Chest pain assessment services: the next steps

Improved care for patients presenting with chest pain remains high on the medical agenda. This is reflected not only in the National Service Framework (NSF),1 but also in the number and variety of publications in this area. The two articles in this issue illustrate that the questions are no longer about whether there should be specialized services for chest pain, but how best to organize such services, and the need to subject them to economic analysis. Just a year ago the question was posed: ‘Chest pain—please admit’: is there an alternative?2 The accepted answer now must be a conclusive ‘yes’. The challenge that remains is to refine the alternatives. This of itself represents a great (if as yet incomplete) victory for the protagonists of chest pain clinics and for the NSF. Patients with suspected ischaemic chest pain present across a spectrum of illness, from acute, haemodynamically unstable patients with evolving myocardial infarcts to ambulant patients with recent‐onset exertional angina. The characteristics and design of services, together with the placing in context of published reports, require an appreciation of where along this spectrum a service lies. At one end are Emergency Departments and Coronary Care Units (CCU) and their related new services, often called Chest Pain Assessment Units (CPAUs). These receive a high proportion of acute coronary syndromes and are an alternative to the standard Emergency Department facilities. Monitored beds are required, with patients staying potentially for some hours, and high subsequent admission rates. At the other end of the spectrum are Rapid Access Chest Pain Clinics (RACPCs), specifically excluding suspected acute coronary syndromes in their referral criteria, for patients to receive prompt assessment focussed around exercise stress testing. Although in practice these distinctions become blurred, and many seen in CPAUs have exertional angina, while RACPCs report a proportion, rarely below 5%, of acute coronary syndromes amongst their referrals,1,3 the division remains important. Referral criteria may give a clue to the position of services in this scheme. More often a better guide is the reported proportion with acute coronary syndromes and subsequent admission rates. Examples where the position along this spectrum has implications, are in deciding the role of cardiac injury markers, and assessing whether the likely benefits of the service are in saved out‐patient appointments or saved admissions. For those establishing such services, this positioning will direct the facilities needed and their relationship with other primary and particularly secondary care services in the locality.