When should a patient with chest pain be admitted to the hospital, considering their past medical history, such as cardiovascular disease (CVD), diabetes, or hypertension (HTN), and clinical presentation, including electrocardiogram (ECG) changes or elevated troponin levels?

Hospital Admission Criteria for Chest Pain Patients

Patients with chest pain should be admitted to the hospital if they present with ongoing ischemic symptoms, ST-segment or T-wave changes on ECG, elevated cardiac troponin, or hemodynamic instability; all other patients can be managed in a chest pain unit or emergency department observation area with serial testing. 1

Immediate Hospital Admission Required

Admit patients who present with any of the following high-risk features 1:

• Ongoing chest pain lasting >20 minutes despite rest or nitroglycerin 1, 2
• ECG changes: ST-segment depression, ST-segment elevation, dynamic T-wave inversion, or new left bundle branch block 1
• Positive cardiac biomarkers: Any elevation in cardiac-specific troponin 1
• Hemodynamic instability: Systolic blood pressure <100 mmHg, heart rate <40 or >100 bpm, signs of heart failure (elevated JVP, pulmonary rales), or Killip class II-IV 1
• Severe dyspnea or respiratory distress with oxygen saturation <90% 1
• Syncope or presyncope accompanying chest symptoms 1, 2
• Life-threatening arrhythmias: Ventricular tachycardia or high-degree AV block 1

These patients require telemetry monitoring and should be managed on an inpatient cardiology service with consideration for urgent coronary angiography 1.

Chest Pain Unit or ED Observation (Not Inpatient Admission)

Patients with possible or definite ACS but without the above high-risk features can be safely managed in a chest pain unit or ED observation area 1:

Inclusion Criteria for Observation 1:

• Recent chest discomfort at rest (not entirely typical of ischemia) but currently pain-free
• Normal or nondiagnostic ECG (no ST-segment changes, no new conduction abnormalities)
• Initial cardiac troponin is normal
• Stable vital signs (systolic BP >100 mmHg, heart rate 40-100 bpm)

Observation Protocol 1:

• Serial cardiac biomarkers at 0,3, and 6 hours (or 0 and 1-3 hours if high-sensitivity troponin used) 1
• Serial ECGs every 4-6 hours or with recurrent symptoms 1
• Continuous telemetry monitoring 1
• Observation period typically 9-24 hours 1
• Stress testing (exercise ECG, stress echo, or nuclear imaging) before discharge or within 72 hours as outpatient 1, 2

Convert to inpatient admission if during observation the patient develops recurrent ischemic symptoms, new ECG abnormalities, troponin elevation, or hemodynamic instability 1.

Risk Stratification Tools

Use validated risk scores to guide disposition decisions 1, 3:

HEART Score (Preferred) 3, 4:

• Score 0-3 (Low Risk): Safe for discharge with outpatient stress testing within 72 hours (LR 0.20) 3
• Score 4-6 (Moderate Risk): Chest pain unit observation with serial testing 3, 4
• Score 7-10 (High Risk): Hospital admission required (LR 13 for ACS) 3

TIMI Score 1, 3:

• Score 0-1 (Low Risk): Consider discharge with close follow-up (LR 0.31) 3
• Score 2-4 (Intermediate Risk): Chest pain unit observation 1
• Score 5-7 (High Risk): Hospital admission (LR 6.8 for ACS) 3

Special Populations Requiring Lower Threshold for Admission

Consider hospital admission even with borderline findings in 1, 5:

• Age >75 years: Higher risk of atypical presentations and adverse events 1
• Diabetes mellitus: May have silent ischemia or atypical symptoms 1, 5
• Known coronary artery disease: Prior MI, prior revascularization, or documented CAD 1, 3, 5
• Renal insufficiency: Increased cardiovascular risk 1
• Women: More likely to have atypical presentations and microvascular disease 1, 5

Safe for Discharge Without Observation

Patients can be discharged directly from the ED if they meet all of the following 1, 2:

• Atypical or non-cardiac chest pain characteristics 1, 2
• No cardiovascular risk factors or low pretest probability of CAD 2
• Normal ECG (unchanged from prior if available) 1
• Two negative troponin measurements (at 0 and 3-6 hours) 1, 2
• Pain-free at time of evaluation 1
• No history of CAD 1, 2

Critical caveat: A recent study found that even among patients with two negative troponins, normal vital signs, and nonischemic ECG, adverse events occurred in 0.18% during hospitalization, with most being iatrogenic 6. This supports the use of observation units rather than routine inpatient admission for intermediate-risk patients.

Discharge Instructions for Observation Patients 2:

• Return immediately if chest pain lasts >5 minutes despite nitroglycerin or is more severe than previous episodes 2
• Provide sublingual nitroglycerin with instructions (call 911 if pain persists after 3 doses given 5 minutes apart) 2
• Schedule outpatient stress testing within 72 hours if not performed during observation 1, 2
• Prescribe aspirin and consider beta-blocker while awaiting stress test results 2
• Follow-up with primary care physician within 72 hours 2

Common Pitfalls to Avoid

• Do not rely on a single troponin measurement: Serial troponins at 0 and 3-6 hours are mandatory; a single negative troponin is insufficient 1, 7
• Do not assume normal ECG excludes ACS: Over 50% of patients with chronic stable angina have normal resting ECGs 7
• Do not use nitroglycerin response as diagnostic: Other conditions (esophageal spasm, anxiety) may respond to nitroglycerin 7
• Do not discharge based solely on atypical symptoms: Women, elderly, and diabetics frequently present with dyspnea, fatigue, or nausea rather than classic chest pain 1, 7
• Do not forget to exclude alternative life-threatening diagnoses: Aortic dissection, pulmonary embolism, tension pneumothorax, and pericardial tamponade must be considered before attributing symptoms to low-risk chest pain 1