Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: The High-Risk Discharge - Chest Pain Going Home

Patient Demographics

• Age: 52 years
• Sex: Male
• Occupation: Accountant

Chief Complaint

"I had chest pain this morning but it's gone now."

History of Present Illness

A 52-year-old male presents for evaluation of chest pain that occurred this morning while walking to his car. He describes 10 minutes of substernal pressure that radiated to his left arm, associated with diaphoresis. The pain resolved spontaneously and he "feels fine now." He almost didn't come in but his wife insisted. He has no prior cardiac history but acknowledges he hasn't seen a doctor in years.

Initial Assessment

ESI Level: 2 - Potential ACS despite current symptom resolution

First Impression:

• Appearance: Well-appearing, no distress
• Work of breathing: Normal
• Circulation: Normal

Vital Signs:

• Heart rate: 78 bpm
• Blood pressure: 142/88 mmHg
• Respiratory rate: 14 breaths/min
• SpO2: 99% on room air
• Temperature: 36.8C
• GCS: 15

ED Evaluation

ECG: Normal sinus rhythm, no ST changes, no prior for comparison

Serial Troponins:

• 0 hours: <0.01 ng/mL (negative)
• 3 hours: <0.01 ng/mL (negative)

Chest X-ray: Normal

Basic Labs: Normal BMP, glucose 118

Risk Stratification

HEART Score:

HEART Score Interpretation:

• 0-3: Low risk (discharge with follow-up)
• 4-6: Intermediate risk (observation, further testing)
• 7-10: High risk (admission, cardiology)

Score of 5 = INTERMEDIATE RISK

Disposition Decision Process

Options:

1. Admit for observation and stress testing
2. Discharge with expedited outpatient stress test
3. Observation unit for accelerated diagnostic protocol

Factors Favoring Discharge:

• Negative troponins x2
• Normal ECG
• Symptom-free for hours
• Reliable patient with transportation
• Can obtain stress test within 72 hours

Factors Favoring Admission:

• Highly suspicious history
• Intermediate HEART score
• No established care/no prior testing
• Multiple untreated risk factors

Shared Decision-Making Discussion

Conversation with Patient:

"Mr. Johnson, your tests today look normal - your heart enzyme is negative and your ECG is normal. However, your symptoms this morning were concerning for possible angina, which can be a warning sign of blocked heart arteries.

Your risk isn't zero. Based on your story and risk factors, I estimate you have about a 10-15% chance of having a significant heart problem that we haven't found yet.

We have two main options:

Option 1: Stay overnight for observation and have a stress test tomorrow. This is the safest approach and lets us evaluate you more thoroughly.

Option 2: Go home tonight with a guaranteed stress test within 72 hours. This requires you to take certain precautions and return immediately if symptoms recur.

What questions do you have? What would you prefer?"

Patient Response: "I really need to be at work tomorrow for a big deadline. Can I do the outpatient option?"

High-Risk Discharge Protocol

Requirements for Safe Discharge:

1. Reliable follow-up confirmed: Stress test scheduled for tomorrow morning (within 24 hours)
2. Clear return precautions: Written and verbal
3. Medication management: Started on aspirin, prescribed sublingual nitroglycerin
4. Transportation plan: Wife can drive if symptoms recur
5. Documentation: Thorough, including shared decision-making discussion

Discharge Instructions (Written and Verbal)

Return to ED Immediately If:

• Chest pain or pressure returns
• Pain that doesn't go away within 5 minutes of nitroglycerin
• Shortness of breath
• Sweating with discomfort
• Pain that spreads to arm, jaw, or back
• Dizziness or fainting

Activity Restrictions:

• No strenuous activity until cleared by stress test
• No driving until evaluated
• Someone should stay with you tonight

Medications:

• Aspirin 81mg daily (started)
• Nitroglycerin 0.4mg SL PRN chest pain (instructions provided)
• Continue any home medications

Follow-Up:

• Stress test: Tomorrow 8 AM at Hospital Outpatient Center (confirmed appointment)
• Primary care: Within 1 week for cardiovascular risk management
• Cardiology: Depending on stress test results

Documentation Requirements

Critical Elements for High-Risk Discharge:

1. History and physical documented thoroughly
2. Risk stratification tool documented (HEART score = 5)
3. Test results reviewed (negative troponins, normal ECG)
4. Medical decision-making explained (intermediate risk, shared decision)
5. Alternatives discussed (admission offered)
6. Follow-up confirmed and documented
7. Return precautions documented (reviewed with patient)
8. Discharge instructions given and understood
9. Patient agreement documented

Outcome

Day 1 (next morning):

• Stress test performed: Positive at 6 minutes (ST depression in inferior leads)
• Referred directly to cardiology

Day 2:

• Cardiac catheterization: 85% stenosis of RCA
• PCI with stent placed
• Patient did well, discharged day 3

Teaching Moment: The system worked - high-risk discharge with appropriate safety net led to timely diagnosis and treatment

Teaching Points

1. Risk stratification tools guide decisions: HEART score, TIMI, GRACE - know and use them
2. Intermediate risk is the challenge: Not clear-cut; requires shared decision-making
3. Shared decision-making is essential: Document the conversation
4. Follow-up must be confirmed: Not "see your doctor" but "your appointment is at..."
5. Return precautions must be specific: Written AND verbal, condition-specific
6. Documentation protects everyone: If it wasn't documented, it didn't happen
7. Safety nets catch patients: Appropriate follow-up caught this patient's disease
8. Communicate uncertainty: Patients appreciate honesty about diagnostic limitations

Clinical Image

Image Description: Infographic displaying the HEART score components (History, ECG, Age, Risk factors, Troponin) with point values for chest pain risk stratification in the emergency department.

Attribution: Image adapted from HEART score validation studies. Educational use. Source: https://www.mdcalc.com/heart-score-major-cardiac-events

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