The two main goals of chest pain units are the early, accurate diagnosis of acute coronary syndromes and the rapid, efficient recognition of low-risk patients who do not need hospital admission. Many clinical, practical, and economic reasons support the establishment of such units. Patients with chest pain account for a substantial proportion of emergency room turnover and their care is still far from optimal: 8% of patients sent home are later diagnosed of acute coronary syndrome and 60% of admissions for chest pain eventually prove to have been unnecessary. We present a systematic approach to create and manage a chest pain unit employing specialists headed by a cardiologist. The unit may be functional or located in a separate area of the emergency room. Initial triage is based on the clinical characteristics, the ECG and biomarkers of myocardial infarct. Risk stratification in the second phase selects patients to be admitted to the chest pain unit for 6-12 h. Finally, we propose treadmill testing before discharge to rule out the presence of acute myocardial ischemia or damage in patients with negative biomarkers and non-diagnostic serial ECGs.
Keywords
Unstable angina
Diagnosis
Chest pain
Coronary artery disease
Myocardial infarction
Emergency room
Este artículo solo puede leerse en
pdf
Bibliography
[1]
Farkouh MF, Smars PA, Reeder GS, Zinsmeister AR, Evans RN, Meloy TD, et al..
A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) investigators..
N Engl J Med, (1998), 339 pp. 1882-8
[2]
Arós F, Loma-Osorio A..
Diagnóstico de la angina inestable en el servicio de urgencias. Valor y limitaciones de la clínica, el electrocardiograma y las pruebas complementarias..
Rev Esp Cardiol, (1999), 52 pp. 39-45
[3]
Storrow AB, Gibler WB..
Chest pain centers: diagnosis of acute coronary syndromes..
Ann Emerg Med, (2000), 35 pp. 449-61
[4]
Fibrinolytic Therapy Trialists' (FTT) Collaborative Group..
Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomized trials of more than 1,000 patients..
Lancet, (1994), 343 pp. 311-22
[5]
EUROASPIRE Study Group..
EUROASPIRE. A European Society of Cardiology survey of secondary prevention of coronary heart disease: principal results..
Eur Heart J, (1997), 18 pp. 1569-82
[6]
Bosch X, Sambola A, Arós F, López-Bescos L, Mancisidor X, Illa J, et al..
Utilización de la trombólisis en los pacientes con infarto agudo de miocardio en España: observaciones del estudio PRIAMHO..
Rev Esp Cardiol, (2000), 53 pp. 490-501
[7]
Fiol M, Cabadés A, Sala J, Marrugat J, Elosua R, Vega S, et al..
Variabilidad en el manejo hospitalario del infarto agudo de miocardio en España. Estudio IBERICA (Investigación, Búsqueda Específica y Registro de Isquemia Coronaria Aguda)..
Rev Esp Cardiol, (2001), 54 pp. 443-52
[8]
Aguayo E, Reina A, Ruiz Bailén M, Colmenero M, García Delgado M, Ariam G..
La asistencia prehospitalaria en los síndromes coronarios agudos. Experiencia del grupo ARIAM..
Aten Primaria, (2001), 27 pp. 478-83
[9]
Arós F, Loma-Osorio A, Alonso A, Alonso JJ, Cebadés A, Cabadés A, Cona I, et al..
Guías de actuación clínica de la Sociedad Española de Cardiología en el infarto agudo de miocardio..
Rev Esp Cardiol, (1999), 52 pp. 919-56
[10]
Sitges M, Bosch X, Sanz G..
Eficacia de los bloqueadores de los receptores plaquetarios IIb/IIIa en los síndromes coronarios agudos..
Rev Esp Cardiol, (2000), 53 pp. 422-39
[11]
Zalenski RJ, Selker HP, Cannon CP, Farin MM, Gibler WB, Goldberg RJ, et al..
National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia..
Ann Emerg Med, (2000), 35 pp. 462-71
[12]
Grading of recommendations and levels of evidence used in evidence based cardiology. Evidence Based Cardiology. London: BMJ Books, 1998; p. 525-75.
[13]
López-Bescós L, Fernández-Ortiz A, Bueno H, Coma I, Lidón RM, Cequier A, et al..
Guías de práctica clínica de la Sociedad Española de Cardiología en la angina inestable e infarto sin elevación ST..
