Evaluation of chest pain suspicious for acute coronary syndrome: use of an accelerated diagnostic protocol in a chest pain evaluation unit

Abstract

Management of patients presenting to the emergency department with chest pain suggestive of acute myocardial infarction (AMI) remains a continuing challenge. A low threshold for admission has been traditional because of concern for patient welfare and the litigation potential associated with the inadvertent discharge of patients with ischemic events. Because of this approach, <30% of patients admitted for chest pain ultimately are found to have an acute coronary syndrome. To reduce unnecessary admissions, maintain patient safety, and enhance cost-effectiveness, innovative strategies have been applied to the management of patients with chest pain. It is now recognized that a low-risk group can be identified by the clinical presentation and initial electrocardiogram. Chest-pain centers have been developed to provide further risk stratification and systematic management of these patients. We employ an accelerated diagnostic protocol based on immediate exercise treadmill testing to evaluate low-risk patients. Moderate-risk patients are assessed over a 6-hour observation period with serial electrocardiograms and evaluation of cardiac-injury markers. Patients with positive evaluations are admitted. Those with negative results undergo either exercise echocardiography or rest myocardial perfusion imaging utilizing technetium-99m sestamibi. Patients with positive functional tests are admitted. Those with negative studies are discharged with outpatient follow-up. These strategies have provided a safe and accurate means of patient disposition from the emergency department with the potential for vital cost savings.