First-class training from first-class emergency medicine physicians
The Chest Pain Evaluation Unit ("CPEU") was initiated in 1993 as a joint program of the Department of Emergency Medicine and the Division of Cardiovascular Medicine with the support of the UC Davis Heart Center. Its development was stimulated by the tradition of admitting large numbers of low risk patients with chest pain to Coronary Care Units ("CCU") to "rule out" myocardial infarction. This practice, which is virtually universal, has resulted in a diagnosis of acute myocardial infarction in as few as 15-20% of patients admitted to CCUs, an inefficient strategy in clinical and economic terms.
Close cooperation between the two departments has been an essential feature of the CPEU, which is administered by the Department of Emergency Medicine with close consultation by the Division of Cardiovascular Medicine. The director is J. Douglas Kirk, M.D., professor of emergency medicine and the associate directors are Sam Turnipseed, M.D., professor of emergency medicine and Ezra A. Amsterdam, M.D., professor of cardiovascular medicine.
Goals of the CPEU:
The CPEU is an integral part of the emergency department process of patient management but focuses on non-critical patients, thereby allowing emergent cardiac patients to receive a concentrated, fast-track approach from emergency department physicians dedicated to these patients. The CPEU is staffed by three physicians who have completed residency in internal medicine with further training in emergency cardiovascular care. The CPEU is covered daily by one of these physicians who is dedicated to this service. Consultation is available to these physicians at all times by the CCU attending cardiologist in selected cases as needed. During off hours, CPEU patients are managed by the Cardiology Inpatient Service (CIS).
Immediate excercise treadmill testing
Patients presenting to the emergency department with chest pain suspicious of an acute coronary syndrome (ACS) who are identified as low risk by clinical criteria for an ischemic event and its complications are triaged to the CPEU. If low risk is confirmed (clinically stable and resting ECG being normal or having only minor nonspecific repolarization abnormalities) and other serious causes of chest pain are absent on screening evaluation, the patient usually undergoes immediate exercise treadmill testing (IETT) performed by the CPEU physician with support from the cardiology technical staff.
Patients with positive IETTs are admitted for further evaluation and those with negative tests are discharged from the emergency department. The majority of patients with nondiagnostic (non-ischemic) tests are discharged from the emergency department with referral for outpatient management. With this approach, nearly 90% of patients previously identified as requiring admission to exclude an ACS, can be safely discharged. This strategy has provided a safe, efficient and cost-effective method of stratifying this patient population into those requiring admission and those who can be discharged and managed as outpatients. This program improves utilization of telemetry beds, affords vital cost savings and maintains sound patient care.
As anticipated, this experience with IETT has been an area of active clinical research. This area of further cooperation between emergency medicine and cardiology has resulted in presentations at national meetings and in scientific papers 1-18 and is an important area of growth in the CPEU.
Low-risk patients in whom IETT is not applicable (e.g., inability to exercise; repolarization abnormalities in the resting ECG; moderate suspicion for ischemic event) are admitted for monitoring to the CSSU where they are managed by the CPEU physician. Depending on the individual patient's presentation, one of a number of approaches can be implemented, including noninvasive cardiac imaging (i.e., echocardiography or myocardial perfusion imaging) or direct referral for coronary angiography. Patient disposition is usually accomplished on this service within 24 hours, with a majority discharged home and those diagnosed with an ACS admitted to the CIS.
Conclusions and future directions
The CPEU has been a model for demonstrating the advantages of an integrated effort between two disciplines with overlapping interest in this low risk, but challenging, patient population. The joint expertise of emergency medicine and cardiology has provided a departure from the traditional, inefficient and costly approach to these patients. It has also been a source of active clinical research which has attracted regional and national interest. An important aspect has been its singular contribution to resident and fellow training. Expansion of the patients evaluated by the CPEU is underway and includes congestive heart failure and uncomplicated supraventricular arrhythmias.
- Amsterdam EA, Kirk JD. Chest Pain Units. Progress in Cardiovascular Diseases 2004;46(5) March/April:377-378.
