In an adult with persistent central chest (sternal) pain, what are the recommended initial investigations and long‑term management?

Evaluation and Long‑Term Management of Persistent Sternal Chest Pain in Adults

In an adult with persistent central chest (sternal) pain, obtain a 12‑lead ECG within 10 minutes and measure high‑sensitivity cardiac troponin immediately to exclude acute coronary syndrome, even when symptoms have been present for weeks or months. 1

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Immediate Life‑Threatening Exclusions (First 10 Minutes)

Mandatory Initial Testing

• Acquire a 12‑lead ECG within 10 minutes of presentation, regardless of symptom duration or setting (office, urgent care, or emergency department). 1
• Measure high‑sensitivity cardiac troponin immediately because it is the most sensitive biomarker for myocardial injury; a single normal value does not exclude acute coronary syndrome—repeat at 3–6 hours. 1
• Perform a focused cardiovascular examination assessing for pulse differentials between arms (aortic dissection), new murmurs (valvular disease, aortic regurgitation), pericardial friction rub (pericarditis), unilateral absent breath sounds (pneumothorax, pulmonary embolism), and signs of hemodynamic instability. 1

Critical Conditions to Rule Out

• Acute coronary syndrome presents with retrosternal pressure building over minutes, radiating to left arm/jaw/neck, accompanied by diaphoresis, dyspnea, nausea, or syncope; however, a completely normal physical examination does not exclude uncomplicated myocardial infarction. 1, 2
• Aortic dissection causes sudden "ripping" or "tearing" chest or back pain maximal at onset, with pulse differential between extremities (30% of patients), systolic blood‑pressure difference >20 mm Hg between arms, or new aortic regurgitation murmur (40–75% of type A dissections). 1, 2
• Pulmonary embolism manifests as acute dyspnea with pleuritic chest pain; tachycardia occurs in >90% of patients and tachypnea in ~70%. 1, 2
• Pericarditis produces sharp, pleuritic chest pain that worsens when lying supine and improves when sitting forward, often with a pericardial friction rub and fever. 1, 2
• Tension pneumothorax presents with dyspnea, sharp chest pain worsening with inspiration, unilateral absence of breath sounds, and hemodynamic instability. 1, 2

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Risk Stratification After Initial ECG and Troponin

High‑Risk Features Requiring Urgent Invasive Evaluation

• Recurrent ischemia (persistent or recurrent chest pain despite medical therapy, dynamic ST‑segment changes, or transient ST‑elevation). 1, 3
• Elevated troponin levels (≥99th percentile) confirm myocardial injury and mandate admission to a coronary care unit, dual antiplatelet therapy (aspirin + P2Y₁₂ inhibitor), anticoagulation, and urgent coronary angiography. 1, 3
• Hemodynamic instability (hypotension, pulmonary rales, shock). 1, 3
• Major arrhythmias (repetitive ventricular tachycardia, ventricular fibrillation). 1
• Diabetes mellitus or early post‑infarction unstable angina. 1

Intermediate‑Risk Patients

• Normal or nondiagnostic ECG with normal initial troponin but intermediate clinical suspicion (age ≥60 years, hypertension, hyperlipidemia, family history of coronary disease, or atypical symptoms in women/elderly/diabetics). 1
• Perform serial ECGs every 15–30 minutes if symptoms persist or recur, because up to 6% of patients with evolving ACS are discharged with a normal initial ECG. 4
• Add posterior leads (V7–V9) when intermediate‑to‑high suspicion exists and the standard ECG is nondiagnostic, to detect posterior myocardial infarction from left circumflex or right coronary artery occlusion. 1, 4
• Repeat high‑sensitivity troponin at 3–6 hours; if both measurements are normal, proceed to outpatient anatomic (coronary CT angiography) or functional (stress testing) evaluation within 72 hours. 1

Low‑Risk Patients

• Stable symptoms for ≥5 days without crescendo pattern, pain reproducible with chest‑wall palpation or arm movement, normal vital signs, and relief with non‑cardiac measures (e.g., warmth, NSAIDs) classify the patient as low‑risk for ACS. 1, 2
• Defer immediate testing but arrange outpatient stress testing or coronary CT angiography within 72 hours for adults ≥60 years with cardiovascular risk factors. 1

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Differential Diagnosis of Persistent Sternal Pain (After ACS Exclusion)

Musculoskeletal Causes (Most Common After Cardiac Exclusion)

• Costochondritis accounts for approximately 43% of chest‑pain presentations in primary care when cardiac causes are excluded. 2, 5, 6
• Diagnostic features: tenderness of costochondral joints on palpation, pain reproducible with chest‑wall pressure, and pain affected by breathing, turning, twisting, or bending. 1, 2, 5, 6, 7
• Treatment: NSAIDs (e.g., ibuprofen 600–800 mg three times daily for 1–2 weeks), reassurance, and avoidance of aggravating movements. 2, 7
• Critical pitfall: Up to 7% of patients with reproducible chest‑wall tenderness still have ACS; therefore, ECG and troponin testing remain mandatory before diagnosing costochondritis. 2

