Does a patient with a history of Coronary Artery Disease (CAD) post stent placement and persistent chest pain warrant hospital admission?

Hospital Admission for Persistent Chest Pain in a Patient with CAD Post-Stent Placement

A patient with persistent chest pain and history of coronary artery disease (CAD) post stent placement warrants hospital admission for further evaluation and management due to the high risk of acute coronary syndrome.

Risk Assessment and Decision Making

Persistent chest pain in a patient with known CAD and previous stent placement represents a high-risk scenario that requires prompt evaluation. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guidelines for chest pain evaluation, patients with definite acute coronary syndrome (ACS) and ongoing ischemic symptoms should be admitted to the hospital for further management 1.

The decision to admit is based on several factors:

1. History of CAD with stent placement:

   • Patients with known CAD who have new onset or worsening symptoms are at increased risk for adverse events 1
   • Recurrent chest pain in patients with previous stent placement may indicate stent thrombosis, restenosis, or progression of disease 2

2. Persistent nature of symptoms:

   • Persistent chest pain, especially in a patient with known CAD, is a high-risk feature
   • The 2013 ACCF/AHA guidelines state that "patients who experience recurrent ischemic discomfort should be admitted to the hospital" 1

3. Risk of adverse outcomes:

   • The European Society of Cardiology (ESC) guidelines indicate that recurrent or ongoing chest pain refractory to medical treatment is a very-high-risk criterion warranting an immediate invasive strategy 1

Recommended Evaluation Pathway

Initial Assessment (Emergency Department)

• 12-lead ECG to assess for new ischemic changes
• Cardiac biomarkers (high-sensitivity troponin)
• Continuous ST-segment monitoring to detect dynamic changes 1

Admission Decision

• If ECG shows new ST-segment changes, elevated cardiac biomarkers, or hemodynamic instability: admit to cardiac care unit 1
• If normal or unchanged ECG but persistent symptoms in a patient with known CAD: admit to telemetry unit 1

In-Hospital Management

• Serial cardiac biomarkers and ECGs
• Consider early invasive coronary angiography, especially if:
  • Persistent or recurrent symptoms
  • Dynamic ECG changes
  • Elevated cardiac biomarkers 1

Important Considerations

Stent-Related Complications

Post-stent chest pain may indicate serious complications:

• Stent thrombosis (acute, subacute, or late)
• In-stent restenosis
• Coronary dissection or perforation
• Incomplete revascularization 2, 3

A study by Farkouh et al. found that patients with post-PCI chest pain required more repeat revascularization than those without chest pain after the procedure 4.

Non-Ischemic Causes

While evaluating for ACS, consider other causes of chest pain:

• Post-procedural pericarditis
• Musculoskeletal pain
• Gastrointestinal causes 2

However, these should be diagnoses of exclusion after ruling out acute coronary syndrome.

Pitfalls to Avoid

1. Premature discharge: Approximately 8% of patients with chest pain discharged from the ED are later diagnosed with ACS 5

2. Relying solely on chest pain characteristics: The chest pain history alone is not powerful enough to rule out ACS 6

3. Discontinuing antiplatelet therapy: Premature discontinuation of antiplatelet medications increases the risk of stent thrombosis, MI, and death 7

4. Delaying angiography: For patients with very high-risk features (persistent pain, dynamic ECG changes), immediate invasive strategy (<2 hours) is recommended 1

In conclusion, persistent chest pain in a patient with CAD post-stent placement represents a high-risk scenario that warrants hospital admission for comprehensive evaluation and management to prevent potentially life-threatening complications.