Statistics from Altmetric.com
I read with interest the paper by Miller et al.1 The “high risk” patients with acute coronary syndrome are kept in hospital these days for a possible early intervention. This is in line with the FRICS-II recommendations.
One of the fundamental principles of the National Service Framework (NSF) for coronary heart disease is to reduce the inequality in the provision of cardiac services across the UK. Miller et al showed that patients admitted to a district general hospital with acute coronary syndrome are at a disadvantage in terms of access to interventions, compared with patients with the same condition admitted to a hospital with a tertiary centre on-site.1
I agree with the authors that equity of access could be achieved by establishing independent function for an invasive facility so that the tertiary centres can serve in a more uniform manner.
A number of patients admitted to a district general hospital with acute coronary syndrome are not referred at all. The reluctance is partly due to the difficulties in referring patients in time for interventions, and partly due to the fact that the pressure of beds remains high at all times. District general hospitals follow a stringent protocol to “fast track” only the high risk patients.
Innovative action plans, such as the introduction of chest pain observation units (CPOUs) suggested by Goodacre et al,2 seem like a cost effective way for evaluating patients with undifferentiated chest pain. In a survey of 238 British hospitals, however, CPOUs were present only in 38 (21%).3 CPOUs in the United States attempt to improve the diagnostic accuracy of acute coronary syndrome. Patients are subjected to a battery of tests. If all the tests are negative the patient is sent home and if the tests are positive or equivocal they are referred for further investigations.
In the UK, with much less interventional radiology and higher discharge rates from emergency departments, such a policy may appear to be a non-starter. On the contrary, it is worrying to note that in the UK 6% of patients discharged from emergency departments after attendance with acute chest pain were found to have prognostically significant myocardial damage.4
To achieve the NSF goal of removing any inequality of coronary heart disease services, district general hospitals may have to formalise a uniform guideline so that they can risk stratify the cases of chest pain effectively in a CPOU.2,3 They should aim to risk stratify the cases of acute coronary syndrome as per Braunwald’s classification.3 They will then be able to “fast track” the highest of the high risk patients and thereby reduce congestion at the tertiary centres.
In the ROMEO rule out trial it was evident that it was feasible to provide consistent care for people with acute chest pain who presented to emergency departments in the UK.5 It is to be hoped that more UK hospitals adopt such a policy to reduce congestion at tertiary centres. This may also help remove the inequality that is present in UK hospitals so far as the management of acute coronary syndrome is concerned.