Let guidelines guide, but also trust judgment
NEW ORLEANS — CVD puts a significant burden on health care in the United States, making the right diagnosis critical; however, a presenter here at the American College of Physicians Internal Medicine Meeting reminded attendees that using their own judgment is just as important.
“Chest pain is the second-leading reason for ED visits in the U.S. and cardiovascular disease remains the number one cause of mortality in the United States. This makes it important for all physicians to familiarize themselves with the signs and symptoms of these diseases,” Robert Roswell, MD, director of the outpatient cardiology department at Bellevue Hospital in New York City told Healio Family Medicine.
Pinpoin ting the condition
He provided some questions primary care physicians and internists can ask to help pinpoint the exact stable ischemic heart disease.
- Get the patient’s medical history. “This includes finding out if the patient has a known coronary artery disease? Do they have cardiac risk factors, and do they have other medical conditions that can help make the diagnosis?”
- Determine the extent and nature of the patient’s pain. “Is it pressure-like? Dull?, Sharp?, Pleuritic?, Ripping? Have there been similar symptoms in the past?”
- Have the patient describe the onset of pain, precipitating factors, its location and what is it associated with. “Is it acute? Is it related to stress or exertion, or does it happen when they are resting, conducting physical activity and what are the stressors? Is the pain centered within the chest, does it progress to the abdomen, arm, back, jaw, and does the patient experience diaphoresis, nausea, shortness of breath and stomach pain?”
- Ascertain what makes the pain go away. “Do medications help? Does adjusting position or resting make the situation better?”
- Patients at low risk for major adverse cardiac events can be discharged and followed up as outpatients, according to Roswell, adding that the Emergency Department Assessment of Chest Pain Score (EDACS) and HEART score can be used alone or in combination to help guide physicians whether or not to admit a patient.
Roswell cautioned attendees that it’s best to come up with consistent definitions when analyzing HEART scores.
“Some physicians will think certain behavior is suspicious, others will think its moderately suspicious, some will think some behavior is not suspicious at all. And that can really change HEART scores,” he said. “If the history of your patients at your institution shows you are either admitting too many patients, or not admitting enough, you should come up with criteria as to what is suspicious, what is moderately suspicious and what is not suspicious.”
“PCPs and internists should also interpret EDACS cautiously,” Roswell said.
“I have some issues with the EDACS score in that sex is the main driver for ascertaining risk of acute coronary syndrome. Although female patients present less often than male patients, when females patients do present with acute coronary syndrome, they have a higher risk of death and higher risk of heart failure,” he said.
“It is important to balance both the EDACS and HEART scores when using them. Don’t classify a patient’s risk if the score isn’t capturing that risk because of their sex.”
Additional cardiological assessment tools
Roswell also discussed:
- T-wave abnormalities can be suggestive of ischemia but can be nonspecific. Wellens T waves signify high risk regardless of the risk scores and patients should be treated as such.
- Stress tests can be used to diagnose coronary artery disease or risk stratify those with the condition. If there is still a suspicion for coronary artery disease with a negative stress test, one could evaluate for the condition with a cardiac catheterization or cardiac computed tomography angiogram.
- Other risk scores internists and PCPs can consider using to ascertain a person’s mortality risk for assorted cardiovascular diseases. include ADAPT (2-Hour Accelerated Diagnostic Protocol to Assess Patients With Chest Pain Symptoms Using Contemporary Troponins as the Only Biomarker); ASPECT (Asia Pacific Evaluation of Chest Pain Trial); GRACE (Global Registry of Acute Coronary Events); and MACS (Manchester Acute Coronary Syndromes).
- Additional tools include NACPR (North American Chest Pain Rule); PURSUIT (Platelet Glycoprotein IIb/IIIa in Unstable Angina Receptor Suppression Using Integrilin); Sanchis (named after its inventor); TIMI (Thrombolysis In Myocardial Infarction) and VANCOUVER (Vancouver Chest Pain Rule).
Despite all the recent advances in cardiology and promise of the future, nothing can replace the well-informed decision of an internist or primary care physician, Roswell told attendees.
“Risk scores are great, but there are certain patients where you should move forward regardless of what the risk score is because it’s only a guideline,” he said. “Even though medical innovation has significantly advanced the field, it still does not supersede clinical judgment,” he said. – by Janel Miller
Aldous S, et al. J Am Coll Cardiol. 2010;doi:10.1016/S0735-1097(10)61005-4. Accessed April 8, 2018.
de Araujo Goncalves, P et al. Eur Heart J. 2005; doi:10.1093/eurheartj/ehi187.
Family Practice Notebook. “Vancouver Chest Pain Rule.” https://fpnotebook.com/CV/Exam/VncvrChstPnRl.htm. Accessed April 8, 2018.
Healio.com. “Learn the heart.” https://www.healio.com/cardiology/learn-the-heart. Accessed April 7, 2018.
Hess EP, et al. Ann Emerg Med. 2012;doi:10.1016/j.annemergmed.2011.07.026. Accessed April 8, 2018.
Roswell R. Evaluation of Cardiac Chest Pain and Chronic Management of Angina. Presented at: American College of Physicians Internal Medicine Meeting; April 17-21, 2018; New Orleans.
Sanchis J, et al. J Am Coll Cardiol. 2005;doi:10.1016/j.jacc.2005.04.037. Accessed April 7, 2018.
Than M, et al. J Am Coll Cardiol. 2012;doi:10.1016/j.jacc.2012.02.035. Accessed April 8, 2018.
Disclosure: Roswell reports no relevant financial disclosures.