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ED eval is really the trop and the EKG

if ekg is abnormal the disposition is easier to make.

the issue is what to do if ekg is normal? how to use the troponin?

--article from 9/13 bmj suggests algorithm

--new data from sweden suggests single value sufficient if low trop and normal ekg

high sensitivity troponin and chest pain eval

i would argue that to use either of these or a combo of the two then we need to reconsider pretest probability of coronary artery disease in out pts and consider some other scales that can help us. one example is to use the TIMI scoring system and/or statistical odds that a particular pt. has CAD

new data from sweden suggests if ekg is normal and single first trop is undectable, ie <5 then no acs and discharge is ok

  • suspect acs...
  • ekg normal...
  • trop #1...
  • trop #2 after 3 hours
  • if #1 is >99 centile and #2 is >20% higher then acs
  • if #1 is <99 centile and #2 is >99 centile and > 50% change then acs
  • if #1 and #2 < 99 centile no acs

i think we can use a combo of NICE/European data and BMJ algorithm (BMJ sept. 28, 2013) and the swedish data (JACC march 2014)

if #1 trop is > 3 hours from pain onset and < 5 and the EKG is normal then i think you can stop acs w/u

otherwise, follow the bmj algorithm

2

Thank You!

TIMI SCORE

  • age > 64
  • 3 or more risk factors: fam hx, tob, DM,hi lipids, htn
  • asa use in last 7 days
  • 2 or more angina events in last 24 hours
  • elevated trops
  • ST changes
  • prior coronary lesion 50% or more
  • one point for each, score more than 2 is intermediate risk, more than 4 is high risk for death or MI in next 14 days (original paper was from JAMA 2000 vol 284)

ECG

62

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