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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 resolve.

"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 percent."

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