Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine:
From the Society of Chest Pain Centers, Columbus, OH.
Conflicts of interest and sources of funding: none declared.
Reprints: Raymond D. Bahr, MD, FACC, 2901 Boston Street, Apartment 609, Baltimore, MD 21224. E-mail: RDB60@aol.com.
In an effort to improve the strategy to reduce heart-attack deaths in the United States, the American Heart Association has joined forces with the Society of Chest Pain Centers. Chest pain centers in emergency rooms first developed in the United States in the early 1980s in response to a need to better prepare the emergency room for patients presenting with heart attacks. Ward Kennedy, MD, had observed in the MITI research study that a hospital's performance rapidly fell after they finished the study. Although heart attack mortality in the study was reduced from 6% to 1.2% when thrombolytic therapy was given in <70 minutes, Dr. Kennedy felt that the reduction in the hospital's performance was important and needed to be addressed.
Hospital care of heart attacks first improved in the 1960s through the development of coronary care units. This was easily accomplished and seemingly occurred overnight in every hospital in the United States. It was fueled by the driving force of “an idea whose time had come” and was easily carried out on the medical service of the hospital by cardiologists and nurses who came to be known as coronary care nurses. However, heart attack care in the emergency room (later emergency department) would have to be a different form of preparedness; it would involve emergency physicians, cardiologists, and the community. Furthermore, it would have to offset the “Get Out of My Emergency Room unless you have severe chest pain” mentality existing in the emergency room at that time, and replace it with a more user-friendly “Thank you for coming into the hospital with your mild chest discomfort to be checked out.” The need for this change in attitude came about when there was a reawakening of awareness that heart attacks having early (prodromal) symptoms that could be recognized and acted upon. The importance of this was seen in an editorial in the New England Journal of Medicine by Dr. E. Braunwald entitled, “Acute Myocardial Infarction—The Value of Being Prepared.” Dr. Braunwald stated that we all should know that 50% of patients with heart attacks experience mild forms of angina (so called “heralded MI”). Such patients by giving thrombolytic therapy do well and even better if the time to treatment is reduced (so called prodromal myocardial infarction). However, if such patients are recognized earlier and intervention of the process is successful, there may not even be any heart damage. It is here where acute prevention of the heart attack occurs and is the desired outcome for patients presenting with chest complaints.
The Mission of the Society of Chest Pain Centers, from the beginning, had been to develop a strategy to significantly reduce heart attack deaths in the United States. It set out to accomplish this through a collaborative effort of emergency physicians, cardiologists, and critical care nurses in the development of protocol driven critical care pathways for patients presenting with acute myocardial ischemia, but placing emphasis on the management of the low-risk patient. The paradigm shift to this subset of patients was the strategy conceived to achieve the Society's mission. Shortly after the Society of Chest Pain Centers officially incorporated as a nonprofit organization in 1998, it was requested that the Society undertake the task of Accreditation (2003) to assure quality performance and process improvement in the chest pain centers that met the standards for admission. Accreditation was not to be a one-time effort but would require periodic evaluation and updates (cycles). Perhaps, that which greatly helped the chest pain center movement was the incorporation and development of the observation unit that would serve as the machinery to sort out the low-risk ischemic patients into the 15% who would need admission and the 85% who could be safely discharged.
The partnership, now developed between the American Heart Association and the Society of Chest Pain Centers, will focus on the 250,000 patients who present with an acute myocardial infarction (STEMI) to improve their care and reduce the time that it takes to provide this. However, Accredited Chest Pain Centers will be able to offer even more care by providing the pathway for the management of the low-risk patient and picking up early myocardial ischemia.... before infarction takes place.
The chest pain center movement has been set up to properly prepare hospital emergency rooms throughout the United States for the heart attack problem facing our nation. Joining forces with the American Heart Association allows the chest pain center movement to take a giant step forward to accomplishing our mission.