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Rapid Responses: Rapid Responses published:
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There are a thousand suns....
- Sergio Stagnaro (30 January 2004)
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'Chest Pain Observation Unit' is a Misnomer
- Edward J Jones (5 February 2004)
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Chest pain observation unit is what it says
- Andrew P Webster (5 February 2004)
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Chest pain observation units - are they necessary?
- Brian P McNicholl, Laurence G Rocke, Brian P McNicholl, Declan Hughes , Fergal Dunn (10 February 2004)
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Another clinical perspective for the evaluation of chest pain
- M E Nassar, M.D., Ph.D. (21 February 2004)
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Managing chest pain: beyond cardiac causes
- Peter OL Unge (31 March 2004)
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why not bring the benefits of CPOU to our routine practice
- Mohammed A M SIDDIQUI (30 March 2007)
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CPOU : Reliable care of intermediate risk cardiovascular event
- Kaushik Sanyal (2 April 2007)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genova) Italy
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Sirs, The conclusions of the paper’s authors (1) can surely be accepted if we ignore that today it exists, beside the traditional physical semeiotics, also the biophysical semeiotics (See webb site HONCode 233736, www.semeioticabiofisica.it). In fact, their conclusions would be really different if doctors could recognize clinically the real origin of the chest pain: cardiac, oesophageal, pulmonary, aortic, a.s.o. In other words, care in a chest pain observation unit can improve outcomes and may reduce costs to the health service, only if doctors know exclusively the traditional physical examination. On the contrary, costs could be less expensive if physicians, around the world, would learn also the new semeiotics. In fact, nowadays, all common diagnoses, including chest pain real causes, must be and are firstly “clinical”, and corroborated subsequently by laboratory and/or image department (performed always in patients rationally selected) in both chest pain unit or in ER, as allows me to state a 46 year-long clinical experience. In addition, under such circumstances, if a test results pathological, but clinical examination, i.e. the clinical result of biophysical semeiotics, is normal (I ask “why” an individual, evaluated at the bed-side in healthy condition as regards his coronary artery (2, 3, 4), must undergo a useless instrumental or laboratory examination) and this “patient”, moreover, is working all day long and is even able to perform physical exercise, physician is allowed to state that in such (really numerous) cases, laboratory and image department are wrong. To conclude, first of all physical (or better speaking, biophysical semeiotic) examination, and then laboratory and image departement. 1) Goodacre S., Nicholl J., DixonS., et al. Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004;328:254 (31 January), doi:10.1136/bmj.37956.664236.EE (published 14 January 2004) 2) 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. 3) Stagnaro S. A clinical efficacious maneouvre, reliable in bed-side diagnosing coronary artery disease, even initial or silent, as well as “heart coronary risk”. 3rd TCVC Argentine Congress of Cardiology, September 2003 . http://www.fac.org.ar/tcvc/marcoesp/marcos.htm 4) Stagnaro-Neri M., Stagnaro S. Introduzione alla Semeiotica Biofisica. Il Terreno Oncologico. Travel Factory, Rome, in press. Competing interests: None declared |
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Edward J Jones, SpR Geriatric and General Medicne Hull Royal Infirmary, HU3 2JZ
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Sir, I read with interest the paper by Goodacre et al. However, I feel that the name 'chest pain observation unit' is a misnomer, the unit should be called 'exclusion of ischaemic heart disease unit'. These units, which have appeared in various other hospitals, appear to assume that there is only one serious cause for chest pain ie. ischaemic heart disease. Although I agree that ischaemic heart disease is a serious disease that needs exclusion in those attending with chest pain, the finding of a normal ECG, troponin T and exercise tolerance test should not necessarily prompt early discharge, as appears to be advocated by the paper, but reassessment for an alternative cause. The chest pain unit described in the paper excluded people with ECG changes diagnostic of acute coronary syndrome, and therefore, the population seen in the unit were those patients with genuine diagnostic uncertainty as to the aetiology of the chest pain. It is precisely these patients that need an un-blinkered approach in their assessment. I would be interested to know if a chest Xray was performed routinely on these patients and if an audit is planned to check that the unit is not missing other (non-coronary artery) causes of chest pain. Perhaps there is an irony that this paper appeared in the edition of the BMJ entitled "The epidemic of mesothelioma", I wonder how many cases would be picked in the 'chest pain observation unit'. Competing interests: None declared |
