What are the next management steps for a patient with chest pain and a negative troponin?

From the Guidelines

For a patient with chest pain and a negative troponin, the next management steps should focus on risk stratification and identifying the underlying cause, with consideration of serial troponin measurements and additional cardiac testing such as stress testing or coronary CT angiography based on the patient's risk profile, as recommended by the 2015 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.

Key Considerations

• Initial management includes obtaining a thorough history and physical examination, followed by an ECG
• For patients with intermediate to high risk features, admission for observation and serial troponin measurements (typically at 0,3, and 6 hours) is recommended to rule out acute coronary syndrome, as a single negative troponin does not completely exclude acute coronary syndrome 1
• Low-risk patients may undergo expedited outpatient evaluation, with empiric treatment often including aspirin 81-325mg daily, consideration of a statin, and symptom management with medications like nitroglycerin 0.4mg sublingual as needed for chest pain
• Non-cardiac causes of chest pain should also be investigated, including pulmonary, gastrointestinal, or musculoskeletal etiologies

Risk Stratification

• Patients can be classified as low-risk or high-risk based on clinical, electrocardiographical, and biochemical data, with low-risk patients having no recurrence of chest pain, no ST-segment depression or elevation, and no elevation of troponin or other biochemical markers of myocardial necrosis on the initial and repeat measurement 1
• High-risk patients may require more aggressive management, including coronary angiography and revascularization, depending on the presence of significant ischemia during stress testing

Additional Testing

• Stress testing, such as exercise stress testing or stress echocardiography, may be recommended to confirm or establish a diagnosis of coronary artery disease and to assess the risk for future events in patients with coronary artery disease 1
• Coronary CT angiography may also be considered as an additional testing modality to evaluate coronary artery disease

Treatment

• Empiric treatment often includes aspirin, consideration of a statin, and symptom management with medications like nitroglycerin, with beta-blockers such as metoprolol 25-50mg twice daily may be appropriate for patients with tachycardia or hypertension
• The use of troponins at 0 and 2 hours as a stand-alone measure for excluding the diagnosis of ACS is strongly discouraged, and instead, negative high-sensitivity troponin I measured at 0 and 2 hours may be used together with low-risk stratification or negative cardiac troponin I or cardiac troponin T measured at 0 and 3 to 6 hours with very-low risk stratification to identify those patients who have a less than 1% 30-day risk of a major adverse cardiac event (MACE) 1

From the Research

Next Management Steps for a Patient with Chest Pain and a Negative Troponin

• A negative troponin result does not entirely rule out cardiac issues, but it significantly reduces the likelihood of myocardial infarction 2.
• Patients with chest pain and negative troponin should undergo further evaluation to determine the cause of their symptoms, which may include:
  • Electrocardiogram (ECG) to check for ischemic changes or other abnormalities.
  • Echocardiography to assess cardiac function and structure.
  • Stress testing to evaluate for inducible ischemia.
  • Coronary angiography if high-risk features are present.
• It is essential to consider non-cardiac causes of chest pain, such as pulmonary embolism, pneumothorax, or gastrointestinal issues, especially if the patient has risk factors or symptoms suggestive of these conditions 3, 4.
• The patient's clinical presentation, medical history, and other diagnostic test results should guide the management plan.
• In some cases, a negative troponin result may be seen in patients with non-atherosclerotic heart diseases, such as supraventricular tachycardia or cardiac surgery, where troponin elevation may not necessarily indicate myocardial infarction 5, 6.
• Close monitoring and repeated troponin measurements may be necessary to ensure that no cardiac damage occurs, especially if the patient's symptoms persist or worsen.