What is the appropriate initial evaluation and management for an elderly patient with sudden onset chest pain and bilateral sternal tenderness persisting for four days?

Evaluation and Management of Geriatric Chest Pain with Bilateral Sternal Tenderness

Initial Assessment Must Rule Out Life-Threatening Causes First

Despite the presence of bilateral sternal tenderness suggesting costochondritis, you must immediately obtain a 12-lead ECG within 10 minutes and draw a high-sensitivity cardiac troponin to exclude acute coronary syndrome, as musculoskeletal findings do not rule out concurrent cardiac pathology. 1

Critical Context for Geriatric Patients

• Older adults (≥75 years) frequently present with atypical symptoms including isolated dyspnea, syncope, acute delirium, or unexplained falls without classic chest pain, making the diagnosis of ACS particularly challenging in this population. 1
• A completely normal physical examination does not exclude acute myocardial infarction; approximately 30-40% of acute MIs present with normal or nondiagnostic initial findings. 1, 2, 3
• The presence of reproducible chest wall tenderness does not exclude cardiac ischemia; approximately 13% of patients with pleuritic-type chest pain have acute myocardial ischemia. 1

Immediate Diagnostic Protocol (First 10 Minutes)

Mandatory Testing

• Obtain a 12-lead ECG within 10 minutes to identify STEMI (≥1 mm ST-elevation in contiguous leads), ST-depression, T-wave inversions, or pericarditis patterns (diffuse ST-elevation with PR-depression). 1, 2
• Draw high-sensitivity cardiac troponin immediately because it is the most sensitive and specific biomarker for myocardial injury and remains valid regardless of musculoskeletal findings. 1, 2
• Measure vital signs bilaterally (heart rate, blood pressure in both arms, respiratory rate, oxygen saturation) to detect pulse or pressure differentials suggestive of aortic dissection. 1

Focused Physical Examination

• Assess for high-risk cardiac findings: diaphoresis, tachypnea, tachycardia, hypotension, pulmonary crackles, S3 gallop, new murmurs, or jugular venous distension. 1
• Evaluate for alternative life-threatening causes: unilateral absent breath sounds (pneumothorax), pericardial friction rub (pericarditis), subcutaneous emphysema (esophageal rupture). 1
• Document the exact location and reproducibility of sternal tenderness by palpating the costochondral joints bilaterally. 1

Life-Threatening Differential Diagnoses to Exclude

Acute Coronary Syndrome

• Presentation in elderly patients may include jaw/neck pain, nausea, fatigue, dyspnea, or epigastric discomfort rather than classic retrosternal pressure. 1
• Four days of intermittent symptoms is consistent with unstable angina or crescendo angina pattern requiring urgent evaluation. 1, 2
• Management if ACS confirmed: Activate emergency medical services immediately; target door-to-balloon time <90 minutes for STEMI or admit to coronary care unit with continuous monitoring for NSTE-ACS. 1, 2

Acute Pericarditis

• Presentation: Sharp, pleuritic chest pain that worsens when supine and improves when sitting forward; may have fever and pericardial friction rub. 1
• ECG findings: Diffuse concave ST-elevation with PR-segment depression. 1
• Bilateral sternal tenderness can coexist with pericarditis, as inflammation may cause anterior chest wall discomfort. 1

Aortic Dissection

• Presentation: Sudden, severe "ripping" or "tearing" chest or back pain maximal at onset. 1
• Physical clues: Pulse differential between extremities (~30% of cases), systolic BP difference >20 mmHg between arms, new aortic regurgitation murmur. 1
• Critical action: Withhold aspirin and anticoagulation if dissection suspected; arrange immediate imaging (CT/MRI/TEE). 1

Pulmonary Embolism

• Presentation: Sudden dyspnea with pleuritic chest pain worsening on inspiration; tachycardia present in >90% of patients. 1
• Risk factors in elderly: Recent immobilization, surgery, malignancy, heart failure. 1

Serial Monitoring Strategy When Initial Tests Are Nondiagnostic

• Repeat high-sensitivity troponin at 1-3 hours (or conventional troponin at 3-6 hours) because a single normal result does not exclude ACS, especially when symptoms have been present for 4 days. 1, 3
• Obtain serial ECGs every 15-30 minutes if clinical suspicion remains high, as ischemic changes may evolve over time. 1, 3
• Add posterior leads (V7-V9) when suspicion for ACS is intermediate-to-high and the standard ECG is nondiagnostic. 1

Risk Stratification Algorithm

High-Risk Features Requiring Immediate Admission

• Ongoing rest pain >20 minutes 1
• Hemodynamic instability (SBP <100 mmHg, HR >100 or <50 bpm) 1
• Troponin above the 99th percentile 1, 3
• New heart failure signs (crackles, S3 gallop, elevated JVP) 1
• Dynamic ECG changes 3

Intermediate-Risk Features

• Age ≥75 years with chest pain 1
• Prior myocardial infarction or known coronary artery disease 1
• Diabetes mellitus, hypertension, hyperlipidemia 1
• Rest angina lasting 4 days with recurrent episodes 1, 2

Low-Risk Criteria (All Must Be Present)

• Normal or nondiagnostic ECG 1, 3
• Negative troponin at presentation and 6-12 hours after symptom onset 1, 3
• Stable vital signs 1
• No ongoing chest pain 1
• No heart failure signs 1

Disposition Based on Initial Findings

If STEMI or New Ischemic Changes Present

Activate emergency medical services immediately and arrange urgent transfer to a 24/7 cardiac catheterization center; target door-to-balloon time <90 minutes. 1, 2

If Initial ECG and Troponin Normal

Admit to a monitored unit (coronary care or telemetry) for serial troponin testing and continuous cardiac monitoring until ACS is definitively excluded, given the 4-day duration of symptoms and geriatric age. 1, 3

If All Testing Remains Normal After Serial Monitoring

Consider chest pain unit observation for 10-12 hours or arrange outpatient stress testing within 72 hours to definitively rule out obstructive coronary disease. 1, 3

Costochondritis Diagnosis Is One of Exclusion

Costochondritis can only be diagnosed after life-threatening causes have been excluded through objective testing (ECG, troponin, imaging), not based on physical examination findings alone. 1

• Typical costochondritis features: Tenderness of costochondral joints that is reproducible with palpation, sharp pain worsening with movement or deep breathing. 1
• However, bilateral sternal tenderness in a geriatric patient with 4 days of symptoms warrants full cardiac evaluation before attributing symptoms to a benign musculoskeletal cause. 1

Critical Pitfalls to Avoid

• Do not assume reproducible chest wall tenderness excludes cardiac disease; musculoskeletal and cardiac pathology can coexist. 1
• Do not rely on a single normal ECG to exclude ACS when clinical suspicion remains high; 30-40% of acute MIs present with normal initial ECG. 1, 2, 3
• Do not discharge based on a single troponin drawn <6 hours from most recent symptom onset; troponin may not be elevated early. 2, 3
• Avoid the term "atypical chest pain"; instead describe as "cardiac," "possibly cardiac," or "noncardiac" to prevent misinterpretation as benign. 1
• Do not delay emergency department evaluation for additional history-taking or office-based testing when ACS is suspected. 1, 2