What is the best course of action for a patient with a history of chest pain that occurred 2 days ago and was relieved by nitroglycerin (nitroglycerin), considering potential cardiac and non-cardiac causes, including gastroesophageal reflux disease (GERD)?

Management of Chest Pain That Occurred 2 Days Ago and Was Relieved by Nitroglycerin

You must urgently evaluate this patient with a 12-lead ECG and serial troponin measurements regardless of current symptom status, as nitroglycerin response does not reliably distinguish cardiac from non-cardiac chest pain and cannot exclude acute coronary syndrome. 1, 2, 3

Critical Initial Actions

Immediate Cardiac Evaluation Required

• Obtain a 12-lead ECG within 10 minutes to assess for ST-segment elevation, new Q-waves, T-wave inversions, or ST-segment depression suggesting ischemia, and compare with any prior ECGs if available 1

• Draw serial cardiac biomarkers immediately (troponin and CK-MB), as patients presenting within 2 days of symptom onset may still have elevated markers indicating myocardial infarction 4, 1

• Do not rely on nitroglycerin response as a diagnostic tool - research demonstrates that 41% of patients WITHOUT active coronary artery disease had chest pain relief with nitroglycerin, while only 35% of patients WITH active coronary artery disease experienced relief (no significant difference, p>0.2) 3

• The European Society of Cardiology explicitly warns that nitroglycerin response "can be misleading" and should not be used as a diagnostic maneuver 1

Risk Stratification Based on Findings

If ST-Elevation or New LBBB Present

• Diagnose STEMI and activate emergency reperfusion protocol immediately, regardless of current symptom status 1
• Time-sensitive intervention is critical even 2 days post-symptom onset, though benefit decreases with time 4

If ST-Depression, T-Wave Inversions, or Troponin Elevation Present

• Diagnose NSTEMI/unstable angina and admit for cardiology evaluation 1
• Consider early angiography within 24 hours for patients with ongoing ischemic symptoms or high-risk features 4, 1

If ECG and Initial Troponins Are Normal

• The patient still requires observation with serial troponins at 3-6 hours to exclude myocardial infarction, as a single normal troponin does not rule out acute coronary syndrome 4, 1

• Serial sampling of cardiac markers ideally within 8-12 hours of symptom onset is recommended to definitively exclude MI 4

• Consider stress testing or coronary CT angiography before discharge if biomarkers remain negative 1

Important Clinical Pitfalls

Symptom Resolution Does Not Exclude Cardiac Disease

• Complete symptom resolution does not exclude ongoing acute coronary syndrome - silent ischemia and intermittent coronary occlusion can present this way 1

• Low-risk patients without persistent ischemic pain, CHF, hypotension, heart block, or hemodynamically compromising ventricular arrhythmias can be safely transferred out of the CCU within 24-36 hours if they remain asymptomatic, but initial evaluation is still mandatory 4

Atypical Presentations Are Common

• Elderly patients, women, and diabetics may present with atypical symptoms such as dyspnea, nausea, fatigue, or syncope rather than classic chest pain 4, 1

• These atypical presentations should not delay cardiac evaluation 1

Non-Cardiac Causes: GERD Consideration

When to Consider GERD

• Only after cardiac source has been definitively excluded through appropriate testing (ECG, serial troponins, and potentially stress testing or angiography) 5, 6

• GERD is the most common gastrointestinal cause of non-cardiac chest pain and may be the cause in 10-50% of patients with chest pain after cardiac disease is excluded 5, 6

Diagnostic Approach for GERD

• The PPI test is the diagnostic/therapeutic approach of choice - high-dose proton pump inhibitor therapy for one week has excellent sensitivity/specificity and provides economic savings by reducing unnecessary diagnostic procedures 5, 7

• Barium studies, endoscopy, and esophageal manometry have little value in diagnosing GERD-induced chest pain 7

• Patients with confirmed GERD-related chest pain require long-term PPI therapy, commonly double the standard dose 5

Patient Education and Follow-Up

• Educate the patient to seek immediate medical attention if chest pain recurs or worsens, and instruct not to take more than 3 nitroglycerin doses (one every 5 minutes) before seeking emergency care 8

• If pain persists after 3 tablets in a 15-minute period, or if the pain is different than typically experienced, the patient should call 9-1-1 or seek emergency help immediately 9, 8

• Document the exact nature of the chest pain including location, radiation, duration, associated symptoms, and response to nitroglycerin 1