For a patient with typical anginal chest pain and severe hypertension (~200/100 mm Hg), whose 12‑lead electrocardiogram shows no ST‑T changes, high‑sensitivity troponins are negative, and bedside echocardiography shows normal left‑ventricular systolic function, what is the recommended immediate management and diagnostic work‑up?

Management of Typical Anginal Chest Pain with Severe Hypertension and Initial Negative Workup

Despite a normal initial ECG, negative troponins, and preserved left ventricular function, this patient with typical anginal chest pain and severe hypertension requires serial troponin measurements, repeat ECGs, aggressive blood pressure control, and continued observation because a normal ECG occurs in 1-6% of acute coronary syndrome cases and does not exclude ongoing myocardial ischemia. 1

Immediate Management Priorities

Blood Pressure Control

• Initiate intravenous nitroglycerin immediately for dual benefit of blood pressure reduction and relief of myocardial ischemia 1
• The severe hypertension (200/100 mm Hg) represents a potential Type 2 myocardial infarction mechanism through supply-demand mismatch, even without coronary plaque rupture 1
• Administer supplemental oxygen if oxygen saturation is <90% 1
• Consider intravenous morphine sulfate if symptoms persist despite nitroglycerin 1

Serial Cardiac Monitoring

Obtain serial troponin measurements at 3-6 hours after symptom onset, as a single negative troponin is insufficient to exclude acute coronary syndrome 1

• High-sensitivity troponin assays provide >99% negative predictive value only when obtained serially 1
• If troponins remain negative at 6 hours but clinical suspicion persists, obtain additional measurements beyond 6 hours 1

Repeat 12-lead ECGs at 15-30 minute intervals during the first hour, especially if symptoms recur 1

• A normal ECG does not exclude ACS and occurs in 1-6% of such patients 1
• Consider supplemental leads V7-V9 to detect electrically silent left circumflex occlusions 1, 2
• Right-sided leads (V3R-V4R) may be warranted if inferior changes develop 1

Critical Diagnostic Considerations

Why This Patient Remains High-Risk

The combination of typical anginal symptoms (not atypical chest pain) with severe hypertension creates a high pretest probability for acute coronary syndrome despite initial negative testing 1

Left circumflex or right coronary artery occlusions can be electrically silent on standard 12-lead ECG 1

• These occlusions may not produce ST-segment changes on standard leads
• Posterior leads (V7-V9) should be obtained given the intermediate-to-high clinical suspicion 1, 2

Exclude Alternative Life-Threatening Diagnoses

Obtain chest X-ray to evaluate for aortic dissection (widened mediastinum), pulmonary embolism, or other thoracic pathology 1

• The severe hypertension raises concern for aortic dissection as a differential diagnosis 1
• Consider CT angiography of the chest if aortic dissection or pulmonary embolism cannot be excluded clinically 1

Disposition and Risk Stratification

Admission Criteria

This patient requires hospital admission with continuous ECG monitoring 1

• Typical anginal symptoms at rest mandate admission regardless of initial negative biomarkers 1
• Severe hypertension (200/100 mm Hg) represents hemodynamic instability requiring inpatient management 1
• The patient should be placed on bed rest with continuous ECG monitoring for ischemia and arrhythmia detection 1

Risk Score Application

Apply validated risk scores (HEART score, TIMI score) to guide management intensity 1

• Risk stratification models are Class I recommendations for all patients with suspected NSTE-ACS 1
• These scores help determine timing of invasive coronary angiography if ACS is confirmed 1

Subsequent Diagnostic Pathway

If Serial Troponins Remain Negative and Symptoms Resolve

Proceed with non-invasive stress testing or coronary CT angiography before discharge 1, 3

• Stress testing with imaging (stress echocardiography or nuclear perfusion) is preferred for functional assessment 3
• Coronary CT angiography provides >95% negative predictive value in low-to-intermediate risk patients with normal troponins 3
• Testing should occur within 72 hours if outpatient, or during hospitalization if risk stratification suggests intermediate-to-high risk 3

If Troponins Become Positive or ECG Changes Develop

Immediate coronary angiography is indicated for any of the following: 1

• Rising troponin pattern on serial measurements 1
• New ST-segment depression or T-wave inversion on repeat ECG 1
• Recurrent chest pain despite medical therapy 1
• Hemodynamic instability or new heart failure 1

Common Pitfalls to Avoid

Do not discharge this patient based solely on initial negative troponin and ECG 1

• Serial measurements over 3-6 hours are mandatory for adequate sensitivity 1
• Typical anginal symptoms carry high pretest probability regardless of initial testing 1

Do not attribute symptoms solely to hypertensive urgency without excluding ACS 1

• Severe hypertension can cause Type 2 MI through supply-demand mismatch 1
• Hypertension may also be a physiologic response to cardiac ischemia 1

Do not overlook electrically silent coronary occlusions 1

• Left ventricular hypertrophy from chronic hypertension can mask ischemic changes 1
• Posterior leads should be obtained in this clinical context 1, 2