Phoenix, AZ - A new study concludes that emergency care of chest pain in the US needs to be improved. Dr Jipan Xie (division for heart disease and stroke, Centers for Disease Control and Prevention, Atlanta, GA) and colleagues report their findings today at the American Heart Association 46th Annual Conference on Cardiovascular Disease, Epidemiology, and Prevention [1].

Xie told heartwire that this was the first national survey of emergency care of chest pain, and it showed that the majority of people presenting with this condition do not get a clear final diagnosis. Also, use of ambulances is less than optimal, and there may be racial disparities in emergency care related to chest pain, she and her colleagues found.

We feel that we can use this information to try to raise awareness of the problems.

However, she notes that the findings "are really exploratory. We didn't adjust for confounders or look at how hospitals were conducting their services, and so further investigations are needed. But we feel that we can use this information to try to raise awareness of the problems, educate the public, and formulate national policies on chest pain for emergency departments."

Xie notes that chest pain is the number-two reason for all emergency-department (ED) visits and can be associated with acute coronary syndrome, impending myocardial infarction, and arrhythmias. In their survey, using the 2003 National Hospital Ambulatory Medical Care Survey (NHAMCS), there were 6.1 million initial ED visits due to non-injury-related chest pain, which accounted for 6% of all initial ED visits.

Xie and her team included a sample of these, comprising 35 517 visits, of which 2125 were for non-injury-related chest pain. The data were weighted to provide national estimates, and the mean and standard error of various ED visit times were calculated and compared by race, age, and gender.

The discharge diagnosis was "ill-defined chest pain" in 48.5% of those attending the ED. Only 7.8% were diagnosed with coronary heart disease (CHD) and 5.1% with "other circulatory disease." The remainder of patients had diagnoses of digestive disease, respiratory disease, or "other"; the latter made up 19.2% of the total.

Although there is much room for improvement, there were some encouraging signs, in that those with a final diagnosis of CHD saw the doctor sooner and were more likely to arrive by ambulance and be classified as an emergency.

The researchers compared four ethnic groups: non-Hispanic whites, non-Hispanic blacks, Hispanics, and others. They found that blacks were less likely to use an ambulance compared with whites (p=002), and blacks and Hispanics waited longer to see a doctor than whites (p<0.01).

Among those with a final diagnosis of CHD, however, there were no significant racial differences in use of an ambulance or waiting time to see a doctor.

"The study provides a profile of current emergency care related to chest pain," say Xie et al, "and sheds light on the necessity to improve ED services and the rate of diagnosis related to chest pain."

However, they emphasize that this was an exploratory study and so did not address the reasons for suboptimal care related to chest pain, nor did it determine what caused the observed racial/ethnic disparities.

"This study presents a number of opportunities for the CDC's division for heart disease and stroke to engage in further studies and to set policies for hospital emergency rooms," they conclude.