How should I document the impression for a patient presenting with chest pain and cough who has two serial negative troponin results?

Clinical Impression for Chest Pain with Cough and Two Negative Troponins

For a patient with chest pain, cough, and two serial negative troponins, document the impression as "Low-Risk Chest Pain, Acute Myocardial Infarction Ruled Out" and proceed with accelerated discharge planning after excluding alternative life-threatening diagnoses. 1

Risk Stratification Framework

Based on validated accelerated diagnostic pathways, two serial negative high-sensitivity troponin results (at presentation and 2 hours later) combined with a nonischemic ECG predict a 30-day major adverse cardiovascular event (MACE) rate of less than 1%, allowing safe discharge from the emergency department. 1

Key Elements to Document in Your Impression:

• Cardiac risk exclusion: State explicitly that acute coronary syndrome has been ruled out based on serial negative troponins at appropriate intervals (minimum 2 hours apart, with at least one sample obtained ≥6 hours from symptom onset if possible) 1, 2

• Timing of troponin measurements: Document the exact timing of both troponin draws relative to symptom onset, as troponin elevation can be delayed up to 8-12 hours 1

• ECG findings: Specify whether the ECG shows ST-segment depression >1mm, T-wave inversions >1mm, or is nonischemic 1

Alternative Diagnoses to Consider with Cough

The presence of cough alongside chest pain shifts your differential diagnosis away from pure cardiac etiologies:

Pulmonary Causes (Most Likely):

• Pleuritic chest pain from pneumonia or pleuritis: Look for fever, productive cough, focal crackles on examination, and obtain chest X-ray 1
• Pulmonary embolism: Assess Wells score, consider D-dimer if low-to-intermediate probability 1
• Acute bronchitis or tracheobronchitis: Typically presents with substernal burning chest discomfort worsened by coughing 3

Cardiac Causes with Respiratory Symptoms:

• Myopericarditis: Troponin may be elevated but can be negative in isolated pericarditis; look for positional chest pain, pericardial friction rub, and diffuse ST elevation on ECG 4
• Heart failure with pulmonary congestion: Assess for orthopnea, elevated jugular venous pressure, and pulmonary edema on chest X-ray 1

Critical Pitfall:

Troponin can be elevated in non-ischemic conditions including myocarditis, heart failure, and pulmonary embolism—negative troponin does NOT exclude these diagnoses. 1 The clinical context (chest pain character, cough, physical examination) must guide your differential.

Documentation Template for Your Impression

Suggested impression statement:

"Low-risk chest pain with cough, acute myocardial infarction excluded by serial negative troponins at [time 1] and [time 2], nonischemic ECG. Differential diagnosis includes [pleuritic chest pain/bronchitis/pneumonia]. Plan: [chest X-ray if not done], discharge with outpatient follow-up in 1-2 weeks, return precautions for recurrent symptoms." 1

Discharge Planning Requirements

• Do NOT routinely order stress testing, coronary CT angiography, or myocardial perfusion imaging before discharge in low-risk patients with ruled-out MI 1

• Arrange follow-up within 1-2 weeks; if no follow-up is available, consider further testing or observation before discharge 1

• Provide explicit return precautions: Instruct patient to return immediately for prolonged chest pain >20 minutes, chest pain at rest, or worsening dyspnea 1

High-Risk Features That Would Change Management

If any of the following are present, the patient does NOT qualify for accelerated discharge and requires admission:

• Recurrent chest pain at rest or with minimal exertion 1
• Dynamic ST-segment changes (depression or transient elevation) 1
• Hemodynamic instability (hypotension, pulmonary edema) 1
• Diabetes mellitus with ongoing symptoms 1
• History of coronary artery disease with recurrent symptoms 3

Common Pitfalls to Avoid

• Discharging too early: Ensure at least one troponin is drawn ≥6 hours from symptom onset; earlier negative results may miss evolving MI 2

• Ignoring the 99th percentile threshold: Many centers still use outdated troponin cutoffs; verify your laboratory uses the guideline-recommended 99th percentile upper reference limit 1

• Missing non-cardiac serious diagnoses: With cough present, obtain chest X-ray to exclude pneumonia, pneumothorax, or widened mediastinum (aortic dissection) 1, 5

• Labeling as "noncardiac chest pain" prematurely: In patients with traditional cardiovascular risk factors (hypercholesterolemia, diabetes, prior CAD), an initial impression of noncardiac chest pain still carries a 2.8% rate of 30-day adverse cardiac events 3