Cardiac Testing? The History Wins Again

When should you order further cardiac evaluation for the hospitalized patient?
https://www.medscape.com/viewarticle/cardiac-testing-history-wins-again-2025a10004ut?src=soc_yt

--TRANSCRIPT--
Monee Amin, MD: Welcome back to The Curbsiders. I'm Dr Monee Amin with my effervescent friend and cohost, Dr Meredith Trubitt. We're going to discuss acute coronary syndrome (ACS) for the hospitalist based on a recent podcast with Dr Sanjeev Francis.

Where should we start?

Meredith Trubitt, MD: We'll start with the history. When we think about chest pain, we should actually be thinking about chest discomfort to broaden the horizon for who is included in the ischemic disease picture. Words such as central pressure — like squeezing, gripping, heaviness, tightness, exertional, retrosternal — all of those should cue you into an ischemic event. In medical school, we were taught that women and other populations can present differently, but the studies haven't borne that out. So, whenever you hear any of these keywords, regardless of patient population, you should follow the appropriate pathway for ACS.

Amin: If you have the thought, then you need to pursue it. Like in meningitis, if you have the thought that someone needs a lumbar puncture, don’t talk yourself out of it. I found that to be a very pertinent teaching point.

Trubitt: If you're thinking about other life-threatening events — dissection, pulmonary embolism — make sure you have rolled out those processes as well. Don’t focus solely on the life-and-limb, organ-threatening condition of ACS and forget about other conditions that could present similarly.

Amin: The history wins again. Getting a good history helps you determine the patient’s risk for a cardiac event. Let’s talk about the risk assessment phase and risk-stratification tools such as the HEART score.

photo of Coronary evaluation
A HEART score of 0-3 is considered low risk. Those patients can safely be discharged. Moderate risk is a score of 4-6. A score greater than six poses a very high risk for a cardiac event, and you need to think about invasive measures and a cardiology consult. Sometimes we get bogged down on whether this is unstable angina, cardiac, or noncardiac? Slow down and assume it's all potentially cardiac and think about the patient’s level of risk.

Trubitt: We see an array of high heart scores coming out of the emergency room, and I think all of these patient can’t be at such high risk. Obviously, as a hospitalist, I am rarely going to see the low-risk category of patients. The real question for the hospitalist: What is the next step in testing?

Amin: Once you get to that moderate-high risk category, you start doing the workup, going further down the appropriate pathway. Given that the availability of testing may vary between hospitals, I found our discussion about high-sensitivity troponin to be particularly helpful.

Trubitt: Our facility doesn't offer high-sensitivity troponin, so we are less familiar with it. The fourth-generation tests stratified patients into negative or positive concern for ischemia. The fifth-generation tests, being more sensitive, give us

Transcript in its entirety can be found by clicking here:
https://www.medscape.com/viewarticle/cardiac-testing-history-wins-again-2025a10004ut?src=soc_yt