DAMNED IF YOU DO, DAMNED IF YOU DON T. Carissa J. Tyo, MD
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1 DAMNED IF YOU DO, DAMNED IF YOU DON T Carissa J. Tyo, MD
2 NO DISCLOSURES I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and or provider(s) of commercial services discussed in this CME activity I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation
3 OBJECTIVES Learner will be able to recognize the challenges inherent in the complicated Cardiology/Emergency Physician relationship Learner will be able to recognize atypical presentations of patients with suspected cardiovascular disease Learner will be able to recognize the need to adapt the patient care approach to the context of the patient s presentation
4 TO MAKE THE CALL Pavlovian conditioning to the sight of certain EKGs Knee jerk call to the Interventionalist Cardiology doesn t always appreciate the jerk call
5 And so unfolds before you... A SERIES OF UNFORTUNATE EVENTS
6 CASE 1: MRS. WHITE A 72 yo woman with h/o Hypertension, CAD, DM, HL and severe PVD presents to ER for 2 nd opinion regarding revascularization procedure for her left leg. She has been having intermittent claudication for several months with progression of severity of symptoms. OSH recommending Fem-Pop Bypass graft. She presents today to get 2 nd opinion from Tertiary Care Hospital
7 EXAMINATION
8 THE EKG T/B 6:12
9 THE CONVERSATION To the Surgeon: Wait, we may need to discuss this for medical clearance prior to surgery To the Cardiologist: Not sure what to do with this, but I have an asymptomatic patient here with a wildly abnormal EKG I would like to discuss with you. {shows EKG to Cardiologist} ACTIVATE THE CATH LAB!!!
10 THE OUTCOME Severe triple vessel disease, recommended CABG prior to Fem- Pop. Turns out her leg pains had prevented her from any significant exertion and that she only occasionally got chest pressure going up stairs.
11 THE PEARL Vasculopaths often have abnormal EKGs at baseline Manage the patient based on the symptoms at hand
12 CASE 2: MISS SCARLET 8 yo child without PMH presents with c/o ongoing substernal chest pain since yesterday evening. No h/o trauma, non-exertional, no cough/cold. Told mother about it that night and was given ibuprofen and sent to bed. Awoke mother very early in the am due to continued pain.
13 EXAMINATION
14 THE EKG: T/B 0:12
15 THE CONVERSATION To the Interventionalist: I have an 8 yo girl with no pmh here with crushing substernal chest pain since last night. Her EKG shows Anterolateral STEMI From the Cardiologist: So you have an 80 yo with a STEMI? To the Interventionalist: I have an 8 yo girl with a STEMI. I am activating the cath lab. From the Cardiologist: Please don t, just transfer her to the Children s Hospital for further management.
16 THE OUTCOME Troponins trended with evidence of myocardial tissue injury, max troponin of 6. Angiogram done at Children s Hospital with normal coronaries. Able to induce vasospasm with ergonovine easily in LAD thereby resulting in diagnosis c/w Prinzmetal s Angina Started on CCB and subsequently discharged home.
17 THE PEARL Don t let the age fool you. The potential for STEMI transcends ageism depending on the source of the problem.
18 CASE 3: PROFESSOR PLUM 68 yo Asian man with h/o arthritis (though he does not see a physician regularly) presents via EMS for evaluation of acute AMS. Wife called 911 when she was awoken by his jerking movements in bed and she was subsequently unable to successfully waken him. He had gone to bed in his normal state of health. EMS BS of 125, GCS: E3, V2-4, M5 so (I don t speak Cantonese)
19 EXAMINATION
20 THE EKG: T/B 1:38
21 THE CONVERSATION To the Cardiologist: I have a 68yo man here with a history of waking with jerking movements and AMS. He is improved now and voices no complaints but his EKG is strange looking. I have some suspicions, but wanted you to take a look at it. {shows EKG to Cardiologist} ACTIVATE THE CATH LAB!!!
