What is the best course of action for a 60-year-old male with a history of gastric-related issues presenting with left-sided chest pain that is non-radiating?

Immediate Cardiac Evaluation is Mandatory Despite Gastric History

Despite this patient's history of gastric issues, acute coronary syndrome (ACS) must be ruled out immediately with a 12-lead ECG within 10 minutes and cardiac troponin measurement, as left-sided chest pain in a 60-year-old male carries significant cardiac risk regardless of other comorbidities. 1

Initial Risk Stratification

Immediate Actions Required

• Obtain a 12-lead ECG within 10 minutes to identify ST-elevation myocardial infarction (STEMI), ST-segment depression, or T-wave inversions that would indicate acute ischemia 1, 2
• Measure cardiac troponin immediately (preferably high-sensitivity troponin) and repeat at 3-6 hours if initial value is negative, as troponin elevation with chest pain indicates NSTEMI 1
• Assess vital signs including blood pressure in both arms, heart rate, oxygen saturation, and respiratory rate to identify hemodynamic instability or signs of aortic dissection 1, 3

Critical Historical Features to Obtain

The following characteristics help distinguish cardiac from non-cardiac causes:

High-risk cardiac features (require immediate ACS protocol):

• Pain duration >20 minutes at rest suggests possible myocardial infarction 1, 4
• Associated symptoms: diaphoresis, dyspnea, nausea, lightheadedness, or syncope significantly increase ACS likelihood 1
• Pain described as pressure, tightness, heaviness, squeezing, or crushing 1, 3
• Radiation to left arm, jaw, neck, shoulders, or back 1, 4
• Precipitation by exertion or emotional stress (though can occur at rest in ACS) 1, 3

Features suggesting non-cardiac etiology:

• Pain reproducible with palpation or chest wall pressure 1, 3
• Pain affected by breathing, turning, twisting, or bending 1, 3
• Sharp, stabbing quality localized to a very small area 3
• Fleeting pain lasting only seconds 3
• Pain that varies with food intake or is relieved by antacids 3, 5

Addressing the Gastric History

Why Gastric History Does Not Exclude Cardiac Disease

• GERD can coexist with ACS and accounts for only 10-30% of chest pain in patients with non-obstructive coronary disease 5, 6
• Nitroglycerin response is NOT diagnostic of cardiac ischemia, as esophageal spasm and GERD also respond to nitroglycerin—this is a common pitfall 1, 3
• Age and gender are critical risk factors: a 60-year-old male has substantially elevated baseline risk for coronary artery disease regardless of other diagnoses 1

When to Consider GERD as Primary Diagnosis

GERD becomes the likely diagnosis only after cardiac causes are definitively excluded with:

• Two negative troponin measurements at least 6 hours apart 1
• Non-ischemic ECG 1
• Absence of high-risk features 1

GERD-specific features include:

• Burning retrosternal pain related to meals 3, 5
• Pain worsening when bending forward or lying down 4, 3
• Relief with antacids 3, 5
• Associated belching or regurgitation 1, 3

Diagnostic Algorithm

Step 1: Immediate Assessment (First 10 Minutes)

• Obtain 12-lead ECG 1, 2
• Draw cardiac troponin 1
• Perform focused cardiovascular examination for murmurs, rales, signs of heart failure, or hemodynamic instability 1
• Assess for chest wall tenderness 1, 3

Step 2: ECG Interpretation

If ST-elevation or new left bundle branch block present:

• Activate STEMI protocol immediately 2
• Arrange for primary percutaneous coronary intervention (PPCI) or fibrinolysis 2

If ST-depression, T-wave inversions, or dynamic ECG changes:

• Initiate ACS protocol for NSTEMI/unstable angina 1
• Admit for cardiology evaluation 4
• Start dual antiplatelet therapy (aspirin 162-325 mg and P2Y12 inhibitor) and anticoagulation 2

If ECG is non-ischemic:

• Proceed to Step 3 1

Step 3: Troponin-Based Decision Making

If initial troponin is elevated:

• Diagnose NSTEMI 1
• Admit for ACS management 4

If initial troponin is negative:

• Repeat troponin at 3-6 hours 1
• Consider observation in chest pain unit or emergency department 1
• Assess additional risk factors: diabetes, hypertension, hyperlipidemia, smoking, family history of premature CAD 1

If serial troponins remain negative and ECG non-ischemic:

• Consider alternative diagnoses including GERD, musculoskeletal pain, or anxiety 1, 3, 5
• May initiate empiric high-dose proton pump inhibitor (PPI) trial for suspected GERD 5

Common Pitfalls to Avoid

• Never attribute chest pain to GERD without excluding cardiac causes first, especially in a 60-year-old male with cardiovascular risk factors 1, 5
• Do not rely on nitroglycerin or antacid response as diagnostic tests, as both cardiac and esophageal pain may respond 1, 3
• Do not delay cardiac workup based on history of gastric issues—these conditions frequently coexist 5, 6
• Avoid single troponin measurement—serial measurements at least 6 hours apart are required to exclude myocardial injury 1
• Do not discharge without objective testing if any uncertainty exists about cardiac etiology 1

Disposition Decision

Admit to hospital if:

• Elevated troponin or ischemic ECG changes 4
• Ongoing chest pain despite treatment 1
• Hemodynamic instability 1
• High-risk features present (age >75, diabetes, renal insufficiency, prior CAD) 1, 3

Observation unit or outpatient stress testing if:

• Serial troponins negative 1
• Non-ischemic ECG 1
• Pain resolved 1
• Low-to-intermediate risk profile 1

Consider GERD treatment only after:

• Complete cardiac evaluation is negative 5, 6
• High-dose PPI therapy (e.g., omeprazole 40 mg twice daily) for 1-2 weeks can serve as both diagnostic and therapeutic trial 5, 6