In recent years, the incidence of acute myocardial infarction has declined, but instead, admissions for angina and chest pain have increased substantially. Using data from the Scottish morbidity record, 225 512 first hospitalisations for suspected acute coronary syndrome were recently analysed.1 Between 1990 and 2000, population hospitalisation rates for angina increased by 79%, and for chest pain by 110%, while hospitalisations for acute myocardial infarction declined by 33%. Possible reasons for this apparent shift might be a move from presentation with infarction to angina, but also “threshold” changes for admission and diagnosis. Whatever the cause, however, this increase in hospitalisations for angina and chest pain has obvious implications for resources, finances and services.

Observation units for chest pain to avoid admission for non-coronary chest pain have been established, both to reduce waiting times for assessment and to improve risk stratification. Chest pain clinics have been demonstrated to be efficient. Use of a chest pain observation unit reduced the proportion of patients admitted from 54% to 37% and the proportion discharged with acute coronary syndrome from 14% to 6%, while rates of cardiac events were unchanged, and costs were lowered, implying that this mode of delivering care may be an improvement on routine care for this large group of patients,2 although a need for further evaluation of this strategy has been identified.3 However, while patients with coronary disease may be identified and managed more efficiently, the majority of patients are discharged …