Management of Mid-Sternal Chest Pain for 2 Weeks
For a patient with mid-sternal chest pain persisting for 2 weeks, obtain an ECG immediately in the office setting, and if this cannot be done within 10 minutes or if the ECG shows any ischemic changes, transfer the patient to the emergency department by EMS for cardiac troponin testing and comprehensive evaluation. 1
Initial Assessment and Risk Stratification
The 2-week duration suggests this is not an acute presentation requiring immediate ambulance transfer, but cardiac causes must still be systematically excluded before considering non-cardiac etiologies 1.
Key Historical Features to Obtain
Features suggesting cardiac origin (requiring urgent evaluation): 1
- Pain that interrupts normal daily activities
- Associated cold sweats, nausea, vomiting, or anxiety/fear
- Radiation pattern typical of angina (to arm, jaw, or back)
- Exertional component or relief with rest
Features suggesting non-cardiac origin (lower risk): 1
- Pain that varies with respiration, body position, or food intake
- Well-localized pain on the chest wall
- Pain reproduced by palpation of the chest wall, breathing, turning, twisting, or bending
- Pain generated from multiple sites
Immediate Office-Based Actions
The ECG is absolutely critical and must be obtained within 10 minutes: 1
- If you cannot obtain and interpret an ECG within 10 minutes in your office, immediately transfer the patient to the ED by EMS
- Do not delay transfer to perform troponin testing in the office setting—this is harmful 1
- Personal automobile transport should be avoided; use EMS for any suspected acute coronary syndrome 1
Decision Algorithm Based on ECG Findings
If ECG Shows ST-Elevation, New ST Depression, or New LBBB:
- Immediate EMS transfer to ED for STEMI/NSTE-ACS protocol 1
- Administer aspirin 250-500 mg (chewable or water-soluble) immediately 1
- Consider sublingual nitroglycerin if no bradycardia or hypotension present 1
If ECG is Normal or Nondiagnostic:
The likelihood of angina still varies significantly by age and sex: 1
- Men age 30-39: 67% probability with typical angina symptoms
- Men age 60-69: 94% probability with typical angina symptoms
- Women age 30-39: 26% probability with typical angina symptoms
- Women age 60-69: 90% probability with typical angina symptoms
For patients with typical angina history despite normal ECG: 1
- Transfer to ED for cardiac troponin testing (at 0 and 2 hours with high-sensitivity assays) 1
- The odds for coronary artery disease remain high with typical symptoms regardless of initial ECG 1
For patients with atypical features and normal ECG: 1
- Consider outpatient stress testing or coronary CT angiography
- Arrange follow-up within 1-2 weeks 1
- If no follow-up available, consider further testing before discharge 1
Common Non-Cardiac Causes (After Cardiac Exclusion)
Musculoskeletal pain is the most prevalent diagnosis (accounting for the majority of chest pain cases, while cardiac problems account for only 10-34% of episodes): 1
- Reproducible tenderness on chest wall palpation
- Pain affected by position, breathing, or movement
- Costochondral junction tenderness
Other considerations: 1
- Gastroesophageal reflux disease
- Anxiety or panic disorder (look for trembling, dizziness, paresthesias, chills/hot flushes)
- Pericarditis (if ECG shows diffuse ST elevation)
Critical Pitfalls to Avoid
Never delay transfer for troponin testing in the office—this causes harmful delays in diagnosis and treatment 1
Do not rely on physical examination alone—it contributes almost nothing to diagnosing myocardial infarction unless shock is present 1
Do not assume chronicity equals safety—stable angina can progress to acute coronary syndrome, and referral to cardiology is indicated when symptoms don't respond to usual pharmacotherapy 1
Serial ECGs are essential if symptoms persist—repeat the ECG if clinical suspicion remains high despite initial normal findings 1
Age and sex significantly affect pre-test probability—use this to guide your threshold for cardiac workup 1