HEART score in chronic chest pain

[GeneralVeers]

I'm sure we all have them. The high HEART score patient with chronic chest pain who comes back every 2-3 days. I'm curious how you handle them as I got into a fight with one of my PAs who was angry I wouldn't admit the HEART score 5 chronic chest painer with 3 admissions already this month.

I usually document "Patient has chronic chest pain, and this is unchanged from baseline. Workup shows no evidence of acute ischemia".

Some of my colleagues admit these every single time and don't seem to consider chronicity or past recent admissions.

I'm curious as to other approaches.

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[gamerEMdoc]

I'm sure we all have them. The high HEART score patient with chronic chest pain who comes back every 2-3 days. I'm curious how you handle them as I got into a fight with one of my PAs who was angry I wouldn't admit the HEART score 5 chronic chest painer with 3 admissions already this month.

I usually document "Patient has chronic chest pain, and this is unchanged from baseline. Workup shows no evidence of acute ischemia".

Some of my colleagues admit these every single time and don't seem to consider chronicity or past recent admissions.

I'm curious as to other approaches.

I flat out state how many times the patient had been in the ED in the past month(s). Stating, something like: "This is the patients 6th visit this month, with almost 30 this year, with 15 admissions during this time for chest pain without the need for cardiac intervention or revascularization. Despite their heart score, it does not seem feasible or necessary to admit them to the hospital every 3 days. Their ECG and troponin are normal, this is chronic and ongoing, without a clear ischemic etiology despite numerous rule out visits. I feel they are appropriate for discharge home."

 

[RustedFox]

I'm sure we all have them. The high HEART score patient with chronic chest pain who comes back every 2-3 days. I'm curious how you handle them as I got into a fight with one of my PAs who was angry I wouldn't admit the HEART score 5 chronic chest painer with 3 admissions already this month.

I usually document "Patient has chronic chest pain, and this is unchanged from baseline. Workup shows no evidence of acute ischemia".

Some of my colleagues admit these every single time and don't seem to consider chronicity or past recent admissions.

I'm curious as to other approaches.

Did the PA cry?

 

[GeneralVeers]

Did the PA cry?

No but he basically challenged me to a fight in front of everyone. He feels really bad for all the patients and wants to admit everyone.

Unfortunately not much I can do as he's been there longer than me and the other docs are very very conservative with admissions as well.

 

[bravotwozero]

Did the PA cry?

Yes, yes he did. Everytime you discharge home a chronic chest painer with a high heart score, a PA/NP cries.

 

[RustedFox]

No but he basically challenged me to a fight in front of everyone. He feels really bad for all the patients and wants to admit everyone.

Unfortunately not much I can do as he's been there longer than me and the other docs are very very conservative with admissions as well.

Tell him to know his role. You're the physician. Its your name on the chart.

 

[Fox800]

If they've been there 1,000 times you can just reason - what is an observation stay going to accomplish? Risk-stratification? Check lipids? Start on antihypertensives? Get an echo? Probably not. These people will just go home and come back 1-2 days later.

The Kaiser chest pain study validated sending home patients with HEART scores of 0-5 with great success. That's what I'm using. 0-3 was referred to primary care, 4-5 referred to outpatient cardiology.

If the story is super sketchy (legit unstable angina or person that doesn't go to the hospital ever that needs risk stratification) then I will keep them. Otherwise I send 99% of these people home.

 

[ShockIndex]

Recidivist chest pain patients get an ECG and CXR followed by discharge instructions 95% of the time. Rarely I get 2 contemporary sensitivity cTn measurements separated by 3 hours.

I don’t fight or debate PAs.

 

[gamerEMdoc]

Recidivist chest pain patients get an ECG and CXR followed by discharge instructions 95% of the time. Rarely I get 2 contemporary sensitivity cTn measurements separated by 3 hours.

I don’t fight or debate PAs.

