What is the treatment for a patient with chest pain and palpitations, normal electrocardiogram (ECG) and normal troponin I levels?

Treatment for Chest Pain with Palpitations, Normal ECG, and Normal Troponin I

For patients with chest pain and palpitations who have normal ECG and normal troponin I levels, the recommended treatment includes observation in a chest pain unit for 10-12 hours with serial ECG and troponin testing, followed by non-invasive cardiac testing before discharge or within 72 hours. 1

Initial Management

Immediate Assessment

• Ensure patient is hemodynamically stable
• Obtain serial ECGs at 15-30 minute intervals during the first hour if symptoms persist 1
• Perform additional troponin measurements at 3-6 hours after symptom onset 1
• Consider supplemental ECG leads V7-V9 if clinical suspicion remains intermediate-to-high 1

Observation Period

• Monitor in a chest pain unit or telemetry unit with continuous rhythm monitoring for 10-12 hours 2, 1
• This observation period is critical as the risk of missing acute coronary syndrome is high without proper monitoring 2
• Use validated risk scores such as TIMI or GRACE to assess prognosis 1

Pharmacological Management

Symptom Relief

• Administer sublingual nitroglycerin for chest pain relief 2
• Consider aspirin 250-500mg if coronary artery disease is suspected 2

Rate Control for Palpitations

• Beta-blockers (e.g., metoprolol) can be considered for symptomatic palpitations 3
  • Initial dose: metoprolol 25-50mg orally every 6 hours
  • Maintenance dose: 100mg orally twice daily
  • Use with caution in patients with bradycardia, hypotension, or heart failure 3

Diagnostic Testing Before Discharge

One of the following tests should be performed before discharge or within 72 hours 1:

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) 2, 1

Differential Diagnosis Considerations

The treatment approach should consider non-coronary causes of chest pain and palpitations:

• Myocarditis
• Pericarditis
• Primary arrhythmias
• Pulmonary embolism
• Aortic dissection
• Pneumothorax 2, 1

Discharge Planning

For low-risk patients referred for outpatient testing:

• Daily aspirin if coronary artery disease is suspected
• Short-acting nitroglycerin for symptom relief
• Beta-blockers if appropriate for symptom control
• Clear instructions about activity level and follow-up 1

Important Caveats

1. A single negative troponin does not exclude acute coronary syndrome, especially if measured early after symptom onset 1, 4
2. Up to 6% of patients with evolving acute coronary syndrome are discharged from the ED with a normal ECG 1
3. Mildly elevated high-sensitivity troponin (even below conventional detection thresholds) carries prognostic significance and warrants follow-up 4
4. The potential advantages of rapid assessment are lost if there are long waiting times for further investigation 5

This approach balances the need for thorough evaluation with efficient resource utilization while prioritizing patient safety and quality of life outcomes.