Chest Pain


This article in the USA today discusses the stories of 2 men with heart disease, one of whom died, and one of whom did not. Both presented to the ER. One got sent home and was dead 24 hours later. The other was admitted ot the hospital, no diagnosis of heart disease was made. 2 days later a different doctor performed a catheterization and found extensive heart disease including occlusion of bypass vessels from 11 years prior.

My thoughts on the article…first of all, they make ER doctors look like idiots. Second of all, the first ER doctor was an idiot for sending the patient home. An ER visit cannot absolutely rule out heart disease or even a heart attack due to the nature of testing available in the ER and the natural course of a heart attack. Full evaluation requires admission to the hospital, serial cardiac enzymes and the appropriate diagnostic tests such as a stress test or cardiac catheterization.

Because stress tests can have a high number of false negatives as in the case of the 2nd patient, certain groups should skp that test entirely and have a catheterization performed as the first test. The second patient in this article did not get a catheterizataioni during his stay. If he had not run into a different cardiologist in the hospital he may not have had the subsequent life saving care that resulted when the cath showed 80-90 % stenosis of his arteries.

The doctor who cared for the first patient, the one who died, claims he was not having a heart attack at the time of presentation, that his symptoms which brought him to the ER that night were unrleated ot his heart condition, and that he died the next day from “chronic heart disease”. Total Bullshit in my opinion.

Sure anything is easy in hindsight, but an older gentleman with a history of heart disease presenting with chest pain is having what is called “Acute Coronary Syndrome”, a catchall for pain related to underlying heart disease. More specifically, he was having unstable angina…no heart attack is in progress, but he is having symptoms of angina whcih are either new or different than before. He was appropriately ruled out for having a pulmonary embolism or aortic disection, but his disposition should have been admission to rule out unstable angina.

So while the USA today article makes us look like fools, maybe it will help me end my endless arguments with patients about why I would like them admitted ot the hospital. In fact, maybe I’ll start carrying a copy of this article with me to show to them when they insist on going home.

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