Effectiveness of a multidisciplinary chest pain unit for the assessment of coronary syndromes and risk stratification in the Florence area

Abstract

Background: In patients seen at the emergency department (ED) with chest pain (CP), noninvasive diagnostic strategies may differentiate patients at high or intermediate risk from those at low-risk for cardiovascular events and optimize the use of high-cost resources. However, in welfare healthcare systems, the feasibility, accuracy, and potential benefits of such management strategy need further investigation. Methods: A total of 13,762 consecutive patients with CP were screened, and their conditions were defined as high, intermediate, and low risk for short-term cardiovascular events. Patients at high and intermediate risk were admitted. Patients at low risk were discharged from the ED if first line (<6 hours, including electrocardiogram, troponins, and serum cardiac markers) or second line short-term evaluation (<24 hours, including echocardiogram, rest or stress 99m-Tc myocardial scintigraphy, exercise tolerance test, or stress-echocardiography) had negative results. Patients with a diagnosis of coronary artery disease (CAD) were admitted. Patients without evidence of cardiovascular disease underwent screening for psychiatric and gastroesophageal disorders. Inhospital mortality rate was assessed in all patients. Results: Among patients at high and intermediate risk (n = 9335), 2420 patients had acute myocardial infarction (26%, 10.6% mortality rate), 3764 had unstable angina (40%, 1.1% mortality rate), 129 had aortic dissection (1.4%, 23.3% mortality rate), and 408 had pulmonary embolism (4%, 27.6% mortality rate). The remaining 2614 had chronic coronary heart disease in the context of multiple pathology (n = 2256) or pleural or pericardial diseases (n = 358). Among patients at low risk (n = 4427), 2672 were discharged at <6 hours (60%, 0.2% incidence rate of nonfatal CAD at 6 months) and 870 patients were discharged at <24 hours (20%, no CAD at follow-up). The remaining 885 patients were recognized as having CAD (20%, 1.1% inhospital mortality rate). Finally, half of the patients without CAD had active gastroesophageal or anxiety disorders. Conclusion: An effective screening program with an observation area inside the ED (1) could be implemented in a public healthcare environment and contribute significantly to the reduction of admissions, (2) could optimize the management of patients at high and intermediate risk and succeed in recognizing CAD in 20% of patients at low risk, and (3) could allow screening for alternative causes of CP in patients without evidence of CAD.