03 8 / 2012
Ryan Radecki’s post got me in a tizzy, a tizzy I’ve been meaning to write about for awhile now, where he talks about validation of the Vancouver Chest Pain Rule; it also ties in nicely with my thoughts on this whole “CT Coronary Angio” NEJM article that’s getting all this buzz, too.
Mel Herbert said this before, and I’m going to say it a little bit differently: we’re sadly moving from the art of medicine to the click of medicine.
Let me explain.
I worry that we as a specialty (Emergency Medicine) are heading toward being as mind-numbing as the trauma services are nowadays:
- You have trauma? You get pan scan.
- You have chest pain? You get troponin.
Obviously there are other causes of chest pain besides acute coronary syndrome (more on that in another post), but once you’ve gotten to a point with the patient that you think you’re down to ACS vs. other atypical weird chest pain you can’t diagnose in the ED but is not life threatening (esophageal spasm, GERD, anxiety, etc), it’s so damn easy to just “Click: EKG, Troponin” (and we’re all reasonably worried about missing an MI for a whole host of reasons) that we just click, without considering pre-test probability in any of this.
So let’s compare these two articles:
You’ll notice that the Vancouver Rule got people to less than 2% risk, which is really, really good — and that with troponins, probably would have been even better.
The NEJM article also had “good” outcomes. But you’ll notice that these people got into the study if they were 40-74, and the Emergency Physician felt like they needed a workup for ACS. That’s the stinker, right there. Have we all just gone crazy (I’m included in the “we” here, too) and decided that everyone needs a workup for ACS? You take a low risk population (negative troponin, non-ischemic EKG, not a good story for ACS), and no matter what test you do on them, you’re not going to find much disease… because they’re low-risk to begin with.
You could take low-risk patients and do a coronary CT on them to decide they don’t have coronary artery disease, but you could also take low-risk patients and apply a silly test to them: you’re low risk if you’ve eaten cheese. (See, it works, because they’re already defined as low risk!)
But it’s just so damn easy to click and order a CT coronary angiogram on them that it’s going to happen to people who didn’t need the test in the first place.
I worry that we’ll start applying this test to low-risk patients — as the NEJM article suggests — and end up first, doing harm. Anyone else feel the same way?