I have been lucky enough to attend ACEP over the last few years, and even luckier to watch David Newman speak. Specifically, I have attended his “Is One Troponin Enough?” lecture, which was practice changing for me. It also encouraged me to drench both my patient discussions and MDM’s in evidence prior to discharging patients. Among others, Newman is at it again in today’s article, found here.
At 3 institutions over 5 years, from July 1, 2008 to June 30, 2013, encompassing over a million ED visits in total at these three institutions combined, the authors sought to determine the incidence of clinically relevant adverse cardiac events in patients hospitalized for chest pain with two negative troponins, normal vital signs at time of arrival to the ED, and nonischemic EKGs throughout their stay. Clinically relevant events were defined as life-threatening arrythmia, inpatient STEMI, cardiac or respiratory arrest, or death during hospitalization.
Essentially, during the 5 year study period, over one million ED visits, and over 11,000 patients admitted with two negative troponins, only 20 patients had an adverse outcome (0.18%). When you exclude abnormal vitals at presentation, ischemic EKG findings, left bundle branch block or a paced rhythm, only 4 events were seen out of 7266 patients (0.06%), with two being non-cardiac, and two (possibly) being iatrogenic.
Let’s process this for a minute. When taking all-comers – not just the low risk observation patient- with two negative troponins (drawn between 60-240 minutes in this study) your risk is quite low at 0.18%, now exclude non-ischemic EKGs, patients with abnormal vitals, a paced rhythm, or a left bundle branch block, and your risk is 0.06% of an adverse outcome – and more likely to be iatrogenic than cardiac!
Now let’s couple the above study with this study, where they examined almost 700,000 private-insurance ED patients in 2011 presenting with chest pain. They followed patients that both did and did not receive additional diagnostic testing (exercise stress test, stress ECHO, myocardial perfusion scintigraphy, or coronary CTA). Essentially, the rate of MI at 7 days and 190 days was low overall (0.11% and 0.33% respectively). Most importantly – patients who did not undergo initial non-invasive testing were no more likely to experience a myocardial infarction than those who did not receive additional testing. Compared to no testing, additional testing was associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI.
So why are we consulting cardiology for observation patients with two negative troponins? Why are we ordering stress testing for inpatient or observation patients? This is yet another example of why it is important to provide well-informed consent for your patient, and a great example of a well-intentioned hospitalization and consultation providing (potentially) more harm than good.
It is high time we cease and desist the scare tactics we employ to patients to strong arm them into either an AMA or admission, rather than providing them a look at the current data before making their decision.