In a 19‑year‑old with constant mild‑to‑moderate sharp central chest pain worsened by stress, onset three weeks after a large ibuprofen overdose, and with normal physical examination, vital signs, and resting 12‑lead electrocardiogram, is further diagnostic work‑up for chest pain required?

No Further Cardiac Work-Up Is Needed—Focus on Psychological Evaluation and Possible Gastrointestinal Causes

This 19-year-old meets criteria for low cardiac risk and requires no additional cardiac testing; instead, referral to cognitive-behavioral therapy for likely anxiety-related chest pain is the appropriate next step. 1, 2

Why This Patient Is Low Cardiac Risk

Your patient fulfills all criteria for low-risk chest pain that does not warrant further cardiac investigation:

• Age 19 with zero cardiac risk factors (no smoking, hypertension, diabetes, hyperlipidemia, or family history of early heart disease) 2, 3
• Normal resting 12-lead ECG (no ST-segment changes, T-wave inversions, or Q waves) 1, 2
• Nonexertional pain that is sharp, constant, and worsens with stress—all features that make ischemia highly unlikely 2, 3
• No radiation, no associated symptoms (no dyspnea, diaphoresis, nausea, syncope) that would suggest acute coronary syndrome 2
• Normal physical examination and stable vital signs 2

The 2021 ACC/AHA Chest Pain Guidelines explicitly state that patients with recurrent similar presentations and negative cardiac workup do not require repeated cardiac testing. 1

The Temporal Relationship to Ibuprofen Overdose Matters

Three weeks post-ingestion of 10.4 grams of ibuprofen raises two important considerations:

Medication-Induced Esophageal Injury

• NSAIDs, including ibuprofen, are known causes of pill esophagitis and can produce persistent chest discomfort 4
• However, your patient lacks the classic alarm symptoms of medication-induced esophageal injury (severe odynophagia, dysphagia, or weight loss) 4
• If the patient develops difficulty swallowing or worsening pain with eating, urgent upper endoscopy within 2 weeks would be indicated 4

Psychological Sequelae of Suicide Attempt

• The suicide attempt itself is the critical context here—this represents significant psychological distress 1
• Chest pain that is "worse during stress" in a patient with recent suicide attempt strongly suggests anxiety or panic disorder as the primary etiology 1, 2
• The 2021 ACC/AHA Guidelines give a Class IIa recommendation for referral to cognitive-behavioral therapy in patients with recurrent chest pain and negative cardiac workup 1

What You Should Do Instead of More Cardiac Testing

Immediate Actions:

• Screen for ongoing suicidal ideation and ensure psychiatric follow-up is in place (this is the most important intervention for morbidity and mortality) 1
• Consider a trial of proton pump inhibitor therapy if gastroesophageal reflux disease is suspected, as GERD can present as sharp chest pain worsened by stress 1, 2
• Assess for chest wall tenderness on examination to evaluate for costochondritis, which is common in young adults 2, 3

Definitive Management:

• Refer to cognitive-behavioral therapy—this has the highest level of evidence (Class I) for anxiety disorders and is specifically recommended for recurrent chest pain without physiological cause 1, 5
• Avoid repeated cardiac testing, which reinforces illness behavior and increases healthcare costs without improving outcomes 1
• Reassure the patient that cardiac causes have been adequately excluded and that the prognosis for noncardiac chest pain is excellent with regard to cardiac complications 1

Common Pitfalls to Avoid

• Do not order stress testing, echocardiography, or cardiac biomarkers in this zero-risk patient—these tests have extremely low pretest probability and high false-positive rates in young patients 1, 2
• Do not dismiss the psychological component—only 10% of clinicians document or refer for psychological factors even when anxiety is self-reported 1
• Do not use the term "atypical chest pain"—this can be misinterpreted as benign when the pain may still require evaluation for noncardiac causes 2
• Do not overlook the suicide attempt—addressing the underlying mental health crisis is paramount for this patient's overall morbidity and mortality 1

If Symptoms Change or Worsen

The only scenarios requiring additional workup would be:

• Development of exertional symptoms, radiation to arm/jaw, or associated diaphoresis/dyspnea—then repeat ECG and consider troponin 2, 3
• Severe odynophagia or inability to swallow—then urgent GI referral for upper endoscopy to evaluate for esophageal injury from the ibuprofen overdose 4
• Recurrent identical episodes specifically triggered by stress—this further supports panic disorder and strengthens the indication for psychiatric referral 5