What is the likely diagnosis and management for an elderly female patient with a history of hypertension, presenting with waxing and waning lower chest pain radiating upwards, alleviated with Mylanta (famotidine), and a negative troponin (proponent) after 8 hours, with a normal ECG showing no significant ST elevation?

Likely Diagnosis: Gastroesophageal Reflux Disease (GERD)

This elderly female patient with chest pain relieved by Mylanta (antacid), negative troponin at 8 hours, and normal ECG most likely has gastroesophageal reflux disease rather than acute coronary syndrome. 1

Clinical Reasoning

Why This is NOT Acute Coronary Syndrome

• Normal ECG excludes high-risk ACS: The absence of ST-segment elevation, ST-segment depression >1mm, or new T-wave inversions makes unstable angina or myocardial infarction highly unlikely 1
• Negative troponin at 8 hours effectively rules out MI: Cardiac troponin T or I measured 8 hours after symptom onset has excellent negative predictive value for myocardial infarction 1
• Symptom relief with antacid is characteristic of GERD: Pain that responds to Mylanta (aluminum hydroxide/magnesium hydroxide) strongly suggests esophageal rather than cardiac origin 2, 3
• Waxing and waning pattern over one day: While ACS can present with intermittent symptoms, the combination with antacid relief and negative cardiac workup points away from cardiac etiology 1

Why This is Likely GERD

• GERD accounts for 50-60% of non-cardiac chest pain cases in patients presenting with chest symptoms after cardiac causes are excluded 3
• Lower chest/esophageal location with upward radiation is classic for esophageal reflux rather than the typical anginal pattern of substernal pain radiating to jaw/left arm 1
• Elderly patients with hypertension can have atypical presentations of both cardiac and non-cardiac chest pain, making the diagnostic workup essential 1

Important Caveats

Troponin Elevation in Hypertension Without ACS

Be aware that hypertensive patients can have detectable troponin elevations without acute coronary syndrome. 4, 5 However, in this case:

• The troponin is explicitly negative (not just mildly elevated) 1
• Chronic troponin elevation from hypertensive heart disease is typically stable, not acutely rising 5, 6
• Serial troponins showing no rise over 8 hours effectively excludes acute myocardial injury 1, 5

Don't Miss These Red Flags

Even with negative initial workup, immediately reconsider cardiac etiology if: 1

• New ECG changes develop (ST-segment shifts, T-wave inversions, new Q-waves)
• Troponin becomes positive on repeat testing
• Pain becomes more severe, prolonged (>20 minutes), or unresponsive to antacids
• New symptoms develop: diaphoresis, dyspnea, hemodynamic instability

Management Approach

Immediate Actions

1. Confirm the ECG is truly normal by comparing to prior tracings if available, as elderly patients may have baseline abnormalities 1
2. Document that pain is currently controlled with antacid therapy 2
3. Ensure no high-risk features are present: no ongoing chest pain, hemodynamically stable, no arrhythmias 1

Disposition and Follow-up

This patient can be managed as outpatient GERD with: 3

• Proton pump inhibitor therapy trial
• Dietary and lifestyle modifications
• Cardiology follow-up only if symptoms recur or change character
• Return precautions for any concerning cardiac symptoms

When to Reconsider Cardiac Workup

Pursue further cardiac evaluation if: 1

• Symptoms don't respond to GERD therapy within 2-4 weeks
• Pain pattern changes to become more exertional or severe
• New risk factors emerge or clinical status changes
• Patient develops typical anginal symptoms (exertional, relieved by rest)

Critical Pitfall to Avoid

Do not assume all chest pain in elderly hypertensive patients is cardiac. 3 While maintaining appropriate vigilance for ACS, recognize that gastroesophageal causes are extremely common and the negative cardiac workup (normal ECG, negative troponin at 8 hours) combined with antacid response makes GERD the most likely diagnosis. 1, 3

However, maintain a low threshold for repeat evaluation if symptoms evolve, as elderly patients can have atypical presentations of ACS. 1