When should a patient with left-sided chest pain be admitted?

Admission Criteria for Left-Sided Chest Pain

Patients with left-sided chest pain should be admitted to the hospital if they have high-risk features including chest pain lasting >20 minutes at rest, hemodynamic instability, recent syncope/presyncope, ECG changes suggesting ischemia, elevated cardiac biomarkers, or clinical features consistent with acute coronary syndrome or other life-threatening conditions. 1

Initial Risk Assessment

High-Risk Features (Immediate Admission Required)

• Chest pain or discomfort at rest lasting >20 minutes 1
• Hemodynamic instability (hypotension, tachycardia) 1
• Recent syncope or presyncope 1
• New or presumably new ST-segment deviation (≥1mm) or T-wave inversion in multiple precordial leads 1
• Elevated cardiac troponin (TnI, TnT) or CK-MB 1
• Presence of heart failure signs (pulmonary edema, rales) 1
• Transient mitral regurgitation murmur 1
• Diaphoresis with chest pain 1
• Known history of coronary artery disease including prior MI 1

Intermediate-Risk Features (Admission Usually Required)

• Chest pain consistent with typical angina but not currently present 1
• Age >70 years 1
• Male sex with diabetes mellitus 1
• ST depression 0.5-1mm or T-wave inversion >1mm 1
• Extracardiac vascular disease 1

Low-Risk Features (May Not Require Admission)

• Chest discomfort reproduced by palpation 1
• Sharp or stabbing pain 1
• Pain primarily in middle or lower abdominal region 1
• Normal ECG and cardiac biomarkers 1
• No recurrence of chest pain during observation 1

Diagnostic Approach

1. Immediate ECG (within 10 minutes of arrival) to evaluate for STEMI or other ischemic changes 1, 2
2. Cardiac biomarkers (preferably high-sensitivity troponin) as soon as possible after presentation 1, 2
3. Focused cardiovascular examination to identify complications or other serious causes 1
4. Chest radiography within 30 minutes to evaluate alternative causes 2

Decision Algorithm for Admission

Definite Admission

• Patients with high-risk features as listed above
• Patients with known or suspected ACS 1
• Patients with ECG changes suggestive of ischemia (ST depression, T-wave inversion) 1
• Patients with elevated cardiac biomarkers 1
• Patients with hemodynamic instability or signs of heart failure 1
• Patients ≥75 years with chest pain plus shortness of breath, syncope, acute delirium, or unexplained fall 1

Consider Admission (Observation Unit if Available)

• Patients with intermediate-risk features but normal initial ECG and biomarkers 1
• Patients with atypical symptoms but multiple risk factors for CAD 1
• Patients with concerning symptoms but non-diagnostic initial workup requiring serial testing 1

May Not Require Admission

• Patients with low-risk features AND:
  • Normal ECG
  • Normal cardiac biomarkers
  • No recurrence of symptoms during observation
  • Low-risk score on validated risk stratification tools (HEART score 0-3, TIMI score 0-1) 2, 3

Important Caveats and Pitfalls

• Women with chest pain are at risk for underdiagnosis; always consider cardiac causes and look for accompanying symptoms more common in women with ACS 1
• Elderly patients (≥75 years) may present with atypical symptoms; consider ACS when shortness of breath, syncope, or acute delirium are present 1
• ECG interpretation pitfalls: ST depression in leads V1-V3 with tall R waves may indicate posterior infarction; diffuse ST depression with elevation in aVR may suggest left main or triple-vessel disease 4
• Serial ECGs are crucial when the initial ECG is non-diagnostic but clinical suspicion remains high 1
• Delayed transfer from outpatient settings to the ED for troponin testing should be avoided; patients with suspected ACS should be transported urgently to the ED 1

Institutional Requirements for Admitted Patients

For high-risk ACS patients, admission to a coronary care unit with:

• Continuous rhythm monitoring
• Frequent assessment of vital signs and mental status
• Documented ability to perform rapid defibrillation
• Adequate staff-to-patient ratio 1

For intermediate-risk patients, admission to an inpatient unit with:

• Continuous ECG monitoring
• Availability of resuscitation equipment
• Appropriate staffing arrangements 1

By following this structured approach to evaluating left-sided chest pain, clinicians can ensure appropriate triage decisions that minimize both the risk of missing serious cardiac conditions and unnecessary hospital admissions.