Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
there's nothing casual about E.D. approach to chest pain
- Steve Meek (14 September 2001)
-
Don't forget non-cardiac chest pain
- Jonathan Pitts (14 September 2001)
-
Early bed-side diagnosis of CAD, even clinically silent.
- Sergio Stagnaro (16 September 2001)
-
Why "Same Day", rather than all the time?
- Patrick K Plunkett (16 September 2001)
-
A common cause of non cardiac chest pains
- Carlos A Selmonosky (16 September 2001)
-
What's a Casualty department?
- Diane Campbell (17 September 2001)
-
An end to the "casual" assessment of chest pain.
- Robert Dowsett (17 September 2001)
-
CHEST PAIN CLINICS: ONE STEP FORWARD, TWO STEPS BACK?
- Guy D Eslick, David S Coulshed (17 October 2001)
|
|
|||
|
Steve Meek, cons ruh bath
Send response to journal:
|
Professor Wood's call for evidence to support the use of rapid access chest pain clinics is laudable but the language he used in his description of Emergency Department (A&E) management suggests he is unaware of the massive changes which have taken place in many EDs. The "Casualty Officer" may indeed have difficulty in distinguishing cardiac from non-cardiac pain, as will his seniors, which is why the ED Registrar and Consultant working alongside will ensure safe practice is followed, perhaps with the use of a troponin-based rapid rule out pathway. Many EDs, ourselves included, have now abolished SHO-based emergency care through adequate registrar staffing levels: We no more have unsupported "Casualty Officers" than we grind our own foxgloves to treat the dropsy. The contribution the specialty of Emergency Medicine, working in partnership with Cardiology, can make to the management of acute chest pain should not be underestimated. Steve Meek
|
|||
|
|
|||
|
Jonathan Pitts, Staff Cardiologist Conquest Hospital, Hastings
Send response to journal:
|
I wholeheartedly support the suggestion of a national database of chest pain clinics. Vast amounts of data are being collected by clinics around the country and collaboration is needed to ensure that these clinics are developed in the most effective way. However, three-quarters of the patients coming to chest pain clinics have non-cardiac chest pain. A significant proportion of these patients will continue to have disabling chest pain. Chest pain clinics provide the opportunity for providing rapid diagnosis and reassurance to these patients and the provision of for intensive support for patients with ongoing symptoms. Assessment of the various clinic models needs to include the evaluation of the care given to low-risk patients. |
|||
|
|
|||
|
Sergio Stagnaro, Specialist in Blood, Gastrointestinal and Metabolic Diseases Riva Trigoso (Genoa) Italy
Send response to journal:
|
Sirs, I read in your article that patients presenting for the first time to their general practitioner with suspected angina can now be assessed by a specialist through a “rapid” access chest pain clinic. Apart from the frequent “silent” CAD, diagnosing acute coronary disease at the bed-side exclusively by the aid of traditional physical semeiotics is frequently a difficult task. Consequently, conditio sine qua non for senting such patients promptly and directly to chest pain clinic is the correct and early “clinical” diagnosis. A long well established clinical experience allows me to state that nowadays is easy to perform such diagnosis at the bed-side, even in case of initial or silent CAD: doctor can recognize “clinically” the so- called “impending infarction”, as I did fortunately on myself last 9 july (http://digilander.iol.it/semeioticabiofisica), preventing the serious consequences of ventricular fibrillation and cardiac arrest (1). Stagnaro Sergio MD, Member NYAS and AAAS. 1) Stagnaro-Neri M., Stagnaro S., Deterministic Chaos, Preconditioning and Myocardial Oxygenation evaluated clinically with the aid of Biophysical Semeiotics in the Diagnosis of ischaemic Heart Disease even silent. Acta Med. Medit. 13, 109 1997 |
|||
|
|
|||
|
Patrick K Plunkett, Consultant in Emergency Medicine Emergency Department, St James's Hospital, Dublin, Ireland
Send response to journal:
|
Cardiologists have an increasing workload in interventional cardiology, ranging from diagnostic angiography, through PTCA to stenting and even electrophysiological studies and intervention. This leaves them less available to assess and manage acutely the multitude of patients with exertional chest pain, most of whom can be adequately filtered, and treatment commenced, by Emergency Physicians in their own departments. Modern management means that most thrombolysis for acute myocardial infarction should now occur in the Emergency Department, under the care of a Consultant in Emergency Medicine. Short-term admission to a Chest Pain Assessment Unit for continuous ST-segment monitoring, with rapid evaluation of changes in cardio-specific markers, allows for the secondary triage of patients who might benefit from more active cardiological evaluation. This also now occurs under the umbrella of Emergency Medicine in some institutions, my own amongst them. Early stress testing and risk factor analysis can be included to enable those likely to benefit to have medical and life-style interventions with the aim of reducing their medium to long-term risks. This is particuarly important as even patients admitted with chest pain who have no evidence of an acute ischaemic event, have a less favourable long-term prognosis than the population at large. I have difficulty with the concept that patients with chest pain should be seen in “rapid-access” clinics on a same day basis – weekends excluded. Presumably, this also excludes evenings and nights. There is no valid reason why such evaluations should be limited to 25% of the week. This is an inefficient use of resources. It leaves patients without access when they most require it. That “Casualty Officers” – an outmoded term, if ever there were one – find chest pain “worrying” is pejorative, even if it might be accurate. It is surely time to put to bed the concept that “Casualty Departments” are capable only of giving oxygen and pain relief, important as they may be in the care of patients with potentially critical presentations. Modern Emergency Departments are capable of mounting an extended hours availability of senior clinical decision-makers, even if current Consultant contracts shy away from the American and Canadian models of 24- hour presence, 7 days a week. Recent options suggested by the British Association for Accident and Emergency Medicine allow for Consultant presence 12 hours per day, with Specialty Registrars and NCCG doctors extending the service even more. Emergency Medicine on its own is not in a position to “take-over” this patient cohort. Close co-operation with Community-based Primary Care (aka General Practice), with Cardiology and with experts in hypertension, diabetes and other related areas will enable patients to have the best care provided, when they need it. The use of a “systems”-driven approach allows Best Practice management to occur regardless of the time of day. Surely this is the way we should progress, rather than tinkering with “working hours” clinics. |
