Differential Diagnosis: Bilateral Sternal Pain with Negative Cardiac Workup
With a normal ECG, normal high-sensitivity troponin T (13 ng/L is below the typical 99th percentile of 14-20 ng/L), negative D-dimer, and normal ESR after 4 days of symptoms, acute coronary syndrome is effectively ruled out, and the differential diagnosis should focus on musculoskeletal causes (costochondritis being most likely), gastroesophageal reflux disease, or less commonly myopericarditis. 1
Cardiac Causes Effectively Excluded
Acute myocardial infarction is ruled out because your hsTnT of 13 ng/L is below the 99th percentile threshold (typically 14-20 ng/L depending on the assay), the ECG shows no ischemic changes, and symptoms have persisted for 4 days—well beyond the timeframe where troponin would have risen if MI were present. 1
Pulmonary embolism is excluded by the negative D-dimer, which has excellent negative predictive value in this clinical context. 1
Unstable angina remains a theoretical consideration but is highly unlikely given the normal ECG during 4 days of ongoing pain; ST-segment depression >1 mm or T-wave inversions would be expected if significant coronary ischemia were present. 1
The 4-day duration with persistently normal troponin makes any acute coronary syndrome extremely improbable, as troponin rises within 1 hour of symptom onset with high-sensitivity assays and would have normalized or shown dynamic changes by day 4 if MI had occurred. 1
Most Likely Diagnoses
Costochondritis/Musculoskeletal Pain (Primary Consideration)
Bilateral sternal pain with a dull quality lasting 4 days is classic for costochondritis, especially when cardiac markers and inflammatory markers (ESR) are normal. 2
Key clinical features to confirm: Pain reproduced by palpation of the costochondral junctions, worsening with movement or deep breathing, and no relief pattern suggesting cardiac or esophageal origin. 2
The normal ESR argues against inflammatory conditions like rheumatologic disorders but does not exclude costochondritis, which is typically a non-inflammatory mechanical process. 1
Gastroesophageal Reflux Disease
GERD commonly presents with substernal chest discomfort that can be bilateral and dull, particularly when the pain has an esophageal location with potential upward radiation. 3
Diagnostic clues include: Relief with antacids (which strongly suggests esophageal rather than cardiac origin), relationship to meals or lying down, and absence of exertional component. 3
A therapeutic trial with proton pump inhibitors is both diagnostic and therapeutic; symptom resolution within 2-4 weeks supports GERD as the diagnosis. 3
Myopericarditis (Less Likely but Important)
Myopericarditis can present with normal or minimally elevated troponin (your value of 13 ng/L is at the borderline), normal ECG in some cases, and chest pain lasting several days. 1, 4
However, the normal ESR argues against this diagnosis, as pericarditis typically causes elevated inflammatory markers. 1
If suspected clinically, echocardiography and potentially cardiac MRI would be indicated to assess for pericardial effusion or myocardial inflammation patterns. 4
Clinical Pitfalls to Avoid
Do not assume cardiac safety based solely on a single troponin measurement if symptoms started within 3 hours of testing, but in your case with 4 days of symptoms, serial measurements are unnecessary. 5
Do not discharge without considering the HEART score: With your presentation (normal ECG, age-dependent risk factors, no troponin elevation), a HEART score ≤3 would support safe discharge with outpatient follow-up within 1-2 weeks. 5, 6
Do not pursue extensive cardiac imaging (stress testing, coronary angiography) in patients with normal troponin and non-ischemic history, as this leads to unnecessary downstream testing without clinical utility. 2, 7
Recommended Diagnostic Approach
Perform focused physical examination looking for chest wall tenderness at costochondral junctions (positive in costochondritis) and epigastric tenderness (suggests GERD). 3, 2
Assess response to empiric therapy: Trial of NSAIDs for musculoskeletal pain or proton pump inhibitors for suspected GERD, with reassessment in 1-2 weeks. 3
Arrange outpatient cardiology follow-up only if symptoms change character to become exertional, pain pattern becomes typical for angina (exertional with relief by rest), or new high-risk features develop. 3
Consider echocardiography if clinical features suggest myopericarditis (positional pain, pericardial rub on examination, or if troponin trends upward on repeat testing), though this is unlikely given your normal inflammatory markers. 4