When to admit a patient with chest pain (angina)?

From the Guidelines

Chest pain patients should be admitted to the hospital when there are signs of a potentially life-threatening condition, such as confirmed acute coronary syndrome, abnormal cardiac biomarkers, concerning ECG changes, hemodynamic instability, or respiratory distress, as outlined in the ACC/AHA 2007 guidelines 1.

Key Indications for Admission

• Confirmed acute coronary syndrome (including STEMI, NSTEMI, or unstable angina)
• Abnormal cardiac biomarkers (particularly elevated troponin levels)
• Concerning ECG changes (such as ST-segment elevation, depression, or new T-wave inversions)
• Hemodynamic instability (hypotension, arrhythmias)
• Respiratory distress
• Severe, prolonged (>30 minutes), or unresponsive chest pain
• Significant risk factors like advanced age, diabetes, prior cardiovascular disease, or multiple comorbidities

Evaluation and Management

According to the ACC/AHA 2007 guidelines 1, patients with probable or possible acute coronary syndrome (ACS) but whose initial 12-lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring, and repeat ECG and cardiac biomarker measurements should be obtained at predetermined time intervals.

Low-Risk Patients

For low-risk patients, observation units may be appropriate for 12-24 hours of monitoring before making a final disposition decision, as suggested by the European Society Guidelines on unstable angina and non-Q wave infarction 1.

High-Risk Patients

Patients with definite ACS, ongoing ischemic symptoms, positive cardiac biomarkers, new ST-segment deviations, new deep T-wave inversions, hemodynamic abnormalities, or a positive stress test should be admitted to the hospital for further management, with admission to the critical care unit recommended for those with active, ongoing ischemia/injury or hemodynamic or electrical instability 1.

From the FDA Drug Label

If the pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than is typically experienced, prompt medical attention is recommended

• Admission criteria:
  • Chest pain that persists after a total of 3 tablets of nitroglycerin in a 15-minute period
  • Chest pain that is different from what is typically experienced
• Action to take: Prompt medical attention is recommended in these cases 2, 2

From the Research

Admitting Patients with Chest Pain

When deciding to admit a patient with chest pain, several factors should be considered, including:

• The patient's medical history and risk factors for acute coronary syndrome (ACS) 3
• The results of the initial history, physical examination, electrocardiogram (ECG), and risk scores, such as the History, Electrocardiogram, Age, Risk Factors, Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) risk scores 3
• The presence of cardiac biomarkers, such as cardiac troponins, which are highly sensitive diagnostic biomarkers in patients with ACS 4

Key Components of Chest Pain Assessment

The following are key components of an effective chest pain assessment:

• Patient history, including the use of the SOCRATES mnemonic to differentiate cardiac from non-cardiac pain 5
• Physical examination, including evaluation of vital signs and evidence of murmurs, rubs, heart failure, tension pneumothoraces, and chest infections 5
• 12-lead ECG, which should be interpreted within 10 minutes of first medical contact to identify ST elevation myocardial infarction (STEMI) 5
• Cardiac biomarkers, including high-sensitivity troponins, which can improve the rapid rule-out of myocardial infarction (MI) and confirmation of non-ST elevation MI (NSTEMI) 5, 4

Management of Acute Coronary Syndrome

The management of ACS, including STEMI and NSTEMI/unstable angina pectoris (UAP), involves:

• Urgent reperfusion, including primary percutaneous coronary intervention (PPCI) if available, and fibrinolysis if PPCI is not available 6, 5
• Essential adjunctive therapies, including antiplatelet therapy (aspirin, P2Y12 inhibitors), anticoagulation (heparin or low-molecular-weight heparin), and cardiac monitoring 6, 5
• The use of proton pump inhibitors to prevent bleeding due to antiplatelet and anticoagulation use in patients at higher than average risk of gastrointestinal bleeding 6
• The use of statins, angiotensin-converting enzyme inhibitors, beta blockers, nitroglycerin, and morphine (to relieve chest pain), and oxygen 6