Advances create opportunities: implementing the major tenets of the new unstable angina guidelines in the emergency department

Of all the clinical syndromes with which emergency physicians must deal, chest pain of coronary cause has benefited from the most striking recent advances both in diagnostic approach (cognitive and technologic) and in therapeutic options. Chest pain evaluation and management have become important foci of research in emergency medicine, and entire units are dedicated to its clinical prosecution in emergency departments and elsewhere in the hospital. New diagnostic tools are proposed and studied on a regular basis. Antiplatelet, antithrombin, and fibrinolytic agents unknown in clinical practice as recently as 5 years ago have secured places in the emergency physician's armamentarium for treating acute coronary syndrome. Many of these diagnostic and therapeutic tools have been developed in the coronary care unit and in the cardiac catheterization laboratory. Although intuitively they may also be useful outside of those settings, they have unreliably been brought to the ED for implementation and resultant appropriate prompt and early care of the coronary patient who does not meet fibrinolytic criteria. As emergency physicians seek to bring accurate chest pain risk stratification into their practice and begin to use new therapeutic agents to minimize myocardial damage before turning the patient's care over to other specialists, it is essential that they are familiar with the data supporting these approaches. In this commentary, we seek to place the American College of Cardiology/American Heart Association unstable angina guidelines into the clinical context of the ED.