- Amsterdam EA, Kirk JD, Diercks DB, Lewis WL, Turnipseed SD. Early Exercise Testing in the Management of Low Risk Patients in Chest Pain Centers. Progress in Cardiovascular Diseases 2004;46(5) March/April:438-452.
- Diercks DB, Kirk JD, Sites FD, Shofer FS, Hollander JE. Derivation and Validation of a Risk Stratification Model to Identify Coronary Artery Disease in Women who Present to the Emergency Department with Chest Pain. Academic Emergency Medicine 2004;11:630-634.
- Amsterdam EA, Kirk JD, Diercks DB, Turnipseed SD, Lewis WR. Early Exercise Testing for Risk Stratification of Low-Risk Patients in Chest Pain Centers. Critical Pathways in Cardiology 2004;3(3):114-20.
- Kirk JD, Diercks DB, Amsterdam EA. The Use of Vasodilators in the Treatment of Acute Decompensated Heart Failure: Novel versus Conventional Therapy. Critical Pathways in Cardiology 2004;3(4):216-20.
- Diercks DB, Boghos E, Guzman H, Amsterdam EA, Kirk JD. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain. Ann Emerg Med. 2005Jun; 45(6):581-5.
- Amsterdam EA, Kirk JD. Preface: Chest Pain Units. In Amsterdam EA, Kirk JD (eds.), Cardiology Clinics. Chest Pain Units. November 2005;23(4):xiii-xiv.
- Diercks DB, Kirk JD, Peacock WF, Weber JE. Emergency Department Heart Failure Patients:Identification of an Observation Unit Appropriate Cohort. Am J Emerg Med. 2006 May;24(3):319-24.
- Kirk JD, Diercks DB, Amsterdam EA. Stress Testing. Cardiovascular Emergencies, Peacock F, Tiffany B, (editors). McGraw-Hill. New York, NY. 2006, pp195-207.
- Diercks DB, Kirk JD, Lindsell CJ, Pollack CV, Hoekstra JW, Gibler WB, Hollander JE. Door to ECG Time in Patients with Chest Pain Presenting to the Emergency Department. Am J Emerg Med. 2006 Jan;24(1):1-7.
- Turnipseed SD, Bair AE, Kirk JD, Diercks DB, Tabar P, Amsterdam EA. Electrocardiogram Differentiation of Benign Early Repolarization Versus Acute Myocardial Infarction by Emergency Physicians and Cardiologist. Acad Emerg Med 2006:13(9):961-6.
- Diercks DB, Kirk JD, Turnipseed SD, Amsterdam EA. Assessing the Need for Functional DiagnosticTesting in Low-Risk Women With Chest Pain. Critical Pathways in Cardiology. June 2006;5(2):123-26.
- Kirk JD. Reducing the door to balloon time: is bypassing the emergency department really the answer?
Int J Cardiol. 2007 Jul 31;119(3):359-61.
- Diercks DB, Kirk JD, Turnipseed SD, Amsterdam EA. Evaluation of Patients with Methamphetamine and Cocaine Related Chest Pain in a Chest Pain Observation Unit. Crit Pathw Cardiol. 2007 Dec;6(4):161-4.
- Kirk JD, Filippatos G, Gheorghiade M, Pang PS, Levy P, Amsterdam EA for the Society of Chest Pain Centers Acute Heart Failure Committee. Acute Heart Failure Treatment: Society of Chest Pain Centers Recommendations for the Evaluation and Management of the Observation Stay Acute Heart Failure Patient. Crit Pathw Cardiol. 2008 Jun;7(2):83-6.
- Turnipseed SD, Trythall WS, Diercks DB, Laurin EG, Kirk JD, Smith DS, Main DN, Amsterdam EA. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med. 2009 Jun;16(6):495-9.
- Kirk JD, Parissis JT, Filippatos G. Pharmacologic stabilization and management of acute heart failure syndromes in the emergency department. Heart Fail Clin. 2009 Jan;5(1):43-54
- Kirk JD, Kontos M, Amsterdam EA. Provocative testing. Short Stay Management of Chest Pain. Peacock WF, Cannon, CP (Eds.) Humana Press Inc. Totawa, New Jersey 2009, XII, 272 p.