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Andrew P Webster, SPR in Emergency Medicine Barnsley District General Hospital, S75 2EP
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Having worked in the Emergency Department where the study has been carried out I have to take issue with some of Dr Jones comments. Though it may be unsatisfying for some purists/physicians that we can not give each person a diagnostic label, in the field of Emergency medicine we are used to managing risk. Excluding life threatening conditions i.e. acute coronary syndromes, and in addition pulmonary embolism and dissecting aneurysm are the main priority for emergency physicians and takes place in the unit in Sheffield. Alternative diagnosis which do not carry an immediate threat to life such as GORD, peptic ulcer disease, can be left to the physicians to investigate in out patients. The vast majority of patients had a chest x-ray performed unless there is a good reason not to carry one out. I suspect that most patients who are admitted more conventionally via general medicine are managed in a similar fashion, and leave hospital without an exact diagnosis, even after extensive investigation. This chest pain unit has demonstrated that it can safely manage risk in a patient population that is a significant resource issue for most emergency and general medical departments in the UK. Dr Jones wonders whether audit was carried out on discharged patients. As was stated in the paper, all patients were offered follow up following discharge, which the majority participated in. This degree of follow up is more than most medical patients would recieve after their "exclusion of a coronary syndrome". Competing interests: I have worked in the Northern General where the "Chest Pain observation unit" exists |
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Brian P McNicholl, consultant in Emergency MEdicine Royal Victoria Hospital, Groevenor rd Belfast BT 12 6 BA, Laurence G Rocke, Brian P McNicholl, Declan Hughes , Fergal Dunn
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Rocke LGR, McNicholl BP, Hughes D, Dunn F. Chest Pain Observation units – are they necessary? Editor, Goodacre et al(1) describe the effectiveness of a chest pain observation unit, where patients are monitored for up to six hours. An alternative is the use of a 90 minute rule-out method, incorporating Myoglobin(2,3). This has a sensitivity and negative predictive value of 100% for myocardial infarction, reduces coronary care unit(CCU) admissions by 40%, and does not require a dedicated observation unit(2). Patients presenting with chest pain suggestive of acute myocardial ischaemia but with a non-diagnostic ECG are tested for Myoglobin, Troponin I and CK-MB at the point of care. The ECG and cardiac markers are repeated over the next 90 minutes. Patients with a rise in myoglobin of 25% or more (even if both values are normal) or a sustained elevation of CK-MB or Troponin I are referred to CCU. If ECGs and markers are normal, patients may be discharged. Further management is weighted by clinical risk assessment. We have used a similar pathway(2), for two years, in our Emergency Department. We found a 44% reduction in admissions and earlier and more appropriate referrals to CCU in the first 197 patients studied. Our audit included a 30-day follow up. One adverse event was noted in patients who were discharged; this patient was a protocol violation. We did not need any additional staffing to implement this pathway. Triple marker testing costs £30 per patient, for two serial tests. The pathway works 24 hours a day, seven days per week, and requires little additional training for medical and nursing staff. We suggest this pathway is effective in the Emergency Department assessment of patients with acute chest pain. Goodacre S, Nicholl J, Dixon X, Cross E, Angelini K, Revill C, et al . Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ 2004;328:254-7. Ng S Krishnaswamy P, Morissey R, Clapton P, Fitzgerald R, Maisel AS. Ninety minute accelerated critical pathway for chest pain evaluation. Am J Cardiol 2001;88:611-617. McCord J , Nowak RM, McCullough P, Foreback C, Borzak S, Tokarski G, et al. Ninety-minute exclusion of acute myocardial infarction by use of quantitative point of care testing of myoglobin and Troponin I.. Circulation 2001;104:1483-1488. Competing interests: The test panels for the initial pilot study of 90 patients were provided by Biosite Inc., the manufacturer. LGR received part funding for one conference. |
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M E Nassar, M.D., Ph.D., physician consultant 17 Cobblefield Way, Pittsford, NY 14534 USA
