What could be causing sudden onset chest pain in a patient with a history of myocardial infarction (MI) in the apex of the heart, recent cardiac catheterization lab evaluation without stenting, and anxiety, and when should they seek emergency care?

Potential Causes of Brief Chest Pain in This Patient

This patient's brief 10-30 second chest pain episode is most likely non-cardiac in origin given its extremely short duration, but the history of prior MI and recent cardiac catheterization warrants careful consideration of both cardiac and non-cardiac causes. 1

Most Likely Causes

Non-Cardiac Causes (Most Probable)

• Musculoskeletal pain (costochondritis): Brief, sharp chest pain lasting seconds is characteristic of chest wall inflammation or muscle strain, particularly if reproducible with palpation 2
• Anxiety/panic disorder: Given the documented anxiety history, this can manifest as brief chest discomfort, though this should only be considered after excluding organic causes 2
• Gastroesophageal reflux: Can cause brief episodes of chest discomfort, though typically lasts longer than 30 seconds 2

Cardiac Causes (Less Likely But Must Consider)

• Microvascular angina: Can occur with normal epicardial coronaries (as demonstrated by recent catheterization showing no need for stenting), more common in patients with prior MI 2
• Pericarditis: May present with brief, sharp chest pain, particularly if there was transient friction rub that was missed 2
• Unstable angina: While typical anginal episodes last longer than 20 minutes at rest, brief episodes can occur, especially in patients with known coronary disease 1

Critical Point About Duration

Pain lasting only 10-30 seconds is atypical for acute coronary syndrome, which typically presents with discomfort lasting at least several minutes and often exceeding 20 minutes at rest. 1 However, the patient's history of apical MI means complete dismissal of cardiac causes would be premature.

When to Seek Emergency Care Immediately (Call 9-1-1)

The patient should call 9-1-1 immediately rather than self-transport if any of the following occur: 1

High-Risk Features Requiring Immediate EMS Activation

• Chest pain or pressure lasting more than 5 minutes despite rest or after one nitroglycerin dose (if prescribed) 2
• Chest pain lasting more than 20 minutes at rest, regardless of severity 1
• Associated symptoms with chest discomfort: shortness of breath, diaphoresis (sweating), nausea, vomiting, pain radiating to arm(s), jaw, neck, or back 1, 3
• Pain described as pressure, tightness, heaviness, squeezing, or crushing rather than sharp or stabbing 4
• Lightheadedness, syncope (fainting), or feeling of impending doom 4
• Abnormal heart beating or palpitations with chest discomfort 3
• Symptoms that are increasing in intensity or frequency (crescendo pattern) 1
• Hemodynamic instability: feeling faint, cold sweats, or extreme weakness 4

Action Plan While Waiting for EMS

• Take aspirin immediately: Chew and swallow one adult 325-mg tablet or 2-4 low-dose 81-mg tablets if no allergy or recent bleeding 1
• Use prescribed nitroglycerin: One tablet sublingually, repeat every 5 minutes for up to 3 doses total. If pain persists after first dose, call 9-1-1 immediately 1
• Do not drive yourself to the hospital - always call EMS for suspected cardiac symptoms 1

When Urgent (Not Emergency) Evaluation Is Needed

Contact your physician or go to the emergency department (can be driven by someone else) within hours if: 2

• Recurrent brief episodes of chest pain occurring multiple times per day
• New pattern of chest pain different from previous episodes
• Chest pain with exertion that resolves with rest (even if brief)
• Increasing frequency of episodes over days to weeks

When Outpatient Follow-Up Is Appropriate

Schedule an appointment with your primary care physician or cardiologist within 72 hours if: 1, 2

• Single, isolated episode of very brief (10-30 seconds) chest pain that has completely resolved
• Pain is reproducible with chest wall palpation or movement
• Pain is sharp and positional (worse with breathing or position changes)
• No associated cardiac symptoms (no sweating, shortness of breath, radiation, nausea)

Important Caveats and Pitfalls

Do not rely on nitroglycerin response as a diagnostic test - other conditions like esophageal spasm may also respond to nitroglycerin 2

Do not assume a normal recent catheterization excludes all cardiac causes - microvascular angina can occur with normal epicardial arteries, and new acute events can develop even shortly after catheterization 2

Atypical presentations are common - patients with prior MI, diabetes, elderly patients, and women may present with fatigue, dyspnea, or vague discomfort rather than classic chest pain 2

Brief pain does not automatically mean benign - while 10-30 second episodes are less typical for ACS, the patient's cardiac history mandates a lower threshold for evaluation if symptoms recur or change 1, 4

Recommended Next Steps

• Palpate the chest wall to assess for reproducible tenderness suggesting musculoskeletal cause 2
• Ensure stress testing was completed during or after the recent catheterization, as this is essential for risk stratification 2
• Verify cardiac medications are optimized, including aspirin, beta-blockers, and anti-ischemic therapy given the prior MI history 2
• Consider anxiety management if organic causes are excluded, but only after thorough cardiac evaluation 2
• Maintain clear instructions on when to seek emergency care, as patient delay is the longest component of treatment delay in ACS 1