EM:RAP Special Edition- A Defensible Chest Pain ADP

Dr. Mattu reviews the ADP that he endorses for chest pain patients based on the current guidelines of the American Heart Association. An important topic for all Emergency Physicians and presented gratis by EM:RAP

Feb 2015 CP Shared Medical Decision Making 5-1

Feb 2015 Low Risk Chest Pain Evaluation and Disposition Guideline-final-1

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28 thoughts on “EM:RAP Special Edition- A Defensible Chest Pain ADP

  1. dillertime23

    Love it. What’s your practice with this approach and the “unstable angina” patient? I know that is a loaded term that has gotten a lot of discussion from you all, but does this algorithm still apply? Would you discharge someone with a HEART score < 3 and negative trop x2 if they are still having active chest pain in your ED? Just curious to hear your thoughts. Thanks, Dave

    Reply
    1. EMgold Post author

      “This is a great question. In short, I’m doing nothing different. I had a similar question…does the use of HEART change if the patient has had on and off symptoms or ongoing chest pain, etc. I emailed Simon Mahler, the lead researcher at Wake Forest about this. Simon and his group at WF are doing tons of research on this and presenting the data at AHA (last fall) and I think they’ll be presenting at SAEM also, with publications soon. Anyway, Simon said that they do NOT change their protocol for these types of variations in chest pain. Simon says ‘no’ and so I do the same.”

      Thanks.
      Amal

      Reply
    2. Amal Mattu

      Remember that this all applies to patients with what you consider “low risk” chest pain. If someone has a really good story and you are clearly worried, forget about this! Do what you think is right. But if you think the patient is low risk, but still have a bit of concern, those are the patients to use this for. That’s my take on this.
      In discussing this with the authors of the papers, they made no distinction of whether or not patients were still having pain or not.

      Reply
  2. Joe McCaslin, MD

    We have been using the HEART score for about a year and to our knowledge have not had any MACE in those we sent home.

    Reply
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  5. Sunil Shroff, MD

    Hi Amal,

    My group is in the process of updating our low risk CP protocol as well. I had been focusing on “2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes”.

    As you mentioned early in your talk these guidelines are important – did you have any specific takeaways from that recent guideline?

    Thanks,

    Sunil

    Reply
    1. Amal Mattu

      Those ACC/AHA guidelines are really intended to be used for patients with fairly clear-cut ACS, not for the low risk chest pain patients, so I don’t think they influence the low-risk discussion very much. The most important things I think they bring out are the indications for emergent cath of NSTE-ACS (post-arrest, hemodynamic or electrical instability, intractable ischemic pain, etc.).

      Reply
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  7. Erik Deede

    Thank you for sharing your guidelines- very timely for me as we are working on a chest pain protocol with our cardiologists.
    2 Questions:

    1. HEART score ECG- what if there are ST depressions or T wave inversions that are unchanged from before? Do they still get the 1 or 2?

    2. Abnormal baseline troponin- do you have any strategy for patients with baseline elevations every time they’ve been checked before? Do you just give them the score of their first troponin? Our dialysis patients often have baselines above 0.12 (our upper limit of normal is 0.04 so 0.12 is 3x normal). There probably isn’t enough data on these specific patients regarding their risk for future MACE to make any recommendations?

    Thanks,
    Erik

    Reply
    1. Amal Mattu

      I’ll give you my own interpretation, but will defer to Dr. Backus. 0 points = normal. 1 point for < 1 mm ST change, or repol abnormalities with BBB or LVH or dig (and I assume if abnl but NSC from prior ECG); and 2 points if 1 mm or more ST change in the absence of the above.

      Reply
      1. Amal Mattu

        For the TN issue, I’ll just use whatever the TN is regardless of prior values…until further research comes out and says we should do something different.

  8. AM

    Thank you for a great talk as always. I’m a european colleague and I have some questions I hope you can help me with:
    1) I have trouble with the fact that you get the same amount of points for having several risk factors as a clearly elevated troponin or ischemic ECG changes. Makes no sense to me and not in accordance with what the literature shows, what’s your take on that? As an example, if you have a patient that’s 42 years old, has a moderately suspicious history, no cardiac risk factors and normal troponinx2, but has >1 mm ST depression that is new, you get a total of 3p. Are you sending that patient home? Shouldn’t an absence of new ischemic ECG changes also be a requisite for clearing someone for discharge? On the plus side I would however want to add that I like the fact that your assessment of the history is incorporated, and I’ve also heard that Dr Backus is super nice so I’m hoping for success with this score.
    2) Also, do you personally use 1mm as cut off for significant ST-depression or 0,5mm? The universal MI guidelines recommend 0,5mm but that only gives you 1p according to HEART.
    3) You mentioned TIMI + troponin but that it has limited value. If I’m not mistaken they published a study showing that TIMI 0-1p + 2 sets of negative hs-TnI taken at 0 and 2h accurately identifies 40% of chest pain patients with a <1% risk of MACE (ref: Cullen et al. Validation of High-Sensitivity Troponin I in a 2-Hour Diagnostic Strategy to Assess 30-Day Outcomes in Emergency Department Patients With Possible Acute Coronary Syndrome).
    What’s your take on that study?
    4) I read the discussion above regarding ongoing pain and fear of unstable angina. Has anyone ever shown that patients with normal troponins but with pain that has not resolved have a higher UA risk than those who are pain-free? If a patient has been having pain for hours and still have normal troponins, shouldn’t it, if anything, lower the probability of it being cardiac as you otherwise should have seen evidence of necrosis?

