Each year over 6 million people visit Emergency Departments throughout the U.S. for evaluation of chest discomfort. Another million or so are admitted to coronary care units because of acute ischemic syndromes including unstable angina. Of the remaining patients, most prove not to have significant heart disease. However, many of these patients are admitted to telemetry beds or even to the CCU where they remain for 1-3 days undergoing evaluation. The identification and treatment strategies for patients presenting to the Emergency Department with chest pain have undergone extensive restructuring over the last several years as the concept of a Chest Pain Evaluation Center has emerged.
Several tools are available to aid in the diagnosis and management of chest pain patients.
Unfortunately, clinical symptoms and the electrocardiogram are associated with low sensitivity and specificity. Enzymatic markers of myocardial injury such as CPK-MB and troponin have added considerably to the identification of patients with an infarct. These markers are also associated with high negative predictive value and are thus useful for determining which patients can safely be sent home from the Emergency Department. Other useful tools for decision making including two-dimensional echocardiography and nuclear perfusion imaging. Accompanying the development of Chest Pain Evaluation Programs has been the creation of clinical pathways for management of patients with differing types of coronary syndromes.