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Dear Editor: The paper of Drs Steve Goodacre, Jon Nicholl et al(1), offers a fresh approach to the cost effective evaluation of patients with chest pain in the emergency department utilizing chest pain unit vs routine evaluation. However, since their premise was cost effective medical practice it does limit some important clinical perspectives for chest pain diagnosis and its relation to coronary artery disease syndromes. The introduction of cost effectiveness puts some restraints on clinical practice. To wit, a primary emphasis should be on patient history and exam and in particular, the cardiovascular exam which so far in the equation has beneficial economic value without cost: The examiner would look for pulsus alternans seen in severe myocardial disease, or gallop rhythm again seen with left ventricular failure which may result from myocardial infarction, or paradoxical splitting of the second heart sound which maybe secondary to left bundle branch block, or coronary artery disease. When it comes to studies, aside from the ecg, chest x ray and cardiac enzymes (cpk -mb, troponin 1), myoglobin determination is highly indicative of myocardial injury. Furthermore, instead of an exercise treadmill test, a 2 d -echocardiogram offers a better prognosis for patients with chest pain and non diagnostic ecg S T elevation of myocardial infarction(2), and rapidly evaluates abnormal left ventricular wall motion seen in chest pain of coronary origin and also gives, with doppler timed studies, an approximation of ventricular ejection fraction. There is in no weighted evidence that being precise in pursuing chest pain evaluation is more or less cost effective in the overall patient evaluation. M E Nassar, M.D. References: 1-BMJ,doi:10.1136/bmj.37956.664236.EE(Published 14 Jan 2004). 2-Muscholl MW,Oswald M, et al. Int. J Cardiol 2002 Aug:24(2-3) 217- 225 Competing interests: None declared |
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Peter OL Unge, Senior Consultant Department of Medicine, Bollnäs Hospital, SE-821 81 Bollnäs, Sweden
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The recent article by Goodacre and colleagues on the management of patients presenting to hospital with acute chest pain provides useful evidence on the cost-effectiveness of different approaches to managing this frequent cause of hospital admission [1]. The authors show that the higher costs of a chest pain observation unit compared to standard care are more than offset by reduced costs of hospital admission and follow up. Furthermore, this type of care was associated with improved patient quality of life in the following six months. These are welcome data, showing the value of careful cardiac assessment of chest pain to both patients and healthcare providers. However, chest pain is a heterogeneous condition with a number of non- cardiac causes, and other forms of assessment may also be of value. While musculoskeletal, psychiatric and oesophageal causes of chest pain are rarely life-threatening, they are frequently chronic and can cause a substantial impairment of patient quality of life. In a study of chest pain patients discharged from an emergency unit, those who received a diagnosis of myocardial infarction subsequently had better quality of life than those who did not [2], most likely because undiagnosed and untreated chest pain is a cause of continued discomfort and distress [3]. As a result, up to a quarter of patients with unexplained chest pain are likely to re-attend emergency departments in the months following discharge [4, 5], a trend reflected in the study by Goodacre and colleagues. Unexplained chest pain, therefore, deserves to be taken seriously, even once cardiac causes have been excluded. A recent study in Sweden has shown that effective management of unexplained chest pain in patients without acute myocardial infarction is likely to be cost-effective and improve quality of life [5]. Patients who were re-evaluated in a chest pain clinic within a week of discharge from hospital and offered advice and further investigation of their chest pain had significantly lower rates of readmission and rehospitalization than patients receiving routine care (17% vs. 25% and 16% vs. 24%, respectively). Gastro-oesophageal reflux may account for unexplained chest pain in up to half of all patients [6], making acid suppression a potentially valuable therapeutic approach. In studies of patients with unexplained chest pain that is not of cardiac origin, proton pump inhibitors significantly improve symptoms and reduce the number of days with chest pain compared to placebo [7-10]. As a result, a short course of acid suppression has been suggested as a cost-effective approach to diagnosing the underlying cause of unexplained chest pain [10]. Chest pain is a common complaint, in hospital and primary care settings, and in the community [6]. Cross-sectional studies indicate that between a quarter and a third of the general population report chest pain in the absence of likely cardiac causes [11, 12]. There is clearly an opportunity to improve the management of chest pain, whether or not it indicates underlying ischaemic heart disease, and this has the potential to bring benefits to patients, healthcare providers and the medical profession as a whole. References 1. Goodacre, S., et al., Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ, 2004. 