    Thanks

    Reply
    1. Amal Mattu

      These are all great questions. Remember that this protocol is not intended to supersede common sense! As I mentioned in our Maryland protocol, we’ve decided that if someone has a positive TN, we use common sense instead of HEART and will admit the patient for a workup. Similarly, if a patient with active chest pain, moderate story, presents with NEW 1 mm ST depression, I would workup the patient and not use HEART. The people that did the research might disagree, and my guess is that such a patient is ENORMOUSLY rare…almost always those patients with have cardiac risk factors or something else that bumps their score to > 3 and therefore they get workups. Probably the same was found to be true for the positive TNs in the study…pretty much everyone with ischemic/infarction causes of positive TN will have other things in the HEART that bump their TN to > 3, so I think it would be enormously rare for someone to have 0 for HEAR but positive ischemia/infarction TNs. But I’m just guessing.

      Bottom line which is true for EVERY decision instrument and scoring system out there is to use common sense first. We’ll use HEART only if we have mild/moderate concern, but not for patients for whom we have 0 concern and not for patients for whom we have significant concern. Same for PERC. Same for NEXUS. Same GENEVA. Same for Wells. And so on.

      Reply
  9. John

    In your HEART scoring, what criteria do you use to decide if the patient’s history is highly suspicious, moderately suspicious, or non-suspicious? Is this simply clinical gestalt? It seems like there should be something more objective for his part of the scoring system.

    Reply
  10. Amal Mattu

    Just to be clear, I/we didn’t create HEART. It was created by Barbra Backus and colleagues in the Netherlands. If you want to know their exact criteria, you can find them on the internet. We have chosen to use it in a revised for in our network (revised in our approach to TNs, and also we get TNs at 0 and 3 hours rather than a single TN). I believe they used clinical gestalt, and that’s what we’ve chosen to do.

    Reply
  11. Kris

    Dr. Mattu,

    I had a question on your practice pattern with respect to an up-trending but still negative troponin. Example being our institution’s cut off is 0.034, say the initial troponin is <0.012 and the repeat at 3 hours is 0.02, still less than the 'positive' level and considered negative but is technically an up-trending troponin. Would this patient be admitted for further evaluation at your institution?

    Love your work, thanks for your help!

    Kris

    Reply
    1. Amal Mattu

      Kris,
      I’m not sure how they handled this issue in the derivation and validation and other subsequent HEART studies, and it might be worth contacting the authors to find out what they did. My opinion is that technically, you’ve got 2 negative TNs so you could justify calling this negative x 2. With current generation assays, this is analogous to getting a WBC of 4 and then a repeat one is 9…you’ve got 2 negative results. If there’s any qualms, though, you could always get a third TN and see if there’s a continuing upward trend.
      Amal

      Reply
  12. stephen

    Please correct me if I’m mistaken. The ADAPT trial (which I’m assuming you’re referencing in speaking of the ADP trials in Southeast Asia/Australia) did not use hs Troponins. They used contemporary troponin assays.

    Reply
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  15. Erik Deede

    Dr. Mattu,
    We want to initiate a similar protocol to yours at our hospital. Do we need permission to reproduce a version of your shared decision aid to give to patients, or are there any other copyright considerations? We will modify it (take out UMd obviously) somewhat for our own needs.

    Thank you for your work on this!
    Erik Deede

    Reply
    1. Amal Mattu

      Erik,
      I’m not aware of any copyright considerations. Feel free to take the protocol and use it!
      Amal

      Reply
  16. Taylor

    Where did the idea for a three hour delta trop come from? Troponin is not an “early” marker of cardiac injury. Many guidelines say troponin CAN elevate within 2 hours of chest pain, but can be delayed it as long as 4-6 hours, and up to 8-12 hours. Can you explain what made a 3 hour delta trop the magic number for this protocol?

    Reply

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