[HSF] Sympathy anyone.......

[Ani Anyanwu]

> Whatever your cookbook says, dissections are by no means always a one day > presentation. > Bob
 
Of course I agree with you Dr Frater but in the primary care setting such presentations *for patients with chest pain* are the exception rather than the rule. Although we consider the denominator as all patients with type A, and therefore recognize subacute presentations are not infrequent, in the primary care setting their denominator is the thousands of patients who have chest pain on a daily basis and such subacute presentations will be rare, well below 1% of patients they see with chest pain.
 
In ordering diagnostic testing some system, consciously or subconsciously has to guide choice of testing. Many will use the Bayes Theorem - although Marfans may be more likely to dissect, the fact remains that a tall patient with chest pain is still far more likely to have a myocardial infarct than a dissection, so on initial presentation the pre-test probability (for myocardial infarction) in the view of most primary care doctors will be high. Then they do the first screening test and find ST elevation and high troponin, the post-test probability for AMI now becomes very high. So the next step is to order a confirmatory test (cardiac catheterization) which will turn out positive in the vast majority of patients. Remember the cardiologists did not get this patient of the street and they essentially are providing a service (diagnostic test to confirm coronary stenosis plus therapeutic intervention), the clinical assessment and diagnosis having been done by the primary or ER doctor and in many hospitals the patients literally move to the cath lab (on the order of the ER doctor) without a cardiological assessment. The antiplatelet agents are often now given in the ER before the cardiologist gets hold of the patient.  If the same patient had a normal ECG then the post test probability for AMI would be low and other diagnoses would have come into consideration.  Similarly if the patient had a wide mediastinum on CXR or aortic regurgitation then the post-test probability for AMI will be low and dissection goes high up the list.
 
Most ERs see thousands of patients with chest pain in a year, of which acute aortic dissection will constitute no more than a handful, so it is IMHO expecting too much to ask they recognize atypical presentations. I last month operated on a patient who had a dissection that went undiagnosed for 3 weeks - in that three week period he attended hospital thrice include a one week admission for 'pneumonia'. It is not as easy as we see it to recognize rare diseases in the primary care setting. This is partly why some are testing immediate cardiac CT, rather than direct coronary angiography, as the next step diagnostic test for chest pain or dyspnoea as it will immediately differentiate patients with the three most life threatening conditions - AMI, acute dissection and pulmonary embolizsation.
 
All who have worked in an ER or primary care setting will recognize where I am coming from as we have all sent home the odd patient with a diagnosis of flu, cold, gastritis etc, that comes back a day later with a myocardial infarct, meningitis, appendicits etc or worse (death).
 
Ani
 
 



> From: Rwmfglycar at aol.com> Date: Fri, 2 May 2008 05:09:00 -0400> Subject: Re: [HSF] Sympathy anyone.......> To: OpenHeart-L at lists.hsforum.com> CC: > > > > In a message dated 5/1/2008 11:36:34 P.M. Eastern Daylight Time, > anianyanwu at hotmail.com writes:> > four day history moreso will push most doctors to a diagnosis of acute > coronary syndrome - even if there are truly marfanoid features - as in the > emergency medical cookbook, dissection is an acute presentation and not a four day > one. > > > > > Whatever your cookbook says, dissections are by no means always a one day > presentation. Dissections can stutter along; in fact they can mimic numerous > other symptom patterns for numerous diseases. Marfan patients are particularly > prone to less than critical dissections prior to the big one.> The truth of the matter is that the cardiologists were thinking down their > own little alley and not engaging in the old fashioned exercise of differential > diagnosis.> Bob> > > > **************Wondering what's for Dinner Tonight? Get new twists on family > favorites at AOL Food. > (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
_________________________________________________________________

Discover and Win with Live Search

http://clk.atdmt.com/UKM/go/msnnkmgl0010000007ukm/direct/01/