You'll Shoot Your Eye Out!

Pearls:

• The diagnosis of ACS in the acute care setting has three parts, history, ECG and troponin. Even if one is unremarkable, don’t ignore the other two!

EKG PITFALLS

• In the acute care setting, roughly 25%-50% of cases of missed ACS are, in retrospect, attributable to misread EKGs with not so subtle findings.

• “Nonspecific” is not the same thing as normal and should prompt one to scrutinize the EKG with great attention to detail.

• Compare a new EKG to an old EKG if available.

• If an EKG is of poor quality and has a lot of artifact, get a new one to provide a quality baseline.

• If a patient has ongoing chest pain, one EKG is not sufficient to thoroughly evaluate for ACS. The ACCHA guidelines specifically recommends serial 12-leads EKGs every 15 to 30 minutes for the first hour in patients with a concerning story for ACS.

• 15-20% of STEMIs end up being diagnosed on the repeat 12-lead. If you're not repeating your ECGs, you're missing STEMIs

HISTORY PITFALLS

• The most common misdiagnosis sitting on the chart of a malpractice case for a missed MI is gastric reflux.  

• It's very common for patients with acute coronary syndrome to present with reflux type of symptoms. There are several reasons why:

• 50% of patients with an MI will report an increase in belching during their ischemic pain.

• 20% of patients, when they're describing their ACS pain, use the words burning or indigestion.

• 15% of patients get some relief with antacids while 8% get total relief of their ACS pain with antiacid.

• 8% of of patients reported that their ACS pain began while eating a meal.

• Another pitfall is failure to appreciate the risk in young patients even in their late teens. For these patients it is important take a good history and if the patient  has a concerning history, perform an EKG.

• The failure to appreciate the atypicality of presentations in women is another common pitfall for providers.  

• Women are more likely to present with pain that radiates down the right arm instead of the left and more likely to present with just isolated shortness of breath or nausea and vomiting instead of chest pain.

• 10 to 12% of elderly with ACS will present with upper abdominal pain instead of chest pain. Anything in the chest can produce belly pain just the way anything in the belly can produce chest pain.

• In patients with upper abdominal pain without much tenderness, check a 12-lead.

TROPONIN PITFALLS

• Don’t ignore a really concerning history and/or EKG, if the troponins are negative. You can still have ACS even in the presence of negative troponins!

• In Dr. Mattu’s experience, two thirds of the MedMal cases that he’s seen have had negative troponins on the chart.