Can a 33-year-old male patient with chest pain be evaluated, given that his last 4 electrocardiograms (EKGs) this month were normal?

From the Guidelines

I strongly recommend seeing this 33-year-old male patient with chest pain promptly, despite his four normal EKGs this month, as chest pain can indicate various conditions ranging from benign musculoskeletal issues to life-threatening cardiac events. The assessment should include a detailed history of the pain characteristics (onset, duration, quality, radiation, aggravating/relieving factors), associated symptoms, risk factors, and a physical examination. According to the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain 1, the goals in patients presenting with acute chest pain are to identify life-threatening causes, determine clinical stability, and assess the need for hospitalization versus safety of outpatient evaluation and management.

Key Considerations

• Normal EKGs are reassuring but don't exclude all cardiac pathologies, as conditions like coronary vasospasm, microvascular angina, or early coronary disease may not show EKG changes.
• Non-cardiac causes like gastroesophageal reflux, pulmonary conditions, anxiety, or musculoskeletal pain should also be considered.
• Additional testing beyond EKGs may be necessary, such as cardiac enzymes (troponin), chest X-ray, stress testing, or coronary CT angiography depending on clinical suspicion.
• The ACC/AHA STEMI and NSTE-ACS guidelines categorize chest pain cause into 4 types: STEMI, NSTE-ACS, stable angina, and noncardiac, and the 12-lead ECG is pivotal in the evaluation because of its capacity to identify and triage patients with STEMI to urgent coronary reperfusion 1.

Recommendations

• Prompt evaluation is essential to establish a diagnosis and appropriate treatment plan for this patient's recurring chest pain.
• Consideration of the full extent of clinical data is necessary to assign patients with chest pain into one of four categories: noncardiac diagnosis, chronic stable angina, possible ACS, and definite ACS, as recommended by the ACC/AHA guidelines 1.
• Patients with probable or possible ACS but whose initial 12-lead ECG and cardiac biomarker levels are normal should be observed in a facility with cardiac monitoring, and repeat ECG and cardiac biomarker measurement should be obtained at predetermined, specified time intervals 1.

From the FDA Drug Label

Nitroglycerin is used to treat a type of chest pain called angina. Angina is a pain or discomfort that keeps coming back when part of your heart does not get enough blood Nitroglycerin sublingual tablets can relieve this pain.

The patient is a 33-year-old male with chest pain and four normal EKGs in the last month.

• Chest pain can be a symptom of angina, which is the primary indication for nitroglycerin.
• Given the patient's symptoms and the fact that nitroglycerin is used to treat angina, it may be considered as a treatment option.
• However, it is crucial to consult a doctor before administering nitroglycerin, especially considering the patient's age and medical history.
• The doctor will assess the patient's condition and determine if nitroglycerin is the appropriate treatment, considering the potential side effects and interactions with other medications 2, 2.

From the Research

Evaluation of Chest Pain

The patient, a 33-year-old male, presents with chest pain, and has had four normal EKGs in the past month. The following points are relevant to his evaluation:

• Chest pain can have various causes, including cardiac and non-cardiac conditions, and a thorough history, physical examination, and diagnostic tests are necessary to determine the underlying cause 3.
• The patient's normal EKGs do not rule out cardiac causes of chest pain, and further evaluation may be necessary to determine the risk of acute coronary syndrome or other conditions 4.
• For patients with stable chest pain and a normal resting ECG, stress testing or coronary computed tomography angiography can be used for further risk stratification 4, 5.
• Exercise stress echocardiography and exercise myocardial SPECT are diagnostic tests that can be used to evaluate patients with chest pain, and have been compared in terms of their performance in diagnosing coronary artery disease 6.
• The 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain provides recommendations for the assessment and evaluation of chest pain, including risk stratification and diagnostic workup, and emphasizes the importance of shared decision-making with patients 7.

Diagnostic Considerations

Some key considerations in the diagnostic evaluation of this patient include:

• The patient's age and risk factors for cardiac disease, which may influence the likelihood of cardiac causes of chest pain 3, 4.
• The characteristics of the patient's chest pain, including its location, duration, and triggers, which can help to determine the underlying cause 3, 4.
• The results of the patient's normal EKGs, which do not rule out cardiac causes of chest pain, but may suggest a lower risk of acute coronary syndrome 4, 5.
• The potential use of stress testing or coronary computed tomography angiography to further evaluate the patient's risk of cardiac disease 4, 5.