Rev Esp Cardiol, (2000), 53 pp. 838-50
[14]
American College of Emergency Physicians..
Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina..
Ann Emerg Med, (2000), 35 pp. 521-5
[15]
Roberts R, Graff LG..
Economic issues in observation unit medicine..
Emerg Med Clin North Am, (2001), 19 pp. 19-33
[16]
American College of Emergency Physicians..
Physicians medical direction of emergency medical services dispatch programs..
Ann Emerg Med, (1999), 33 pp. 372
[17]
López de Sa E..
Identificación de los pacientes de alto riesgo en la evaluación inicial de la angina inestable. Importancia de la clínica, el electrocardiograma, el Holter y los marcadores bioquímicos de lesión miocárdica..
Rev Esp Cardiol, (1999), 52 pp. 97-106
[18]
Ryan TJ, Antman EM, Brooks NH, Califf RM, Hillis LD, Hirazaka LF, et al..
ACA/AHA Guidelines for the Management of Patient With Acute Myocardial Infarction: Executive Summary and Recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Acute Myocardial Infarction)..
Circulation, (1999), 100 pp. 1016-30
[19]
Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al..
ACC/AHA guidelines for the management of patients with unstable angina and non-ST segment elevation myocardial infarction: executive summary and recommendations. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee on management of patients with unstable angina)..
Circulation, (2000), 102 pp. 1193-209
[20]
Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al..
Missed diagnoses of acute cardiac ischemia in the emergency department..
N Engl J Med, (2000), 342 pp. 1163-70
[21]
Bertrand ME, Simoons ML, Fox KA, Wallentin LC, Hamm CW, McFaden E, et al..
Management of acute coronary syndromes: acute coronary syndromes without persistent ST segment elevation. Recommendations of the Task Force of the European Society of Cardiology..
Eur Heart J, (2000), 21 pp. 1406-32
[22]
Agarwal JB, Khaw K, Aurignac F, LoCurto A..
Importance of posterior chest leads in patients with suspected myocardial infarction, but nondiagnostic, routine 12-lead electrocardiogram..
Am J Cardiol, (1999), 83 pp. 323-6
[23]
The Joint European Society of Cardiology/American College of Cardiology Committee..
Myocardial infarction redefined. A consensus document of the Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of acute myocardial infarction..
Eur Heart J, (2000), 21 pp. 1502-3
[24]
Bholasingh R, De Winter RJ, Fischer JC, Koster RW, Peter RJ, Sanders GT, et al..
Safe discharge from the cardiac emergency room with a rapid ruleout myocardial infarction protocol using serial CK-MB (mass)..
Heart, (2001), 85 pp. 143-8
[25]
Newby LK, Storrow AB, Gibler WB, Garvey JL, Tucker JF, Kaplan AL, et al..
Bedside multimarker testing for risk stratification in chest pain units: the chest pain evaluation by creatine kinase-MB, myoglobin, and troponin I (CHECKMATE) study..
Circulation, (2001), 103 pp. 1832-7
[26]
Arós F, Boraita A, Alegría E, Alonso AM, Bardaji A, Lamiel R..
Guías de práctica clínica de la Sociedad Española de Cardiología en pruebas de esfuerzo..
Rev Esp Cardiol, (2000), 53 pp. 1063-94
[27]
Diercks DB, Gibler WB, Liu T, Sayre MR, Storrow AB..
Identification of patients at risk by graded exercise testing in an emergency department chest pain center..
Am J Cardiol, (2000), 86 pp. 289-92
[28]
Stein RA, Chaitman BR, Balady GJ, Fleg JL, Limarcher MC, Pina IL..
Safety and utility of exercise testing in emergency room chest pain centers. An advisory from the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association..
Circulation, (2000), 102 pp. 1463-7
[29]
Diercks DB, Kirk JD, Turnipseed S, Amsterdam EA..
Exercise treadmill testing in women evaluated in a chest pain unit..
Acad Emerg Med, (2001), 5 pp. 565
[30]
Peral V, Vilacosta I, San Román JA, Castillo JA, Batlle E, Hernández M, et al..
Prueba no invasiva de elección para el diagnóstico de enfermedad coronaria en mujeres..
