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The second video has a great overview of the options available to us when investigating chest pain.However, it seems to imply that all patients with chest pain need to have some sort of provocative test or cardiac imaging. The value of testing very low risk patients with stress tests is debatable, and leads to false positives and false reassurance.Also, talking about the negative predictive value of the test without a clear discussion of prevalence, pre and post test probabilities leaves us unclear.I don't know if this answers the challenge initially presented in the first video - what is the appropriate disposition of chest pain patients?
Really appreciate this blog and all the contributors! I'm a physician assistant working in the urgent care side of our emergency department. The information you provide sparks all kinds of learning, guidance, tips, etc...!! Thanks!
I believe the point regarding provocative testing is for low-pretest probability patients with CP (not all chest pain patients). Everyone varies slightly on who is low pretest but needs testing and low pretest but doesn't need testing, for the reasons you mention.Good point about the NPV. This video was meant to open the discussion of CP without delving too deep into the statistics. Ah, what IS the disposition of chest pain patients? That's the eternal debate. It was my impression that it was a question to broach this subject. So many questions, so few definitive answers in Medicine. Thanks for commenting!
Thanks for the reply, Ben. As Nikita said below, I'm purposefully avoid controversy here. My audience for these videos are my medical students, so I purposefully avoid some of the nuances. I think it's more important they learn where we are starting and then later we can talk about deviations and subtleties. Your point is well taken. There is a lot more to ordering and interpreting stress testing then I went into here. That is a discussion for when working when a student asks their attending, "but I thought we were supposed to stress them, why aren't we?"
All you have to do is listen to any low risk CP podcast on EMRAP to know how complicated this debate is!! I go through this battle multiple time a shift!