What is the appropriate management for a patient with intermittent left-sided chest pain that occurs every 2 minutes and lasts 5-10 seconds?

Management of Intermittent Left-Sided Chest Pain Lasting 5-10 Seconds

This presentation is highly unlikely to represent acute coronary syndrome and does not require emergency intervention, but an ECG must still be obtained to definitively exclude cardiac pathology before attributing symptoms to a benign musculoskeletal or anxiety-related cause. 1

Why This is NOT Acute Coronary Syndrome

The clinical characteristics strongly argue against myocardial ischemia:

• Fleeting chest pain lasting only seconds is unlikely to be related to ischemic heart disease, as anginal symptoms gradually build over minutes, not seconds 1
• Typical anginal pain lasts at least 20 minutes and does not respond to nitroglycerin in the setting of acute myocardial infarction 2
• Sharp, stabbing pain that is intermittent and brief suggests musculoskeletal etiology rather than cardiac ischemia 1
• The absence of associated symptoms (diaphoresis, dyspnea, nausea, radiation to arm/jaw/neck) significantly reduces the likelihood of acute coronary syndrome 1

Mandatory Initial Evaluation

Despite the low-risk presentation, cardiac causes must be systematically excluded:

• Obtain a 12-lead ECG immediately, even in the outpatient setting 1, 3
• If an ECG cannot be obtained and interpreted within 10 minutes in the office, transfer the patient to the emergency department by EMS 3
• The ECG serves to exclude ST-segment elevation, new bundle branch block, and other ischemic changes 1
• Even with a normal ECG, 5-40% of patients with acute myocardial infarction can present with normal initial tracings, making clinical judgment essential 4

Most Likely Diagnosis: Musculoskeletal Pain

The pattern described is classic for costochondritis or chest wall pain:

• Musculoskeletal pain is the most prevalent diagnosis in patients with chest pain, accounting for the majority of cases 3
• Positional chest pain or pain affected by breathing, turning, twisting, or bending suggests musculoskeletal etiology 1
• Pain that is well-localized to a specific area and reproducible with palpation confirms musculoskeletal origin 1, 3
• Conservative management with NSAIDs is recommended for costochondritis 1

Alternative Consideration: Anxiety-Related Chest Pain

If musculoskeletal examination is negative, consider psychological etiology:

• Noncardiac chest pain has a close association with anxiety, panic disorder, and somatoform disorders 4
• The intermittent nature occurring every 2 minutes could represent hyperventilation or anxiety-driven sympathetic activation 4
• In low-risk chest pain patients without cardiac disease, anxiety disorders exceed coronary artery disease by almost 10-fold 4

Management Algorithm

If ECG is normal and physical examination reveals chest wall tenderness:

• Provide reassurance that cardiac causes have been excluded 1
• Prescribe NSAIDs for symptomatic relief 1
• Advise return precautions for chest pain lasting >20 minutes, associated with diaphoresis, dyspnea, or radiation 4

If ECG is normal but no musculoskeletal findings:

• Consider anxiety or panic disorder as the underlying cause 4
• Provide definitive reassurance once cardiac workup is negative 4
• Refer for cognitive-behavioral therapy if anxiety symptoms are present, which shows a 32% reduction in chest pain frequency over 3 months 4

If ECG shows any ischemic changes (ST depression, T-wave inversions, new Q waves):

• Transfer immediately to the emergency department by EMS 1, 3
• Administer aspirin 250-500 mg immediately 2
• Consider sublingual nitroglycerin if no contraindications 5

Critical Pitfalls to Avoid

• Do not skip ECG testing based solely on the brief duration of symptoms, as women and elderly patients may present with atypical symptoms 1, 4
• Avoid extensive repetitive cardiac testing once initial workup is definitively negative, as this reinforces illness behavior 4
• Do not assume chronicity equals safety—stable patterns can progress to acute coronary syndrome 3
• Never rely on physical examination alone to diagnose or exclude myocardial infarction, as it contributes almost nothing unless shock is present 3