Chest pain units: a modern way of managing patients with chest pain in the emergency department

It is estimated that 5 to 8 million individuals with chest pain or other symptoms suggestive of myocardial ischemia are seen each year in emergency departments (ED) in the United States 1,2, which corresponds to 5 to 10% of all visits 3,4. Most of these patients are hospitalized for evaluation of possible acute coronary syndrome (ACS). This generates an estimated cost of 3 - 6 thousand dollars per patient 5,6. From this evaluation process, about 1.2 million patients receive the diagnosis of acute myocardial infarction (AMI), and just about the same number have unstable angina. Therefore, about one half to two thirds of these patients with chest pain do not have a cardiac cause for their symptoms 2,3. Thus, the emergency physician is faced with the difficult challenge of identifying those with ACS - a life-threatening disease - to treat them properly, and to discharge the others to suitable outpatient investigation and management.     

Chest pain units: management of special populations

Chest pain units provide an important alternative to traditional hospital admission for patients who present to the emergency department with symptoms compatible with acute coronary syndrome and a normal or inconclusive initial evaluation. Although patient subgroups such as women, diabetics, those with established coronary artery disease,and those with symptoms related to stimulant use present unique challenges,management in a chest pain unit appears to be appropriate in these populations. Judicious application of accelerated diagnostic protocols and current testing methods can promote safe, accurate, and cost-effective risk stratification of special populations to identify patients who can be safely discharged and patients who require hospital admission for further evaluation.     

Chest pain units: state of the art of the management of patients with chest pain in the emergency department]

Chest pain is one of the most common reasons for patients coming to emergency departments. Most of these individuals end up being hospitalized due to uncertainty of the cause of their complaint. This aggressive and defensive attitude is taken by emergency physicians because some 10 to 30% of these patients actually have acute coronary syndrome. As the admission electrocardiogram and serum CK-MB level have a sensitivity of about 50% for the diagnosis of acute myocardial infarction, serial evaluation is mandatory for non-low risk patients. Inspite of this knowledge, an average of 2-3% of patients with acute myocardial infarction are erroneously released from emergency departments, what is responsible for expensive malpractice suits in the United States. Chest Pain Units were introduced in emergency practice two decades ago to improve medical care quality, reduce inappropriate hospital discharges, reduce unnecessary hospital admissions and reduce medical costs, thus making patient's assessment cost-effective. This is achieved mostly with the use of systematic diagnostic protocols by qualified and trained personnel in the emergency department setting and not in the coronary care unit.     

Chest pain in the emergency room. Importance of a systematic approach

OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74% of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12%) had AMI without ST segment elevation and 202 (31%) had unstable angina (UA). In route 2 (high probability of ACS) 17% of patients had AMI and 43% had UA, whereas in route 3 (low probability) 2% had AMI and 7 % had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49%), with a positive predictive value considered only satisfactory (79%). CONCLUSION: A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.     

Chest pain units. Organization and protocol for the diagnosis of acute coronary syndromes

The two main goals of chest pain units are the early, accurate diagnosis of acute coronary syndromes and the rapid, efficient recognition of low-risk patients who do not need hospital admission. Many clinical, practical, and economic reasons support the establishment of such units. Patients with chest pain account for a substantial proportion of emergency room turnover and their care is still far from optimal: 8% of patients sent home are later diagnosed of acute coronary syndrome and 60% of admissions for chest pain eventually prove to have been unnecessary.We present a systematic approach to create and manage a chest pain unit employing specialists headed by a cardiologist. The unit may be functional or located in a separate area of the emergency room. Initial triage is based on the clinical characteristics, the ECG and biomarkers of myocardial infarct. Risk stratification in the second phase selects patients to be admitted to the chest pain unit for 6-12 h. Finally, we propose treadmill testing before discharge to rule out the presence of acute myocardial ischemia or damage in patients with negative biomarkers and non-diagnostic serial ECGs.     

Chest pain in the emergency department: potential role of multidetector CT

The evaluation of patients presenting with chest pain to the emergency department remains a significant challenge. The primary goal is to distinguish clinically insignificant etiologies from life-threatening causes such as myocardial ischemia, aortic dissection, and pulmonary embolism. The conventional evaluation consisting of history, electrocardiography, and biochemical markers is often inconclusive and noninvasive imaging techniques may prove valuable. This article describes some of the available options and focuses on the potential role of CT angiography to assess indeterminate chest pain.     

Chest pain in the emergency room—an interesting case presentation

A 61‐year‐old woman presented to the emergency room with atypical chest pain, non‐diagnostic electrocardiogram, and an initial troponin level that was normal. A coronary computed tomography angio (CCTA) was performed, and on initial review, it appeared to be normal. Subsequent review including evaluation of functional data from the retrospective scan identified a distal left anterior descending occlusion and an apical wall‐motion abnormality with no other evidence of heart disease. This case illustrates the complementary contribution of anatomic and functional data and serves to remind us that on rare occasions, what looks “normal” is not always normal.