What is the appropriate investigation and management for an adult presenting with chest pain and palpitations, but with a normal electrocardiogram (ECG) and normal troponin I levels?

Investigation and Management of Chest Pain with Palpitations in Adults with Normal ECG and Troponin I

For patients with chest pain and palpitations but normal ECG and troponin I, serial ECGs and additional troponin measurements should be performed, followed by non-invasive cardiac testing before discharge or within 72 hours. 1, 2

Initial Assessment and Risk Stratification

Serial Testing

• Perform serial ECGs at 15-30 minute intervals during the first hour, especially if symptoms persist or clinical condition deteriorates 1, 2
• Obtain additional troponin levels 3-6 hours after symptom onset 2
  • A single negative troponin does not exclude ACS, especially if measured early after symptom onset 2
  • High-sensitivity troponin is preferred due to more rapid detection/exclusion of myocardial injury 1

Monitoring

• Patients should be observed in a chest pain unit or telemetry unit with continuous rhythm monitoring until ACS is definitively ruled out 2
• Use validated risk scores (TIMI or GRACE) to assess prognosis 2

Diagnostic Testing

Chest Radiography

• A chest radiograph is useful to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms 1

Supplemental ECG Leads

• Consider supplemental ECG leads V7-V9 in patients with intermediate-to-high clinical suspicion when initial ECG is nondiagnostic 1, 2

Advanced Cardiac Imaging

Before discharge or within 72 hours, one of the following tests should be performed 2:

1. Treadmill ECG stress test
2. Stress myocardial perfusion imaging
3. Stress echocardiography
4. Coronary CT angiography (particularly useful in patients with low-to-intermediate likelihood of CAD)

Cardiac MRI

• Consider cardiac MRI for patients with persistent symptoms despite normal initial testing
• CMR provides detailed information on cardiac morphology, function, tissue edema, and pattern of tissue damage that can help differentiate many etiologies of cardiac injury 3

Alternative Diagnoses to Consider

When chest pain and palpitations occur with normal ECG and troponin, consider:

• Non-cardiac causes: pulmonary embolism, aortic dissection, pneumothorax, gastrointestinal disorders 4
• Cardiac non-ischemic causes: myocarditis, pericarditis, arrhythmias 1
• Panic disorder or anxiety

Management Approach

For Low-Risk Patients

• Daily aspirin
• Short-acting nitroglycerin for symptom relief
• Beta-blockers if appropriate for palpitations
• Clear instructions about activity level and follow-up 2

For Intermediate-Risk Patients

• Continue observation with serial ECGs and troponin measurements
• Consider advanced imaging (stress testing or coronary CTA)
• Monitor for arrhythmias that may explain palpitations

For High-Risk Patients (Despite Normal Initial Tests)

• Consider admission for observation
• More extensive cardiac monitoring
• Earlier advanced cardiac imaging

Important Caveats

• Up to 6% of patients with evolving ACS are discharged from the ED with a normal ECG 2
• Palpitations may represent arrhythmias that are not captured on initial ECG
• Normal troponin and ECG do not exclude all serious cardiac conditions
• Consider non-cardiac causes that can present with similar symptoms (e.g., pulmonary embolism, aortic pathology) 4

Remember that chest pain with palpitations represents a symptom complex that requires thorough evaluation even when initial tests are normal, as intermittent cardiac abnormalities may be missed on a single ECG or troponin measurement.