April 11, 2008

New unit brings cardiac, emergency expertise together

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David Maron, M.D., is the attending cardiologist in Vanderbilt’s Emergency Department. (photo by Neil Brake)

New unit brings cardiac, emergency expertise together

In most medical centers, when a patient presents to an Emergency Department with chest pain, the ED physician makes an initial diagnosis and, if needed, a cardiology consult is obtained over the phone rather than in person.

Vanderbilt has taken the natural synergy between cardiology and emergency medicine to a new level by placing a full-time attending cardiologist in the ED, resulting in improved communication as well as streamlined, optimal care for patients.

“We believe we are the only major university emergency department to have a full-time, board certified cardiologist based in the Emergency Department practicing emergency cardiology,” said Corey Slovis, M.D., professor of Emergency Medicine and chair of the department. “Unless an emergency condition exists, cardiologists do not usually become involved in the evaluation of lower-risk chest pain patients. Having a cardiologist in the ED is unique and sets a new standard for the care of these patients.”

David Maron, M.D., associate professor of Medicine and Emergency Medicine, accepted the post in July and works in the ED Monday through Friday. One of his responsibilities is overseeing the recently organized chest pain observation unit for low to moderate risk cardiac patients.

“Patients at low risk for heart attack who come into the ED in the evening with chest pain are now admitted to the chest pain observation unit where our protocol is observed,” Maron said. “They get serial cardiac enzymes and ECGs, and then in the morning I see them and decide upon the most appropriate strategy to evaluate their pain.”

Some studies indicate that 50 percent of patients hospitalized with chest pain eventually receive a non-cardiac diagnosis. Oftentimes their pain is musculoskeletal in nature. Maron's presence in the ED has helped to ensure that patients are admitted to the inpatient cardiac unit only when appropriate.

“At Vanderbilt, a high percentage of patients admitted as inpatients with a presumed acute coronary syndrome actually have it,” Maron said.

Keith Churchwell, M.D., associate medical director of the Vanderbilt Heart & Vascular Institute, said he has seen a difference in efficiency.

“Our attempt to ensure that we admit only those patients who really need inpatient care has been extremely helpful in making the cardiology service run more effectively,” he said.

One of the tools Maron uses to evaluate the cause of chest pain is CT angiography. If the ECG is not worrisome, and he has a low suspicion that the pain is angina, Maron often obtains a 64-slice coronary CT angiogram, which provides a non-invasive image of the coronary arteries. In less than 30 minutes he can rule out the presence of coronary artery disease.

“In a much shorter period of time we can assess if coronary artery disease is present, and if it's not, we can send a patient home with a high level of confidence that it's safe to do so,” Maron said.

On the other hand, when Maron is concerned that a patient in the ED may be at high risk for a heart attack, he is able to facilitate a quick referral to the cath lab.

“I enjoy working with my new colleagues in the ED, sharing with them how a cardiologist approaches different types of cardiac problems,” he said.

As an ambassador from the inpatient cardiology service, Maron brings a cardiologist's perspective to the ED and takes the Emergency Department's perspective to the cardiologists. ED physicians and nurses are under enormous pressure to never make a mistake when it comes to the heart. While as many as 5 percent of heart attack patients are inappropriately discharged from emergency rooms across the country, this is not the case at Vanderbilt.

“The likelihood of us inappropriately discharging a patient at risk for a heart attack is close to 0 percent,” Slovis said.