Newer understanding of the significance of prodromal symptom presentations of acute coronary syndromes and their treatment with glycoprotein IIB/IIIa platelet receptor inhibitors for such patients in the emergency department alone and in combination with the subsequent need for PTCA and CABG.

Working with patients with thrombosed coronary vessels with newer thrombolytic agents and angioplasty stents does not seem to be the only way of the future. Shifting the paradigm to earlier presentations of ischemic heart disease and overcoming the self-imposed barrier to this approach may allow us to put the knowledge we already have to its best use and point us in the direction of benefiting patients with acute coronary syndromes. "Unrelentless" pursuit of the open vessel needs to be accompanied by an "unrelentless" pursuit of prodromal symptom recognition of the heart attack patient and reengineering the hospital system to make it work. The linkage of the two gives us the "community sarcomere," which conceptually can become the strategy that allows us to penetrate the community where the heart of the heart attack problem lies.

Why Chest Pain Centers?

In treating patients with a heart attack, a lack of preparation in hospitals can be overcome with Chest Pain Centers that plan a comprehensive and systematic management approach to patients presenting with chest pain. Critical pathways can be developed in such centers that provide not only an attack strategy for patients crashing with acute myocardial infarction, but also an observation strategy for patients with low probability of having ischemic heart disease where 80% of such patients can be discharged home avoiding inappropriate admission as well as mistakenly sending an MI home. This low probability pathway has been proven to be cost effective and has allowed Emergency Departments to have the machinery necessary to sort out low probability cases, thereby opening the door to the community for more aggressive awareness programs to bring in patients with stuttering chest symptoms, not perceived emergency enough to previously have come into the hospital.

Why Expand the "Chain of Survival" To Include Early Heart Attack Care (EHAC)?

The "Chain of Survival" represents emergency cardiac team work necessary to save lives. It applies best in the situation of cardiac arrest. It applies also to acute myocardial infarction patients who are crashing with severe chest pain or having complications such as cardiogenic shock, acute pulmonary edema, ventricular tachycardia or complete heart block. It has trouble applying in patients with beginning acute myocardial infarction who present with intermittent chest symptoms, not deemed emergency enough to seek such care. Since we now know that this occurs in 50% of heart attack patients (heralded myocardial infarction)², it is important to capture these patients early with an awareness program that identifies chest pain as a risk factor for acute myocardial infarction and works to strengthen the "Chain of Survival" with an Early Heart Attack link presently not available. It is not presently perceived as an emergency, but it can quickly become an emergency by setting off a cascade of events leading to a crashing MI and the cardiac arrest.

¹ Hoekstra JW, Gibler WB. Chest Pain Evaluation Units Ð An Idea Whose time Has Come JAMA, November 1997 Ð Vol. 278 No. 20

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