How should I manage a patient with intermittent chest pain for a week who refuses EMS transport and emergency department evaluation?

Management of Intermittent Chest Pain Over One Week with Patient Refusing Emergency Care

You must strongly counsel this patient that EMS transport to the emergency department is the standard of care and strongly recommended, even with intermittent symptoms, as approximately 1 in 300 patients with chest pain transported by private vehicle experiences cardiac arrest en route. 1

Immediate Risk Communication

The patient needs to understand these critical facts:

• Intermittent chest pain over a week represents a potentially unstable cardiac syndrome that can progress to myocardial infarction or sudden cardiac death at any time 1
• Patients with acute coronary syndromes commonly delay seeking care due to symptoms that come and go, which is a dangerous pattern associated with worse outcomes 1
• EMS transport is associated with substantial reduction in treatment delays and ischemic time compared to self-transport, and provides life-saving interventions if cardiac arrest occurs 1

If Patient Continues to Refuse EMS

Document the refusal thoroughly and provide these specific instructions:

Aspirin Administration NOW

• Instruct the patient to chew and swallow 162-325 mg of non-enteric coated aspirin immediately unless they have a known aspirin allergy or recent bleeding 1
• Early aspirin administration (median 1.6 hours from pain onset) is associated with higher survival compared to late administration (median 3.5 hours) 1
• The mortality benefit of aspirin in acute myocardial infarction is well-established across multiple large studies 1, 2

Nitroglycerin Protocol (If Previously Prescribed)

• If the patient has been prescribed nitroglycerin, instruct them to take one sublingual tablet at the first sign of chest pain 3
• If symptoms are unimproved or worsening 5 minutes after one dose, they MUST call 9-1-1 immediately 1
• Do not wait for three doses before calling EMS - this outdated recommendation has been modified to encourage earlier EMS activation 1
• The patient should sit down when taking nitroglycerin to prevent falls from lightheadedness 3

Absolute Contraindications to Communicate

• Do not take nitroglycerin if the patient has used erectile dysfunction medications (sildenafil, tadalafil, vardenafil) as this can cause life-threatening hypotension 3
• Do not take aspirin if there is known aspirin allergy or recent/active bleeding 1, 2

Specific Red Flags Requiring IMMEDIATE 9-1-1 Call

Instruct the patient to call 9-1-1 immediately if they experience:

• Chest pain lasting more than 5 minutes that does not improve with one nitroglycerin dose (if prescribed) 1
• Any chest pain different in character from their usual pattern 1, 3
• Associated symptoms including: shortness of breath, sweating, nausea, lightheadedness, pain radiating to jaw/arms/back 1
• Hemodynamic instability signs: severe weakness, near-syncope, or altered mental status 1

Follow-Up Within 24 Hours

If the patient absolutely refuses immediate ED evaluation, they must be seen in person within 24 hours for:

• 12-lead ECG to evaluate for ischemic changes 1
• Cardiac biomarkers (troponin) to assess for myocardial injury 1
• Risk stratification using validated scores (TIMI, GRACE) 1
• Definitive disposition planning including likely hospital admission for observation and stress testing or coronary angiography 1

Critical Pitfall to Avoid

Do not allow the intermittent nature of symptoms to provide false reassurance. Unstable angina and non-ST elevation myocardial infarction commonly present with crescendo or intermittent symptoms over days to weeks, and this pattern indicates high risk for progression to complete vessel occlusion 1. The fact that symptoms come and go does NOT mean the patient is safe - it may indicate critical coronary stenosis with intermittent thrombosis.

Documentation Requirements

Document explicitly:

• That EMS transport was recommended and refused 1
• Aspirin and nitroglycerin instructions provided 1
• Red flag symptoms explained 1
• Patient's understanding of risks of refusing immediate evaluation 1