Case 1: Rule-in. An 80-year-old woman
An octogenarian woman who had been suffering from chest pain and made recurring emergency visits. She was always told that it was just postoperative pain or psychological pain. She came to the emergency unit again when I was on night shift. Because of her 10-yr long history of a right bundle branch block, the electrocardiogram data was hard to interpret. So, I switched to the 0/1h algorithm. The assessment was a rule-in case because her troponin level was 52 at the time of the visit, but elevated to 131 in an hour. Indeed, it was hard to judge during history taking, but I made the call to take her in and carried out a semi-emergency catheterization exam. The result: RCA#1: 90%; LAD#6: 90%; LCX#11: 90%. This clearly indicate triple vessel disease. After the diagnosis, the patient and her family were grateful that they were able to figure out what the disease was, after suffering from it for over a year.
Case 2: Rule-in. A case where the 0h/1h algorithm successfully revealed an AMI patient whose ECG and physical exam was inconclusive
This could be due to the fact that each patient has different ways of describing the pain they are experiencing. Here is one example (without revealing the name of the hospital): a young resident used the 0/1h algorithm on his patient, made a call of “rule in”, and then asked the opinion of an on-shift cardiologist. The interventionist cardiologist looked at the electrocardiogram data and considered how the patient had described the chest pain, and concluded from his own experience that it would unlikely be ischaemic heart disease. They let the patient go home, only to find the patient being brought back into the ER just half a day later with an ST elevation myocardial infarction. This taught us a lesson, which was that a “rule-in” call made by the algorithm should be taken seriously, even if it doesn’t always indicate an ACS.
Case 3: Observe Zone. A 57-year-old man
A 57-yr-old man who experienced chest pain two days prior. Feeling the pain again prompted him to see a physician. His high sensitivity troponin level was 19 at the time of visit and increased to 23 an hour later. This put him into the “observe” group. We gave him the appropriate prescription and then performed a catheterization exam after 2 days. The result: RCA#2; 99%, LAD#6; 90%, LCX#11; 90%, triple vessel disease. After the treatment, LV wall motion remained normal and no complications were found.
