LETTER
Evaluation of Chest Pain in the Emergency Department
Arthur L. Kellermann
15 August 1995 | Volume 123 Issue 4 | Pages 314-318
TO THE EDITOR:
In their editorial, Drs. Kaul and Abbott [1] assert that emergency physicians are less adept than cardiologists at differentiating chest pain of ischemic origin. No literature is cited to support this claim. The authors also recommend that emergency physicians consult a cardiologist whenever they are confronted with chest pain of uncertain origin. If this advice were followed, emergency physicians would generate millions of additional consultation requests each year. The authors also assert that patients with evolving myocardial infarction are more likely to have early reperfusion if care is delayed until the arrival of a cardiologist. This position is contrary to the recommendations of the American Heart Association [2] and of the National Institutes of Health [3].
Why was this editorial written? Insight can be gained by viewing it in the context of person, place, and time. Dr. Kaul is a cardiologist who specializes in noninvasive imaging of patients with acute chest pain. The article he cites to support of the use of cardiac imaging is his own [4]. He practices at the University of Virginia, an institution that has been slow to embrace the specialty of emergency medicine. The time is now, when economic pressures threaten to erode the income of hospital-based specialists.
Studies of diagnostic errors in the emergency department often do not control for the level of training of the physicians who work there. Annals recently published an essay about moonlighting that practically celebrated the experience as a rite of passage [5]. Because too few emergency medicine residency programs exist to meet demand, only one third of the physicians who work in hospital emergency departments are formally trained to practice emergency medicine.
Annals should not publish self-serving editorials.
1. Kaul S, Abbott RD. Evaluation of chest pain in the emergency department (Editorial). Ann Intern Med. 1994; 121:976-8.
2. American Heart Association. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA. 1992; 268:2171-242.
3. National Heart Attack Alert Program Coordinating Committee 60 Minutes to Treatment Working Group. Emergency department: rapid identification and treatment of patients with acute myocardial infarction. Ann Emerg Med. 1994; 23:311-29.
4. Sabia P, Abbott RD, Afrookteh A, Keller MW, Touchstone DA, Kaul S. The importance of two-dimensional echocardiographic assessment of left ventricular systolic function in patients presenting to the emergency room with cardiac-related symptoms. Circulation. 1991; 84:1615-24.
5. Kasman DL. When a heart stops. Ann Intern Med. 1994; 120:432-3.
About Letters
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
Top
References
Article
