Effectiveness of Chest Pain Units

Acute chest pain is responsible for one in four emergency medical admissions in the UK. Identifying which patients at low risk of acute coronary syndrome can be safely sent home and which patients need further observation and investigation is not easy, especially when the consequences of misdiagnosis include infarction, arrhythmia, and death. The strategy of evaluating such patients in a chest pain unit based within or near the emergency department is used in 30% of emergency departments in the United States. In theory, a chest pain unit should improve outcomes—but does it? The ESCAPE (effectiveness and safety of chest pain assessment to prevent emergency admissions) cluster randomised controlled trial (Goodacre et al, 2007) enrolled 14 hospitals, seven of which had a chest pain unit. In people admitted to hospitals with a chest pain unit, serial electrocardiography was performed over two to six hours, biochemical markers were measured, and an exercise treadmill test was performed. People admitted to hospitals without a chest pain unit received the usual service typically consisting of admission for troponin measurements over 12 hours, with no early exercise testing. The outcomes were measured the year before and the year after either the introduction of the chest pain unit or continuance of the same service. The introduction of a chest pain unit had no significant effect on the proportion of people attending the emergency department with chest pain, the proportion of people with chest pain who were admitted, or the number of people admitted over the next 30 days. Mike Clancy, BMJ 2007;335:623-624 (29 September)