfunction, or dehydration with a minimally elevated troponin and normal EKG.

A burnt out cards fellow angry at ER docs? Never.

 

[goodoldalky]

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.

I do not expect you to understand what I do or why I may or may not order a certain test. Understandably, you do not know how to treat a pulmonary embolism, and you may not not know that cardiac enzyme elevation is one of the factors we use to decide whether someone needs to be admitted, or whether someone needs thrombolytics. When I have a patient with an ECG consistent with pericarditis, I do "send that troponin to find myopericarditis," because patients with pericarditis and a troponin of 0 can go home. Someone with myopericarditis and a troponin of 4 needs to be admitted. I've had both of these cases in the last week, and for what it is worth, cardiologists were involved in both cases, where troponins were indicated, ordered, and positive for reasons that were not "acute MI". And they both did an excellent job.

I don't draw a troponin to "pass the buck on" to anyone else. Everything I do is in order to take care of the patient in front of me, and although you do not understand why I order a certain test does not mean it should have "never been drawn in the first place".

Maybe you could rotate through my emergency department, before you are done with your training. Perhaps we could teach you a few things about what we do... and about troponins.

 

[TooMuchResearch]

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)

We should definitely be telling the patients they are getting admitted before calling the admitting service or transfer facility.

I typically tell the hospitalist the trop is a bit up, I don't really think it's ACS. They order two more trops without other immediate workup and go about treating the underlying etiology of the patient's AMS/weakness/whatever.

 

[TooMuchResearch]

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



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.

Troponin is often checked to risk stratify, especially in conditions other than ACS.

 

[TooMuchResearch]

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.

The other day had an elevated trop in a guy in his 30s with chest pain and a story that didn't sound like ACS (though the interpreter wasn't great), abnormal ECG but not a STEMI. Told the hospitalist I thought it wasn't ACS and started treatment for myo/pericarditis.

It's fine if you think we don't know how to do our jobs or know medicine. It doesn't mean you're right.

 

[TooMuchResearch]

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.

Do you work in the ED? If you do, then you know on a busy day you might have 3 minutes with the altered old person and no family for hours, if ever. They're not getting an 8 hour serial workup as family shows up one by one and adds a piece to the puzzle.

 

[Arcan57]

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.

To preface: for my shop a positive trop is 0.4, borderline trops are 0.05-0.39, and negative are <0.05.

Your risk tolerance is out of sync with you attending brethren and the medical community at large. That's somewhat understandable given that you're a fellow. As well as that viewpoint is working for you now, it doesn't generalize nearly as neatly as you would like. If your service is primary on all these patients with positive troponins regardless of primary disease process than I definitely understand the bitterness. If you're the consulting service that's brought in to determine need for further cardiac evaluation, that's kind of going to be your life if you do in-patient work.

The patient that you would never think about cathing (let's say the 90yo AMS w/ + trop) is someone that I've seen taken to the lab multiple times in my career. Being consulted to explain to family the medical futility of further treatment is a suck job but it's a standard part of services that own specialized procedures. GenSurg gets the NH dweller with mesenteric ischemia, neurosurg gets the non-survivable head bleed, and cards gets it's share AMI in patients with non-stentable lesions. Except in completely obvious cases (DNR - comfort care, etc), an individual specialist attending's practice pattern can be difficult to predict. The idea of writing off a salvageable patient because I didn't get an expert's opinion is scary.

Also, I don't know that railing against troponins in historypenic patients is the hill you want to die on. Regardless of whether it f$%#s with your job satisfaction or not, NSTEMI is on the list of things that cause hypotension, AMS, and worsened dyspnea. Demand ischemia is a diagnosis of exclusion during the initial evaluation. Think of it as if we blew off every EKG showing STEMI or every floridly + trop in a middle aged woman w/o risk factors that had just gotten into a fight with her daughter as stress-induced cardiomyopathy. You may be strongly suspicious this isn't primary AMI but you're still obligated to investigate.

 

[RustedFox]

The patient that you would never think about cathing (let's say the 90yo AMS w/ + trop) is someone that I've seen taken to the lab multiple times in my career.

Multiple times in your career ?

Down here in Florida, its multiple times a week. No exaggeration.

 

[nlax30]

Instatewaiter, you are listed as a fellow? Might I guess you're getting burnt out by a training culture where you and your fellow cardiologists are consulted on every troponin >0.01 regardless of the cause or comorbidities? I would very much understand that. I'm out in the community where I rarely call cardiology for a minimal troponin bump-- and if I do, its usually a patient who appears to be in that moderate risk / possible unstable angina-angina zone and we together decide the next best move for them. I surely never call about someone with sepsis, or renal dysfunction, or dehydration with a minimally elevated troponin and normal EKG.

