What to do for a patient with intermittent sharp left-sided chest pain that lasted 20 minutes and resolved spontaneously, with a normal electrocardiogram (ECG) and negative troponin?

Management of Resolved Chest Pain with Normal ECG and Negative Troponin

This patient requires serial troponin measurements and repeat ECG monitoring, as a single negative troponin and normal ECG do not exclude acute coronary syndrome (ACS), particularly given the recent symptom onset. 1

Immediate Next Steps

Serial Cardiac Biomarker Testing

• Obtain a second high-sensitivity troponin measurement at 3-6 hours from the initial draw (or 6-12 hours if using conventional troponin assays), as troponin rises rapidly but may not be detectable immediately after symptom onset 1
• A single negative troponin is insufficient to rule out myocardial infarction, especially when symptoms occurred within hours of presentation 1
• High-sensitivity troponin is the preferred biomarker because it enables more rapid detection or exclusion of myocardial injury 1

ECG Monitoring Strategy

• Perform serial ECGs, especially if symptoms recur, clinical condition changes, or troponin becomes positive 1
• A normal initial ECG does not exclude ACS—up to 6% of patients with evolving ACS are discharged from the ED with a normal ECG 1, 2
• Repeat ECG should be obtained with any recurrence of chest pain or change in clinical status 1, 3

Risk Stratification Considerations

Clinical Features to Assess

• Evaluate the character of the pain: Sharp, intermittent chest pain that resolved spontaneously is less typical for ACS but does not exclude it 4
• Age, sex, cardiovascular risk factors, and pain characteristics predict the likelihood of coronary artery disease 4
• The 20-minute duration and spontaneous resolution are somewhat reassuring but require complete evaluation 5

High-Risk Features to Monitor For

• Recurrent or persistent chest pain 2
• Dynamic ST-segment changes on repeat ECG 2, 3
• Rising troponin pattern on serial measurements 1, 6
• Hemodynamic instability or new arrhythmias 2

Observation Protocol

During the Monitoring Period

• Continue cardiac monitoring until ACS is definitively ruled out 3
• Obtain repeat ECG immediately if chest pain recurs 1, 2
• Monitor vital signs for hemodynamic changes 2
• The second troponin measurement is critical—if it rises or becomes positive, this indicates acute myocardial injury requiring urgent intervention 1, 6

If Serial Testing Remains Negative

• An undetectable high-sensitivity troponin (<5 ng/L) combined with a non-ischemic ECG has a 99.8% negative predictive value for MI within 30 days 7
• If both serial troponins are negative and ECGs remain normal without symptom recurrence, the patient can be considered for discharge with outpatient follow-up 7
• Consider stress testing or coronary CT angiography for further risk stratification in intermediate-risk patients before discharge 4

Critical Pitfalls to Avoid

Common Errors in Management

• Do not be falsely reassured by stable vital signs and a single normal ECG—these findings do not exclude evolving ACS 1, 2
• Never discharge a patient based solely on a single troponin measurement, especially if drawn within 3-6 hours of symptom onset 1
• Left ventricular hypertrophy, bundle branch blocks, and ventricular pacing may mask signs of ischemia on ECG 1

Alternative Diagnoses to Consider

• If serial troponins remain negative and ECGs are consistently normal, consider non-cardiac causes: chest wall pain, gastroesophageal reflux disease, anxiety, pericarditis, or pulmonary causes 4, 8
• Not all chest pain with elevated troponin is due to ACS—alternative diagnoses like aortic dissection, pulmonary embolism, or myocarditis must be considered if troponin rises 8

Disposition Decision

If Second Troponin is Positive or ECG Changes Develop

• Initiate dual antiplatelet therapy (aspirin plus P2Y12 inhibitor), anticoagulation, and arrange for coronary angiography 2, 6
• Elevated troponin identifies high-risk patients requiring invasive evaluation during the initial hospitalization 6

If Serial Testing Confirms Low Risk

• Discharge with cardiology follow-up and consideration for outpatient stress testing 4, 7
• Provide clear return precautions for recurrent chest pain 4