1. It’s unclear to me that the cause of death was CAD. The greatest degree of stenosis was 85%, if the cause of death was CAD shouldn't there be a 100% occlusion?
2. On the other hand, I do think that the patient should have been admitted after the abnormal stress test. As an ER doc I’m relatively liberal with discharging patients with chest pain, but I absolutely would have admitted this patient, and I’m curious what the troponin levels would have been. Although it’s not typically done, maybe outpatient troponin levels in this case would’ve been better than not doing them at all.
1. Autopsy didn't find any other cause so the defense really would have faced an uphill battle to even suggest the idea that something else killed him. My understanding is that ischemia caused by stenosis (without 100% occlusion) could cause a fatal arrhythmia, probably more likely if it's diffuse. He may have died without ever having a clear cut STEMI.
2. I'm also very curious about the troponins. It doesn't really seem to be standard of care to order troponins after a positive stress test but I wonder if he had been sent to the ER and they had been checked, if it would have been high enough to prompt an admission.
That’s a good point on #1. On #2 even with a negative trop it’s hard for me to see an ER doc discharging a patient with both cardiac sounding chest pain AND a positive stress test so I feel like he would have been admitted regardless. Honestly even just the story without the stress might have been enough for me. And I am really not conservative with admitting chest pain, but when it sounds so obviously cardiac , I do.
I always operated from the premise that new onset chest pain in this scenario was unstable angina and that impending plaque rupture/MI needed to be averted. We often face pushback from the inpatient teams about admitting too many patients from the ED, but IMO this kind of case gives us more ground to stand on when we insist.
I agree with one major caveat, when it comes to my own practice - for me to admit with negative troponin and ekg, the chest pain has to really sound cardiac. I discharge the majority of chest pain patients I see, since their chest pain is usually “atypical.” This man’s pain was definitely “typical.”
2 of the very first things I learned about the heart were 1) new onset chest pain in a middle aged man is coronary disease till proven otherwise; and 2) the "R" in avR stands for "RESPECT." I think a good case can be made for going directly to cath with that ETT. Yes, hospitals are overburdened, but people get admitted for far less worrisome reasons.
This man had new onset angina of effort and an abnormal stress test. In my jurisdiction, this would lead to emergency admission for serial troponins and early/urgent cardiac catheterisation. Depending on time of day/day of week, the cath might be deferred to next day. If he had a cardiac arrest in a hospital with PCI capability, his survival prospects would be much greater. The primary care physician is a victim here, rather than the fly in the ointment
So he has a positive stress test on Thursday and collapses and dies Saturday. I can’t see how you could blame the PCP for what seems like a dead man walking; while I’m not a doctor, I’m not sure anything could’ve saved him except being told to go straight to the emergency room after the test (or call 911 upon any chest pain with that result).
The cardiologist’s plan seems a bit weird to me; outpatient cath and echo seem more reasonable than stress test again, myoview boogaloo. But getting them in earlier than Monday, two days after he died, is unlikely. So it kinda all hinges on whether the stress test was positive *enough* that the cardiologist should’ve said “Go straight to ER, do not pass go, do not collect $200.”
That was the point the plaintiff’s cardiology and FM expert witnesses were making; he should have been immediately admitted, worked up and treated. Had he been, he might have lived.
Coming from the PCP side I have had many patients who had some intermittent chest pain or dyspnea a few weeks or days prior to the visit. I obtain an EKG and many times there are no clear signs of ischemia and the wait time for a stress test is over a month at least. I document the Marburg or INTERCHEST score and sometimes start them on ASA/BB/Statin and nitro if they have a multiple risk factors or my clinical suspicion is high. I document the importance of going to the ER if they have chest pain again and shared decision making. Many times I document a low MARBURG or INTERCHEST score which gives me the best evidence I can find to support my plan since we don't get troponins outpatient.
I am worried about a patient having an event in the meantime. I see that one expert witness emphasized the stress test was done "routine". I will now order my stress tests as "STAT" even though I know this is equivalent to playing the lottery. I will also document my advice to not do any exertional acitivty until the stress test is performed.
Thanks for the note! Waiting for a month for a stress test seems fairly common these days... when I read this case I was very surprised they were able to get his stress test done the next day. Your approach seems smart and great way to mitigate risk... unfortunately there is always going to be a tiny risk of a catastrophe before any appointment.
I don't think many ED docs would be irritated if this patient got sent to the ED. Feels like "chest pain" is the most common chief complaint we get by a country mile (actually abdominal pain is probably up there too). As a side note, I've noticed many hospitals/cardiologists absolutely do not care about the HEART score at all. Doesn't matter what your HEART score is, if you have HS troponins that are negative or only a little up and repeat is flat, you're going home.
Two points:
1. It’s unclear to me that the cause of death was CAD. The greatest degree of stenosis was 85%, if the cause of death was CAD shouldn't there be a 100% occlusion?
