Task force 2: Acute coronary syndromes: Section 2b-chest discomfort evaluation in the hospital

Safe, cost-effective management of patients presenting to the ED with chest pain is a continuing challenge. The traditional low threshold for admission of these patients, in order not to miss a life-threatening cardiac condition, has resulted in a <30% incidence of coronary events in those admitted for chest pain. This approach has been neither medically optimal nor cost-effective. It is now recognized that the high and low risk groups of patients presenting with chest pain can be recognized on presentation, facilitating urgent therapy for the former and more deliberate evaluation of the latter. Chest pain programs have been developed for systematic implementation of innovative approaches. Most CPCs focus on the low risk group and utilize accelerated diagnostic protocols, usually comprising 6 to 12 h of monitoring and serial cardiac biomarkers, which,if negative, are followed by stress testing (exercise ECG or noninvasive cardiac stress imaging). These methods have been safe and accurate and appear to be cost-effective. Most patients in the low risk group with negative evaluations have a noncardiac source of the chest pain, but follow-up evaluation for noncardiac etiologies has been inadequate and could improve care of these patients.