Maybe I should come work where you are 'cause I'm at a community/private setting and it's no better here and it does get overwhelming.

Even today asked to see a lady we had literally just seen for trops that trended to 9 3 days initially thought to be due to rhabdo (non-cardiac related fall and found on fall) but she even ended up with a Cath, literally 3 days ago with normal coronaries and a trop of 9. Comes back to ED with vertigo and "lightheaded" and gets another trop which was 0.9 and yet again we were consulted.

Is it an easy consult? Yes. The thing that got me was when I called down the ED never bothered looking in the chart and seeing she had a normal Cath 3 days prior and has a trop that has trended down from 3 days prior. All they told the primary was the trop was positive and got us on board. The primary even admitted to me that all he wanted me to do was to document that nothing needed to be done. But even the simplest see and sign off consult adds 30min-1 hour of time to review the chart, see them and then track down my attending to come staff it and listen to them ask why are we even seeing this person. You're exactly right that we get burned out unfortunately.

Honestly if the ED called me and said "hey, I'm sorry but we checked a trop and it's up and I saw that her Cath was normal and it's down from before and she's asymptomatic, do you think we need to do anything further with it?" I wouldn't have as much issue with it as a reflex trop order for some order set without thought or a basic review of the history.

Hopefully it's better elsewhere but from what I hear from our guys at other locations not that much.

 

[Arcan57]

Multiple times in your career ?

Down here in Florida, its multiple times a week. No exaggeration.

Back in the day (i.e. Residency) we had a community cardiologist who's indication for cath was pt having a heart and hospital having an open cath lab.

 

[RustedFox]

I also like Arcan's word "historypenic". Gonna start using that'n.

Last year sometime I remember a gen.surg guy getting all pissy with me because patient (elderly, poor historian) with belly pain, a convincing exam, and a WBC of 30-33K had a history of CML that I couldn't sniff out.

How did he figure it out? The patient's (snowbird from New England) family finally showed up at bedside to give this little bit of history.

Dick Surgeon says to me: "You couldn't get that out of him, huh?"

My retort was: "Yeah, pretty much the only history that I could get out of him was: "OHGODHELPME.MAKETHEPAINSTOP. You think I waste a lot of time getting histories out of patients like that?"


I find that this is a pretty common thing that the IM folk just don't understand. Multiple times a shift, we have to deal with a situation in which we have absolutely NO history to go on, and are expected to "figure it out, quick". They wonder why we "shotgun" labs and practice "brainless" medicine.

 

[deleted109597]

If I had a dollar for every time the inpatient team wanted me to order more testing so "they have a baseline" or "so we know what to treat" I wouldn't have to work anymore.
Our jobs are different. I respect those guys, but when they bitch about the consults, I feel like calling them for every patient I discharge, just to let them know that I don't call them for advice on everyone.

 

[BAM!]

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



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.

I'm assuming you're a cardiologist or internist. It's somewhat concerning to me the lack of understanding because this is basic ED stuff. Let me spell it out:

WE DON'T WANT ORDER TROPONINS. It brings us no pleasure. Admitting a 70 yo with atypical chest pain and a newly elevated trop of 0.1 is NOT exciting or rewarding. The reason we do is that missed MI's result in some of the highest payouts in all of medical malpractice. And in a courtroom, the Standard of Care is a miss rate of 0%.

So it's lose-lose for us. Either we get emotional and financial penalties by patients/courts/administrators drawn out over several years if there's a single bad outcome. Or we get occasional eye rolls from certain inpatient colleagues. After a quick pro/con evaluation, most ED docs end up taking the eye-roll.

 

[BAM!]

(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)

I understand how this is frustrating. And yes, I agree that a proper chart review is important, and often times we could do a better job.

However, you answered your own question inadvertently. If it takes 2o minutes to find a piece of pivotal information, it's unrealistic to ask us to do this type of chart review on all our patients and have any sort of efficiency running a department. Thus exists the consultation of other doctors to help out in caring for select patients. Makes sense. Though it's easy to rationalize in your own mind against this work flow if it shifts more work into your lap.

 

[BAM!]

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



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.

I think you need to go back and read up on the different types of MI.

 

[shookwell]

Wow this thread got derailed quickly.

Regarding the Heart score, just like every other score, it's only useful to have something to write in the chart if it tells you to do what you already want to do. If you think the patient is having an MI, it doesn't matter if the heart score is -15, you're going to admit or obs them, no matter what the cardiology fellow thinks. If you don't think the patient is having an MI, and the heart score is low, then it's nice to write that in your chart after you send them home.