If anyone is arguing with midlevel providers in their department, the dynamics of their department are dysfunctional. I can't imagine a midlevel at our institution fighting about a case with us. They come to us when they need help. We give them the proper help and supervision. They accept that help. Anything else makes zero sense if your name is the one going on the chart.

 

[GeneralVeers]

Tell him to know his role. You're the physician. Its your name on the chart.

I told him that. He for some reason disagrees that the buck stops with me and thought he would get in trouble if this chronic chest painer somehow had an MI. He demanded I go talk to the patient, and amend my chart to reflect that. #assbag

 

[gamerEMdoc]

I told him that. He for some reason disagrees that the buck stops with me and thought he would get in trouble if this chronic chest painer somehow had an MI. He demanded I go talk to the patient, and amend my chart to reflect that. #assbag

How was his funeral?

 

[GeneralVeers]

How was his funeral?

I actually agreed to do what he wanted. It's not worth risking my job and generating a complaint. Some of our PAs have way too much power and influence. I basically told him though that he's no longer welcome to pick up complex or chest pain patients when working with me. He then stated "So you are saying PAs have no value to you?"

 

[gamerEMdoc]

I actually agreed to do what he wanted. It's not worth risking my job and generating a complaint. Some of our PAs have way too much power and influence. I basically told him though that he's no longer welcome to pick up complex or chest pain patients when working with me. He then stated "So you are saying PAs have no value to you?"

Good god

 

[RustedFox]

I actually agreed to do what he wanted. It's not worth risking my job and generating a complaint. Some of our PAs have way too much power and influence. I basically told him though that he's no longer welcome to pick up complex or chest pain patients when working with me. He then stated "So you are saying PAs have no value to you?"

#splitting.

 

[GeneralVeers]

99% of them do what I say and don't give me grief. This one REFUSED to discharge a patient despite my explanation and reasoning. If I was in charge or had any influence in the group he'd be gone.

 

[docB]

I try to discharge these as well. It seems like it's fashionable in my shops to get 2 troponins 3 hrs apart. I document if they've had a stress within the previous 90 days because our place won't redo it in that time.

 

[thegenius]

Recidivist chest pain patients get an ECG and CXR followed by discharge instructions 95% of the time. Rarely I get 2 contemporary sensitivity cTn measurements separated by 3 hours.

I don’t fight or debate PAs.

If they are recidivists, they probably already got a CXR recently. Really an EKG is all you need. (although sometimes I do send one trop but I understand they are meaningless)

We have a patient that comes in every 3rd day for a variety of reasons. She has over 200 visits in 3 years. One day she made a troponin of 0.09! She was admitted, and cath was normal. That cath was the best thing that ever happened to us because now we just look at the EKG when she has chest pain. If same as priors, I don't care what her trop is.

 

[evilbooyaa]

I actually agreed to do what he wanted. It's not worth risking my job and generating a complaint. Some of our PAs have way too much power and influence. I basically told him though that he's no longer welcome to pick up complex or chest pain patients when working with me. He then stated "So you are saying PAs have no value to you?"

Did you say "Most do, but you do not. You LOSE, Good DAY sir!"

Always easier to MMQB these responses, but kudos to your response in the moment.

 

[bravotwozero]

yeah negative cath within 1 year, tintinalli says unlikely to be CAD, if no concern for PE and the patient was here like yesterday with labs, won't even draw labs just GTFO.

 

[GeneralVeers]

What do you guys do with the patient who has had a cath WITH stents placed in the last year? My understanding is that if they get re-occlusion of the stent they should have STEMI changes on the EKG, and that stenosis causing anginal symptoms is unlikely within the first 2 years after the stent is placed.

 

[BoardingDoc]

What do you guys do with the patient who has had a cath WITH stents placed in the last year? My understanding is that if they get re-occlusion of the stent they should have STEMI changes on the EKG, and that stenosis causing anginal symptoms is unlikely within the first 2 years after the stent is placed.

