Is further cardiac testing as an outpatient appropriate for a 74-year-old female with a history of CAD, status post CABG, recent NSTEMI, on heparin, aspirin, and atorvastatin, with intermittent confusion, non-compliance, and moderate chest pain?

No, Outpatient Cardiac Testing is NOT Appropriate for This Patient

This 74-year-old woman with recent NSTEMI, ongoing moderate chest pain this morning, and intermittent confusion requires continued inpatient management and should NOT be discharged for outpatient testing. She meets high-risk criteria that mandate hospital admission and invasive evaluation.

Why This Patient Must Remain Hospitalized

High-Risk Features Present

This patient has multiple features that classify her as high-risk for short-term major adverse cardiac events (MACE):

• Recent NSTEMI with ongoing symptoms: She had moderate chest pain this morning, indicating recurrent ischemia despite being on heparin for 48 hours 1
• Intermittent confusion: This suggests either hemodynamic instability or inadequate cerebral perfusion, which is a high-risk feature 1
• Known severe CAD: History of CABG (2010) indicates multivessel disease 1
• Medication non-compliance: This significantly increases her risk of recurrent events 2

Guideline-Mandated Inpatient Management

Patients with definite ACS and ongoing ischemic symptoms must be admitted to the hospital for further management, with admission to a critical care unit or telemetry step-down unit. 1

The 2021 ACC/AHA guidelines explicitly state that high-risk patients with acute chest pain and suspected ACS who have troponin-confirmed acute myocardial injury should undergo invasive coronary angiography (ICA) as inpatients 1. This patient had an NSTEMI "today" (presumably meaning within the current hospitalization), making her definitively high-risk.

Required Inpatient Interventions

Immediate Management

• Continuous cardiac monitoring: She requires telemetry monitoring for ischemia and arrhythmia detection given her ongoing symptoms 1
• Optimization of anti-ischemic therapy: Her current regimen may be inadequate given this morning's chest pain 1
• Invasive coronary angiography: For patients with worsening symptoms and history of prior CABG with multivessel CAD, ICA is recommended 1

Why Outpatient Testing is Contraindicated

The guidelines reserve outpatient stress testing for low-risk patients only - specifically those with:

• HEART score ≤3
• Non-ischemic ECG
• Negative serial troponins (not elevated as in NSTEMI)
• No ongoing symptoms 3

This patient meets NONE of these low-risk criteria. 1

Critical Safety Concerns

Medication Non-Compliance Risk

Her documented non-compliance creates substantial risk for discharge. Studies show that ACS patients treated with CABG who are suboptimally adherent to secondary prevention medications have significantly higher rates of recurrent MACE (6.2% per year) 2. Discharging her for outpatient testing without addressing this compliance issue and ensuring clinical stability would be inappropriate.

Confusion as a Red Flag

The intermittent confusion is particularly concerning and may indicate:

• Inadequate cardiac output affecting cerebral perfusion
• Medication side effects requiring adjustment
• Underlying delirium that will impair her ability to follow outpatient instructions 1

Patients with hemodynamic abnormalities or altered mental status require critical care unit admission, not outpatient referral. 1

Appropriate Disposition Algorithm

For this patient, the correct pathway is:

1. Continue inpatient monitoring in telemetry or step-down unit 1
2. Optimize medical therapy while addressing medication compliance barriers 1
3. Perform invasive coronary angiography given her high-risk features and prior CABG 1
4. Address the confusion - determine etiology and ensure resolution before any discharge consideration 1
5. Only after stabilization (no recurrent chest pain for 24-48 hours, resolution of confusion, optimized medications) can discharge be considered 1

Common Pitfall to Avoid

Do not be misled by the fact that she is "doing better than yesterday." Relative improvement does not equal low-risk status. She had moderate chest pain this morning despite 48 hours of heparin therapy - this represents treatment failure and ongoing active ischemia requiring escalation of care, not de-escalation to outpatient management 1. The 2014 AHA/ACC guidelines emphasize that patients with continuing or recurrent ischemia despite medical therapy require inpatient management and consideration for urgent revascularization 1.