This case involves an elderly female patient with a history of high blood pressure, peripheral vascular disease, and an enlargement of her aorta who presented to the emergency room with acute onset chest pain. Prior to this, the woman had been taken off of her blood pressure medication by her family medicine doctor. The patient was transported via ambulance to the emergency room, where the woman underwent a series of tests to evaluate the cause of her chest pain. Despite her previous medical history and some concerning test results, the woman was discharged from the hospital without instructions for additional follow up. One day after being discharged from the hospital, the woman suffered a massive heart attack while at work and was pronounced dead on arrival to the hospital.
Question(s) For Expert Witness
- 1. How frequently do you evaluate and treat acute chest pain?
- 2. What criteria must a patient with chest pain meet to be safely discharged home directly from the ED?
Expert Witness Response E-131016
Chest pain is one of the most common complaints of patients presenting to the emergency room. I treat these patients on a daily basis while working clinically in the emergency department. Patients who are low-risk are appropriate for discharge home from the emergency department. Low-risk patients include, but not limited to, those with a HEART score < 4. In my practice, I use the HEART score to risk stratify patients who are safe for discharge home from the emergency department after an appropriate work up for chest pain. A patient such as this is rarely discharged home from the emergency department with chest pain that sounds suspicious, or if they are high risk, and this patient is very high risk due to her medical problems. She requires provocative testing such as a stress test or a cardiac catheterization to further evaluate the pain. She is not an appropraite candidate for discharge home. The complication of sudden cardiac death is widespread in American society. Based on this limited information provided, this is a patient who likely should have been admitted to the hospital or placed in an observation unit for provocative testing.