Admitting. Mostly for liability reasons but that said, unless you're looking at the cath report and feel comfortable that all those areas of 75% stenosis that didn't get stented last time aren't now 95+% and causing their symptoms, I'm leaving that up to cardiology.

Agree with others about the chronic chest pain patients. I typically get an EKG, one trop. No other labs of any kind and discharge.

 

[bravotwozero]

I usually admit those people, as they're simply too high risk. Can't tell you how many people i've seen who won't stop smoking even after getting stents.

 

[GeneralVeers]

Admitting. Mostly for liability reasons but that said, unless you're looking at the cath report and feel comfortable that all those areas of 75% stenosis that didn't get stented last time aren't now 95+% and causing their symptoms, I'm leaving that up to cardiology.

Agree with others about the chronic chest pain patients. I typically get an EKG, one trop. No other labs of any kind and discharge.

Thanks for the feedback! It will be helpful in working on my personal algorithm.

Although we have a few with recent stents who have chronic chest pain. Those are really tough to admit 4-5 times in a month.

 

[pkwraith]

I do x1 ekg and 1 trop. The most annoying part is how much you have to document for CYA.

History is always frustrating too.
"What is different about it today?". It's always "this is the worst I've had." Chart review reveals every visit is the "worst" they've had.
Or "this feels like my last PE." Review of last 10 visits of negative CT PEs, and verbatim in chart of "feels similar to my prior PE."

I remember in residency, we had one woman that has been to the ED for 200 times a year for the same chest pain which improves with nitro (0 PMD visits). CAD with stents history. EKG is always grossly (chronically) abnormal, and all her veins are absolutely destroyed from the venupuctures. Care plan was EKG only +/- troponin, and if you wanted to actually get the troponin, you would have to do fem stick. 0 self awareness. Cost the city so much money from EMS transport that there was a committee that was convened to discuss her personally.

 

[turkeyjerky]

I do x1 ekg and 1 trop. The most annoying part is how much you have to document for CYA.

History is always frustrating too.
"What is different about it today?". It's always "this is the worst I've had." Chart review reveals every visit is the "worst" they've had.
Or "this feels like my last PE." Review of last 10 visits of negative CT PEs, and verbatim in chart of "feels similar to my prior PE."

I remember in residency, we had one woman that has been to the ED for 200 times a year for the same chest pain which improves with nitro (0 PMD visits). CAD with stents history. EKG is always grossly (chronically) abnormal, and all her veins are absolutely destroyed from the venupuctures. Care plan was EKG only +/- troponin, and if you wanted to actually get the troponin, you would have to do fem stick. 0 self awareness. Cost the city so much money from EMS transport that there was a committee that was convened to discuss her personally.

It's facinating. I hear the whole "this feels just like when I had a PE" all the time. I usually work these people up, but I don't think I've ever had a positive.

 

[GeneralVeers]

It's facinating. I hear the whole "this feels just like when I had a PE" all the time. I usually work these people up, but I don't think I've ever had a positive.

I think they know what to say to get drugs or an admission to the hospital. They know that when they say "It feels like a PE" or "Just like my last heart attack" most doctors will just admit them to the hospital and pump them full of narcotics.

 

[MechEDoc]

He then stated "So you are saying PAs have no value to you?"

Good ones have great value, bad ones are worse than not being there, I think the mean lies above zero, but I'm not sure. If they can suture well, that's really nice. I don't like it when they're not sure what nec fasciitis is and then consult another PA who doesn't see the patient and says it isn't nec fasciitis. It was. I was right, the ortho noctor was wrong.

 

[BoardingDoc]

I think they know what to say to get drugs or an admission to the hospital. They know that when they say "It feels like a PE" or "Just like my last heart attack" most doctors will just admit them to the hospital and pump them full of narcotics.

