What are the next steps for a patient with chest pain and normal ECG (electrocardiogram), CXR (chest X-ray), troponin levels, and CT (computed tomography) angiopulmonary with contrast?

Next Steps for Chest Pain with Normal Initial Workup

For patients with chest pain and completely normal ECG, chest X-ray, troponin, and CT pulmonary angiography, the focus should shift to evaluating for non-cardiac causes of chest pain, considering coronary microvascular dysfunction if symptoms persist, and arranging close outpatient follow-up rather than pursuing additional inpatient testing. 1

Immediate Management

Patients at low clinical risk for ACS who have remained stable with negative serial ECGs and cardiac biomarkers have very low rates of major adverse cardiac events at 30 days and can be safely discharged from the ED. 1

• Do not routinely use further diagnostic testing (coronary CT angiography, stress testing, myocardial perfusion imaging) before discharge in low-risk patients in whom acute MI has been ruled out 1
• The comprehensive negative workup (normal ECG, troponin, CXR, and CT angiography) places this patient in the low-likelihood category for acute coronary syndrome 1

Risk Stratification and Disposition

Arrange follow-up in 1 to 2 weeks for low-risk patients in whom MI has been ruled out. 1 If no follow-up is available, consider further testing or observation before discharge 1.

The patient's presentation falls into the "low likelihood" category based on:

• Normal cardiac markers (troponin) 1
• Normal or nondiagnostic ECG 1
• Normal chest imaging excluding pulmonary embolism 1

Differential Diagnosis to Consider

With cardiac causes effectively ruled out, focus on common non-cardiac etiologies:

Musculoskeletal Causes

• Evaluate for costochondritis or Tietze syndrome by examining for tenderness of costochondral joints 1
• Assess for chest wall pain syndromes through palpation—pain reproducible by palpation is more likely musculoskeletal than ischemic 1, 2
• Consider thoracic spine disorders and cervical osteoarthritis 3

Gastrointestinal Causes

• Gastroesophageal reflux disease (GERD) is a common cause—consider empiric trial of proton pump inhibitor (esomeprazole 40 mg for 7 days) 4
• Examine for epigastric tenderness suggesting esophagitis or peptic ulcer disease 1
• Evaluate for right upper quadrant tenderness and Murphy sign if gallbladder disease suspected 1

Psychiatric Causes

• Screen for panic disorder using a two-item questionnaire 2
• Assess for anxiety and depression, which are present in approximately 57% of patients with non-cardiac chest pain 4
• Patients with psychiatric disorders experience more frequent chest pain and diminished quality of life compared to those with GERD 4

Special Considerations for Coronary Microvascular Dysfunction

If symptoms are frequent or persistent despite normal coronary anatomy, consider the INOCA (Ischemia with Non-Obstructive Coronary Arteries) pathway. 5

• Advanced testing options include stress PET MPI or stress CMR with myocardial blood flow reserve assessment to evaluate for microvascular dysfunction 5
• Optimize preventive therapies as first-line approach 5
• Consider cardiac rehabilitation to determine if symptoms are consistent with angina and assess symptom severity 5

Common Pitfalls to Avoid

Do not delay transfer to the ED for additional cardiac testing if the patient was initially evaluated in an office setting—this is explicitly harmful. 1 However, once comprehensive negative testing is completed in the ED, further cardiac testing before discharge is not beneficial 1.

Avoid using inpatient-derived risk scoring systems to identify patients who may be safely discharged from the ED—these are useful for prognosis but not recommended for discharge decisions 1.

Do not assume all chest pain relieved by nitroglycerin is cardiac—this is not diagnostic of myocardial ischemia 1.

Outpatient Follow-up Plan

• Reassure the patient of the excellent intermediate-term prognosis given the negative workup 1
• If musculoskeletal cause identified, specific treatment often produces good results 3
• If GERD suspected, trial of PPI with reassessment 4
• If psychiatric disorder identified, combined psychiatric evaluation and treatment is warranted as these patients exhibit pathologic coping strategies 4
• Regular reassessment of symptoms and treatment efficacy is necessary 5