We read with interest Kaul and Abbott's recent editorial on evaluation of chest pain in the emergency department [1]. We have been applying these methods at William Beaumont Hospital for the last 2 years [2, 3]. Patients presenting to our chest pain clinic are immediately evaluated by a team of emergency physicians, cardiologists, and specially trained nurses. Patients with definite evidence of acute coronary ischemia are immediately triaged and treated. Those whose chest pain remains unexplained have radioisotope single-photon emission computed tomographic imaging in the emergency center with Tc-99m sestamibi using a dedicated camera. The resulting images are immediately sent by computer network to a nuclear medicine physician for interpretation. Thus, 24-hour coverage is provided.

The activation of this chest pain clinic using Kaul and Abbott's strategy has improved efficiency and reduced cost. The addition of radionuclide imaging has had an additional dramatic effect. In patients with unexplained chest pain, the radionuclide scan changed the physicians' management decision in 34 of the first 50 patients (68%). All but one of these patients were sent to a lower-intensity destination. Twenty-nine of these 34 patients (29 of the first 50 patients [58%]) were sent home from the emergency center on the basis of the scan. Initial follow-up has shown that no patient sent home on the basis of the scan subsequently had a significant adverse cardiac event. The cost savings was $1771 per patient. A total of 69.4 inpatient hospital days were avoided in the first 50 patients seen.

This team approach using emergency, cardiology, and nuclear medicine physicians has permitted patients with chest pain to be evaluated and managed quickly, efficiently, and cost-effectively. Although Kaul and Abbott are correct that nuclear imaging techniques are not yet widely used in this setting, these results indicate that their implementation would be economically advantageous. The use of nuclear perfusion imaging combined with today's rapid computer networks allows skilled nuclear medicine physicians (at centralized or remote locations) to quickly and cost-effectively provide physicians who are evaluating patients with chest pain in the emergency center with critical diagnostic and prognostic information.