The Lown Institute continues their conference today on avoidable care in the U.S., so this study is a lovely glimpse into one of the worst offenders in Emergency Medicine – chest pain.
Coming from the University of Pennsylvania, this is a retrospective review of patients 805 patients for whom an ED observation protocol of rapid rule-out and stress testing was performed. The supposed point of this article is to demonstrate the potential safety of stress testing after two sets of cardiac troponin 2-hours apart, and, in theory, they do demonstrate this. Of these 805 patients, 16 patients were diagnosed with acute myocardial infarction on index visit through this protocol – and within 30 days, 1 patient had AMI and 2 received revascularization.
The authors conclusion: “…serial troponins 2 hours apart followed by stress testing is safe and … rapid stress testing represents another option to expedite care of patients with potential ACS”.
789 of 805 patients received serial troponins and a negative stress test to identify a handful of higher than minimal risk folks. The 16 AMI diagnoses were based on 12 patients with negative troponins and positive stress tests, 1 patient with troponins that rose from <0.02 to 0.16 ng/mL and a negative stress test, and 3 patients with troponins rising from <0.02 to 0.06-0.09 ng/mL and positive stress tests. But, in order to dredge up these soft diagnoses of ACS, hundreds of thousands of dollars in financial damage were inflicted on the remaining cohort.
These authors feel rapid stress testing is an alternative to CTCA for preventing avoidable admissions. In the spirit of the Lown Institute, and of Rita Redberg’s NEJM editorial regarding CTCA, the true strategy for preventing an avoidable admission is simply to discharge the majority of these patients. A less than 2% yield for an expensive observational diagnostic strategy is far more grossly negligent a failure of medicine than an occasional missed minor MI. We can do nearly as well, for much less cost – but if only we continue to address our “zero-miss” cultural expectations surrounding diagnosis and treatment.
“Safety of a rapid diagnostic protocol with accelerated stress testing”
http://www.ncbi.nlm.nih.gov/pubmed/24211281