328(7434): 254. 2. Karlson, B.W., et al., Prognosis, severity of symptoms, and aspects of well-being among patients in whom myocardial infarction was ruled out. Clin Cardiol, 1994. 17(8): 427-31. 3. Ockene, I.S., et al., Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status. N Engl J Med, 1980. 303(22): 1249-52. 4. Fitzpatrick, M.A., et al., The burden of non-cardiac chest pain in Australia (abstract). Aust N Z J Med, 2000. 30: 134. 5. Karlson, B.W., et al., Impact of a chest pain clinic on recurrency of symptoms and readmissions among patients early discharged from hospital after acute myocardial infarction was ruled out. Eur J Emerg Med, 1998. 5(1): 29-35. 6. Eslick, G.D., D.S. Coulshed, and N.J. Talley, Review article: the burden of illness of non-cardiac chest pain. Aliment Pharmacol Ther, 2002. 16(7): 1217-23. 7. Achem, S.R., et al., Effects of omeprazole versus placebo in treatment of noncardiac chest pain and gastroesophageal reflux. Dig Dis Sci, 1997. 42(10): 2138-45. 8. Xia, H.H., et al., Symptomatic response to lansoprazole predicts abnormal acid reflux in endoscopy-negative patients with non-cardiac chest pain. Aliment Pharmacol Ther, 2003. 17(3): 369-77. 9. Pandak, W.M., et al., Short course of omeprazole: a better first diagnostic approach to noncardiac chest pain than endoscopy, manometry, or 24-hour esophageal pH monitoring. J Clin Gastroenterol, 2002. 35(4): 307- 14. 10. Fass, R., et al., The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology, 1998. 115(1): 42-9. 11. Eslick, G.D., M.P. Jones, and N.J. Talley, Non-cardiac chest pain: prevalence, risk factors, impact and consulting--a population-based study. Aliment Pharmacol Ther, 2003. 17(9): 1115-24. 12. Locke, G.R., 3rd, et al., Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology, 1997. 112(5): 1448-56. Competing interests: I have or have had consultancy agreements, mainly medical and scientific advice, with AstraZeneca, Abbott Laboratories and Schering-Plough. |
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Mohammed A M SIDDIQUI, SHO Acute Medicine Bishop Auckland General Hospital, DL14 6AD
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The idea of Chest pain observation units has come in from USA but in UK its implementation will have to take into account the cost effectiveness I feel that better results can be obtained by improving the present system in which not only the myocardial ischaemia pain but also other causes of chest pain are excluded. The work done by our colleagues in Sheffield is indeed commendable but have they thought of or looked into how many patients with minor or submassive PE have been missed, how many patients with Gastro oesophageal Reflux Disorder (GORD) and Dyspepsia have been missed. Once cardiac pain is ruled out in Chest Pain Observation Unit (CPOU) would the patient be discharged without looking into other possibilities or would the patient be again admitted to routine wards as previously for further evaluation. If the patient is discharged then that would increase the readmission rate and with it the cost of health care. If the patient is admitted again for further evaluation then it will increase the time of stay in the hospital and cost of the health care. Hence I think we can improve the outcome without CPOU if we improve the standards of care and implement the benefits of CPOU in our routine practice. Competing interests: None declared |
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Kaushik Sanyal, Department of Medicine Norfolk and Norwich University Hospital ,Norwich ,United Kingdom
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Less than 10% of coronary artery disease patient were discharged inappropriately from emergency department. Chest pain observation unit (CPOU) allows rigorous assessment of chest pain. Typically patients are closely monitored for 6-12 hours and subjected to sensible diagnostic test. This leads to rapid categorisation of patients. Patient satisfaction is an essential outcome in the CPOU.The unit is a reliable cost-effective means with intermediate risk cardiac ischemic event. There is enough statistical evidence to persuade health authorities to support the introduction of this new dedicated service. What we need is now a broader randomised controlled trial to make it a conventional reality. However let us keep in mind that there is no strong evidence that a CPOU will improve outcome if routine practise is good. Competing interests: None declared |
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