What is the best course of action for a patient with left chest pain after consuming caffeine, with a normal electrocardiogram (EKG)?

Management of Left Chest Pain After Caffeine Use with Normal ECG

Despite a normal initial ECG, this patient requires serial cardiac troponin measurements and repeat ECGs, as a single normal ECG is insufficient to exclude acute coronary syndrome (ACS), particularly given the temporal relationship with caffeine consumption which can trigger coronary vasospasm or thrombotic events. 1

Immediate Diagnostic Workup

Serial ECG Monitoring

• Perform repeat ECGs immediately if chest pain persists, recurs, or if the clinical condition changes, as up to 6% of patients with evolving ACS are inappropriately discharged with a normal initial ECG 1, 2, 3
• Continue serial ECGs until cardiac troponin results and risk stratification are complete, as left ventricular hypertrophy, bundle branch blocks, and ventricular pacing can mask ischemic changes 1, 2
• Consider supplemental posterior leads (V7-V9) if clinical suspicion remains intermediate-to-high, as left circumflex or right coronary artery occlusions causing posterior wall ischemia are often "electrically silent" on standard 12-lead ECG 1, 2

Cardiac Biomarkers

• Measure high-sensitivity cardiac troponin immediately if not already obtained, as troponin is the most sensitive test for myocardial injury 1, 3, 4
• Repeat troponin measurement at 6-12 hours from symptom onset to detect rising or falling patterns that indicate myocardial injury 3, 4
• A single troponin measurement drawn less than 6 hours from symptom onset may miss myocardial injury and should never be used alone to exclude ACS 3, 4

Additional Testing

• Obtain a chest radiograph to evaluate for other potential cardiac, pulmonary, and thoracic causes of chest pain 1

Caffeine-Specific Considerations

Documented Cardiovascular Risks

• Excessive caffeine consumption, particularly from energy drinks, has been associated with acute myocardial infarction, coronary vasospasm, and thrombotic events in young adults without traditional cardiovascular risk factors 5, 6, 7
• Energy drinks containing caffeine, taurine, and other stimulants can cause coronary artery vasoconstriction, hypercoagulable states, and increased platelet aggregation 5, 7, 8
• Case reports document STEMI and coronary thrombosis occurring within hours of consuming large quantities of caffeinated beverages in patients as young as 17-28 years old 5, 6, 7

Clinical Context

• While moderate caffeine intake (regular coffee/tea) does not typically cause arrhythmias or ACS in most patients, energy drinks represent a distinct and higher-risk category due to their concentrated stimulant content 9
• The temporal relationship between caffeine consumption and symptom onset should raise clinical suspicion for caffeine-induced coronary vasospasm or thrombosis 5, 7

Risk Stratification and Disposition

High-Risk Features Requiring Admission

• Admit to an inpatient unit with continuous cardiac monitoring if any of the following are present: recurrent or persistent chest pain, dynamic ECG changes, positive second troponin measurement, hemodynamic instability, or elevated initial troponin 3, 4
• Consider urgent coronary angiography if recurrent ischemia, elevated troponin, or hemodynamic instability develops 3, 4

Medical Management if ACS Suspected

• Initiate aspirin 75-325 mg daily immediately if ACS is suspected and no contraindications exist 3, 4
• Administer low molecular weight heparin or unfractionated heparin 3, 4
• Use beta-blockers and oral or intravenous nitrates for persistent or recurrent chest pain 4

Low-Risk Disposition

• If serial troponins remain negative, ECGs show no dynamic changes, and symptoms resolve, the patient may be considered for discharge with outpatient follow-up within 72 hours 3, 4
• However, never rely on a single normal ECG to discharge a patient with ongoing chest pain or high clinical suspicion for ACS, as this is the most dangerous error in chest pain evaluation 2

Critical Pitfalls to Avoid

• Do not assume the normal ECG excludes cardiac pathology—one-third of patients with acute chest pain have a normal admission ECG, yet 5-40% of these patients have evolving myocardial infarction 4
• Do not delay repeat ECGs waiting for scheduled intervals if symptoms change; symptom-driven timing takes priority 2
• Do not discharge without serial troponin measurements, as a single negative troponin drawn early may miss evolving myocardial injury 3, 4
• Specifically counsel this patient to avoid energy drinks and excessive caffeine consumption, given the documented association with acute coronary events in young adults 5, 6, 7, 8

Follow-Up Recommendations

• Ensure outpatient cardiology follow-up within 72 hours if discharged, with clear instructions to return immediately for recurrent chest pain 3
• Provide explicit counseling about limiting or avoiding energy drinks and excessive caffeine intake, as this represents a modifiable risk factor for future cardiovascular events 5, 9, 8