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Evaluation of Chest Pain in the Emergency Department
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
TO THE EDITOR:
The recent editorial by Kaul and Abbott [1] promotes basic misconceptions on the care of patients with chest pain in the emergency department.
Clinicians with specialized formal training in emergency medicine are required to identify a relatively small number of patients with acute ischemic coronary syndromes from a large undifferentiated population of patients reporting chest pain who present to the emergency department. Unless the cardiologists of a particular institution are willing to provide a constant physical presence in the emergency department to evaluate every patient with even a remote possibility of myocardial ischemia, emergency physicians are the ideal provider of this service. Advances have been made by emergency physician researchers to offer better diagnostic strategies for these patients, as cited by Drs. Kaul and Abbott. Our primary goal has been to differentiate the acute ischemic coronary syndrome from noncardiac chest pain through objective data provided by serial early serum markers such as myoglobin and creatine kinase-MB levels [2, 3]. Unfortunately, the use of clinical history with an initial 12-lead electrocardiogram obtained by a cardiologist or emergency physician offers a low specificity for detecting acute ischemic coronary syndrome in the typical patient presenting to the emergency department.
Emergency physicians are also available 24 hours a day in the emergency department to evaluate and treat patients with evolving acute myocardial infarction. This reality has been recognized by the American Heart Association and by the National Heart Attack Alert Program of the National Heart, Lung, and Blood Institute [4]. Both organizations have stated that emergency physician should identify and treat any patient with a clear presentation of acute myocardial infarction in the emergency department, preferably within 30 minutes, without the delay of consultation.
Finally, emergency physicians and cardiologists must work together to develop appropriate diagnostic and treatment protocols that enhance the care of patients with possible ischemic heart disease in the emergency department. At our institution, emergency medicine and cardiology combine resources to evaluate patients using serial creatine kinase-MB measurement, serial electrocardiograms, echocardiography, and graded exercise testing in an emergency department chest pain evaluation and treatment unit that has evaluated more than 1200 patients since 1991 [5]. I was particularly surprised that the editorial by Drs. Kaul and Abbott minimizes the role of emergency physicians in this evaluation and treatment of chest pain, given that the University of Virginia has developed a similar unit based on a visit to our emergency department several years ago by cardiologists from Dr. Kaul's institution.
W. Brian Gibler
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
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