The PAIN Pathway for the Management of Acute Coronary Syndrome

Abstract

Acute coronary syndrome (ACS) subsumes a spectrum of clinical entities, ranging from unstable angina to ST-elevation myocardial infarction [1]. The management of ACS is deservedly scrutinized, as it accounts for 2 million hospitalizations and a remarkable 30% of all deaths in the Unites States each year [2]. Clinical guidelines on the management of ACS, which are based on clinical trials, have been updated and published [3, 4]. Large-scale registries—the NRMI [5], CRUSADE [6], and GRACE [7] registries—have consistently demonstrated a major gap between ACS management guidelines and their practical application in the real world. Accordingly, a major message that emerges from these quality-improvement registries is that there is an urgent need to incorporate the evidence-based guidelines into our daily management of ACS. In an attempt to achieve this goal, we have developed a new pathway for the management of ACS at our institution, St. Luke’s Roosevelt Hospital Center (SLRHC), which is a university hospital of Columbia University College of Physicians and Surgeons. The necessity to develop such a pathway at our institution is compelling yet typical of the need at many similar medical centers. The evidence-based information obtained from the large-scale clinical trials and from the guidelines is increasingly complex. Specifi cally, it has become exceedingly diffi cult for all house staff and emergency room staff to grasp all of the subtleties in the management of ACS patients. To address this problem, we have developed a unifi ed pathway for the management of patients presenting with acute chest pain or its equivalent. The pathway has been designated by the acronym PAIN (Priority risk, Advanced risk, Intermediate risk and Negative/low risk), which refl ects a patient’s most immediate risk stratifi cation upon admission (Fig. 2.1). This risk stratifi cation refl ects a patient’s 30-day risks for death and myocardial infarction after the initial ACS event. The PAIN pathway is color-coded (P, red; A, yellow; I, yellow; N, green) and will guide patient management according to a patient’s risk stratifi cation. These colors—similar to the road traffi c light code—have been chosen as an easy reference for the provider about the sequential risk level of patients with ACS [8].