Chest Pain Centers are no different in their development than Coronary Care Units were back in the 1960's. At that time Coronary Care Units were initially looked upon as not necessarily important in a hospital to render heart attack care. 25 years later, articles began to appear in the literature crediting Coronary Care Units for reduction in heart attack mortality, but this was not the case early in their development. Every hospital in the United States now has a Coronary Care Unit as a result of this idea "whose time had come". It made sense to focus attention within the hospital on patients with heart attacks and do a better job.

An abstract to be presented at the American College of Cardiology meeting in March 2000 in Anaheim California makes the observation from the National Registry of Myocardial Infarction that patients treated in CPEU's with documented myocardial infarction was not associated with improved processes of care or lower hospital mortality. I think it is important to point out that this is registry data and not a scientific study. Registry data comes from information supplied by the individual hospitals with no attempt made to document accuracy in reporting. For example, hospitals may list themselves as having a Chest Pain Center without actually have the necessary components described in the American Journal of Cardiology (1)

The following components are required to be called a Chest Pain Center:

1. Attack Program
2. Observation Program
3. Outreach Program with an awareness message to the community
4. Unit Management Continuous Quality Improvement (CQI) process in place
5. Unit Staffing
6. Unit Design and Equipment

It is not known whether or not any of this information was available on these Chest Pain Centers. The study focused only on mortality in patients with acute myocardial infarction but what makes Chest Pain Centers in Emergency Departments so unique is the emphasis on shifting the paradigm to earlier care. Observation programs in Chest Pain Centers screen out patients for early ischemia preventing missed MI's from being discharged and inappropriate patients from being admitted to the hospitals. In so doing, Chest Pain Centers provide the hospital with the machinery to sort out patients with low probability of ischemic heart disease. This opens the door to patients arriving early because of an awareness program alerting the public that heart attacks need not always present as crashing events. Two excellent articles this past year in the Journal of American Medical Association (2) and in the New England Journal of Medicine (3) describe scientific studies pointing out the cost effectiveness of these observation units. Editorials in both journals describe Chest Pain Centers as an "idea whose time has come" (4) as well as "prime time for Chest Pain Centers".(5)

The Outreach Awareness message to the community in Chest Pain Centers is very much needed for patients to come in early with beginning symptoms of a heart attack to prevent myocardial infarction. This "infarctus interruptus" results from having a comprehensive approach to the patients with chest pain and is a necessary component of the Chest Pain Center program. The present abstract does not measure patients being saved with this type of acute prevention.

Thus the observations for the National Registry of Myocardial Infarction abstract may be accurate from the data collected from the various hospitals but lacks in depth the data needed to know whether the necessary components of these Chest Pain Centers were present to carry out the above stated comprehensive approach to reduce heart attack deaths by shifting the paradigm in capturing patients early in the course of their ischemic heart disease.(6)

Thus as one can see it is very important that the Society of Chest Pain Centers take on a leadership role to standardize and analyze as best as possible Chest Pain Centers so that scientific studies can be carried out finding whether or not such units are beneficial to the community. This will take time as evidenced by the late results from Coronary Care Units and patience in allowing this information to surface.

Sincerely and Respectfully,

Raymond D. Bahr, MD
President

1. Graff L, Joseph T, Andelman R, Bahr R et al. American College of Emergency Physicians information paper: chest pain units in emergency departments - a report from the short-term oberservation services section. Am J of Cardiol 1995;76:1036-1039.
2. Roberts, R, Zalenski, R, Mensah, E, Rydman, R, Ciavarella G, et al. Costs of an emergency department - based accelerated diagnositc protocol vs hospitalization in patients with chest pain, JAMA 1997;278:1670-1676.
3. Farkouh, M. Smars P, Reeder, G, Zinsmeister, A, Evans R, et al. A clinical trial of a chest pain observation unit for patients with unstable angina. N Engl J Med. 1998;339:1882-8.
4. Hoekstra, J, Gibler, WB, Chest pain evaluation units. JAMA, 1997;278:1701-1702.
5. Newby, K, Mark, D, The chest pain unit - ready for prime time? N Engl J Med. 1998;339:1930-32
6. Bahr R, Chest pain centers: moving toward proactive acute coronary care. International Journal of Cardiology 72 (2000) 101-110