From the Guidelines
An echocardiogram is not automatically required for all patients presenting with chest pain who have normal troponin levels, but it should be considered based on clinical suspicion of cardiac etiology, risk factors, and other findings, as recommended by the 2020 ESC guidelines 1. When evaluating a patient with chest pain and normal troponin levels, the decision to order an echocardiogram should be guided by clinical judgment and risk stratification.
- If the chest pain is suspected to be cardiac in origin despite normal troponins, an echo may be appropriate to evaluate for structural heart disease, wall motion abnormalities, valvular issues, or pericardial disease that could explain symptoms.
- For patients with low-risk features, reassuring ECG, normal troponins, and an alternative explanation for chest pain, an echo might not be necessary. However, if there are concerning features such as new murmurs, ECG changes, heart failure symptoms, or if the patient has significant cardiovascular risk factors, an echocardiogram would provide valuable diagnostic information, as suggested by the European Association of Cardiovascular Imaging recommendations 1. The echo can detect regional wall motion abnormalities that might indicate coronary artery disease even when troponins are normal, as well as other cardiac conditions that could cause chest pain such as hypertrophic cardiomyopathy, pericarditis, or aortic pathology, as noted in the 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation 1. In patients with no recurrence of chest pain, normal ECG findings, and normal levels of cardiac troponin, but still with a suspected acute coronary syndrome, a non-invasive stress test or coronary computed tomography angiography (CCTA) is recommended before deciding on an invasive approach, as stated in the 2020 ESC guidelines 1.
From the Research
Ordering Echo for Chest Pain with Normal Troponin
- When a patient presents with chest pain but has a normal troponin level, the need to order an echo (echocardiogram) depends on several factors, including the patient's medical history, the presence of other symptoms, and the results of other diagnostic tests 2, 3.
- A normal troponin level does not necessarily rule out cardiac causes of chest pain, as some conditions, such as myopericarditis, may not cause significant troponin elevation 2.
- In patients with acute chest pain and normal high-sensitivity cardiac troponin levels, additional cardiac investigations, such as an exercise test, may be necessary to discriminate between patients with unstable angina pectoris and those with a non-cardiac cause of chest pain 3.
- However, in the large majority of patients with normal high-sensitivity cardiac troponin levels, further cardiac imaging, including echo, may not be indicated if the medical history does not raise suspicion of angina pectoris and an exercise test shows normal results 3.
- The use of echo and other cardiac imaging tests, such as coronary angiography, may be influenced by the results of troponin testing, even in patients without acute myocardial infarction 4.
- In patients with chest pain but no myocardial infarction, high-sensitivity cardiac troponin T levels may be elevated due to various factors, including age, sex, and renal function, rather than cardiac disease 5.
Considerations for Ordering Echo
- The decision to order an echo should be based on a thorough evaluation of the patient's clinical presentation, medical history, and the results of other diagnostic tests 2, 6.
- In patients with chest pain and normal troponin levels, the presence of other symptoms, such as shortness of breath or palpitations, may indicate the need for further cardiac evaluation, including echo 2.
- The use of echo and other cardiac imaging tests should be guided by clinical judgment and the results of other diagnostic tests, rather than relying solely on troponin levels 3, 4.