Rapid assessment of chest pain
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7313.586 (Published 15 September 2001) Cite this as: BMJ 2001;323:586
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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
Director of Emergency Medicine
Emergency Department,
Westmead Hospital,
PO Box 533,
Wentworthville NSW 2145
Competing interests: No competing interests
Didn't Minerva promise that the BMJ would stop using what in
Australia is now referred to as the "C-word?"
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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
Consultant
Emergency Department,
RUH Bath
Competing interests: No competing interests
CHEST PAIN CLINICS: ONE STEP FORWARD, TWO STEPS BACK?
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.
Competing interests: No competing interests