THOUGHTS FROM THE RECENT AMERICAN COLLEGE OF CARDIOLOGY
NEW ORLEANS, MARCH 1999

CORONARY CARE CHEST PAIN CENTERS AND BEYOND

The question may arise whether the Chest Pain Center strategy in heart attack care is sufficient enough to take us into the next century. In correspondence , Dr. Eugene Braunwald offered his approval in moving the concepts of coronary care from the Coronary Care System to the Emergency Room but further added that ultimately it needs to go into the patient's home (community). This follows the evidence being gathered at the conference that the earlier we treat the better the results. We already have evidence for this with thrombolytic therapy but it seems also to apply to platelet inhibitors whether this be aspirin or glycoprotein IIb/IIIa receptor inhibitors. A Paradigm shift in this direction may provide us in the future with prophylactic prevention in patients crashing with acute myocardial infarction who have total coronary occlusion with thrombosis as the final event.

Additionally the easy use of thrombin inhibitors is also possible especially with the use of low molecular weight Heparin as administration is associated with low side effects and the absence of significant CNS bleeds. This may allow us to take such therapy into the home. Beginning ischemic symptoms in the future may be treated immediately with an aspirin and an injection of low molecular weight Heparin before calling 911.

Perhaps a more radical approach may be seen in the English and Scottish approach where care is often given at the bedside and the patient not hospitalized. If that be the case then the infusion of platelet inhibitors in the home along with aspirin (Ticlid, Plavix) and low molecular Heparin can be conceptionalized and put into practice by the home care nurse utilizing her skills before admission rather than after hospital discharge. Arrhythmia management (Ventricular Arrhythmia) may not be the concern in the future if control of the platelet embolization source can be blocked with the platelet inhibitors.

In summary, Coronary Care Units have dramatically changed over the last 5 years. No longer do we see the frequent use of xylocaine, swan ganz catheters and temporary pacemakers but see patients being ischemic protected before going to percutaneous coronary intervention or coronary bypass surgery. If this were to continue, then Coronary Care Units may turn out to be an event in the past with the new emphasis on Chest Pain Centers and the Ischemic Holding Areas.