Cardiology and emergency medicine: United We Stand, divided we fall☆

Evolution of care for ACS 

Since the early 1960s, emergency cardiovascular care has enjoyed phenomenal growth in monitoring, diagnostics, and therapy.1, 2, 3, 4 For the diagnosis and treatment of ACS, care has progressed from passive monitoring for cardiac dysrhythmias in the coronary care unit to the current aggressive strategies that include serial 12-lead ECG surveillance, serial troponin testing, antithrombin and glycoprotein IIb/IIIa receptor inhibitor infusion, fibrinolytic therapy, and percutaneous coronary intervention.5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 Through these advances, mortality resulting from acute myocardial infarction (AMI) has decreased from nearly 20% to its current level of approximately 6%. Collaboration between the disciplines of emergency medicine and cardiology has resulted in better coordinated approaches to patients with ACS.19

Traditional cardiology collaboration 

In the past, cardiologists have traditionally developed collaborative partnerships with “in-hospital” disciplines such as internal medicine, cardiac surgery, and radiology. Over the past 2 decades, research protocols and the development of clinical care guidelines have emphasized that, for optimal care to be delivered in patients with ACS, and AMI in particular, rapid diagnosis and correct treatment must be initiated as promptly as possible in the emergency department or even in the out-of-hospital environment.10, 11 Cardiologists and emergency physicians in many hospitals in North America found that protocol development required effective, continuing communication with the principals and their staff to ensure reproducible, efficient, evidence-based approaches to patients with ACS presenting to the ED. It is most desirable to see this model develop in an atmosphere of mutual respect and cordiality, in which the differing perspectives and knowledge base of the 2 specialties become aligned toward the common goal of optimal patient care.

Previous successful ventures 

Several examples of successful collaboration between the specialties of cardiology and emergency medicine have emerged over the last decade. In the early 1990s, the use of fibrinolytic therapy for patients with AMI was successfully transitioned from cardiologists to emergency physicians. Multiple placebo-controlled trials using fibrinolytic therapy for AMI in the second half of the 1980s revealed the time dependency of this therapy. Patients treated within the first hours after symptom onset were found to derive the greatest benefit.10 For patients with AMI to receive this early treatment benefit, it became clear that fibrinolytic therapy would have to be given in the ED. Emergency cardiac care specialists from emergency medicine and cardiology subsequently concluded in a cooperative directive from the National Heart Attack Alert Program that patients with AMI ideally should receive therapy within 30 minutes after hospital presentation. It was the understanding of this committee that emergency physicians would need to rapidly identify and treat these patients in the emergency setting if this 30-minute goal was to be accomplished. The highly successful approach to AMI therapy, defined as the 4 “Ds”: door, data, decision, and drug, resulted from this collaboration between cardiology and emergency medicine.11

In a similar fashion, the coordination of efforts between the 2 specialties has recently been established for ACS through the development of the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) Quality Improvement Initiative. With the co-chairs and Steering Committee equally balanced between emergency medicine and cardiology, the CRUSADE Quality Improvement Initiative is designed to support the 2000 American College of Cardiology and American Heart Association guidelines for the care of patients with ACS.20, 21 This effort should ensure that patients with ACS receive optimal care that is evidence-based. Although these 2 examples represent outstanding cooperation between the 2 disciplines, further efforts are necessary to enhance the care of patients with ACS presenting to the emergency setting of every hospital. Scarce resources, competition for research funding and academic recognition, concern for litigation, and increasingly complex patient groups and treatment options can generate tension across this rapidly moving field, placing a high priority on cordial communication and teamwork.

The evolution of the emergency department in appraising chest pain 

The ED in most hospitals in North America now serves as a major diagnostic and treatment center that focuses on the timely, effective triage of patients with ACS. This consists of rapid hospital admission of patients with severe or critical illness, discharge of patients at low risk with appropriate follow-up, and the release of still other patients after extensive diagnostic evaluations and treatment that prevents hospital admission. In the current environment of managed care, increasing patient visits to the ED, fewer in-patient beds for those requiring admission, and more time-consuming and sophisticated workups for all patients, caring for the patient with possible ACS is an even greater challenge.

The burden of enormous amounts of diagnostic and therapeutic clinical trial information for ACS, combined with severe overcrowding of ED beds, can confound any clinician aiming to make rapid and accurate decisions for the patient presenting with possible ACS. For these reasons, cardiologists and emergency physicians at every hospital should seek to develop an evidence-based approach for the care of patients with ACS. This can be facilitated with contemporary information technology and the use of risk models and treatment guidelines. With this paradigm, every patient coming to the hospital with possible ACS will have an efficient, consistent diagnostic evaluation for risk stratification and clearly defined treatment protocols that emphasize timely, safe treatment. Chest pain centers modeled after trauma centers have recently been developed in many EDs to facilitate such care.22

Preparing for other cardiologic advances 

Whereas our paper has emphasized advances made in ACS diagnosis and treatment, substantial progress has been made in other emergency cardiac care arenas. Technological growth in pacemakers, defibrillators, and complex physiologic and electrical monitoring, as well as increased understanding in disease processes such as congestive heart failure, cardiac transplant emergencies, atrial and ventricular arrhythmias, and cardiac arrest, demand similar cooperation between emergency physicians and cardiologists to ensure optimal patient care.

Proposal 

We propose the following approaches for education, clinical research, and patient care to optimize the collaboration between the specialties of emergency medicine and cardiology: