Chest pain unit management of patients at low and not low-risk for coronary artery disease in the emergency department. A 5-year experience in the Florence area

Abstract

In this study, we screened a total of 6723 consecutive patients with chest pain and ECG non-diagnostic for acute myocardial infarction (AMI) on presentation to the emergency department (ED). The aim of the study was to avoid missed AMI, improve safe early discharge and reduce inappropriate coronary care unit (CCU) admission. Chest pain patients were triaged using a clinical chest pain score and managed in a chest pain unit (CPU). Patients with a low clinical chest pain score were considered at very 'low-risk' for cardiovascular events and discharged from the ED; patients with a high chest pain score were submitted to CPU management. Observation and titration of serum markers of myocardial injury were obtained up to 6 hours. Rest or stress myocardial scintigraphy (SPECT) was performed in patients > 40 years or with > or = 2 major coronary risk factors. Exercise Tolerance Test (ETT) or Stress-Echocardiogram (stress-Echo) were performed in younger patients or with < 2 coronary risk factor, or unable to exercise, respectively We discharged directly from the ED the majority of patients (4454; 66%): in this group there was only a 0.2% final diagnosis of coronary artery disease (CAD) at follow-up. The remaining 34% of patients, with non-diagnostic or normal ECG, were managed in the CPU. In this group, 1487 patients (representing 22% of the overall study group) were found positive for CAD, two-thirds because of delayed ECG or serum markers of myocardial injury, and one-third by Echo, SPECT or ETT. In conclusion, CPU based management allowed 22% early detection of myocardial ischaemia and 78% early discharge from the ED avoiding inappropriate CCU admission and optimizing the use of urgent angiography.

Spontaneous rupture of the branches of left subclavian artery

“…We normally consider cardiogenic etiology, such as acute coronary syndrome (ACS) at initial diagnosis. However, as reported by Conti etc, [ 1 ] among all 6723 patients with chest pain in the chest pain unit, only 1487 (22%) patients were found positive for ACS, and 5236 (78%) patients with non-cardiogenic etiologies. Spontaneous rupture of the branches of subclavian artery is extremely rare, and very few cases were reported in the literature.…”

Acute Coronary Syndromes: Presentation with ACS. ARC and NZRC Guideline 2011

“…In patients with suspected ACS there are a variety of imaging techniques which may be utilised to diagnose acute coronary syndrome. These include CT angiography, MRI, nuclear cardiography and echocardiography 63–77 . Any of these non‐invasive test may be considered in selective patients who present to the ED with chest pain and initial non‐diagnostic conventional work‐up.…”

“…These non‐invasive tests may help to improve the accuracy of the diagnosis and they may also, in select groups, decrease cost, length of stay and time of diagnosis. They may provide valuable short and long term prognostic information about the incidence of future major cardiac events 63–83 . (Class B;LOE II).…”

CT Evaluation of Chest Pain: Acute Coronary Syndrome and Acute Aortic Syndrome

“…The remarkable inefficiency of current evaluation strategies is also documented by the fact that Ͻ10% of the six million patients admitted each year in the US ultimately receive a diagnosis of ACS at discharge [16,17]. In-patient care for negative evaluations is a significant economic burden, in excess of $8 billion annually for the US healthcare system [18][19][20].…”