In an otherwise excellent summary of the problems of cost-effective emergency department evaluation of chest pain, Drs. Kaul and Abbott [1] provided two "cost-effective and efficient approaches" that I believe do not realistically apply to the managed care era. For example, they recommend for chest pain of uncertain origin, a cardiology consultation and possible nuclear perfusion imaging, echocardiography, coronary angiography, and percutaneous transluminal angioplasty—procedures that may be unnecessary and are costly. What must first be evaluated is the relative risk for myocardial infarction based on the history, physical examination, electrocardiogram, chest radiograph, and so forth before a specialist is asked to intervene, especially because most chest pain in patients with normal electrocardiograms is noncardiac in origin. Then, if clinical suspicion of myocardial infarction continues, the cardiologist should be called immediately.

The second recommendation—a specialized "chest pain unit" in which new, expensive cardiac enzymes including fibrinogen, ferritin, myoglobin, and troponin T are frequently ordered—is based on the premise that such a unit is not only less expensive than a cardiac care unit admission but is also a realistic option for most hospitals. Few hospitals, however, can afford a special chest pain unit (or, for that matter, an abdominal pain unit or a back pain unit). Direct admission to the cardiac care unit from the emergency department probably will be similarly cost-effective for most hospitals.

Never would it be appropriate for us to avoid emergent care for patients with possible acute myocardial infarction. When the source of chest pain is unclear, however, the emergency department physician does have another reasonably cost-effective option—they may call the managed care internist on call for a telephone or full consultation before requesting a cardiology consultation.