Defining the role of chest pain units.

Safe, cost-effective management of patients presenting to the emergency department (ED) because of chest pain compatible with myocardial ischemia continues to present a major clinical challenge. Current standards mandate rapid institution of proven therapy for reduction of mortality and morbidity in patients with acute coronary syndromes. However, in most patients presenting to the ED with chest pain, this symptom is related to disorders without fatal potential, such as musculoskeletal, gastroesophageal or anxiety syndromes (1), in which an erroneous impression of myocardial ischemia can prompt unwarranted hospital admission, resulting in unnecessary tests and major costs. The balance of these opposing factors has traditionally favored a low threshold for admission for chest pain of possible cardiac origin because of primary concern for patient welfare, as well as litigation potential for failure to detect a coronary event. This approach is consistent with the directive of early innovators of the coronary care unit (CCU) that “patients should be admitted to the CCU solely on suspicion of having an acute myocardial infarction” (2). A low threshold for admission of these patients has also been supported by reports of at least a 2% rate of missed ACS in patients discharged from the ED (3).