What is the evaluation of a 42-year-old male with episodic chest pain, described as heartburn, exacerbated by exercise and accompanied by nausea?

From the FDA Drug Label

1. Warnings and Precautions 5.1 Presence of Gastric Malignancy In adults, symptomatic response to therapy with omeprazole does not preclude the presence of gastric malignancy. Consider additional follow-up and diagnostic testing in adult patients who have a suboptimal response or an early symptomatic relapse after completing treatment with a PPI.

The evaluation of a 42-year-old male with episodic chest pain, described as heartburn, exacerbated by exercise and accompanied by nausea, should consider gastric malignancy as a possible cause, despite the symptoms being suggestive of gastroesophageal reflux disease (GERD).

• Additional diagnostic testing should be considered to rule out gastric malignancy.
• The patient's symptoms do not directly align with the warnings and precautions listed for omeprazole, but it is essential to be cautious and consider all possible causes of the symptoms. 1

From the Research

This 42-year-old male requires immediate medical evaluation, preferably in an emergency department, to rule out acute coronary syndrome. While the chest pain is described as heartburn, several factors raise concern for a potential cardiac event: the patient's age and gender, the occurrence of pain during exercise, and the recent worsening of symptoms with associated nausea. The emergency department can perform an ECG, cardiac enzyme tests, and possibly a stress test or cardiac imaging to definitively rule out a heart attack or unstable angina, as recommended by the most recent study on the diagnosis and treatment of acute coronary syndromes 2. If cardiac causes are ruled out, further evaluation for gastrointestinal causes like GERD can be pursued.

Key Considerations

• The patient's symptoms, although atypical, warrant a thorough cardiac evaluation due to the potential severity of a missed cardiac event 3, 4, 5.
• An ECG should be performed immediately, within 10 minutes of presentation, to distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS) 2.
• High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI, and if levels are elevated, prompt invasive coronary angiography and percutaneous or surgical revascularization may be necessary 2.
• The patient should avoid strenuous activity and take aspirin (325 mg) if not contraindicated, as recommended by previous studies 4, 5.

Evaluation and Management

• The emergency department evaluation should include a history, physical examination, electrocardiograms (ECGs), and cardiac troponin measurements in conjunction with risk calculators, such as the HEART score or TIMI risk score 3, 6.
• If STEMI is diagnosed, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes is recommended, or fibrinolytic therapy if PCI is not possible 2.
• For high-risk patients with NSTE-ACS, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours may be necessary 2.