My hospitalist partners and I hear that several times a week. Everybody knows that chest pain can signal a heart attack, so even if people know it started after they ate that pizza or hurt their ribs in a fall, they come to get it checked out. And if they’re not evaluated appropriately there may be grounds for a lawsuit.
Many hospitals have found that it’s most efficient (and cost-effective) to have a designated chest pain unit for patients who have normal electrocardiograms but aren’t considered safe enough to send home. There’s usually a fill-in-the-blank order sheet for blood tests to make sure there’s no evidence of heart muscle damage, and once those tests are OK the patients move down the hall for some type of stress test. We can usually complete the entire battery of tests and send a patient home in less than the 23 hours allowed by insurance companies for “observation” stays.
But this one-size-fits-all approach doesn’t work for everybody, and when it’s followed slavishly some very bad things can happen to patients. Let’s look at some of the problems.
First of all, coronary artery disease is not the only potentially lethal cause of chest pain. Blood clots to the lung generally follow the formation of clots in the legs or lower abdomen…except when they don’t. Emergency physicians should be alert for risk factors like inactivity (including long drives or plane rides), recent surgery, cancer and old age. But if a patient doesn’t quite fit the profile they often check a D-dimer level for evidence of active clot formation, or just do a lung scan to be sure they haven’t missed a disaster in progress.
Chest X-rays can warn of other life-threatening problems. Air leaking around a lung (pneumothorax) can happen when the lungs are weakened by emphysema, after trauma to the chest, or with no warning at all in healthy people. An aortic aneurysm—abnormal dilation of the giant artery coming out of the heart—causes chest pain in 50% of people who have it, and while textbooks offer a variety of descriptions of the symptoms they are no substitute for a CT scan. If the patient is allergic to the contrast material used in it, and ultrasound test or echocardiogram is less sensitive but may still spot the problem in time for a surgeon to repair it before the aneurysm ruptures or expands enough to affect the heart.
As for coronary artery disease, what about high-risk chest pain patients? The most reliable test is heart catheterization, in which the coronary arteries are injected with dye to let a cardiologist see them up close and measure blood flow through them. Stress tests, even with radioactive contrast that shows the effects of drugs or exercise on the heart’s blood supply, are an acceptable substitute only in low-risk patients. If the patient’s pain is pressure-like and accompanied by trouble breathing, or if he or she has risk factors like smoking and diabetes, the safest thing to do is to call a cardiologist.
One final warning: hospitals are under more and more pressure to “treat ‘em and street ‘em”, with insurers refusing to cover “unnecessary” hospital days and services. Doctors with patients classed as “observation only” can count on getting a phone call as the 23-hour limit approaches, asking if further testing can be done in an outpatient setting. A patient whose chest pain has subsided with a little nitroglycerin and aspirin may be happy to hear that his tests are normal and ask to be discharged. But it’s the doctor’s job to make as sure as possible that leaving the hospital won’t lead to a disaster.
Written by: Medical Internist Expert Witness No. 2711
About the author:
Expert No. 2711 is a physician with over 30 years experience. She is a Hospitalist, and Board Certified in Internal Medicine and has completed a fellowship in emergency medicine. She is actively practicing in Texas.