Rev Esp Cardiol, (1997), 50 pp. 421-7
[31]
Monserrat L, Peteiro J, Vázquez JM, Vázquez N, Castro A..
Valor de la ecocardiografía de ejercicio en el diagnóstico de la enfermedad coronaria en pacientes con bloqueo de rama izquierda del haz de His..
Rev Esp Cardiol, (1998), 51 pp. 211-7
[32]
Candell J, Castell J, Jurado JA, López de Sa E, Nuno JA, Ortigosa FJ, et al..
Guías de actuación clínica de la Sociedad Española de Cardiología. Cardiología Nuclear: bases técnicas y aplicaciones clínicas..
Rev Esp Cardiol, (1999), 52 pp. 957-89
[33]
Ioannidis JP.A, Salem D, Chew PW, Lau J..
Accuracy of imaging technologies in the diagnosis of acute cardiac ischemia in the emergency department: a meta-analysis..
Ann Emerg Med, (2001), 37 pp. 471-7
[34]
Geleijnse ML, Elhendy A, Van Domburg RT, Cornel JH, Rambaldi R, Salustri A, et al..
Cardiac imaging for risk stratification with dobutamine-atropine stress testing in patients with chest pain..
Echocardiography, perfusion scintigraphy, or both? Circulation, (1997), 96 pp. 137-47
[35]
Gómez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB, for the ROMIO Study Group..
An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results for a randomized study (ROMIO)..
J Am Coll Cardiol, (1996), 28 pp. 25-33
[36]
Brogan GX..
Managing chest pain in the emergency room..
Eur Heart J, (2000), 21 pp. 15-21
[37]
Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow L, et al..
Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in patients with chest pain: a randomized controlled trial..
JAMA, (1997), 278 pp. 1670-6
[38]
Antiplatelet Trialists' Collaboration..
Collaborative overview of randomised trials of antiplatelet therapy. I: prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients..
Br Med J, (1994), 308 pp. 81-106
[39]
The Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators..
Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation..
N Engl J Med, (2001), 345 pp. 494-502
[40]
Plaza L, López-Bescós L, Martín-Jadraque L, Alegría E, Cruz JM, Velasco J, et al..
Protective effect of triflusal against acute myocardial infarction in patients with unstable angina: results of a Spanish multicenter trial..
Cardiology, (1993), 82 pp. 388-98
[41]
Eikelboom JW, Anand SS, Malmberg K, Weitz JI, Ginsberg JS, Yusuf S, et al..
Unfractioned heparin and low-molecular-weight heparin in acute coronary syndrome without ST elevation: a meta-analysis..
Lancet, (2000), 355 pp. 1936-42
[42]
O'Connor R, Persse D, Zachariah B, Ornato JP, Swor RA, Falk J, et al..
Acute coronary syndrome: pharmacotherapy..
Prehosp Emerg Care, (2001), 5 pp. 58-64
[43]
Gibbons RJ, Balady GJ, Beasley JW, Bricker JT, Duvernoy WF, Froelicher VF, et al..
ACC/AHA guidelines for exercise testing: executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee of Exercise Testing)..
Circulation, (1997), 96 pp. 345-54
[44]
Weissman NJ, Levangie MW, Guerrero JL, Weyman AE, Picard MH, et al..
Effect of beta blockade on dobutamine stress echocardiography..
Am Heart J, (1996), 131 pp. 698-703
[45]
Gibler WB, Runyon JP, Levy RC, Sayre MR, Kacich R, Hattemer CR, et al..
A rapid diagnostic and treatment center for patients with chest pain in the emergency department..
Ann Emerg Med, (1995), 25 pp. 1-8
[46]
Tatum JL, Jesse RL, Kontos MC, Nicholson CS, Schmidt Kl, Roberts CS, et al..
Comprehensive strategy for the evaluation and triage of the chest pain patient..
Ann Emerg Med, (1997), 29 pp. 116-25
[47]
Stomel R, Grant R, Eagle KA..
Lessons learned from a community hospital chest pain center..
Am J Cardiol, (1999), 83 pp. 1033-7
[48]
Bassan R, Gibler WB..
Unidades de dolor torácico: estado actual y manejo de los pacientes con dolor torácico en los servicios de urgencias..
Rev Esp Cardiol, (2001), 54 pp. 1103-9