I've almost completely stopped giving morphine for chest pain patients at this point. Honestly, I don't know why. I just kinda stopped. They get an ASA. Maybe some toradol. If I'm definitely going to admit them, maybe. But in general I just give ASA +/- NSAIDs if I think there's a chance that they're going home.

 

[GeneralVeers]

I've almost completely stopped giving morphine for chest pain patients at this point. Honestly, I don't know why. I just kinda stopped. They get an ASA. Maybe some toradol. If I'm definitely going to admit them, maybe. But in general I just give ASA +/- NSAIDs if I think there's a chance that they're going home.

Agree completely with toradol. It tends to really ferret out the legitimate worried patients, from the drug seekers. There is no evidence that single dose toradol will have impact on kidney function.

I also like to use the (questionable) studies which associate morphine with increased mortality as evidence to not give narcs.

 

[turkeyjerky]

I've almost completely stopped giving morphine for chest pain patients at this point. Honestly, I don't know why. I just kinda stopped. They get an ASA. Maybe some toradol. If I'm definitely going to admit them, maybe. But in general I just give ASA +/- NSAIDs if I think there's a chance that they're going home.

I've never really been big on giving opioids to chest pain rule outs. Nearly all of them look completely comfortable and seem to be there cause they're nervous.

People with true anginal pain get anti-ischemic therapy. If they have a worrisome HPI or prior history, sometimes I'll give a dose of fentanyl, so I can reassess in an hour and see if they're still having pain.

Exception is obviously dissections

 

[Groove]

I'm sure we all have them. The high HEART score patient with chronic chest pain who comes back every 2-3 days. I'm curious how you handle them as I got into a fight with one of my PAs who was angry I wouldn't admit the HEART score 5 chronic chest painer with 3 admissions already this month.

I usually document "Patient has chronic chest pain, and this is unchanged from baseline. Workup shows no evidence of acute ischemia".

Some of my colleagues admit these every single time and don't seem to consider chronicity or past recent admissions.

I'm curious as to other approaches.

It just depends. I used to admit all of these first starting out. Nowadays, I find myself relying on my gestalt a lot more and that's after reviewing their chart, any recent ACS work ups, last cath, echo, stress, etc.. Sometimes, I'll call cards to buff the chart if I intend to send them home. I document HEART if they meet criteria to let me send them home. Otherwise, I leave it off and explain my rationale in the MDM.

Look on the bright side, at least your MLP is conservative with these cases. Personally, I don't think any of them should be working up chest pain as there's a lot more to these cases than can meet the eye and plenty of subtleties. But hey, at least you're not getting a chart sent to you about a high risk chest pain that they sent home.

The chronic ones that have been worked up a million times and keep coming back, I don't call anybody on those as they are more straightforward.

 

[GeneralVeers]

It just depends. I used to admit all of these first starting out. Nowadays, I find myself relying on my gestalt a lot more and that's after reviewing their chart, any recent ACS work ups, last cath, echo, stress, etc.. Sometimes, I'll call cards to buff the chart if I intend to send them home. I document HEART if they meet criteria to let me send them home. Otherwise, I leave it off and explain my rationale in the MDM.

Agree with all of this. Sometimes I'll even call cards too if I think they will be helpful. To me the chest painer who's had 3 admissions that month and is asking for dilaudid is going to be discharged regardless of HEART score.

Look on the bright side, at least your MLP is conservative with these cases. Personally, I don't think any of them should be working up chest pain as there's a lot more to these cases than can meet the eye and plenty of subtleties. But hey, at least you're not getting a chart sent to you about a high risk chest pain that they sent home.

My MLPs should be more conservative than me. But after discussing the case with me, and having me review everything they can't refuse to discharge a patient. It's not their job to second guess me, and if it makes them that anxious, then they should find another line of work.

 

[Groove]

My MLPs should be more conservative than me. But after discussing the case with me, and having me review everything they can't refuse to discharge a patient. It's not their job to second guess me, and if it makes them that anxious, then they should find another line of work.

