Apr 21, 2017


The story

That pang in your heart when you return from vacation probably doesn't need medical attention. But new research suggests that chest pain without a clear cause is more worrisome than thought.

The background

Life in primary care Britain is apparently a lot like your ED shift: everyone comes in with chest pain. In Britain, that means 1-2% of adults will present to clinic each year with new chest pain symptoms. Doctors can either diagnose coronary disease, pin the chest pain on a non-cardiac cause (commonly GERD, anxiety, or musculoskeletal pain), or leave the pain unattributed. Per UK electronic health records, almost three quarters of patients ultimately fall in the unattributed category, with no diagnosis ever attached to their pain.

The study

Researchers looked at cardiovascular outcomes for chest pain left unattributed for 6 months or more. Over 5 years of follow-up, patients with unattributed chest pain were 2.5x more likely to have a myocardial infarction (MI) as those whose chest pain was labelled non-cardiac, though those diagnosed with angina remained at much greater risk. Because the burden of undiagnosed chest pain is so large, on a population level the excess MIs from unattributed chest pain outnumber the MIs provoked by anginal chest pain. 

The takeaway

Giving a diagnosis of angina starts a cascade of preventative management, while leaving chest pain unassigned triggers very little. This research suggests there may be a role for a middle ground, or even room for unattributed chest pain in prognostic models.

Say it on rounds

When the last slice of cafeteria pizza is within reach

Just because you can doesn't mean you should. The same holds for annual eye screening in type 1 diabetes, where personalized medicine may play an increasing role. Researchers used 30-year follow-up outcomes from the Diabetes Control and Complications Trial to create a model that predicts retinopathy progression based on hemoglobin A1C levels and current retinopathy status. A simple web tool uses the data to personalize screening intervals and reduce unnecessary exams.

When you get disconnected in the middle of obtaining a prior auth

Good luck finding analgesia. Patients with prior GI bleeds are in a similarly tough spot, since nonsteroidal anti-inflammatories (NSAIDs) can put patients at risk for recurrent bleeds. A comparison of celecoxib (Celebrex), a COX-2 selective NSAID, with non-selective naproxen (Aleve) in 500 patients with arthritis, prior GI bleeds, and cardiovascular disease requiring aspirin found that patients treated with celecoxib were half as likely to suffer a recurrent bleed. All patients in the trial were also on proton pump inhibitors. NSAID avoidance is still preferred in this population, but consider celecoxib if inclined to dose.

When your night shift starts with 5 admissions 

It's easy to predict when you'll get no sleep, but harder to tell who'll recover from a significant bleed. A retrospective study of 350 patients found that a blood urea nitrogen (BUN) level rise at 24 hours after a non-variceal GI bleed predicted inpatient death, rebleeding and the need for surgical or radiological intervention when compared to patients with decreased or unchanged BUNs.
Gastrointest Endosc

Brush up

Acute spinal cord compression

Medical context is key to spinal cord compression. So while symmetrical paralysis of the limbs, urinary retention or incontinence, and loss of sensation below a spinal level will prompt you to wheel your patient to MRI in the middle of the night, the overall clinical picture helps. Think bony mets for patients with cancer, epidural abscess in patients with sepsis or IV drug users, epidural hematoma in patients with bleeding disorders or those on anti-coagulation, and traumatic cord compression in patients with injuries or falls.

What's the evidence

For surgery in epidural abscess? Urgent surgery is the treatment of choice for most acute cord compression, and the same holds for epidural abscess despite the possibility of medical management with antibiotics. A 2014 retrospective case review of 128 patients concluded that early surgery and antibiotics improved outcomes vs. antibiotics alone. About 40% of patients treated medically had progression of symptoms and ultimately needed surgical decompression. 

What your Game of Thrones friends are talking about

Sh*t goes down with dragons. And even if most docs don't believe in the mythical properties of dragon's blood, there's a little bit of magic in a promising antibiotic isolated from the Komodo dragon.

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