From the Guidelines
The next step for this 54-year-old male patient with persistent chest pain despite a negative cardiac catheterization would be to investigate non-coronary causes of chest pain. I would recommend a comprehensive evaluation including an echocardiogram to assess for structural heart disease, valvular abnormalities, or hypertrophic cardiomyopathy, as suggested by the American College of Physicians guidelines for evaluating primary care patients with chronic stable angina 1. Additionally, a 24-hour ambulatory blood pressure monitoring would be valuable given his hypertensive response during the stress test, to assess for potential hypertension-related causes of chest pain, in line with the recommendations for chronic chest pain evaluation 1. Gastrointestinal causes should be explored through an upper endoscopy to rule out conditions like gastroesophageal reflux disease or esophageal spasm, considering that nonischemic cardiac and extracardiac etiologies should be considered in the setting of nonexertional or atypical chest pain 1. Pulmonary evaluation with chest imaging and possibly pulmonary function tests would help exclude conditions like pulmonary hypertension or pleural disease. Musculoskeletal causes should also be considered, potentially through physical examination and appropriate imaging. In the interim, symptom management might include a trial of a proton pump inhibitor such as omeprazole 20mg daily for 2 weeks if GERD is suspected, or appropriate analgesics for musculoskeletal pain. The incomplete stress test (reaching only 72% of target heart rate) may have limited its diagnostic value, so consideration of an alternative stress modality like pharmacological stress testing might be warranted if cardiac symptoms remain concerning despite the negative catheterization, as part of a comprehensive approach to determine the presence, extent, and severity of myocardial ischemia 1. Key considerations in the evaluation and management of this patient include:
- Comprehensive assessment for non-coronary causes of chest pain
- Use of imaging studies to evaluate for structural heart disease and other potential causes
- Symptom management through pharmacological and other interventions
- Consideration of alternative stress testing modalities if initial testing is inconclusive.
From the Research
Next Steps for Patient with Persistent Chest Pain
- The patient's symptoms of chest pain, shortness of breath, and chest tightness with a hypertensive blood pressure response during the stress test, but no EKG changes, suggest a possible non-cardiac cause of chest pain 2.
- The negative cardiac catheterization result rules out coronary artery disease, but does not exclude other cardiac causes such as microvascular coronary disease or abnormal cardiac nociception 3.
- Further evaluation is needed to determine the cause of the patient's persistent chest pain, and coronary reactivity testing may be a useful tool to differentiate causes of chest pain 3.
- A thorough history and physical examination, as well as additional diagnostic tests such as measurement of troponin levels, chest radiograph, and electrocardiogram, may be necessary to determine the underlying cause of the patient's symptoms 2.
- The patient's failure to reach the target heart rate during the stress test (only 72%) may limit the interpretation of the results, and further testing may be needed to fully evaluate the patient's condition 3.