Evaluating Chest Pain – Help From The Curbsiders

The Curbsiders is an excellent Internal Medicine podcast that I’ve recently started following. Here is a link to their complete list of episodes. Currently, there are 68 episodes to review.

The first podcast I listened to was #5: Want to dominate chest pain? Wield the power of cardiac imaging and stress testing. APRIL 20, 2016 By TONY SIDARI, MD

Definetely worth listening to, so I have embedded it below:

Here is an excerpt from the show notes:

TAKE HOME POINTS:

  1. History and Physical are IMPORTANT! Make sure you listen…and examine your patient.
  2. Understand who to test and who not to test for acute coronary syndrome.
    1. Low risk? The patient probably doesn’t need a test.
    2. Intermediate Risk? These people need risk stratification.
    3. High risk? These people can go straight to cath.
  3. Don’t be afraid to stick with initial plan!  Negative stress test, but still worried?  Talk with your friendly neighborhood Cardiologist!

See also my post When is The Evaluation of New or Changed Chest Pain Appropriate in the Office From The 2012 SIHD Guideline. Posted on August 5, 2014

The podcasters include links to two excellent articles:

JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735.
Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review [PubMed Abstract].

Here are some excerpts from the above abstract:

About 10% of patients with acute chest pain are ultimately diagnosed with acute coronary syndrome (ACS). Early, accurate estimation of the probability of ACS in these patients using the clinical examination could prevent many hospital admissions among low-risk patients and ensure that high-risk patients are promptly treated.

OBJECTIVE:

To review systematically the accuracy of the initial history, physical examination, electrocardiogram, and risk scores incorporating these elements with the first cardiac-specific troponin.

CONCLUSIONS AND RELEVANCE:

Among patients with suspected ACS presenting to emergency departments, the initial history, physical examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, which incorporate the first cardiac troponin, provided more diagnostic information.

N Engl J Med. 2015 Apr 2;372(14):1291-300. doi: 10.1056/NEJMoa1415516. Epub 2015 Mar 14. Outcomes of anatomical versus functional testing for coronary artery disease [PubMed Abstract] [Full Text HTML] [Full Text PDF].

Here are some extracts from the above abstract:

BACKGROUND:
Many patients have symptoms suggestive of coronary artery disease (CAD) and are often evaluated with the use of diagnostic testing, although there are limited data from randomized trials to guide care.
METHODS:
We randomly assigned 10,003 symptomatic patients to a strategy of initial anatomical testing with the use of coronary computed tomographic angiography (CTA) or to functional testing (exercise electrocardiography, nuclear stress testing, or stress echocardiography). The composite primary end point was death, myocardial infarction, hospitalization for unstable angina, or major procedural complication. Secondary end points included invasive cardiac catheterization that did not show obstructive CAD and radiation exposure.  CONCLUSIONS:                                                                                     In symptomatic patients with suspected CAD who required noninvasive testing, a strategy of initial CTA, as compared with functional testing, did not improve clinical outcomes over a median follow-up of 2 years. (Funded by the National Heart, Lung, and Blood Institute; PROMISE ClinicalTrials.gov number, NCT01174550.).

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