Should an elderly patient with hypertension, presenting with shortness of breath and chest pressure for 3 weeks, and bilateral pleural effusions unresponsive to antibiotics, be referred to the Emergency Department?

Emergency Department Referral for Elderly Patient with Bilateral Pleural Effusions

This patient requires immediate Emergency Department evaluation and should be transported urgently, ideally by EMS. 1

Rationale for Immediate ED Referral

This clinical presentation represents a potentially life-threatening condition requiring urgent evaluation. The combination of:

• 3-week duration of chest pressure and dyspnea in an elderly patient with hypertension mandates exclusion of acute coronary syndrome (ACS), as older patients (≥75 years) frequently present with atypical symptoms including shortness of breath rather than classic chest pain 1
• Bilateral pleural effusions unresponsive to antibiotics suggest a non-infectious etiology that requires immediate diagnostic workup 2
• Chest pressure in this context should be considered "cardiac or possibly cardiac" until proven otherwise 1

Critical Differential Diagnoses Requiring Urgent Exclusion

Cardiac Causes (Highest Priority)

• Acute decompensated heart failure: Hypertension history with dyspnea and bilateral pleural effusions strongly suggests cardiac origin 2
• Acute coronary syndrome: Must be excluded in elderly patients with chest pressure and dyspnea, even without classic anginal symptoms 1
• Pericardial effusion with tamponade physiology: Can present with chest pressure, dyspnea, and bilateral effusions 3, 4

Malignancy

• Lung cancer with mediastinal involvement: The combination of dyspnea and bilateral pleural effusion raises concern for malignancy, which must be urgently excluded 2
• Tension hydrothorax: Rare but life-threatening complication of malignant effusions that can cause hemodynamic compromise 5

Thromboembolic Disease

• Pulmonary embolism: Present in 46% of PE cases with dyspnea and pleural effusion 2

Required Immediate ED Workup

Time-Sensitive Testing

• ECG within 10 minutes of arrival to evaluate for STEMI or ischemic changes 1
• Cardiac troponin measurement as soon as possible after presentation 1
• NT-proBNP or BNP levels: Values ≥1500 pg/mL suggest cardiac origin; <1500 pg/mL makes heart failure less likely 2

Imaging

• CT chest with IV contrast (venous phase) to evaluate for:
  • Pulmonary embolism 2
  • Mediastinal mass or lymphadenopathy 2
  • Superior vena cava obstruction 2
  • Pleural effusion characteristics 2

Laboratory Studies

• Complete blood count with differential to assess for leukocytosis or thrombocytopenia 2
• Basic metabolic panel and renal function given hypertension history 1

Critical Pitfalls to Avoid

• Never delay transfer for outpatient cardiac troponin or diagnostic testing in patients with acute chest pain and suspected ACS—this approach causes harm 1
• Do not assume bilateral effusions are benign transudates; unilateral or asymmetric effusions require thoracentesis unless clearly transudative on clinical grounds 2
• Avoid dismissing chest pressure as "atypical" in elderly patients—accompanying symptoms like dyspnea are common ACS presentations in this age group 1
• Do not delay CT evaluation when facial swelling accompanies pleural effusion, as this mandates urgent evaluation for SVC syndrome 2

Transport Recommendations

Patients with clinical evidence of ACS or other life-threatening causes of acute chest pain should be transported urgently to the ED, ideally by EMS. 1 This ensures:

• Continuous monitoring during transport
• Ability to obtain prehospital ECG
• Advanced life support capabilities if decompensation occurs
• Direct communication with receiving ED for expedited evaluation

The 3-week symptom duration does not exclude acute life-threatening pathology, as progressive heart failure, evolving malignancy, or recurrent pulmonary emboli can present subacutely while still requiring emergent intervention 2, 6.