For a 33‑year‑old man with hypertension, gastro‑esophageal reflux disease, intermittent chest pain that improves when leaning forward, inverted T‑waves in leads V3‑V6 on emergency‑department electrocardiogram, negative serial troponins, normal left‑ventricular size and function on echocardiogram, and a transiently elevated blood pressure after missing his losartan dose, is it appropriate to order high‑sensitivity C‑reactive protein and erythrocyte sedimentation rate, obtain a stress echocardiogram, and postpone any antihypertensive medication adjustments until the next visit?

Evaluation Plan for 33-Year-Old Male with Intermittent Chest Pain and T-Wave Inversions

Direct Answer

Your plan is partially appropriate but incomplete—ordering CRP and ESR is not indicated for suspected pericarditis in this clinical context, and you should prioritize stress echocardiography immediately while deferring blood pressure management is reasonable given the documented explanation for today's elevation. 1

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Critical Analysis of Your Proposed Workup

CRP and ESR Testing: Not Recommended

• CRP and ESR have no established role in diagnosing acute pericarditis when the clinical presentation is atypical. The 2021 ACC/AHA chest pain guidelines emphasize that pericarditis classically presents with sharp, pleuritic pain improved by sitting up or leaning forward, often with a pericardial friction rub and widespread ST-elevation with PR depression on ECG—none of which are present in your patient. 1

• Your patient's T-wave inversions in V3-V6 are NOT consistent with pericarditis. Pericarditis produces diffuse concave ST-elevation with PR-depression, not isolated T-wave inversions in the precordial leads. 1

• The pain relief with ketorolac does NOT exclude cardiac ischemia and should not be used as a diagnostic criterion to support a pericarditis diagnosis. 2

• CRP and ESR are markers of chronic inflammation with limited acute diagnostic value. ESR has a much longer half-life than CRP (reflecting fibrinogen levels), making it useful for monitoring chronic conditions but not for acute diagnosis. 3 In troponin-negative chest pain, elevated CRP/ESR may have prognostic value for future events but do not establish a diagnosis of pericarditis. 4

Stress Echocardiography: Strongly Indicated

• Stress echocardiography is the preferred test for this patient. The 2024 ESC guidelines specifically recommend stress testing—preferably stress echocardiography—in young adults with intermittent chest pain, precordial T-wave inversions, and a normal resting echocardiogram to assess for obstructive coronary artery disease. 2

• T-wave inversions in V3-V6 constitute an abnormal ECG that cannot be dismissed, because 30-40% of acute myocardial infarctions present with a normal or nondiagnostic initial ECG. 2

• In hypertensive patients with chest pain, stress echocardiography is preferentially recommended over myocardial perfusion scanning because stress-induced wall-motion abnormalities are highly specific for epicardial coronary disease, whereas perfusion defects may reflect reduced myocardial flow reserve unrelated to stenosis. 2

• Exercise stress echocardiography should be performed to at least 85% of age-predicted maximum heart rate; a normal study at this workload provides high negative predictive value for excluding obstructive coronary disease. 2

Blood Pressure Management: Appropriate to Defer

• Postponing antihypertensive adjustment until the next visit is reasonable given that:

  • The patient has a documented explanation for today's elevation (missed dose, stressful day). 1
  • He was normotensive during the ER visit and at his primary care physician. 1
  • A single elevated reading in the context of acute stress and medication non-adherence does not warrant immediate escalation. 1

• However, you should counsel the patient on medication adherence and consider home blood pressure monitoring to assess for masked hypertension or white-coat effect. 1

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Correct Diagnostic Algorithm

Step 1: Rule Out Acute Coronary Syndrome (Already Completed)

• ✓ Serial troponins negative × 2 at appropriate intervals
• ✓ ECG shows T-wave inversions (not STEMI)
• ✓ Normal LV size and function on echocardiogram (LVEF 56%)
• ✓ Low LDL (67 mg/dL)

Step 2: Assess for Obstructive Coronary Disease

Proceed directly to stress echocardiography because:

• The patient has persistent chest pain with positional relief (leaning forward/left), which could represent either pericarditis OR ischemia with positional variation. 1
• T-wave inversions in V3-V6 with "LV strain pattern" noted on your ECG review suggest possible ischemia despite normal resting echo. 2
• Negative troponins do not rule out evolving ischemia when T-wave inversions persist or change. 2

Step 3: Alternative Diagnosis Consideration

If stress echo is normal, then consider:

• Gastroesophageal reflux disease (GERD): The patient has a history of GERD, and acid reflux is the most common gastrointestinal cause of noncardiac chest pain. 1, 5, 6 A 4-week trial of twice-daily PPI therapy is recommended by the AGA after cardiac etiology has been carefully considered. 1

• Costochondritis: Reproducible chest wall tenderness on palpation would support this diagnosis. 1

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Common Pitfalls You Are Avoiding (and One You're Not)

✓ Correct Decisions:

• Not relying on ketorolac response to differentiate cardiac from non-cardiac pain—esophageal spasm and musculoskeletal pain also improve with NSAIDs. 2
• Not dismissing the patient based on negative troponins—functional testing is warranted when T-wave inversions persist. 2
• Deferring BP medication changes in the context of documented non-adherence and situational stress. 1

✗ Incorrect Decision:

• Ordering CRP and ESR for "suspected pericarditis" when the clinical presentation does not support this diagnosis and these tests will not change management. 1, 3

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Revised Management Plan

1. Order stress echocardiography immediately (exercise preferred; dobutamine if exercise not feasible). 2

2. Do NOT order CRP or ESR—they are not indicated for this presentation. 1, 3

3. Counsel on medication adherence and consider home BP monitoring. 1

4. If stress echo is normal, initiate a 4-week trial of twice-daily PPI therapy for suspected GERD-related chest pain. 1

5. If stress echo shows inducible ischemia, proceed to coronary angiography. 2

6. Re-evaluate blood pressure at next visit as planned, incorporating home BP readings if available. 1