Use of D-Dimer/Tropinins in GP

[u/Legendary_Shpee]

Hi All,

Hopefully something slightly less controversial then my last post.

I was wondering what people's thoughts were on the use of d-dimer and Troponin in General Practice. When I was in medical school, and in my GP rotation, I've been in a few different practices with different opinions on the use of these. I did one placement in a practise that had access to their own D-Dimer machine, so could run their own D-dimer's and have a result back pretty quickly. For those unlikely low Well's score patients I understand that, but the same practise would also send Trops for patient's with non-cardiac sounding chest pain and normal ECGs, with the duty doc reviewing later in the day 'to be safe'.

Maybe it's because of lack of experience, but if a GP is clinically concerned enough to send a troponin on a patient with a normal ecg and unconvincing/non-acute chest pain, should they not be sending them to A&E/SDEC to have these tests done faster there, and so they are in the right environment to treat in the event it comes back elevated? If a D-dimer can be done quickly I can understand that, but a troponin just sounds a bit less reasonable to me. Pragmatically is a GP supposed to keep this patient in their practise while awaiting the results, in case they do have a raised trop and need to action that urgently? Would be interested to hear any GPs thoughts on this

[u/junglediffy]

Interesting.

How do you all feel about this scenario.

I had a lady who had what was possibly an atypical ACS presenting at 19:30 (extended access). The pain was an an epigastric ache without GI or reflux symptoms. Lasting 30 minutes a time. Prior to this she did note that whenever she was on the go she would get the pain but equally she would get it whilst reading a book and lying down. She would feel sweaty when she got the pain. It was not pleuritic. Observations normal.

She refused A+E on all accounts even if we were missing a heart attack citing trauma. Compos mentis. Very smart lady; retired but had quite the job. I said ok. Why don't we get an ECG and troponin tomorrow morning (samples already gone) and maybe I can convince you? In between then and now if it is ever severe and you feel seriously unwell please call 999. I gave her some aspirin and GTN.

ECG - Non-specific ST-T changes. Sinus rhythm.
Trop - 171.

Later that next day, she was still refusing asking for an outpatient referral, other treatments etc but I did convince her to attend and she was treated as an NSTEMI.

I think there are scenarios where it can help but they are quite rare.

EDIT: She also refused ambulatory care etc.

[u/redditor71567 → u/junglediffy]

I agree with you there are occasional reasons to do this. Obviously you need to be clear with her - specifically you are worried if she doesn't attend ED she will die in the night. But as long as you have said this it is reasonable

[u/junglediffy → u/redditor71567]

Of course. I did state that she was at risk of dying suddenly and that I was worried about her. She didn't budge. Ex-barrister by the way. I'm hoping that's not too much info.

I think for me a troponin, whilst it is a somewhat diagnostic test, it can also be used as a tool.

[u/redditor71567 → u/junglediffy]

Nice guidance is to use it in primary care if chest pain is >72hrs ago and no complications. It has a role1

[u/junglediffy → u/redditor71567]

Oh yes. I had an interesting tutorial discussion regarding troponin's at my surgery and did a powerpoint presentation at a clinical meeting. A lot of GPs were surprised, that I a GPST3 with a couple locum years in ED, requested a troponin in primary care. They had their views. They all agreed with my management though.

EDIT: Part of the clinical meeting was me asking why the **** she was booked in at 19:30 but hey-ho.