What is the most appropriate disposition for a patient with intermittent stabbing chest pain, hypertension, and diabetes, with normal troponin levels and nonspecific repolarization changes on the electrocardiogram (ECG)?

Disposition for Low-Risk Chest Pain with Normal Troponins

This patient should be discharged home with outpatient follow-up with a primary care clinician and cardiologist for further testing, as she meets criteria for low-risk acute coronary syndrome with negative serial troponins and a favorable HEART score. 1

Risk Stratification Using HEART Score Components

The HEART score (History, ECG, Age, Risk factors, and Troponin) is specifically designed for this clinical scenario and guides disposition decisions 1:

• History: Intermittent stabbing chest pain not associated with exertion or eating, resolving spontaneously = low suspicion (0-1 points)
• ECG: Nonspecific repolarization changes without ischemic findings = 0 points 1
• Age: Variable based on patient age
• Risk factors: Hypertension and diabetes = 2 points
• Troponin: Normal at 0 and repeat hours = 0 points 1

A modified HEART score ≤3 identifies patients at low risk (<1% 30-day risk of major adverse cardiac events) who are appropriate for discharge with outpatient testing. 1

Key Supporting Evidence for Discharge

The 2022 ACC Expert Consensus provides clear algorithms for this exact scenario 1:

• Serial negative troponins at 0 and 3-6 hours effectively rule out acute myocardial infarction in patients with nonischemic ECGs 1
• Patients with normal troponin levels, nondiagnostic ECG changes, and low HEART scores can be safely discharged with outpatient noninvasive testing 1
• The observation period (typically 6-12 hours) with serial biomarkers and ECGs has been completed successfully in this case 1

Why Other Options Are Not Appropriate

Cardiac catheterization laboratory activation is reserved for STEMI or STEMI-equivalents with ongoing ischemia—this patient has nonspecific ECG changes and negative troponins 1

Hospital admission with emergent cardiology consultation is indicated for patients with ongoing chest pain, ischemic ECG changes, positive cardiac biomarkers, or hemodynamic instability 1—none of which are present here.

Observation unit admission would have been appropriate before completing the serial troponin protocol, but once negative troponins are confirmed at appropriate intervals with a low HEART score, continued observation provides no additional benefit 1

Outpatient Management Plan

Upon discharge, this patient requires 1:

• Noninvasive stress testing (stress echocardiography, stress nuclear imaging, or coronary CT angiography) within 72 hours to 2 weeks 1
• Cardiovascular risk factor optimization including blood pressure and diabetes management 1
• Clear return precautions for recurrent chest pain, particularly if associated with exertion, diaphoresis, or lasting >5 minutes 1

Critical Pitfalls to Avoid

Do not discharge if any of the following develop during observation 1:

• Recurrent ischemic chest pain
• New ECG abnormalities suggesting ischemia (ST-segment depression ≥0.5mm, T-wave inversions, or dynamic changes) 2
• Rising troponin levels on repeat testing
• Hemodynamic instability

Ensure adequate symptom duration before initial troponin: The first troponin should ideally be drawn ≥3 hours after symptom onset for optimal negative predictive value with contemporary assays 1, 3

Document the specific HEART score calculation in the medical record to support the disposition decision and facilitate risk communication with the patient 1