Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The inpatient admission was not medically necessary.

This patient presented with a four month history of chest pain on exertion. Angina description was atypical in character. No high risk features were noted on ECG at presentation, and serum troponin testing was negative. Physical examination was unremarkable. These findings are not consistent with an acute coronary syndrome (ACS).

Risk assessment of patients presenting with chest pain and no significant ST changes on ECG as well as negative cardiac enzymes was performed by Poldevaart et al. (Reference 1). Using the HEART (History, EKG, Age, Risk factors, initial Troponin) score risk stratification schema, this patient would have a low risk of future myocardial infarction or death within one year.

Other investigators studied patients presenting to the hospital with chest pain and compared outcomes between those admitted to the hospital for short stay admissions and those that were placed in an observation unit at a lower level of care. (References 2&3) They found no significant difference in outcome at 30 days between the two groups.

Fernando Bellolio et al. noted that patients presenting with chest pain that were managed in an observation unit had similar 30 day myocardial infarction rates as those admitted to the hospital. (Reference 3)

Admission to the hospital to treat an acute cardiac event was not medically necessary. In conclusion, this patient could have been managed at a lower level of care.