1. 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,

2. 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

3. 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

4. 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

5. 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

6. New Zealand Cardiovascular Risk Calculator ; table for men

7. 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

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

9. 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

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

11. 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 h.
mean /- SD 22.6h.
median 4.
80% had a second troponin done
All repeated troponins were negative

12. 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

13. 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)

14. 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

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

16. 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.

17. 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.

18. Thank You