2. On the other hand, I do think that the patient should have been admitted after the abnormal stress test. As an ER doc I’m relatively liberal with discharging patients with chest pain, but I absolutely would have admitted this patient, and I’m curious what the troponin levels would have been. Although it’s not typically done, maybe outpatient troponin levels in this case would’ve been better than not doing them at all.
1. Autopsy didn't find any other cause so the defense really would have faced an uphill battle to even suggest the idea that something else killed him. My understanding is that ischemia caused by stenosis (without 100% occlusion) could cause a fatal arrhythmia, probably more likely if it's diffuse. He may have died without ever having a clear cut STEMI.
2. I'm also very curious about the troponins. It doesn't really seem to be standard of care to order troponins after a positive stress test but I wonder if he had been sent to the ER and they had been checked, if it would have been high enough to prompt an admission.
That’s a good point on #1. On #2 even with a negative trop it’s hard for me to see an ER doc discharging a patient with both cardiac sounding chest pain AND a positive stress test so I feel like he would have been admitted regardless. Honestly even just the story without the stress might have been enough for me. And I am really not conservative with admitting chest pain, but when it sounds so obviously cardiac , I do.
I always operated from the premise that new onset chest pain in this scenario was unstable angina and that impending plaque rupture/MI needed to be averted. We often face pushback from the inpatient teams about admitting too many patients from the ED, but IMO this kind of case gives us more ground to stand on when we insist.
A never-ending dispute between the ED and inpatient doctors!
I agree with one major caveat, when it comes to my own practice - for me to admit with negative troponin and ekg, the chest pain has to really sound cardiac. I discharge the majority of chest pain patients I see, since their chest pain is usually “atypical.” This man’s pain was definitely “typical.”
Its interesting because the cardiologist described the chest pain as both "mild" and "atypical". Wish we had more details about the pain.
2 of the very first things I learned about the heart were 1) new onset chest pain in a middle aged man is coronary disease till proven otherwise; and 2) the "R" in avR stands for "RESPECT." I think a good case can be made for going directly to cath with that ETT. Yes, hospitals are overburdened, but people get admitted for far less worrisome reasons.
This man had new onset angina of effort and an abnormal stress test. In my jurisdiction, this would lead to emergency admission for serial troponins and early/urgent cardiac catheterisation. Depending on time of day/day of week, the cath might be deferred to next day. If he had a cardiac arrest in a hospital with PCI capability, his survival prospects would be much greater. The primary care physician is a victim here, rather than the fly in the ointment
So he has a positive stress test on Thursday and collapses and dies Saturday. I can’t see how you could blame the PCP for what seems like a dead man walking; while I’m not a doctor, I’m not sure anything could’ve saved him except being told to go straight to the emergency room after the test (or call 911 upon any chest pain with that result).
The cardiologist’s plan seems a bit weird to me; outpatient cath and echo seem more reasonable than stress test again, myoview boogaloo. But getting them in earlier than Monday, two days after he died, is unlikely. So it kinda all hinges on whether the stress test was positive *enough* that the cardiologist should’ve said “Go straight to ER, do not pass go, do not collect $200.”
That was the point the plaintiff’s cardiology and FM expert witnesses were making; he should have been immediately admitted, worked up and treated. Had he been, he might have lived.
Coming from the PCP side I have had many patients who had some intermittent chest pain or dyspnea a few weeks or days prior to the visit. I obtain an EKG and many times there are no clear signs of ischemia and the wait time for a stress test is over a month at least. I document the Marburg or INTERCHEST score and sometimes start them on ASA/BB/Statin and nitro if they have a multiple risk factors or my clinical suspicion is high. I document the importance of going to the ER if they have chest pain again and shared decision making. Many times I document a low MARBURG or INTERCHEST score which gives me the best evidence I can find to support my plan since we don't get troponins outpatient.
I am worried about a patient having an event in the meantime. I see that one expert witness emphasized the stress test was done "routine". I will now order my stress tests as "STAT" even though I know this is equivalent to playing the lottery. I will also document my advice to not do any exertional acitivty until the stress test is performed.
Great case and thanks for the pearls as always.
Thanks for the note! Waiting for a month for a stress test seems fairly common these days... when I read this case I was very surprised they were able to get his stress test done the next day. Your approach seems smart and great way to mitigate risk... unfortunately there is always going to be a tiny risk of a catastrophe before any appointment.
That is great advice, I will do this moving forward.
I don't think many ED docs would be irritated if this patient got sent to the ED. Feels like "chest pain" is the most common chief complaint we get by a country mile (actually abdominal pain is probably up there too). As a side note, I've noticed many hospitals/cardiologists absolutely do not care about the HEART score at all. Doesn't matter what your HEART score is, if you have HS troponins that are negative or only a little up and repeat is flat, you're going home.