T H E H E A R T U N D E R S T R E S S

R I C K B O D Y I M A G E A T H T T P : / / FA V. M E / D 4 N Z 8 7 I B Y E T H E L A N I T E# S M A C C G O L D

H O W T O T R E AT A B A D LY S T R E S S E D H E A R T

G O I N G T O O FA S T ? S H O C K I T !

G O I N G T O O S L O W ? PA C E I T !

I N FA R C T I N G ? C A T H I T !

T H E L AT E S T E V I D E N C E T H AT W I L L H E L P Y O U T O M A N A G E S U S P E C T E D A C S B E T T E R I N Y O U R P R A C T I C E

T H E A I M O F T H I S TA L K I S T O D I S C U S S . .

I M A G E B Y PA N T H E R A - M E A T H T T P : / / FA V. M E /D 3 E L D Z P

W H E N S H O U L D I S U S P E C T A C S ?Q U E S T I O N 1

4 5 Y E A R O L D M A N W I T H ' I N D I G E S T I O N '

B A S E D O N B O D Y E T A L . R E S U S C I TA T I O N 2 0 1 0 ; 8 1 ( 3 ) : 2 8 1 - 6

C H A R A C T E R O F C H E S T PA I N I S A U S E L E S S D I A G N O S T I C T E S T

B O D Y E T A L . R E S U S C I TA T I O N 2 0 1 0 ; 8 1 ( 3 ) : 2 8 1 - 6

T H E PAT T E R N O F R A D I AT I O N I S U S E L E S S T O O

A C S I S J U S T A S L I K E LY A S I F T H E S Y M P T O M S W E R E T Y P I C A L !

I F Y O U R PA T I E N T ' S S Y M P T O M S A R E A T Y P I C A L . . .

G R E E N S L A D E E T A L , A N N E M E R G M E D 2 0 1 2 ; 6 0 ( 6 ) : 7 7 7 - 8 5

S I M I L A R LY, H AV I N G ' L O T S O F R I S K FA C T O R S ' D O E S * N O T * R U L E I N A C S !

Excluding ACS because a patient has no risk factors is roughly as clever as inserting a left sided chest drain with a trochar

% w

ith A

MI

0

6.5

13

19.5

26

Number of risk factors

0 1 2 3 4 or 5

21.3

13.6

19

24.1

12.2

B O D Y E T A L , R E S U S C I TA T I O N 2 0 0 8 ; 7 9 ( 1 ) : 4 1 - 5

B U T W E ' R E A L L G R E AT D I A G N O S T I C I A N S AT S M A C C G O L D !

S U R E , S U R E .

I M A G E B Y N E L S O N S A N T O S , H T T P : / /U P L O A D . W I K I M E D I A . O R G / W I K I P E D I A / C O M M O N S /C / C 8 / D R . _ H O U S E _ C A R I C A T U R E . J P G

I F Y O U T H I N K H S - T R O P O N I N I S B A D , Y O U S H O U L D S E E H O W N O N - S P E C I F I C * D O C T O R S * A R E !

% w

ith M

AC

E

0

15

30

45

60

"Is this ACS?"

Def not Prob not Could be Prob is Def is

52.8

35.5

16.4

5.49.1

B O D Y E T A L ( M E M C V I I , 2 0 1 3 )

O V E R T R E AT M E N T I S D A N G E R O U S

W I T H P R A S U G R E L P R E - T R E A T M E N T, 2 . 6% O F PA T I E N T S H A D A M A J O R B L E E D W I T H I N A W E E K

M O N TA L E S C O T E T A L , N E J M 2 0 1 3 ; 3 6 9 ( 1 1 ) : 9 9 9 - 1 0 1 0

– W I L L I A M O S L E R

“One must be a professional Ulysses in craft and wisdom not to

sometimes err in estimating the nature of an attack of severe heart

pain”

H O W T O C U R E ' T R O P O N I N I T I S '

Y O U O N LY G E T A ' N O R M A L ' T R O P O N I N I F T H E PAT I E N T ' S C O N D I T I O N I S A L S O ' N O R M A L '

Tro

po

nin

T (n

g/L

)

0

10

20

30

40

99th percentile subgroup

'Normals' All comers

27.7

37.2

29.9

14.4

99th% Males Females

C O L L I N S O N E T A L , C L I N C H E M 2 0 1 2 ; 5 8 ( 1 ) : 2 1 9 - 2 5

I N C K D T H E ' N O R M A L R A N G E ' F O R H S - T R O P T I S U P T O 1 3 9 N G / L

Tro

po

nin

T (n

g/L

)

0

75

150

225

300

CKD 3 CKD 4 CKD 5 All

139

297

136

52

C H O T I VA N A W A N E T A L , J M E D A S S O C T H A I 2 0 1 2 ; 9 5 : S U P P L 2 : S 1 2 7 - 3 2

9 5 T H P E R C E N T I L E S P L O T T E D

T H E R E ' S A G O O D R E A S O N W H Y T H E C U T- O F F I S S O L O W !

B U T. . .

<0.05

0.05-0.19

>0.2

% with death or AMI after a year

0 10 20 30 40

24

21

5

24

39

7

Validation Implementation

M I L L S E T A L , J A M A 2 0 1 1 ; 3 0 5 ( 1 2 ) : 1 2 1 0 - 6

U S E D P R O P E R LY, T R O P O N I N C A N S A V E L I V E S

T H E R I S E A N D FA L L

O F T R O P O N I N

N E V E R R E LY O N A 2 0 % D E LTA T O R U L E I N O R R U L E O U T A M I

E V I D E N C E - B A S E D P E A R L :

W H I C H PAT I E N T H A S A M Y O C A R D I A L I N FA R C T I O N ?

• Trop 1: 10ng/L

• Trop 2: 15ng/L

• Delta 50%

• Central chest pain

• No prior history

• ECG normal

• Nothing else going on

• Trop 1: 2000ng/L

• Trop 2: 2200ng/L

• Delta 10%

S O W H AT S H A L L W E D O ?

• Keep it simple, silly!

• Trop 2 - Trop 1 = 'Absolute delta'

• For trop T, a change >10ng/L is significant

4 5 Y E A R O L D M A N W I T H ' I N D I G E S T I O N '

L A T E R A L S T D E P R E S S I O N A N D A T R O P O N I N O F 5 5 N G / L ( C U T- O F F 1 4 N G / L )

70

CKD 2 (eGFR 60)

– T O M M Y C O O P E R , 1 9 2 1 - 1 9 8 4

"Police arrested two kids yesterday, one was drinking battery acid, the other eating fireworks.

They charged one and let the other off”