The authors of the recent editorial [1] do not support their allegation that without specialized testing, a cardiologist can sort out atypical and bizarre chest pain. Straightforward cases do not require the service or care of a cardiologist. The absence of an acute myocardial infarction does not rule out significant coronary artery disease. The natural history of coronary artery disease is that often, symptoms disappear during rest. Hence, patients who are not hospitalized or who are discharged early are not necessarily healthy. They may go home and have an infarction.

We appear to be competing to see how little care we can deliver and how much we can get away with. Although we can evaluate and stratify patients into low-risk groups, we cannot place them in zero-risk groups, nor can we predict from population statistics what an individual person will do. Consequently, we must bear the risk for death and litigation.

The authors seem to suggest that these patients should be sent for follow-up to a "sudden cardiac death clinic" or to "stable angina clinic." Mechanisms for aggressive follow-up are at best informal and do not exist in the United States.

Detailed guidelines developed by expert panels are generally well behind the state of the art and often bring comfort to plaintiff's attorneys.