Episode 15 Part 1: Acute Coronary Syndromes Risk Stratification

Emergency Medicine Cases

Dr. Anton Helman

Science, Courses, Medicine, Health & Fitness, Education

4.7 • 602 Ratings

🗓️ 21 June 2011

⏱️ 64 minutes

🔗️ Recording | iTunes | RSS

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Summary

In Part 1 of this Episode on Acute Coronary Syndromes Risk Stratification Dr. Eric Letovksy, Dr. Mark Mensour and Dr. Neil Fam discuss common pearls and pitfalls in assessing the patient who presents to the ED with chest pain. They review atypical presentations to look out for, what the literature says about the value of traditional and non-traditional cardiac risk factors, the diagnostic utility of recent cardiac testing, and which patients in the ED should have a cardiac work-up. Finally, in the ED work up of Acute Coronary Syndromes Risk Stratification, they highlight some valuable key points in ECG interpretation and how best to use and interpret cardiac biomarkers like troponin. Drs. Letovksy, Mensour & Fam address questions like: How useful are the traditional cardiac risk factors in predicting ACS in the ED? How does a negative recent treadmill stress test, nuclear stress test or angiogram effect the pre-test probability of ACS in the ED? What does recent evidence tell us about the assumption that patients presenting with chest pain and a presumed new LBBB will rule in for MI and require re-perfusion therapy? How can we diagnose MI in the patient with a ventricular pacemaker? What is the difference between Troponin I and Troponin T from a practical clinical perspective? Is one Troponin ever good enough to rule out MI in the patient with a normal ECG? Should we be using a 2hr delta troponin protocol? How will the new ultra-sensitive Troponins change our practice? and many more.....

Transcript

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0:00.0	Welcome to Emergency Medicine Cases.com.
0:05.7	I'm your host, Dr. Anton Helman, bringing you Canada's brightest minds in emergency medicine from EMC Studios in Toronto.
0:17.0	On this episode number 15 on acute coronary syndromes, we have with us Dr. Eric Latovsky, Dr. Mark Menser, and Dr. Neil Pham. Dr. Latovsky is an emergency position at the Credit Valley Hospital in Mississauga, Ontario, where he's the chief of the emergency department. He's the director of the Division of Emergency Medicine and the Department of Family Medicine at the University of Toronto, where he's a full professor in the faculty of medicine.
0:42.1	Dr. Menser practices emergency medicine and anecology at the Huntsville District Memorial Hospital and South Muscoe Memorial Hospitals and is an assistant professor of emergency medicine
0:46.3	for the Northern Ontario School of Medicine. He's the co-founder of the evidence-based resuscitation
0:50.8	and focus ED stenography courses. Dr. Neil Pham is an interventional cardiologist
0:55.8	in St. Michael's Hospital in Toronto. He's a director of the coronary care unit and an assistant
1:00.0	professor and clinical teacher in the Division of Cardiology at the University of Toronto.
1:04.4	The past 30 years has seen an incredible advancement in the management of ACS with hugely
1:09.0	improved outcomes that the medical community should really be proud of. It's hard to believe that in my lifetime, we've gone from using
1:15.3	the liver enzyme AST as the only cardiac biomarker and having only ASA, nitro, beta blockers, and
1:21.6	morphine to treat ACS to today's cutting edge workup and management. On the other hand, in Canada, we're still missing between 0.8 and 8% of acute coronary
1:32.3	syndromes depending on where you work, and there's still areas in the management
1:36.3	of chest pain and ACS patient that remain very challenging.
1:40.3	For example, which chest pain patients in the ED need a workup?
1:45.6	Which chest pain patients with a normal ECG and one or two sets of troponins need further workup?
1:50.5	And what should that workup be?
1:52.8	For the practicing EM doc, there's an overwhelming amount of literature when it comes to ACS
1:57.4	that's sometimes contradictory, often supported by industry, and having variable
2:01.6	quality that makes decision-making in the ED sometimes really difficult.
2:05.9	Take anticoagulants, for example.
2:08.1	Should we be using IV-unfractionated heparin or low-molecularate heparin or fond of parinox
	...

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