What patient education should be provided for a patient with three days of chest pain, normal electrocardiogram, normal vital signs, and normal chest radiograph?

Patient Education for Chest Pain with Normal Initial Workup

You have had chest pain for three days, and your initial tests—ECG, vital signs, and chest X-ray—are all normal, which is reassuring but does not completely rule out a heart problem or other serious causes.

What These Normal Tests Mean

• A normal ECG is encouraging, but 30–40% of heart attacks present with a normal or nondiagnostic initial ECG, so additional testing is essential 1.
• Normal vital signs and chest X-ray help exclude some immediate life-threatening conditions like tension pneumothorax, large pneumonia, or obvious heart failure 1.
• A single set of normal tests does not rule out acute coronary syndrome (ACS), pulmonary embolism, or early stages of other cardiac conditions 1.

What Happens Next: Required Follow-Up Testing

• You must have blood tests called cardiac troponin measured immediately and repeated 3–6 hours later (or 1–3 hours if high-sensitivity troponin is available) because a single normal troponin does not exclude heart injury 1, 2.
• If both troponin measurements are normal and your symptoms have not worsened, you will need outpatient stress testing or coronary CT angiography within 72 hours to definitively rule out blockages in your heart arteries 1, 3.
• Serial ECGs should be obtained every 15–30 minutes if your chest pain persists or changes, because ischemic changes can evolve over time 1, 2.

Warning Signs That Require Immediate Emergency Care

Call 911 or return to the emergency department immediately if you develop:

• Chest pressure, squeezing, or heaviness that builds over minutes and radiates to your left arm, jaw, neck, or between your shoulder blades 1, 2.
• Shortness of breath, sweating, nausea, vomiting, lightheadedness, or feeling like you might pass out 1, 2.
• Sudden severe "ripping" or "tearing" chest or back pain (suggests aortic dissection) 1, 2.
• Sharp chest pain that worsens when you breathe in, along with sudden shortness of breath (suggests pulmonary embolism or pneumothorax) 1, 2.
• Chest pain that worsens when lying flat and improves when sitting forward (suggests pericarditis) 1, 4.

Why Three Days of Symptoms Requires Urgent Evaluation

• Chest pain lasting multiple days can represent unstable angina or crescendo angina, which are warning signs of an impending heart attack 1, 3.
• Even if your pain is intermittent or mild, recurrent episodes over days increase your risk and require definitive cardiac testing 3, 5.
• Women, older adults (≥75 years), and people with diabetes often have atypical symptoms like jaw pain, nausea, fatigue, or vague discomfort rather than classic chest pressure, making diagnosis more challenging 1, 2.

Common Pitfalls to Avoid

• Do not assume your pain is "just anxiety" or "muscle strain" without completing cardiac testing; approximately 7% of patients with reproducible chest-wall tenderness still have acute coronary syndrome 2, 4.
• Do not rely on whether nitroglycerin relieves your pain to determine if it is cardiac; esophageal spasm and other non-cardiac conditions also respond to nitroglycerin 1, 2.
• Do not delay seeking care because you are young or have no risk factors; heart attacks can occur in young adults without traditional risk factors 1, 2.
• Sharp or stabbing pain does not rule out a heart problem; approximately 13% of patients with sharp, pleuritic chest pain have acute myocardial ischemia 1, 2, 4.

What Could Be Causing Your Chest Pain

Cardiac Causes (Must Be Ruled Out First)

• Acute coronary syndrome (ACS): Blockage in heart arteries causing reduced blood flow 1, 2.
• Pericarditis: Inflammation of the sac around the heart, causing sharp pain that worsens lying down 1, 4.
• Myocarditis: Inflammation of the heart muscle itself, often after a viral illness 1, 4.

Non-Cardiac Causes (Diagnosed After Cardiac Causes Are Excluded)

• Gastroesophageal reflux disease (GERD): Stomach acid irritating the esophagus, accounting for roughly 50% of non-cardiac chest pain 6, 7.
• Musculoskeletal pain (costochondritis): Inflammation of the cartilage connecting ribs to breastbone, tender to touch 1, 8.
• Pulmonary embolism: Blood clot in the lungs, causing sudden shortness of breath and pleuritic pain 1, 2.
• Anxiety or panic disorder: Can cause chest tightness, rapid heartbeat, and shortness of breath 8, 7.

Your Action Plan

1. Complete the recommended troponin blood tests and repeat ECGs as directed 1, 2.
2. Schedule and attend your outpatient stress test or coronary CT scan within 72 hours if troponins remain normal 1, 3.
3. Keep a symptom diary: Note when pain occurs, what brings it on, how long it lasts, and what makes it better or worse 1, 2.
4. Do not drive yourself to the hospital if symptoms worsen; call 911 for emergency transport because approximately 1.5% of chest-pain patients develop cardiac arrest en route 2.
5. Follow up with your primary care doctor within one week to review test results and discuss next steps 1, 5.

Why This Evaluation Is Critical

• More than half of patients with non-cardiac chest pain continue to experience symptoms months later if the underlying cause is not identified and treated 5.
• Early definitive testing reduces your risk of heart attack or death in the next three months compared to no testing (0.9% vs 2.1% heart attack rate; 0.4% vs 3.0% death rate) 9.
• Patients who receive a clear diagnosis and explanation of their chest pain have better outcomes and less anxiety than those left without answers 5.

The bottom line: Normal initial tests are a good start, but you need additional cardiac testing to safely rule out life-threatening causes before considering non-cardiac explanations for your three days of chest pain.