The patient has a history of hypertension, diabetes and cocaine use. The patient presented to the emergency department complaining of chest pain that became worse after using cocaine. The patient was admitted to the hospital to rule out acute coronary syndrome. Repeat troponin levels were normal. The serum potassium level remained normal. The patient left the hospital against medical advice. The health plan's determination is upheld.

This patient, with known coronary artery disease, presented with chest pain that was thought to be suspicious for acute coronary syndrome (ACS). Accordingly, monitoring until ACS could be ruled out was a reasonable approach. However, the patient was hemodynamically stable, with normal cardiac biomarkers, and no acute electrocardiographic changes. While the initial serum potassium level was markedly elevated, this was likely a laboratory error due to hemolysis as there were no other findings suggestive of hyperkalemia. The electrocardiogram, renal function and blood pH were all normal and subsequent potassium levels remained normal after a single dose of "hyperkalemia cocktail." The patient did not require intensive monitoring or infusion of intravenous cardioactive medications. The care this patient received did not require an inpatient admission and could have been provided under a lower level of care status. This approach has been shown to be safe and is in accordance with the 2010 American Heart Association recommendations on the management of patients who present to the emergency department with acute chest pain and who, like this patient, are at low risk for acute coronary syndrome.