Gastroesophageal and Esophageal Causes (10–20% of Presentations)

• Gastroesophageal reflux disease (GERD) produces burning retrosternal pain after meals or at night, worsened by stress and often relieved by antacids. 2
• Esophageal motility disorders (achalasia, distal esophageal spasm, nutcracker esophagus) generate squeezing retrosternal pain or spasm, frequently accompanied by dysphagia. 2
• Empiric proton‑pump inhibitor (PPI) trial is reasonable for suspected GERD; if symptoms persist, proceed to upper endoscopy, esophageal function testing, or pH monitoring. 2
• Critical pitfall: Do not rely on nitroglycerin response to differentiate cardiac from esophageal chest pain, as esophageal spasm may also respond. 1, 2

Cardiac Causes Other Than ACS

• Pericarditis: sharp, pleuritic chest pain worsening supine and improving when leaning forward, with pericardial friction rub and fever; treat with ibuprofen 600–800 mg TID for 1–2 weeks or colchicine 0.6 mg BID for 3 months. 1, 2
• Myocarditis: chest pain with fever and signs of heart failure (S3 gallop); requires cardiac troponin measurement for differentiation from ACS. 1, 2
• Valvular disease (aortic stenosis, aortic regurgitation, hypertrophic cardiomyopathy): characteristic murmurs and pulse alterations on examination. 1, 2

Pulmonary Causes

• Pneumonia: fever, localized pleuritic chest pain, regional dullness to percussion, egophony, or pleural friction rub; confirm with chest radiography. 1, 2
• Pleuritis: sharp chest pain worsening with deep inspiration. 2

Psychiatric Causes

• Panic disorder and anxiety: chest pain with dyspnea, palpitations, and diaphoresis; accounts for 11% of chest pain in general practice and 8% in emergency departments. 2

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Long‑Term Management Algorithm

Step 1: Immediate Evaluation (First 10 Minutes)

1. Obtain 12‑lead ECG within 10 minutes. 1
2. Measure high‑sensitivity troponin immediately. 1
3. Perform focused cardiovascular examination (pulse differentials, new murmurs, pericardial rub, unilateral breath sounds). 1

Step 2: Risk Stratification

• If ECG shows ST‑elevation or new ischemic changes OR troponin is elevated: activate emergency medical services, start dual antiplatelet therapy and anticoagulation, and arrange urgent coronary angiography. 1, 3
• If ECG and initial troponin are normal but clinical suspicion remains intermediate‑to‑high: repeat troponin at 3–6 hours, perform serial ECGs if symptoms persist, and add posterior leads (V7–V9). 1, 4
• If both troponins are normal and pain is reproducible with palpation: diagnose costochondritis, prescribe NSAIDs, and arrange outpatient stress testing or coronary CT angiography within 72 hours for patients ≥60 years with risk factors. 1, 2, 7

Step 3: Targeted Diagnostic Testing (After ACS Exclusion)

• Chest radiography to evaluate for pneumonia, pneumothorax, or mediastinal widening (aortic dissection). 1
• Empiric PPI trial for suspected GERD; if symptoms persist, proceed to upper endoscopy or esophageal function testing. 2
• Echocardiography to assess left ventricular function and exclude valvular disease or pericardial effusion. 1

Step 4: Long‑Term Follow‑Up

• Outpatient stress testing or coronary CT angiography within 72 hours for intermediate‑risk patients with normal serial troponins. 1
• Reassurance and patient education for confirmed musculoskeletal or gastrointestinal causes. 2, 7
• Referral to gastroenterology for recurrent unexplained chest pain despite empiric PPI therapy. 2

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Critical Pitfalls to Avoid

• Never rely on a single normal ECG to exclude ACS; up to 6% of patients with evolving ACS are discharged with a normal initial ECG, and 30–40% of acute myocardial infarctions present with a normal or nondiagnostic ECG. 4
• Do not dismiss ACS in women, elderly patients, or individuals with diabetes based on atypical presentations (sharp, stabbing, or positional pain); they frequently present with non‑classic symptoms. 1, 2
• Do not assume a normal physical examination excludes ACS; uncomplicated myocardial infarction can present with a completely normal exam. 1, 2
• Do not rely on nitroglycerin response to differentiate cardiac from esophageal chest pain, as esophageal spasm may also respond. 1, 2
• Do not assume reproducible chest‑wall tenderness rules out ACS; approximately 7% of patients with palpation‑induced tenderness still have acute coronary syndrome. 2
• Do not delay transfer to the emergency department for troponin testing in office settings; suspected ACS patients should be transported urgently by EMS. 1