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Re: Chest pain obervation unit (CPOU) - A road to a cost effective management of Acute Coronary Syndrome

Dear Editor

I read with interest the paper by Goodacre and Calvert.[1] I agree with the authors that as most patients of undifferentiated chest pain have a benign disorder, admission represents a considerable waste of resources. Nevertheless, it is worrying to note that in UK 6% of patients discharged from emergency departments after attendance with acute chest pain were found to have prognostically significant myocardial damage.[3]

Innovative action-plans, such as the introduction of chest pain observation units ( CPOUs ) seem like a cost effective way for evaluating patients with undifferentiated chest pain. CPOUs in the USA attempt to improve diagnostic accuracy of acute coronary syndrome (ACS).[2] Patients are subjected to a battery of tests, including an exercise ECG. If all these tests are negative, the patient is sent home, but if the tests are positive or equivocal, the patient is admitted for further investigations.[2] In the UK, with much less interventional radiology and higher discharge rates from the emergency departments, such a policy may appear to be a non-starter.[2]

The district general hospitals may have to formalise a uniform guideline so that they can risk stratify the cases of ACS effectively in a CPOU as per Braunwald’s classification.[2] They will then be able to “fast track” the highest of the high risk patients for further investigations and thereby make the CPOU service most cost effective.

I agree with the authors that the diagnostic strategies for acute, undifferentiated chest pain entailing observation and cardiac enzyme testing and a definite on-site exercise testing will be the most cost effective way forward and in this regard the paper by Goodacre and calvert 1 makes an useful contribution.. We can not compromise lives for not including an exercise testing in the ‘plan’ if we have to follow a good and safe practice strategy.

References

(1) Goodacre S, Calvert N. Cost effectiveness of diagnostic strategies for patients with acute, undifferentiated chest pain. Emerg Med J 2003; 20: 429-33.

(2) Sinharay R. Cost-effective strategy to risk stratify acute chest pain cases at a district general hospital. Postgrad Med J 2003; 79: 485.