What is the best course of action for a 76-year-old female presenting with fatigue, vague chest pain, sinus rhythm with frequent PVCs, negative troponin, and slightly elevated D-dimer?

From the Guidelines

The best course of action for this 76-year-old female would be to pursue further cardiac and pulmonary evaluation while addressing her symptoms. Initially, she should undergo a comprehensive cardiac workup including an echocardiogram to assess cardiac function and structure, and a stress test to evaluate for coronary artery disease, as recommended by the European Society of Cardiology guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. Given her slightly elevated D-dimer, a CT pulmonary angiogram should be performed to rule out pulmonary embolism, which can present with these symptoms in elderly patients, in accordance with the guidelines on the diagnosis and management of acute pulmonary embolism by the European Society of Cardiology 1. While awaiting results, symptomatic management with acetaminophen 500-1000mg every 6 hours as needed for chest discomfort is appropriate. The frequent PVCs warrant consideration of a 24-hour Holter monitor to determine their burden and patterns. Laboratory tests should include complete blood count, comprehensive metabolic panel, thyroid function tests, and B12 levels to identify potential causes of fatigue. This approach is justified because her presentation includes multiple non-specific symptoms that could indicate several serious conditions including coronary artery disease, pulmonary embolism, or arrhythmia. The negative troponin suggests acute myocardial infarction is less likely, but doesn't rule out stable coronary disease or other cardiac pathology, as noted in the guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. Her age and symptom complex necessitate a thorough evaluation rather than presumptive treatment.

Some key points to consider in her management include:

• The use of a clinical algorithm for diagnostic evaluation and triage in acute coronary syndrome, as outlined in the 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1.
• The importance of interpreting cardiac troponin and its change during serial sampling as a quantitative marker, with higher levels indicating a higher likelihood of myocardial infarction 1.
• The consideration of other cardiac conditions such as myocarditis, Takotsubo syndrome, or congestive heart failure, as well as non-cardiac conditions like pneumonia or pneumothorax, in the differential diagnosis 1.
• The potential role of novel ECG algorithms using digital ECG data in the diagnosis of non-ST-elevation acute coronary syndromes 1.

Overall, a comprehensive and thorough evaluation is necessary to determine the underlying cause of her symptoms and to guide appropriate management.

From the Research

Patient Presentation

The patient is a 76-year-old female presenting with fatigue, vague chest pain, and an ECG showing sinus rhythm with frequent PVCs. Her troponin is negative, and her D-dimer is slightly elevated at 1.3 mg/L.

Diagnostic Considerations

• The patient's symptoms and ECG findings could be indicative of several conditions, including pulmonary embolism (PE) or cardiac issues 2.
• The negative troponin suggests that an acute coronary syndrome is less likely, but does not rule out other cardiac conditions or PE.
• The slightly elevated D-dimer level may indicate the presence of a thrombotic event, such as PE, but is not specific enough to confirm the diagnosis on its own 3, 4.

Management Strategy

• Given the patient's age, symptoms, and ECG findings, a high degree of suspicion for PE should be maintained, even with a normal or slightly elevated D-dimer level 5.
• Further diagnostic testing, such as computed tomography pulmonary angiogram (CTPA) or ventilation-perfusion scanning, may be necessary to confirm or rule out PE.
• The use of a rapid D-dimer blood test in combination with clinical probability assessment can help to rule out PE in patients with a low or moderate clinical probability 3, 6.
• However, in patients with a high clinical probability of PE, further testing should be pursued regardless of the D-dimer result.

Treatment Options

• If PE is confirmed, treatment options may include anticoagulation, thrombolysis, or catheter-based therapy, depending on the severity of the condition and the patient's overall health status 2.
• In patients with a high clinical probability of PE, empiric anticoagulation may be considered while awaiting further diagnostic testing.