Chest pain centers: Diagnosis of acute coronary syndromes

Chest pain centers in the emergency department have generally been accepted as a safe, cost-effective, and rapid approach to the evaluation, triage, a nd management of patients with potential acute coronary syndromes. These ce nters were initially designed to enhance patient care by decreasing time to treatment for acute myocardial infarction (AMI) and rapidly identifying pa tients with unstable angina. They also included community outreach and educ ational objectives designed to reduce time from the onset of chest pain to ED presentation. In the past decade, health care financial constraints have created addition al impetus to the development of chest pain centers. Cost reduction efforts have occurred to reduce hospitalizations, lengths of slay, and unnecessary treatments and procedures. Practitioners and administrators try to balance these goals with the imperative to provide high-quality patient care. Prot ocol-driven approaches have been developed for specific disease processes i n emergency settings. The chest pain center concept is such an approach for patients with chest pain. Chest pain is the second most common ED presenting complaint and is a sympt om related to the leading cause of death in the United States, coronary art ery disease (CAD). One third of ED patients with chest pain will eventually have a diagnosis of acute coronary syndrome. Many patients with acute coro nary syndromes have atypical presentations that are not diagnosed in the ED with the traditional diagnostic evaluation of a history, physical examinat ion, and 12-lead EGG. If they are not admitted to the hospital for further evaluation, the diagnosis may be missed. The 2% to 5% of AMI patients who a re inadvertently released home often have poor outcomes and result in a lea ding cause of malpractice suits in emergency medicine. More than one half o f ED patients with chest pain have clinical findings after their initial ev aluation consistent with acute coronary syndromes and are admitted to the h ospital. Approximately one half of these patients, after evaluation in the hospital, are found not to have acute coronary syndromes. The cost for thes e negative inpatient cardiac evaluations has been estimated to be $6 billio n in the United States each year. Today, chest pain centers serve as an integral component of many EDs. Their success and safely is the result of a focused, protocol-driven approach di rected at the acute coronary syndrome continuum from unstable angina to tra nsmural a-wave myocardial infarction. New therapies for acute coronary synd romes make ED triage and risk stratification increasingly important. Althou gh different chest pain center protocols have proved effective, all address the diagnosis and rapid treatment of acute myocardial necrosis, rest ische mia, and exercise-induced ischemia. Identifying patients with coronary arte ry disease in one of these stages in the spectrum of myocardial ischemia is the foundation for a successful chest pain center in the ED.