Diagnosis: Chest pain
Issue under review: Inpatient admission

Determination:
The Inpatient admission was medically necessary.

The patient is an adult male who presented to the ED complaining of chest pain, nausea vomiting, shortness of breath and palpitations. Upon arrival in the ED his pulse was noted to have a narrow complex tachycardia at a rate of 192 beats per minute (bpm). Pulse was subsequently noted to slow down to 110 bpm and was irregular; blood pressure was 85/58 mmHg. Electrocardiogram revealed atrial fibrillation with ST-T wave changes suspicious for an acute myocardial infarction. Serial serum troponin levels were mildly elevated. The patient was admitted to the hospital for monitoring and treatment. Echocardiography did not reveal obvious wall motion abnormality. The patient was scheduled for direct current (DC) cardioversion but spontaneously reverted to normal sinus rhythm. He was discharged the following day with outpatient follow up.

Admission for monitoring and treatment was medically necessary. Patients presenting with atrial arrhythmia with ventricular rates up to 160 bpm require acute therapy and further monitoring to ensure that medications control heart rate and rhythm without producing significant bradycardia. This patient presented to the hospital with chest pain and heart rates up to 190 bpm. Moreover his initial systolic blood pressure was below 90 mmHg and ST-T wave changes were noted on ECG. These findings are concerning and merit close monitoring and treatment.

An analysis of 68 million Medicare patients admitted to the hospital for atrial fibrillation over a fifteen year period demonstrated an average length of stay of three days. (Reference 1) This analysis also demonstrated decreased mortality and readmission rates following admission to the hospital. The current standard of care is consistent with hospital admission when patients present with symptomatic rapidly conducted atrial fibrillation.