Does a patient with no history of heart failure, presenting with chest pain and an initial high sensitivity troponin (hs-troponin) level of 30 that decreased to 26 on repeat measurement, and a non-ischemic electrocardiogram (ECG), require hospital admission?

Hospital Admission for Chest Pain with Elevated Troponin

A patient with chest pain and elevated high-sensitivity troponin (30 ng/L decreasing to 26 ng/L) with a non-ischemic ECG should be admitted to the hospital for further evaluation and management, as positive cardiac biomarkers indicate active ischemia requiring inpatient care.

Risk Stratification and Decision-Making

The American College of Cardiology/American Heart Association guidelines provide clear direction for patients presenting with chest pain and elevated cardiac biomarkers:

• Patients with positive cardiac biomarkers (elevated troponin) should be admitted to the hospital even with a non-ischemic ECG 1
• The guidelines specifically state that "patients who present without ST-segment elevation but who have features indicative of active ischemia (ongoing pain, positive cardiac biomarkers, or hemodynamic instability) should be admitted to the hospital" 1
• The presence of elevated troponin, even with a non-ischemic ECG, classifies this patient as having "definite ACS" with features of active ischemia 1

Significance of Elevated Troponin

The elevated high-sensitivity troponin in this case is clinically significant:

• High-sensitivity troponin elevation (>99th percentile of normal) indicates myocardial injury, even if the ECG does not show ischemic changes 2
• A decrease from 30 to 26 ng/L does not rule out acute coronary syndrome, as it still represents an elevated value
• Troponin elevation has been shown to be the strongest predictor of adverse outcomes among patients with cardiac symptoms, with higher 30-day and 1-year mortality regardless of left ventricular ejection fraction 3

Management Pathway

The appropriate management pathway for this patient is:

1. Hospital admission to a telemetry unit for continuous cardiac monitoring 1
2. Serial cardiac biomarker measurements to establish a clear trend
3. Further diagnostic evaluation including:
   • Repeat ECGs to monitor for dynamic changes
   • Echocardiography to assess cardiac function
   • Consider coronary angiography based on risk assessment and clinical course

Why Observation Unit/Discharge Is Not Appropriate

While some patients with chest pain can be managed in observation units or discharged, this patient does not qualify for this approach because:

• The presence of elevated cardiac biomarkers places the patient in a higher risk category requiring inpatient management 1
• The ACC/AHA guidelines clearly state that patients with positive cardiac biomarkers should be admitted to the hospital 1
• Even though the ECG is non-ischemic, the elevated troponin indicates ongoing myocardial injury that requires further evaluation and monitoring 2

Potential Diagnoses to Consider

During hospitalization, several diagnoses should be considered:

• Non-ST elevation myocardial infarction (NSTEMI)
• Myocarditis (accounts for 50% of cases with elevated troponin and unobstructed coronaries) 4
• Stress-induced cardiomyopathy
• Pulmonary embolism
• Other causes of myocardial injury

Common Pitfalls to Avoid

• Do not discharge patients with elevated troponins: This is a high-risk feature requiring admission regardless of ECG findings 1
• Do not rely solely on ECG findings: Normal or non-ischemic ECGs do not rule out significant cardiac events when troponin is elevated 2
• Do not assume a decreasing troponin trend eliminates risk: Even with a small decrease, the values remain elevated and indicate ongoing myocardial injury 3
• Do not underestimate the prognostic significance of troponin elevation: It is associated with increased morbidity and mortality even with non-ischemic ECGs 5

In conclusion, this patient with chest pain, elevated high-sensitivity troponin, and non-ischemic ECG requires hospital admission for further evaluation, monitoring, and management to ensure optimal outcomes and reduce the risk of adverse cardiac events.