From the Guidelines
This 48-year-old female with chest pain, T-wave inversions on ECG, and negative troponin requires urgent cardiology consultation for further evaluation, with initial management including aspirin 325mg, supplemental oxygen if saturation is below 94%, and consideration of sublingual nitroglycerin 0.4mg for ongoing chest pain, as recommended by the 2015 ESC guidelines 1.
Initial Assessment
The patient's presentation with chest pain and T-wave inversions on ECG is concerning for myocardial ischemia, despite the negative troponin result. Her history of anxiety and depression should not lead to premature dismissal of cardiac causes, as these conditions can complicate symptom presentation. A complete cardiac workup is warranted, including:
- Serial troponins (at 0,3, and 6 hours) to rule out myocardial infarction
- Comprehensive ECG analysis to evaluate for signs of ischemia or infarction
- Potential stress testing or coronary CT angiography to assess for coronary artery disease
Risk Stratification
The patient's risk for cardiac events should be assessed based on clinical, electrocardiographical, and biochemical data, as outlined in the European Heart Journal guidelines 1. This will help guide further management and determine the need for additional testing or interventions.
Management
The patient's management should be guided by the results of the cardiac workup and risk stratification. If cardiac causes are ruled out, optimization of her psychiatric medications may be appropriate if anxiety is contributing to her symptoms. However, cardiac causes must be thoroughly evaluated and addressed first, as recommended by the 2015 ESC guidelines 1.
Additional Considerations
The patient's shoulder tendinitis could be contributing to atypical chest pain, but cardiac causes must be ruled out first. Additionally, her anxiety and depression history may complicate symptom presentation, but should not preclude thorough cardiac evaluation. The use of high-sensitivity cardiac troponin assays, as recommended by the 2015 ESC guidelines 1, can help improve diagnostic accuracy and guide management.
From the Research
Patient Presentation
The patient is a 48-year-old female with a history of anxiety, major depressive disorder (MDD), and right shoulder tendinitis, presenting with chest pain (CP) and T wave inversions on electrocardiogram (ECG) with negative troponin levels.
Differential Diagnosis
- Myocardial infarction (MI) is a concern with chest pain and T wave inversions, but negative troponin levels make this less likely 2
- Takotsubo cardiomyopathy is a possibility, given the patient's history of anxiety and the presence of T wave inversions on ECG, as seen in a case study where a patient with a history of hypertension and smoking presented with similar symptoms 3
- Musculoskeletal pain is also a consideration, as T wave inversions can be influenced by respiratory variation, and the patient has a history of right shoulder tendinitis, which could be contributing to the chest pain 4
- Other non-cardiac causes of chest pain, such as pulmonary embolism, pericarditis, or cerebrovascular accident, should also be considered, as T wave inversions can be associated with these conditions 5
Electrocardiographic Findings
- T wave inversions can be a normal variant in asymptomatic adults, but in patients with chest pain, they can indicate coronary artery disease or other cardiac conditions 6
- The morphology of the T wave inversions, including their symmetry and depth, can help differentiate between cardiac and non-cardiac causes 5
- Respiratory variation in T wave morphology can suggest a non-cardiac cause of chest pain, as seen in a case study where a patient's T waves became positive when the ECG was repeated with the patient holding their breath in end inspiration 4
Diagnostic Approach
- Further evaluation, including echocardiography, stress testing, and coronary angiography, may be necessary to determine the underlying cause of the patient's chest pain and T wave inversions 6, 2
- The use of high-sensitivity troponin assays can help expedite and enhance myocardial infarction diagnoses, but negative results do not rule out other cardiac conditions 2