Evaluation of Patients with chest pain Admitted under General Medicine; Has clinical judgment being taken over by serial troponins? Dr. Samantha Herath Advance Trainee in General & Respiratory Medicine Auckland City Hospital Auckland, New Zealand. Dr. David Spriggs, Geriatrician and General Physician Auckland City Hospital,

Introduction In Auckland City Hospital- patients presenting with chest pain are separated in to 2 groups GENERAL MEDICINE Low risk of ACS other causes of chest pain Negative ECG and troponin . CARDIOLOGY Acute Coronary Syndrome (ACS) or high risk

Differentiating Minority(ACS) vs. Majority(others) ACS-needs prompt Treatment OTHER CHEST PAINS Safe, Rapid, Early discharge Musculoskeletal Gastro Respiratory Neurogenic ACS Challenge; high volume junior doctors inexperience afterhours default keep the patient overnight Fear of malpractice Financial implications Work load implications

Aim of this Audit Are we clinically assessing the cardiac risk accurately? Is the Troponin test used appropriately? Are there clinical parameters that can reliably predict the group that need further investigations ? e.g. nature of chest pain cardiac risk score Provide a cost analysis

Methodology Prospective clinical Audit. Patients referred and admitted under General Medical Teams in Auckland City Hospital. 100 consecutive patients. This took 16 days. Inclusion criteria Main presenting complaint is chest pain 1st troponin negative No ECG changes on admission Exclusion criteria Well known to Cardiology or recent discharge (1 month) from Cardiology

New Zealand Cardiovascular Risk Calculator ; table for men

Cardiac Risk Assessment New Zealand Cardiovascular risk Calculator HIGH RISK LOW RISK Following groups should be moved up one risk category (5%) Family history of premature Coronary disease 2. Ethnicity – Indian Subcontinent/ Maori / Pacific People 3.People with Metabolic syndrome/ DM>10y/Hba1c>8

Results Demographics Male: Female 50:50 Age 15-95 wide range/wide etiology Referral source ED -65% GP - 34% Clinic- 1%

Cardiac risk assessment Recording of risk factors Yes No Missing Previous vascular events 23 74 3 Hx of HTN 40 53 7 DM 12 79 9 Smoking 21 66 13 F/hx/Race 17 55 28 High lipid level 32 45 High BMI 2 89

Character of the chest pain Ischemic description – 68% Non ischemic description – 32%

Troponin testing Unnecessary repetitions 100%-1st troponin negative Time of onset of chest pain was not given attention. Gap between 1st-2nd troponin was 8h (mean, mode) Second troponin was done when the gap between chest pain and 1st troponin was >8h in n=23 92% stayed overnight 100%-1st troponin negative Time to the 1st Troponin from the onset of chest pain Range 0.5- 96h. mean 15.6 +/- SD 22.6h. median 4. 80% had a second troponin done All repeated troponins were negative

Cost analysis Cost of medical bed/night- 1000NZD Cost of troponin test 20NZD Total cost for the 92 patients who stayed overnight over 16 days 6000 NZD/day or 6 beds/day For unnecessary serial troponin tests 23 patients were kept over night in the 16 days 1500 NZD/d or 1.5 beds/d

Nature of the pain & cardiac risk; the relationship to the final diagnosis   Frequency (%) High risk of MI (n=39) Low risk of MI (n=31) Ischaemic (n=29) Non ischaemic (n=10) Ischaemic (n=23) Non ischaemic (n=8) ACS 8 (27.6) 0 (0) Atypical chest pain 9 (31.0) 2 (20.0) 7 (30.4) 1 (12.5) GORD 3 (10.3) 5 (21.7) MSK pain 4 (13.8) 4 (40.0) 9 (39.1) 2 (25.0) Other PE/AF/Pneumonia 5 (17.2) 2 (8.7) 4 (50.0)

Atypical chest pain Atypical chest pain is not a diagnosis Reason for atypical chest pain must be sought N=31 was given the diagnosis of atypical chest pain, n=11 had ETT

Conclusion Risk factor recording was inadequate. Esp race/family history/lipid profile/ BMI Decision making was heavily troponin based rather than clinically orientated

limitations Only a snap shot In this group of low risk chest pains, a second troponin was not useful at all. How ever, infrequent positive result found in clinical practice.

Suggestion Low risk chest pain group does not need routine serial troponins Clinical risk need to be assessed adequately using a recognized risk calculator High risk- ischemic pain group need further investigations- regardless of troponin results Atypical chest pain should not be a discharge diagnosis Clinical pathways to be used as guidelines ,when available. AIM- Decrease admission rates Increase patient satisfaction Without, compromising safety.

Thank You