Should a 24-year-old, obese (body mass index (BMI)) former football player with chest pain and shortness of breath, elevated high sensitivity troponin (cardiac biomarker), and normal electrocardiogram (EKG) be discharged from the emergency room (ER) without admission?

This Patient Should NOT Be Discharged and Requires Hospital Admission

This 24-year-old patient with elevated high-sensitivity troponin (65 ng/L initially, 53 ng/L on repeat) and chest pain must be admitted to the hospital for further evaluation and monitoring, regardless of the normal ECG. The elevated troponin indicates myocardial injury and classifies this as a definite acute coronary syndrome (ACS) requiring inpatient management 1.

Critical Risk Factors Present

This patient has multiple concerning features that mandate admission:

• Elevated cardiac biomarkers: High-sensitivity troponin of 65 ng/L exceeds the typical 99th percentile upper reference limit (usually 14-19 ng/L for most hs-cTn assays), indicating myocardial injury 1
• Young age with significant risk factors: At 300 lbs, this patient is severely obese (likely BMI >40), which is a major cardiovascular risk factor, particularly in a former athlete who may have underlying conditions like hypertensive cardiomyopathy or early coronary disease 1
• Active symptoms: The patient has ongoing chest pain (6/10) with shortness of breath, indicating possible active ischemia 1

Why Discharge is Inappropriate

The ACC/AHA guidelines are explicit that patients with positive cardiac biomarkers should be admitted to the hospital, even with a normal ECG 1. Specifically:

• Patients with "features indicative of active ischemia (ongoing pain, ST-segment and/or T-wave changes, positive cardiac biomarkers, or hemodynamic instability) should be admitted to the hospital" 1
• The 2010 AHA guidelines classify elevated troponin as a "high likelihood" feature for ACS, warranting admission regardless of other findings 1
• Patients should be admitted to an inpatient unit with continuous ECG monitoring and resuscitation capabilities 1

Differential Diagnosis to Consider

While ACS is the primary concern, the differential in this young, obese former athlete includes:

• Type 1 MI (acute coronary syndrome): Plaque rupture/thrombosis - most concerning given troponin elevation and symptoms 1
• Type 2 MI (supply-demand mismatch): Possible in setting of obesity, potential hypertension, or undiagnosed cardiomyopathy 1
• Myocarditis: Can present with chest pain, troponin elevation, and normal ECG in young patients 2
• Stress cardiomyopathy (Takotsubo): Less common in young males but possible 2
• Pulmonary embolism: Must be considered with shortness of breath and chest pain, though troponin elevation would be less pronounced 1, 3
• Acute pericarditis: Though typically presents with ECG changes 1, 3

Required Inpatient Evaluation

The patient requires:

• Admission to telemetry or step-down unit with continuous cardiac monitoring for at least 24 hours 1
• Serial troponin measurements to assess for rising or falling pattern (delta change) to distinguish acute MI from chronic elevation 1
• Repeat ECG if symptoms recur or at regular intervals to detect evolving changes 1, 3
• Echocardiography to assess left ventricular function, regional wall motion abnormalities, and rule out structural causes 1
• Risk stratification using TIMI or GRACE scores to determine need for early invasive strategy (cardiac catheterization) 1
• Consideration of early invasive strategy given elevated troponin, which is a high-risk feature 1

Common Pitfalls to Avoid

• Do not be falsely reassured by the normal ECG: Up to 6% of patients with acute MI have normal or non-diagnostic initial ECGs 1
• Do not dismiss troponin elevation in young patients: While less common, young obese individuals can have premature coronary disease, and alternative diagnoses like myocarditis can be life-threatening 2
• Do not attribute symptoms to "atypical chest pain" without full evaluation: The combination of chest pain, dyspnea, and elevated troponin requires definitive exclusion of life-threatening causes 1, 3
• Do not discharge based on a single troponin value: The trend (rising, falling, or stable) provides critical diagnostic and prognostic information 1

Why Observation Unit is Insufficient

Chest pain observation units are designed for low-risk patients with normal biomarkers and non-diagnostic ECGs 1. This patient fails these criteria due to:

• Elevated troponin levels that exceed safe discharge thresholds 1, 4
• Active symptoms requiring more intensive monitoring than observation units typically provide 1
• Need for potential urgent interventions (catheterization) that require full hospital admission 1

The elevated troponin alone, regardless of other findings, mandates hospital admission for comprehensive evaluation and management of potential acute coronary syndrome or other serious cardiac pathology 1, 4.