Chest pain centers on the move
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The widespread introduction of the chest pain center (CPC), also
called the chest pain unit, into emergency departments in many hospitals
smoothed the integration of earlier testing for cardiac markers such
as troponin into clinical care. Rather than send every patient at
risk of heart attack to the coronary care unit, hospitals now retain
many patients in the CPC and monitor them until definitive evidence
of a myocardial infarction is obtained or until the patient's symptoms
"What has happened over the years," says Dr. Raymond Bahr, medical
director of the Paul Dudley White Coronary Care System at St. Agnes
Health Care, Baltimore, "has been development of chest pain centers
that focus on people coming to the ED. This is a system of triage
for patients coming in with chest discomfort to see what category
they fit into." The CPC is essentially an observation center in
the emergency department where patients with a low probability of
MI-chest pain but not typical signs of MI-are kept for six to 12
hours for observation and testing. About 80 percent of patients
in that category can be sent home, Dr. Bahr estimates. "More important,"
he says, "missed MI is reduced from five percent to less than one
Patients who develop signs of a definite acute coronary syndrome
in the chest pain center, such as a rise in troponin at six to eight
hours after presentation, can be taken for immediate treatment.
"For years we just put these patients in the coronary care unit
and closed the curtain," Dr. Bahr says. "The next day, if their
enzymes went up, we said they had a heart attack. If not, we said
they had unstable angina. But we didn't actually do anything for
them." Now, with the combination of chest pain centers, troponin
assays, and proven therapy for acute coronary syndrome, the situation
has changed radically.
Dr. Bahr helped pioneer and promote the development of the CPC.
He wrote an article in 1991 titled "Chest pain emergency rooms:
an idea whose time has come." He calls the CPC "the latest strategy
going across the U.S. now." Already more than 1,200 of the 5,000
hospitals in the United States have a CPC. Dr. Bahr predicts that
in the next three years most hospitals will have established a CPC
in the emergency department.
William Check, PhD