PATIENTS with acute chest pain are a common problem and a difficult challenge for clinicians. Uncertainty and delay are common in the diagnosis of heart attacks and other life-threatening cardiac conditions. Recognising the devastating impact of heart diseases on communities around the world, clinicians continue to search for ingenious and innovative ways to improve outcomes in patients with acute cardiac conditions. As heart doctors frequently say, time is muscle (as in heart muscle) and preservation of heart muscle determines survival in many instances. Time to diagnosis and time to treatment are therefore critical in saving the lives of patients with heart disease.

In the last 25 years, the need for faster, more accurate, and more cost-effective diagnosis and treatment has given rise to the concept of specialised treatment of patients with chest pain in Accident and Emergency departments (A&Es). The original strategy required dedication of a designated section of the A&E and assignment of clinical personnel to the task of rapid intervention in patients with chest pain and heart attacks and to triage these patients to identify low-risk and high-risk patients. Chest pain centres grew quickly in popularity but evolved with a variety of goals, diagnostic resources and levels of commitment. Nevertheless, the advent of chest pain centres led to the implementation of chest pain strategies with the common aims of: screening for the entire spectrum of heart disease, facilitating urgent intervention to save lives, resolving non-emergency situations quickly and avoiding unnecessary admissions, and using multiple diagnostic platforms to improve diagnostic accuracy and survival.

While designating a section of the emergency department for evaluation and treatment of chest pain seemed progressive, many patients still experienced preventable negative outcomes because of the inefficiencies in dealing with life-threatening chest pain syndromes constrained by shared resources. In Jamaica, the conflict in resource allocation and utilisation is even more acute given the limited resources in the A&E departments that must be shared with such critical emergencies as trauma and gunshot wounds. Additionally, many physicians and other clinical personnel working in these departments may not have the necessary skills, experience or equipment to appropriately intervene in patients with life-threatening cardiac problems. In light of these concerns, it became obvious to clinicians that a more effective strategy must be implemented in order to help patients with heart attacks and other chest pain-related emergencies. The paradigm shift generated by this thinking gave rise to the birth of Chest Pain Emergency Care Centres.

The evaluation of chest pain in the emergency setting should be systematic, risk-based and goal driven. An effective programme must be able to evaluate all patients with equal thoroughness under the assumption that any patient with chest pain could potentially be having a heart attack or other potentially life-threatening cardiovascular condition. The initial evaluation is based on detailed history, a focused physical examination, and the electrocardiogram. This information is often sufficient to categorise patients into groups at high, moderate, and low risk. Patients at high risk need rapid initiation of appropriate therapy: in the case of a heart attack, the use of clot bursting treatment or preferably, an intervention that would open up the blocked vessel with balloon dilatation and insertion of a metal mesh (stent) to hold the vessel open or aspirin/heparin for the patients with unstable angina. Patients at moderate risk need to quickly be ruled in or out for an acute coronary syndrome and additional issues addressed promptly. Patients at low risk also need to be evaluated, and once the likelihood of an unstable acute coronary syndrome is eliminated, they can be discharged with further evaluation performed as outpatients. Subsequent evaluation should attempt to assign a definitive diagnosis while also addressing issues specific to risk reduction, such as blood pressure control, cholesterol lowering and smoking cessation.

Chest pain and related cardiovascular symptoms like shortness of breath and fatigue are among the most common presenting complaints in many A&Es. These symptoms are often related to the leading cause of death and disability in Jamaica, cardiovascular disease (CVD). Nearly half of such patients will eventually have a diagnosis of heart attack or acute coronary syndrome. Many patients with acute coronary syndromes or heart attack, especially women would present with atypical or unusual symptoms like fatigue and shortness of breath. In such cases the diagnosis may be missed as many A&Es lack the expertise of trained cardiovascular personnel at critical moments and are also without the benefit of more sophisticated and reliable diagnostic techniques found in dedicated chest pain emergency care centres. A recent study by the National Institutes of Health (NIH) suggested that 90 per cent of primary care doctors are unaware that heart disease kills more women than men and that about 1/3 of women having heart attack experience no chest pain but may present with other unusual complaints.

Such patients would require additional diagnostic testing in a timely manner for quick evaluation so that proper treatment strategy could be formulated. Patients who are inadvertently released with improper diagnosis often have poor outcomes. This is where a chest pain centre trumps a traditional A&E in the diagnosis and treatment of patients with symptoms suggestive of heart disease. Chest pain centres have generally been shown to be a safe, cost-effective, and rapid approach to the evaluation, triage and management of patients with potentially life-threatening acute coronary syndromes. These centres are designed to enhance patient care by decreasing time to treatment for acute myocardial infarction (heart attack) and to rapidly identify those patients with unstable chest pain syndromes. Chest pain centres actively engage in community outreach and educational objectives designed to reduce time from the onset of chest pain to presentation at the Chest pain centre. While this trend has gained momentum in many countries over the past decade, Jamaica has not benefited from this trend.

Jamaica’s first dedicated 24-hour Chest Pain Emergency Care Centre opened on September 15. The Chest pain centre at HIC (Heart Institute of the Caribbean) has been designed to facilitate urgent diagnosis and treatment of patients with acute heart attack and other life-threatening chest pain or cardiac emergencies. The centre is staffed by four interventional cardiologists who are on-call 24 hours a day, seven days a week, to handle any cardiovascular emergency, who are supported by a team.

We are confident that a structured and protocol-driven approach such as this will significantly improve access to care for patients with acute cardiovascular problems.

Professor Ernest Madu, founder of the Heart Institute of the Caribbean, is an internationally acclaimed cardiologist and expert on innovative health solutions. HIC is a centre of excellence for cardiovascular care in the English-speaking Caribbean. Please send questions and comments to emadu@caribbeanheart.com or call 906-2105-8.