From the Guidelines
Based on the clinical presentation, I recommend conservative management for what appears to be musculoskeletal chest pain, as the normal troponin, D-dimer, CBC, CMP, and EKG findings suggest this is not cardiac in origin but rather related to muscle strain from lifting the heavy barn door, as supported by the guidelines for managing patients with non-ST-elevation acute coronary syndromes 1. The patient's symptoms of chest pain and arm discomfort that started after lifting a heavy barn door, along with the normal laboratory and EKG findings, point towards a musculoskeletal etiology rather than a cardiac one.
- The troponin level of 0.01 is within normal limits, which, according to the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes, suggests that serial cardiac troponin levels should be obtained at presentation and 3 to 6 hours after symptom onset to identify a rising and/or falling pattern of values 1.
- The D-dimer level of 0.35 is also within normal limits, which further supports the diagnosis of musculoskeletal chest pain.
- The EKG showing sinus rhythm without any ischemic changes also supports the diagnosis of musculoskeletal chest pain.
- The temporal relationship between the heavy lifting and pain onset strongly supports a musculoskeletal etiology. Treatment should include:
- Rest from heavy lifting for 3-5 days
- Over-the-counter pain medications such as ibuprofen 400-600mg every 6-8 hours with food or acetaminophen 500-1000mg every 6 hours as needed for pain
- Applying ice to any tender areas for 15-20 minutes several times daily for the first 48 hours, then switching to heat therapy The patient should gradually return to normal activities as pain permits, using proper lifting techniques (bending at the knees, keeping the back straight, and avoiding twisting while lifting). If symptoms worsen, persist beyond 7-10 days, or if new concerning symptoms develop such as shortness of breath or increased pain with breathing, prompt medical reevaluation is warranted, considering the use of clinical algorithms such as the HEART scoring system and newer biochemical tests such as high sensitivity troponins, as suggested by the ACR Appropriateness Criteria for acute nonspecific chest pain-low probability of coronary artery disease 1.
From the Research
Patient Presentation
- The patient presents with chest pain and arm discomfort that started 2 hours ago, after lifting a heavy barn door.
- The patient's troponin level is 0.01, which is slightly elevated, but not significantly high 2.
- The d-dimer level is 0.35, which is within normal limits.
- The complete blood count (CBC) and comprehensive metabolic panel (CMP) are unremarkable.
- The electrocardiogram (EKG) shows a sinus rhythm, with no signs of ST-segment elevation or depression.
Diagnosis and Treatment
- Based on the patient's symptoms and test results, acute coronary syndrome (ACS) is a possible diagnosis, but the troponin level is not significantly elevated 3, 4.
- The patient's symptoms and EKG results do not suggest ST-segment elevation myocardial infarction (STEMI) 3.
- Non-ST-segment elevation ACS (NSTE-ACS) is a possible diagnosis, but the patient's troponin level is not significantly elevated 3, 4.
- Treatment for ACS typically includes aspirin, dual antiplatelet therapy, parenteral anticoagulation, statins, beta blockers, and oxygen 5.
- Cardiology consultation may be considered, especially if the patient has a history of coronary artery disease (CAD) 6.
Management
- The patient should be monitored closely for any changes in symptoms or EKG results.
- Further testing, such as cardiac catheterization or stress testing, may be considered to evaluate the patient's coronary arteries and cardiac function 3, 4.
- The patient should be treated with aspirin and other medications as indicated, and should be advised to avoid heavy lifting and strenuous activity until further evaluation and treatment can be completed 5.