22 THE OUTCOME Troponins remained normal throughout hospital course. Angiogram done showed mild atherosclerotic disease of 10-30% in a variety of vessels without hemodynamically significant blockage. EKG shown to EP specialist who agreed it had Brugada morphology and plan for AICD during the sentinel admission.
23 THE PEARL Not all ST segment abnormality is true ischemic change. Prioritize the life threats. Maintain an open dialogue with your consultants.
24 CASE 4: MRS. PEACOCK 65 yo woman with h/o Htn, DM presents for evaluation of palpitations and chest tightness. Pt admits to feeling quite anxious. Pt states she was seen 2 days ago at OSH for same complaint and that they had done an EKG/CXR, labs and sent her home. Pt with same pain again tonight so son brought her in to find out what is going on.
25 EXAMINATION
26 THE EKG: T/B 0:05
27 SHOULD CONFIRM LBBB Resident called OSH to confirm LBBB not new Reported d/c dx of Anxiety
28 THE CONVERSATION To the Cardiologist: I have a 65yo woman here with c/o chest pain and EKG shows new LBBB. She was just at an OSH 2d ago and I got them to fax me the EKG. It was narrow complex. Here she is hypertensive, tachycardic and appears anxious. I gave aspirin and am giving a little morphine to address pain and anxiety From the Cardiologist: Send me the EKGs {Fax Sent} From the Cardiologist: I guess we activate the Cath Lab
29 THE OUTCOME As the patient relaxed, HR decreased with evidence of regression to NSR Repeat EKG looked just like the EKG from OSH 2d prior By the time the Interventionalist arrived, Pt with no pain, NSR on EKG w/o focal abnormality Aborted plan to do angiogram. Instead bedside TTE with no RWMA, mild LV hypertrophy with impaired relaxation.
30 THE PEARL LBBB has fallen out of favor as a clear marker for acute ischemic heart disease. Newest guidelines do not advocate for invasive testing for isolated new LBBB.* *Wilner, et al. LBBB in Patients With Suspected MI: An Evolving Paradigm. Expert Analysis Amer College of Cardiology. February 28, 2017
31 CASE 5: MR. GREEN 52 yo man with h/o CAD, Pacemaker, Htn, Dm, CKD and Bipolar d/o presents with c/o sharp chest pain. Mild dyspnea w/o sweating/nausea. Chronic leg swelling. H/o similar in the past but not sure if this was like the pain associated with prior heart attacks. Last intervention was 3 years ago with prior stent placed. OTW compliant with current plan of care for all disorders.
32 EXAMINATION 202 mg/dl
33 THE EKG: T/B 0:08
34 THE CONVERSATION To the Cardiologist: I have a 52yo man here with a extensive cardiac hx here now with an atypical c/o chest pain. Not sure if similar to past cardiac chest pain. His EKG is paced but looks like exaggerated ST seg deviation from baseline." From the Cardiologist: So he s paced? To the Cardiologist: Yeah, but it looks different. From the Cardiologist: So we can t interpret it for ischemia. To the Cardiologist: Huh? I am applying pacemaker criteria. From the Cardiologist: I ll send in the fellow to get an Echo now, hold off on activation. To the Cardiologist: Okay. {Documents full conversation}
35 THE OLD EKG
36 THE OUTCOME Bedside Echo w/o new RWMA. Globally depressed LVSF. BNP elevated 1,223 Troponins through hospital course. Pt diuresed with improvement in symptoms. Medications optimized and given CKD, deferred invasive testing. EKG changes believed to be rate related and presentation more c/w CHF.
37 THE PEARL Elevated HR may exaggerate ST deviations Sometimes the ER Doc is more familiar with the atypical EKG signs of potential ischemia so remember to advocate for your patient. Keep the advocacy in context. And just document your logic.
38 GETTING A CLUE
39 WORKING RELATIONSHIPS
40 EM CARDIOLOGY Cardiology is a complex topic and deeply nuanced Know what you know and when to ask for help Advocate for your patients Cooperation is key to providing best care for the patients Keep learning: Always a new EKG trick to learn.
41 Thank you for your audience! QUESTIONS?
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