What is the diagnosis for a patient presenting with chest pain and a normal electrocardiogram (EKG)?

From the Guidelines

Chest pain with a normal EKG should be evaluated by a healthcare provider with a comprehensive approach, including history, physical examination, and additional tests such as blood tests for cardiac enzymes, chest X-ray, stress test, or CT scan, as recommended by the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline 1.

Key Considerations

• A normal EKG does not exclude all potential causes of chest pain, and common non-cardiac causes include musculoskeletal problems, gastrointestinal issues, anxiety, or pulmonary conditions.
• The European Society Guidelines on unstable angina and non-Q wave infarction suggest that a chest X-ray should be taken in patients with chest pain and no obvious myocardial ischaemia to reveal e.g. pleuritis, pleuro-pneumonia, pneumothorax and intrathoracal tumours 1.
• The 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation recommend that patients with acute chest pain but no persistent ST-segment elevation should be differentiated based on their ECG changes, and those with high-risk features should undergo immediate coronary angiography and revascularization if appropriate 1.

Diagnostic Approach

• A careful history and clinical examination are essential in evaluating chest pain with a normal EKG.
• Additional tests such as blood tests for cardiac enzymes, chest X-ray, stress test, or CT scan may be recommended depending on the patient's symptoms and risk factors.
• The electrocardiographic-directed management of chest pain, as outlined in the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline, provides a framework for evaluating and diagnosing chest pain 1.

Management

• Patients with chest pain and a normal EKG should be managed based on their individual risk factors and symptoms.
• Those with high-risk features, such as severe continuing pain, ischaemic ECG changes, a positive troponin test, left ventricular failure, and other haemodynamic abnormalities, should be prioritized for admission to a coronary care unit or intensive care unit 1.
• The use of antithrombin treatment with heparin, platelet glycoprotein IIb/IIIa inhibitors, and aspirin combined with clopidogrel may be beneficial in high-risk patients, as recommended by the European Society Guidelines on unstable angina and non-Q wave infarction 1.

From the Research

Chest Pain with Normal EKG

• Chest pain is a common complaint encountered by Emergency Medicine physicians in the emergency department (ED) 2.
• A normal electrocardiogram (ECG) does not rule out the possibility of a coronary obstruction or myocardial infarction 3.
• Patients with chest pain and a normal ECG are at extremely low risk for acute myocardial infarction, but it is still important to consider other risk factors such as age, gender, hypertension, diabetes, smoking, and known coronary artery disease 4.

Diagnostic Approaches

• High-sensitivity troponins can be used to rapidly rule out myocardial infarction and confirm non-ST elevation MI (NSTEMI) 2, 5.
• A 12-lead ECG should be interpreted within 10 minutes of first medical contact to identify ST elevation myocardial infarction (STEMI) 6.
• Other diagnostic tests such as myocardial perfusion scintigraphy (SPECT and Gated-SPECT) can be used to assess myocardial perfusion and ventricular function 3.

Management and Disposition

• Patients with chest pain and a normal ECG may be considered for discharge without additional testing, but should be evaluated on a case-by-case basis using common risk stratification tools 2, 4.
• Patients with abnormal ECGs or other high-risk features should be admitted to the hospital for further evaluation and management 4, 6.
• The use of high-sensitivity troponins and other diagnostic tests can help to identify patients who are at low risk for acute coronary syndrome and can be safely discharged from the ED 2, 5.