Yeah, there's a fine line between professional disagreement and insubordination. After all, the buck stops with you. Can you just take over the pt? I can't think of too many encounters where I've really butted heads to that degree with a MLP, but when it has happened or I'm worried about their care, I usually just tell them that I'll take over management of the pt and handle their disposition myself without ruffling too many feathers. I mean, what are they going to say? No?

 

[GeneralVeers]

Yeah, there's a fine line between professional disagreement and insubordination. After all, the buck stops with you. Can you just take over the pt? I can't think of too many encounters where I've really butted heads to that degree with a MLP, but when it has happened or I'm worried about their care, I usually just tell them that I'll take over management of the pt and handle their disposition myself without ruffling too many feathers. I mean, what are they going to say? No?

I ended up having to do it. But does that sound reasonable for me to assume care completely just to put in a discharge order?

 

[Groove]

I ended up having to do it. But does that sound reasonable for me to assume care completely just to put in a discharge order?

Ordinarily no, but APCs these days are full of attitude. Apparently the clinical training has changed. They don't produce "physician extenders" anymore, all they produce are "experts". Eeeeverybody's an expert...

 

[RustedFox]

Ordinarily no, but APCs these days are full of attitude. Apparently the clinical training has changed. They don't produce "physician extenders" anymore, all they produce are "experts". Eeeeverybody's an expert...

My God. So much this.
The freaking attitude so many of them have...

 

[deleted109597]

I only calculate a heart score (in the chart) if it agrees with my plan.

There are patients there for suture removal that would have Heart scores of 5 or more. Teaching the scribes when to do it is important.

 

[GeneralVeers]

I only calculate a heart score (in the chart) if it agrees with my plan.

There are patients there for suture removal that would have Heart scores of 5 or more. Teaching the scribes when to do it is important.

Exactly. And one can finesse the first part of it "slightly suspicious" to 0 if it meets the plan. Drives me nuts when my midlevels put highly suspicious on someone who could otherwise be discharged and bump their score up to 4 or 5.

 

[RustedFox]

Exactly. And one can finesse the first part of it "slightly suspicious" to 0 if it meets the plan. Drives me nuts when my midlevels put highly suspicious on someone who could otherwise be discharged and bump their score up to 4 or 5.

Mine did the exact opposite; they'd write "crushing chest pain, radiating to left arm and neck w/ SOB" and then score it a zero.

It seriously took me to read one of their HPIs out loud to them and ask them; "Now what about what I've read is NOT highly suspicious?"

That was before they all were fired without exception. Now we have two good ones. Just two.

 

[GeneralVeers]

Mine did the exact opposite; they'd write "crushing chest pain, radiating to left arm and neck w/ SOB" and then score it a zero.

It seriously took me to read one of their HPIs out loud to them and ask them; "Now what about what I've read is NOT highly suspicious?"

That was before they all were fired without exception. Now we have two good ones. Just two.

They sound like complete idiots.

I always write my HPI and MDM after I've made my decision whether they should be admitted or discharged. Everything I write should support the decision.

 

[MechEDoc]

I calculate the HEART score for all chest pain type patients, if it is high and I'm going to discharge, I write something like "low risk history, none of the positive values were influenced by today's presentation... given an alternative diagnosis, hospitalization is not indicated."

 

[RustedFox]

They sound like complete idiots.

I always write my HPI and MDM after I've made my decision whether they should be admitted or discharged. Everything I write should support the decision.

I do this, too.

Oh, and they were complete idiots. Worst part was; we "shared" our MLPs with our sister hospital.
Over at the other shop, they had no oversight and did whatever they wanted to do completely unchecked.
Thus, it led to a situation where it was like parenting a child with shared custody.
"But MOM never makes me do that over at HER house!"

They were told to get in line, or they would get tossed out.
Welp.