What is the best course of action for a 22-year-old athlete presenting with chest pain and heaviness, malaise, and a normal electrocardiogram (ECG)?

Immediate Evaluation and Management of Chest Pain in a Young Athlete

This 22-year-old athlete with chest pain, heaviness, and malaise requires immediate cardiac evaluation with ECG (already done), high-sensitivity cardiac troponin, and echocardiography to exclude myocarditis and other serious cardiac pathology before any return to training. 1

Critical Initial Assessment

Symptoms Requiring Urgent Workup

• Chest pain with heaviness during or after exertion in an athlete is a red flag symptom that mandates complete cardiac evaluation regardless of normal ECG 1
• The combination of chest pain and malaise raises specific concern for myocarditis, which can present with subtle symptoms and normal or near-normal ECG findings 1
• A normal ECG does not exclude serious cardiac pathology—only 50% of acute myocardial infarctions show diagnostic ECG changes initially, and myocarditis frequently presents with nonspecific or normal ECG 2, 1

Required Diagnostic Triad

The athlete needs immediate "triad testing" consisting of: 1

• 12-lead ECG (completed—review for subtle abnormalities including T-wave inversions, ST changes, or PR depression)
• High-sensitivity cardiac troponin (hs-cTn) - must be drawn at least 24-48 hours after last exercise to avoid false elevation from exertion 1
• Transthoracic echocardiography to assess for structural abnormalities, wall motion abnormalities, ventricular dysfunction, or pericardial effusion 1

Specific Concerns to Exclude

Myocarditis/Pericarditis

• Myocarditis is a critical diagnosis to exclude as it represents a substrate for sudden cardiac death during athletic activity 1
• Clinical presentation may be subtle: recent viral illness, chest pain, malaise, and decreased performance with only mildly elevated inflammatory markers 1
• ECG findings are often nonspecific; isolated or complex ventricular arrhythmias on exercise testing may be the first manifestation 1
• Echocardiography may show regional wall motion abnormalities, mild LV dysfunction, or pericardial effusion 1

Anomalous Coronary Arteries

• Accounts for approximately 17% of sudden cardiac deaths in competitive athletes 1
• ECG is unreliable for screening—50% of sudden deaths from coronary anomalies were first events without prior symptoms 1
• Echocardiography should include careful attempts to identify coronary artery origins 1

Other Cardiac Pathology

• Cardiomyopathies (hypertrophic, dilated, arrhythmogenic) 1
• Coronary vasospasm 3
• Valvular abnormalities 1

Management Algorithm

If Triad Testing is Normal

• Graded return to play protocol over 7-10 days with close monitoring for recurrent symptoms 1
• Athlete should report any recurrence of chest pain, palpitations, syncope, or excessive dyspnea 1
• Consider stress testing if clinical suspicion remains despite normal initial workup 1

If Any Abnormality Detected

• Complete restriction from all athletic activity until diagnosis established 1
• Cardiac MRI is the gold standard for diagnosing myocarditis (showing late gadolinium enhancement, elevated T2 signal, increased T1/ECV) 1
• If myocarditis confirmed: minimum 3-6 months restriction from exercise, with repeat imaging before clearance 1
• Presence of late gadolinium enhancement on CMR is a strong predictor of adverse events and requires extended surveillance 1

If Symptoms Persist Despite Normal Testing

• Long-term ambulatory rhythm monitoring (implantable loop recorder) is reasonable if clinical uncertainty remains 1
• Consider advanced imaging with cardiac MRI even if initial echocardiography normal, as ECG abnormalities may represent early cardiomyopathy before structural changes evident 1
• Athletes with repolarization abnormalities should have annual imaging surveillance even without structural disease initially 1

Critical Pitfalls to Avoid

• Never clear an athlete with exertional chest pain based on normal ECG alone—the ECG has poor sensitivity for many life-threatening conditions 1, 2
• Do not obtain troponin within 24-48 hours of exercise—strenuous exercise causes transient troponin elevation that peaks and resolves by 24-48 hours, which differs from pathological release 1
• Do not dismiss "atypical" or vague chest symptoms in young athletes—50% of sudden deaths from coronary anomalies had no prior symptoms 1
• Do not attribute symptoms to musculoskeletal causes without excluding cardiac pathology first 4, 5
• Malaise combined with chest pain increases concern for systemic process like myocarditis rather than isolated musculoskeletal pain 1

Immediate Action Required

This athlete should be restricted from all training and competition immediately until the diagnostic triad is completed and results reviewed. 1 The presence of cardiopulmonary symptoms (chest pain/heaviness) with malaise mandates this evaluation before any return to athletic activity, regardless of the normal ECG. 1