When should a patient return to the hospital after discharge with intermittent episodes of feeling flushed and hot flashes, and occasional chest pains, despite initial negative testing?

When to Return to Hospital After Discharge with Intermittent Flushing and Chest Pain

She should return immediately to the emergency department if chest pain lasts more than 20 minutes, worsens in severity, occurs at rest without relief after 5 minutes, or is accompanied by shortness of breath, lightheadedness, nausea, or diaphoresis. 1

Immediate Return Criteria (Call 911)

Your patient needs clear, specific instructions about when to seek emergency care. She should return to the hospital immediately for any of the following:

• Chest pain lasting >15-20 minutes despite rest 2, 1
• Chest pain that is more severe than her previous episodes 2
• Chest pain at rest that does not improve within 5 minutes 1
• Chest pain accompanied by:
  • Severe shortness of breath or difficulty breathing 2, 1
  • Lightheadedness, dizziness, or near-syncope 2
  • Nausea or vomiting 2
  • Diaphoresis (sweating) 2
  • Palpitations or irregular heartbeat 3

The ACC/AHA guidelines emphasize that patients with high-risk characteristics including continuous chest pain >20 minutes at rest, hemodynamic instability, or severe dyspnea require immediate transfer to a higher level of care 1. Even though her initial testing was negative, a normal ECG and negative biomarkers do not exclude acute coronary syndrome, particularly in the early hours after symptom onset 1, 4.

Urgent Outpatient Evaluation (Within 24-48 Hours)

She should contact you or be seen urgently if:

• Pattern of chest pain changes - becoming more frequent, occurring with less exertion, or new characteristics 2
• Hot flashes or flushing episodes become associated with chest discomfort (currently separate, but if they converge this suggests a different pathophysiology requiring evaluation) 3
• New or worsening breathlessness even without chest pain 2, 3
• Persistent symptoms despite reassurance - ongoing chest discomfort that is tolerable but concerning 2

The ACC/AHA guidelines recommend that patients with possible ACS who were discharged after negative initial testing should have follow-up within 2-6 weeks for low-risk patients, but higher-risk patients or those with changing symptoms should return in 1-2 weeks 2.

Outpatient Stress Testing Timeline

She should undergo outpatient stress testing within 72 hours of discharge if not already completed 1. The American Heart Association supports early exercise testing (within 6-12 hours after excluding acute coronary syndrome) as safe and cost-effective for risk stratification 2. Studies show that appropriately selected patients with negative serial ECGs and cardiac biomarkers are at low risk (0.6% fatal cardiac events) for short-term adverse outcomes when discharged for subsequent outpatient testing 5.

Important Clinical Context

The intermittent hot flashes/flushing episodes that are separate from her chest pain are less concerning for acute cardiac ischemia, as ischemic symptoms typically cluster together 2, 3. However, the "little chest pains in between" warrant close attention:

• Atypical chest pain in younger patients (if applicable) often has non-cardiac causes including musculoskeletal pain, gastroesophageal reflux, or anxiety 2, 4
• Associated symptoms matter - breathlessness occurs in two-thirds of patients with atypical chest pain, followed by dizziness and palpitations 3
• Patient perception is important - only one-third of patients with atypical chest pain believe their doctor's diagnosis, often suspecting cardiac causes despite reassurance 3

Critical Pitfall to Avoid

Do not assume negative initial testing means she is completely safe. The ACC/AHA explicitly states that patients with possible ACS require additional observation and definitive evaluation even after initial negative results 2. Her ongoing symptoms, even if "little," require either completion of stress testing or re-evaluation if symptoms change in character, frequency, or severity 2, 1.

Provide her with sublingual nitroglycerin if not contraindicated, with instructions to use it for chest pain and seek emergency care if pain persists after 3 doses given 5 minutes apart 2, 1.