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Vol. 55. Issue 2.
Pages 143-154 (February 2002)
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Vol. 55. Issue 2.
Pages 143-154 (February 2002)
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Chest pain units. Organization and protocol for the diagnosis of acute coronary syndromes
Unidades de dolor torácico. Organización y protocolo para el diagnóstico de los síndromes coronarios agudos
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Julián Bayón Fernándeza, Eduardo Alegría Ezquerraa, Xavier Bosch Genovera, Adolfo Cabadés O'Callaghana, Ignacio Iglesias Gárriza, José Julio Jiménez Náchera, Félix Malpartida de Torresa, Ginés Sanz Romeroa
a On behalf of the working group on ischemia heart disease of the SEC
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Fig. 1. Proposed protocol for the management of patients seen in the emergency service for chest pain (see explanation in text). CK-MB indicates MB fraction of creatine kinase; ECG, electrocardiogram; ND, non-diagnostic; Rx, chest X-ray; Tn, troponins; CU, coronary unit; CPU, chest pain unit. *Consider admission in case of possible coronary pain in the presence of risk markers: history of infarction, coronary angioplasty or surgery, heart failure or peripheral vasculopathy. **Exclude aortic dissection and pulmonary thromboembolism.
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The two main goals of chest pain units are the early, accurate diagnosis of acute coronary syndromes and the rapid, efficient recognition of low-risk patients who do not need hospital admission. Many clinical, practical, and economic reasons support the establishment of such units. Patients with chest pain account for a substantial proportion of emergency room turnover and their care is still far from optimal: 8% of patients sent home are later diagnosed of acute coronary syndrome and 60% of admissions for chest pain eventually prove to have been unnecessary. We present a systematic approach to create and manage a chest pain unit employing specialists headed by a cardiologist. The unit may be functional or located in a separate area of the emergency room. Initial triage is based on the clinical characteristics, the ECG and biomarkers of myocardial infarct. Risk stratification in the second phase selects patients to be admitted to the chest pain unit for 6-12 h. Finally, we propose treadmill testing before discharge to rule out the presence of acute myocardial ischemia or damage in patients with negative biomarkers and non-diagnostic serial ECGs.
Keywords:
Unstable angina
Diagnosis
Chest pain
Coronary artery disease
Myocardial infarction
Emergency room
Los dos objetivos primordiales de las unidades de dolor torácico son la detección temprana y efectiva del síndrome coronario agudo y la identificación rápida y eficiente de los pacientes de bajo riesgo que pueden ser tratados de forma ambulatoria. La necesidad de su creación se apoya en diversas razones de carácter clínico, práctico y económico. Los pacientes que acuden al servicio de urgencias con dolor torácico suponen una proporción significativa del volumen de urgencias y su atención aún dista de ser óptima: el 8% son dados de alta sin que se diagnostique el síndrome coronario agudo que en realidad padecen y en un 60% de los ingresos hospitalarios por dolor torácico finalmente se demuestra que no tenían un síndrome coronario agudo. La Sección de Cardiopatía Isquémica y Unidades Coronarias de la SEC propone un protocolo de funcionamiento de las unidades de dolor torácico, bien sean funcionales o físicas, ubicadas en el área de urgencias, atendidas por personal especializado y dirigidas por un cardiólogo. Se contempla como procedimiento de evaluación inicial la clínica, el electrocardiograma y los marcadores bioquímicos de necrosis. El segundo paso, la estratificación del riesgo, permite seleccionar a los pacientes que serán ingresados en la unidad de dolor torácico durante 6-12 h. Finalmente, se propone la realización de un test de provocación de isquemia, generalmente una prueba de esfuerzo, antes del alta de la unidad para descartar la presencia de cardiopatía isquémica en los pacientes con marcadores bioquímicos negativos y electrocardiogramas no diagnósticos.
Palabras clave:
Angina inestable
Diagnóstico
Dolor torácico
Enfermedad coronaria
Infarto de miocardio
Urgencias
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Revista Española de Cardiología (English Edition)

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