Evaluation of chest pain suspicious for acute coronary syndrome: Use of anaccelerated diagnostic protocol in a chest pain evaluation unit

Management of patients presenting to the emergency department with chest pa in suggestive of acute myocardial infarction (AMI) remains a continuing cha llenge, A low threshold far admission has been traditional because of conce rn for patient welfare and the litigation potential associated with the ina dvertent discharge of patients with ischemic events. Because of this approa ch, < 30% of patients admitted for chest pain ultimately are found to have an acute coronary syndrome. To reduce unnecessary admissions, maintain pati ent safety, and enhance cost-effectiveness, innovative strategies have been applied to the management of patients with chest pain, It is now recognize d that a tow-risk group can be identified by the clinical presentation and initial electrocardiogram. Chest-pain centers have been developed to provid e further risk stratification and systematic management of these patients, We employ an accelerated diagnostic protocol based on immediate exercise tr eadmill testing to evaluate low-risk patients, Moderate-risk patients are a ssessed over a 6-hour observation period with serial electrocardiagrams and evaluation of cardiac-injury markers. Patients with positive evaluations a re admitted, Those with negative results undergo either exercise echocardio graphy or rest myocardial perfusion Imaging utilizing technetium-99m sestam ibi. Patients with positive functional tests are admitted, Those with negat ive studies are discharged with outpatient followup. These strategies have provided a safe and accurate means of patient disposition from the emergenc y department with the potential for vital cost savings. (C)2000 by Excerpta Medica, Inc.