How to manage a patient with sharp chest pain, palpitations, and left arm heaviness despite normal ECG and previous cardiac investigations?

Management of Chest Pain with Normal ECG and Previous Normal Cardiac Investigations

For a patient with sharp chest pain, palpitations, and left arm heaviness despite normal ECG findings, a comprehensive diagnostic approach focusing on both cardiac and non-cardiac causes is required, with particular attention to musculoskeletal causes given the chest wall tenderness on examination.

Initial Assessment and Risk Stratification

• Despite a normal ECG, up to 6% of patients with evolving acute coronary syndrome (ACS) may be discharged from the emergency department with a normal ECG, making it essential to not rely solely on a single normal ECG for decision-making 1, 2
• Serial ECGs should be performed when clinical suspicion of ACS is high, symptoms are persistent, or the clinical condition deteriorates 1
• The presence of chest wall tenderness on palpation suggests a musculoskeletal etiology, which is a common non-cardiac cause of chest pain 1
• Normal previous cardiac investigations (treadmill test and CTCA in 2022) reduce the likelihood of coronary artery disease but do not completely exclude it 1

Diagnostic Workup

Immediate Investigations

• Cardiac biomarkers (troponin) should be measured to detect or exclude myocardial necrosis, even with a normal ECG 1
• Chest radiography is useful to evaluate for other potential cardiac, pulmonary, and thoracic causes of symptoms 1
• If symptoms recur during evaluation, repeat ECG immediately to detect potential ischemic changes 1

Further Investigations Based on Clinical Suspicion

• For palpitations: Consider 24-48 hour Holter monitoring to capture arrhythmias that may be causing symptoms 3, 4
• For persistent chest pain with normal initial workup: Consider echocardiography to evaluate for non-ischemic cardiac causes such as pericarditis, myocarditis, or valvular abnormalities 1, 5
• For patients with intermediate-to-high clinical suspicion for ACS and nondiagnostic initial ECG, supplemental electrocardiographic leads V7 to V9 are reasonable to rule out posterior MI 1

Management Approach

For Suspected Cardiac Causes

• If cardiac biomarkers are elevated or if ECG changes develop during observation, manage according to NSTE-ACS guidelines 1
• For suspected arrhythmia-related symptoms, consider beta-blockers (already on metoprolol) for rate control and symptom management 6, 4
• Given family history of MI before age 60 and current hyperlipidemia, ensure optimal lipid management (currently on atorvastatin 10mg) 1

For Suspected Non-Cardiac Causes

• If musculoskeletal pain is confirmed (chest wall tenderness present), consider appropriate analgesics and physical therapy 1
• Address potential psychosocial stressors (unemployment, caring for multiple family members) that may contribute to symptoms 1
• Consider lifestyle modifications including regular exercise and stress management techniques 1

Follow-up Plan

• Schedule follow-up within 1-2 weeks to reassess symptoms and response to management 1
• If symptoms persist or worsen despite initial management, consider referral to cardiology for further specialized testing 1
• Educate patient about warning signs that should prompt immediate medical attention (prolonged chest pain >20 minutes, associated shortness of breath, syncope) 1

Important Considerations and Pitfalls

• Avoid premature exclusion of cardiac causes based solely on a normal ECG or previous normal investigations, especially with family history of premature coronary artery disease 1, 2
• Consider the impact of psychosocial stressors (caring for multiple family members, recent unemployment) on symptom presentation and perception 1
• Be aware that intermittent left bundle branch block can cause chest pain and ECG changes that mimic ischemia in the absence of obstructive coronary disease 6
• Remember that rate-related cardiac symptoms may respond to heart rate control with beta-blockers 6, 4