BY TONI LAPP
 |
Face it: When the stakes are life or death, the differential diagnosis of chest pain can be an awesome challenge for the family physician. Since a missed diagnosis of acute myocardial infarction is the most commonly lodged malpractice claim against FPs, "no one wants to take a risk," said Clare Hawkins, M.D., associate professor of family medicine at Baylor College of Medicine, Houston.
Hawkins, who also is family medicine residency director at San Jacinto Methodist Hospital in Baytown, Texas, discussed four coronary syndromes -- stable angina, unstable angina, non-ST elevation myocardial infarction and acute myocardial infarction -- in his Oct. 1 Scientific Assembly presentation, "Acute Coronary Syndromes."
Differential diagnosis
Many's the physician who was about to diagnose what seemed to be a straightforward case of gastroesophageal reflux disease but -- in the interest of being thorough -- did a complete work-up, fearing hidden heart problems, said Hawkins.
In addition to GERD, the differential diagnosis includes pericarditis, myocarditis, aortic dissection, pneumonia, pleural effusion and dyspepsia. Patients' jaw, arm or back pain could be caused by heart problems; it's important to keep an open mind, Hawkins said.
Array of tests
The meticulous physician has an array of tests to choose from, said Hawkins, but FPs will want to be familiar with the pitfalls of those tests. For instance, 15 percent of electrocardiograms are normal at initial presentation, and only 50 percent are sensitive for detecting an MI, Hawkins said. Echocardiograms offer subjective results. Some "flashy tests" such as C-reactive protein and interleukin-6 assays may be tempting, but when it comes to predictive value, "biochemistry's not there yet," said Hawkins.
Physicians need to view the issue with the knowledge that, put simply, a coronary problem points to an area of the heart that's not getting oxygen when it needs it, Hawkins said. Stress tests are quite effective in this regard.
Posthospitalization
"Most patients want to be cured, not just managed," said Hawkins, and that's where FPs come in.
The fact is, where cardiologists leave off, FPs often must pick up the ball. And acute phase risk -- when the danger is highest -- is two months after discharge following a cardiac event, said Hawkins.
He encouraged FPs to take advantage of the "teachable moment" presented by a heart attack. This is the time to talk with patients about lifestyle choices, be it smoking cessation, diet or exercise.
It's also time to talk to the patient (and family) about the patient's goals -- reducing anxiety, returning to driving, returning to work, returning to sex. And just as hospice care is advisable for certain cancer patients, it is sometimes advisable for certain heart patients and should be discussed, Hawkins said.
FP Report is published by the
AAFP News Department.
Copyright © 2003 by
American Academy of Family Physicians.