AW: [HSF] Sympathy anyone.......

Mon May 5 09:58:43 EDT 2008

Good idea to begin with a CT if you can have a good quality for coronary
arteries and perform it quickly.
No dissection ---> antiplatelets, etc.
Roberto

-----Ursprüngliche Nachricht-----
Von: openheart-l-bounces at lists.hsforum.com
[mailto:openheart-l-bounces at lists.hsforum.com] Im Auftrag von Ani Anyanwu
Gesendet: Freitag, 2. Mai 2008 13:29
An: openheart-l at lists.hsforum.com
Betreff: RE: [HSF] Sympathy anyone.......

> 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)>
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