|||
|
|
|||
|
Carlos A Selmonosky, Gilmer Medical Center
Send response to journal:
|
As Dr. Pitts has stated three quarters of patients presenting to an Emergency Department or Clinic the etiology is not cardiac.Thoracic outlet syndrome is a forgotten cause of chest pains,a simple triad of physical signs will help to identify these patients. See www.tos-syndrome.com where these manuevres are described. It is important to make the diagnosis of Thoracic outlet syndrome because these patients wil continue to come back to the Health System repeatedily whith the frustation for the patients and expenses for the Health System. |
|||
|
|
|||
|
Diane Campbell, Itinerant Emergency Physician Bunbury Hospital
Send response to journal:
|
Didn't Minerva promise that the BMJ would stop using what in Australia is now referred to as the "C-word?" |
|||
|
|
|||
|
Robert Dowsett, Director of Emergency Medicine Westmead Hospital
Send response to journal:
|
Much of what the authors say is correct but I must disagree with where chest pain assessment is done. As resources and expertise are increased in Emergency Departments that is where the assessment should be occurring. This will complement what is already happening and can provide a service for extended hours. The use of the archaic term "casualty" seems to imply that the authors are unaware of the trends in Emergency Medicine or the need to continue to develop the capabilities of the modern Emergency Departments. Dr Robert Dowsett
|
|||
|
|
|||
|
Guy D Eslick, Gastroenterological Society of Australia (GESA) Biomedical Scholar; Staff Specialist in Cardiology Department of Medicine, The University of Sydney; Dept. Cardiology, Nepean Hospital,Australia, David S Coulshed
Send response to journal:
|
The recent editorial by Wood et al.1 on the rapid assessment of chest pain using the in vogue chest pain clinics in hospitals in the U.K. raised some interesting points. Over the last decade a large number of hospitals have seen a decline in the number of acute myocardial infarction presentations, while there has been a proportionately greater increase in patients presenting with unstable angina or non-cardiac chest pain. In the U.S. chest pain clinics have generally been accepted as cost-effective, safe and providing a rapid evaluation and management of patients with suspected acute coronary syndromes.2 We believe, however, that the value of such clinics will be considerably reduced if too much emphasis is placed on excluding cardiac ischaemia, without achieving a definite diagnosis to explain the symptoms. We disagree with the authors on a number of issues. Firstly, the authors comments are based purely from the point of view of a cardiologist (all the authors appear to be cardiologists), there was very little mention of non-cardiac chest pain and the role of the gastroenterologist or other medical specialists which in our opinion should be an essential part of all chest pain clinics. Secondly, we firmly believe that all patients with chest pain should be initially reviewed in the Emergency Department. Chest pain clinics in Australia and undoubtedly the U.S. are for "in house" referral only. General practitioners do not refer patients directly to a chest pain clinic, when an urgent elective consultation by a cardiologist can be arranged. In addition, the authors write "for most patients with chest pain considered by a specialist to be non-cardiac, rapid access clinics provide swift reassurance."1 We do not believe this is true. The majority of patients with non-cardiac chest pain will not only have a persistence of symptoms, but also an impaired functional status and an increase in the number of representations. The authors appear to be under the misconception that if chest pain clinics can successfully rule out a cardiac cause for the patient's chest pain then the job is done. Unfortunately this is not the case, with almost two-thirds of all chest pain presentations to hospital Emergency Departments being non-cardiac in origin.3 Non-cardiac chest pain is a hetergeneous syndrome with considerable symptom overlap and accounts for approximately 2 to 5% of all emergency presentations.4 There needs to be a greater emphasis on correctly diagnosing non-cardiac chest pain. If this is not done, many patients will simply re-present as one study has reported, with up to 39% of chest pain patients representing to hospital Emergency Departments over a four month period.5 This causes prolonged distress and reduced quality of life in the individuals, and will overload the new chest pain clinics. The issue of chest pain clinics is not a simple one. There remain many complex issues. These include a lack of reassurance for patients with non- cardiac chest pain partly due to an inadequate diagnostic process for this difficult select group. There is a lack of long-term clinical outcome data for these patients, and the social and economic costs related to these patients. Non-cardiac chest pain has for too long been viewed as a difficult syndrome to diagnose and treat. We do not have an adequately co- ordinated response to this challenge, and cardiologists and other health professionals need to work together to take the next step forwards. REFERENCES 1. Wood D, Timmis A, Halinen M. Rapid assessment of chest pain: the rationale is clear, but evidence is needed. BMJ 2001;323:586-587. 2. Storrow AB, Gibler WB. Chest pain centers: diagnosis of acute coronary syndromes. Ann Emerg Med 2000;35:449-461. 3. Eslick GD, Jones MP, Talley NJ. Acute chest pain and health care seeking behaviour: role of reflux symptoms. J Gastroenterol Hepatol 2001;16 (suppl):A329. 4. Eslick GD, Talley NJ. Non-cardiac chest pain: squeezing the life out of the Australian healthcare system? Med J Aust 2000;173:233-234. 5. Fitzpatrick MA, Dodd M, Schoevers D, Tracey E. Do management algorithms improve chest pain triage? Med J Aust 1999;171:402-406. |
|||