What is the next step in managing a patient with left-sided chest swelling and pain, with a normal chest X-ray (Chest Radiograph) and normal electrocardiogram (ECG)?

Management of Left-Sided Chest Swelling with Pain and Normal Initial Workup

With a normal chest X-ray and ECG, the next critical step is to obtain serial cardiac troponin measurements and repeat ECGs while simultaneously evaluating for non-cardiac causes of localized chest wall swelling. 1, 2

Immediate Actions Required

Continue Cardiac Evaluation Despite Normal Initial Tests

• A normal ECG does NOT exclude acute coronary syndrome (ACS) – up to 6% of patients with evolving ACS are discharged from the ED with a normal ECG, and 30-40% of acute MI patients present with nondiagnostic initial ECGs 1, 3

• Measure cardiac troponin (cTn) immediately if not already done, with high-sensitivity troponin preferred for rapid detection of myocardial injury 2, 3

• Repeat troponin at 6-12 hours from symptom onset (not from presentation time) to detect evolving myocardial injury, as a single troponin measurement drawn less than 6 hours from symptom onset may miss cardiac injury 3

• Perform serial ECGs every 15-30 minutes during the first hour if symptoms persist or change, as ischemic changes may evolve over time 1, 3

• Consider supplemental ECG leads V7-V9 to rule out posterior myocardial infarction, particularly if clinical suspicion for ACS remains intermediate-to-high 1, 2

Evaluate for Non-Cardiac Causes of Localized Chest Wall Swelling

The presence of visible swelling distinguishes this presentation from typical cardiac chest pain and mandates evaluation of musculoskeletal and other local causes:

Musculoskeletal Causes

• Examine for costochondritis or Tietze syndrome by palpating the costochondral joints for tenderness – these conditions cause localized chest wall pain and swelling 1

• Assess for chest wall trauma history including recent surgery, as pericardial fat necrosis can present as acute unilateral chest pain with swelling and normal initial cardiac workup 4

Life-Threatening Non-Cardiac Causes

• Evaluate for esophageal rupture (Boerhaave's syndrome) by checking for history of vomiting, subcutaneous emphysema on examination, and pneumothorax on chest X-ray (present in 20% of cases) 1, 5

• Consider CT chest if clinical suspicion exists for conditions not visible on plain radiograph, particularly if there is history of vomiting preceding chest pain 5

• Assess for herpes zoster by examining for pain in dermatomal distribution triggered by touch and characteristic unilateral rash 1

Other Pulmonary Causes

• Re-examine chest X-ray for pneumothorax (unilateral absence of breath sounds, dyspnea and pain on inspiration) or pneumonia (fever, localized pleuritic pain, regional dullness) 1

Risk Stratification and Disposition

High-Risk Features Requiring Admission

• Recurrent or persistent chest pain despite initial evaluation 3
• Dynamic ECG changes on serial testing 3
• Positive or rising troponin pattern 3
• Hemodynamic instability or life-threatening arrhythmias 3

Low-Risk Criteria Allowing Outpatient Follow-Up

• No recurrent chest pain after 6-12 hours of observation 3
• Normal or unchanged ECG on serial testing 3
• Two negative troponin measurements (initial and 6-12 hours) 3
• No high-risk features present 3

Critical Pitfalls to Avoid

• Never rely on a single normal ECG or troponin to exclude ACS when clinical suspicion exists – serial testing is mandatory 1, 3

• Do not assume chest pain is always cardiac – the presence of visible swelling strongly suggests a musculoskeletal or local inflammatory process 1, 6

• Avoid delayed transfer for troponin testing from office settings, as this worsens outcomes 2

• Do not miss esophageal rupture – this diagnosis is often delayed when initially treated as ACS, and early surgical intervention is critical for survival 5

Diagnostic Algorithm

1. If troponins remain negative at 6-12 hours AND serial ECGs show no changes AND no high-risk features: Consider musculoskeletal causes (costochondritis, Tietze syndrome, pericardial fat necrosis) or dermatologic causes (herpes zoster) 1, 4

2. If any troponin elevation or ECG changes develop: Manage as ACS per guidelines with risk stratification for invasive angiography versus stress testing 1, 2

3. If history includes vomiting or subcutaneous emphysema: Obtain urgent CT chest to evaluate for esophageal rupture 5

4. If all cardiac testing negative and no alternative diagnosis: Consider outpatient stress testing or coronary CT angiography for intermediate-risk patients, or defer testing for low-risk patients 1, 2