Chest Pain Centers - Where Do We Go From Here?
As we begin to put together the New Society's structure, operating activities and modus operandi we must first recognize the science based information that has allowed us to focus on patients presenting with chest pain to the emergency department as it brings about efficiency through protocol driven algorithms resulting in a higher quality of medicine that is cost effective.
WHERE THEN DO WE GO FROM HERE? My thoughts are offered at this time to provide practical suggestions how we can continue to develop a learning curve of progress similar to the one seen with the Coronary Care Unit development in the early 1960's.
Perhaps one of the most important contributions to the present Chest Pain Center development has been the development of a comprehensive and systematic triage system for patients presenting to the emergency department with chest pain/chest discomfort. Joseph P. Ornato and Robert Jesse from the Medical College of Virginia and others have now contributed greatly to this schematic understanding.
Building upon this initial effort we have already begun to see a great deal of work being carried out in the subset patients with nonQ-wave myocardial infarction and high risk unstable angina. Before such patients were admitted to the Coronary Care Unit for several days on aspirin, tridil and heparin. Only later was it discovered that the cardiac enzymes had risen indicating myocardial damage had taken place. Now we are beginning to see an aggressive approach being applied to such patients early in their course because therapy is available with GPIIb/III a platelet inhibitors and early catheterization should the instability continue. Within the near future we hope to see improvement in the identification of such patients in the early course of their acute coronary syndrome as we begin to understand better ways of identifying patients with prodromal symptoms in the community who are waiting for the severity of their chest pain to increase before coming to the "EMERGENCY R! OOM". Perhaps if we can change the name of the emergency room to a more user friendly term, we may be able to capture such patients earlier. What appears to be very promising in this subset of patients is "point of care" bedside testing with cardiac markers that includes troponin but also myoglobin and CPK-MB as well. Quantitative myocardial enzyme results that come back too late do not help decision making whereas immediate qualitative results may allow rapid stratification of these patients.
Chest Pain Centers also have started to focus on patients with low to moderate probability of ischemic heart disease. More work needs to be done in this area but the use of Nuclear Scanning with Sestamibi (study to be completed in 1999) may allow progress to be made in this area very fast. Recent articles in the New England Journal of Medicine (1) and the Journal of American Medical Association (2) on the cost effectiveness of this approach resulted in editorials (3,4) stating that Chest Pain Centers represent "an idea whose time has come" and "that they are ready for prime time".
Another thought has to do with data collection and the registry of patients being seen in the Chest Pain Centers. It appears that a significant number of these patients are discharged home. Many times the patients are identified as having high risk factors or a positive stress test that needs to be further evaluated. Questions arise... "Can the use of this Chest Pain experience motivate individuals to practice a more healthy lifestyle? Can it be shown that an increase in compliance for taking the "statin drugs" (reducing hyperlipidemia) results from this chest pain experience? If so, the Chest Pain Center Strategy would advance in progress with this link that connects acute prevention with a Primary Risk Factor Program.
Finally the question arises... can awareness programs be developed that enhance the operation of the Chest Pain Center by providing more patients with earlier manifestations of heart disease? If this occurs then penetration into the community will result and expand our ability to significantly reduce heart attack deaths.
These editorial thoughts are provided only to have you consider the possibility that a systematic and comprehensive approach to patients presenting with chest pain to the emergency departments bringing together emergency physicians and cardiologists and critical care nurses, can provide a platform for testing newer techniques and treatment and help to support the hypothesis that benefits can accrue with a learning curve of progress made in this direction. In the near future, it is hoped this discussion in our Steering Committee will address these issues and appoint various subcommittees to review the literature and publish Consensus Reports in the various areas of the Chest Pain Centers.
References
1. Farkouh ME, Smars PA, Reeder GS. A clinical trial of a chest-pain observation unit for patients with unstable angina. New England Journal of Medicine 1998 339:26 1882-88.
2. Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow L, Das K, Kampe LM, Dickover B, McDermott MF, Hart A, Straus HE, Murphy DG, Rao R. Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in pateients with chest pain: a randomized controlled trial. JAMA 1997 278:20 1670-1676.
3. Newby LK, Mark DB. The chest pain unit- ready for prime time? Editorial -New England Journal of Medicine 1998 339:26 1930-32
4. Hoekstra JW, Gibler WB. Chest pain evaluation units. Editorial - JAMA 1997 278:20 1701-02
