Low risk Chest Pain in GP land

OK, low risk chest pain in the GP clinic setting.  It can be a vexing issue – we always worry about the big, bad diseases we might be missing – but is there a risk (and logistical headache) in doing a thorough workup and serial enzymes / Troponins on all chest pains?

It kinda depends where you practice as to how you will play this one.

Here is a discussion with a few super Smart GP registrars all over the country.
click HERE to listen to the 35 minute brain storm on the topic.

My bottom line – you need to define your background / pre-test probability of badness before embarking on investigation pathways that can lead to invasive, expensive and unpleasant tests in low risk patients.

Enjoy and comment on this is very welcome – there is certainly no right answer here!

Casey

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5 thoughts on “Low risk Chest Pain in GP land

  1. It’s the vibe, it’s Mabo, it’s all that… I rest my case.. (The Castle)

    Very interesting discussion! I think the chest pain in the 50yo with risk factors is not really low risk. I think on the AHF guidelines he would be intermediate risk at least? Which requires a chest pain pathway and investigation. In rural Camperdown (22 bed hospital 1.5hr from tertiary) we just followed the local hospital guideline (Geelong) and discussed with cardiologist if req’d.

    My initial question on twitter was a 24yo smoker with sharp central pain that went down left arm which lasted 10 minutes about 6hrs ago -who presented to my regional GP clinic (Hospital 25mins away). Firstly, I need to decide if his symptoms sound like ACS. According to the podcast I’m not very accurate at this (and BMJ article). So I have to assume it could be (though it sounds atypical). Next I think of his pretest probability which is low. But then I also hear horror stories of the young person with atypical chest pain that the GP sends home and dies. Also there has been mention of coroners on twitter etc… Ok, so now I’m worried. I could do an ECG in my clinic – cheap, simple, AND part of risk stratifying based on ACS. So I do my ECG and its normal! Hurray! Now what?

    Ok so I send him on his way with analgesia and tell him could be MSK but if pains recur he should (A – go to hospital, or B – come back to the clinic… Where we start again!)

    Ok, so he comes back again and he’s had these pains on and off, maybe some sweating and heart racing. He’s not in pain now… What now?! Do I send him to hospital? Repeat tests? Add TNI? Talk to cardiologist? Tell him it’s just MSK and call my lawyer?

    True story! This is where this debate kicked off.

    My unfortunate conclusion is does anyone want to study A: what GPs do on these scenarios? B: what are patient outcomes like? C: can we make a risk stratification tool for chest pain in general practice?

    All tricky stuff. Interesting though! Into the grey we go with oir stethoscopes held high!! 😉

    • Hi – thanks for that comment. It is a minefield

      The 50 with 1 or 2 risk factors actually comes back to low risk once he has had negative ECG and trop. His risk is now about what it was before he got the pain oddly enough.
      After 40 the classical risk factors are not really good predictors of acs etc.
      For reference I will direct you yo smartem with Dr David Newman – he does a really deep dive on this.
      So doing a stress test on the 50 yo with negative tests is basically the same as doing it on the next 50 yo who wanders past with no symptoms
      Casey

      • Thanks Casey. I was referring to the AHF ACS guidelines which have >10mins of ACS sounding pain becomes high risk and therefore requires me to send them in to hospital for serial ECG’s, TNI, and possibly an EST – these are easy disposition decisions in GP and ED will be happy with my referral. Didn’t mean that he could not be low risk down the track – I understand why you included the case and I think it helps illustrate the differences in chest pain management well.
        As we see, the ambiguity lies in “>10 mins of chest pain consistent with ACS” and as we know picking the “consistent” symptoms and signs is difficult sometimes.
        Great discussion though! Hopefully in the not so distant future we may have some more hard numbers to help out us GP’s in clinic land! Rob.

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