In a 52-year-old man with hypertension controlled on losartan who has persistent mechanical right‑shoulder pain unresponsive to topical diclofenac, heat and massage and now reports sharp chest‑wall pain radiating to the back and epigastric discomfort, and who is taking cyclobenzaprine and omeprazole while awaiting Helicobacter pylori urea breath test results, what are the appropriate next diagnostic and therapeutic steps?

Immediate Cardiac Exclusion and Next Steps

This patient requires immediate cardiac evaluation with a 12-lead ECG and high-sensitivity troponin measurement to exclude acute coronary syndrome (ACS), because sharp chest-wall pain radiating to the back in a 52-year-old man with hypertension does not rule out myocardial ischemia—approximately 13% of patients with sharp or pleuritic-type pain still have acute myocardial ischemia. 1

1. Urgent Diagnostic Evaluation (Within 10 Minutes)

• Obtain a 12-lead ECG immediately to identify ST-elevation, ST-depression, T-wave inversions, new left bundle branch block, or other acute ischemic changes. 1

• Measure high-sensitivity cardiac troponin now, as it is the most sensitive and specific biomarker for myocardial injury (>90% sensitivity, >95% specificity). 1

• Repeat troponin at 3–6 hours if the initial value is normal, because a single normal troponin does not exclude ACS—30–40% of acute myocardial infarctions present with a normal or nondiagnostic initial ECG. 1

• Measure blood pressure in both arms to detect a systolic difference >20 mm Hg, which suggests aortic dissection. 1

• Assess vital signs (heart rate, respiratory rate, oxygen saturation) to identify tachycardia (>90% of pulmonary embolism cases) or hemodynamic instability. 1

2. Why This Patient Cannot Be Assumed Musculoskeletal

• Sharp chest pain does NOT exclude ACS: The Multicenter Chest Pain Study found acute ischemia in 22% of patients with sharp or stabbing pain and 13% with pleuritic-type pain. 1

• Radiation to the back is a classic ACS pattern: Cardiac pain is visceral and poorly localized, frequently radiating to the shoulder blades, interscapular region, and back. 1, 2

• Age 52 years with hypertension is intermediate-to-high risk: Male sex and age >55 years outweigh all historical factors, including the nature of chest pain, in predicting coronary artery disease. 1

• Chest-wall tenderness does NOT rule out ACS: Up to 7% of patients with reproducible chest-wall tenderness on palpation still have acute coronary syndrome. 2

• A normal physical examination does NOT exclude myocardial infarction: Uncomplicated MI can present with entirely normal findings. 1, 2

3. High-Risk Features Present in This Patient

• Pain radiating to chest and back: This pattern is consistent with both ACS (radiation to back/shoulder) and aortic dissection (sudden "ripping" pain to back). 1

• Unresponsive to conservative measures: Persistent pain despite topical diclofenac, heat, and massage suggests a non-musculoskeletal etiology. 3

• Hypertension on losartan: Hypertension is a major risk factor for both coronary artery disease and aortic dissection. 1

• Epigastric discomfort: This can represent an anginal equivalent, especially in the context of chest pain. 1

4. Immediate Management Algorithm

Step 1: If ECG shows STEMI or new ischemic changes OR troponin is elevated (≥99th percentile)

• Activate emergency medical services immediately—do not delay for additional testing. 1
• Administer chewed aspirin 162–325 mg unless contraindicated. 1
• Initiate dual antiplatelet therapy (aspirin + P2Y12 inhibitor) and anticoagulation. 1
• Arrange urgent coronary angiography. 1

Step 2: If initial ECG and troponin are normal

• Repeat troponin at 3–6 hours to safely exclude evolving myocardial injury. 1
• Obtain serial ECGs every 15–30 minutes if pain persists or recurs, to capture evolving ischemic patterns. 1
• Add posterior leads (V7–V9) if suspicion remains high and standard ECG is nondiagnostic, to detect posterior MI. 1

Step 3: If both ECG and serial troponins are normal

• Perform focused cardiovascular examination for pulse differentials (aortic dissection), unilateral absent breath sounds (pneumothorax), pericardial friction rub (pericarditis), or new murmurs. 1
• Palpate costochondral junctions to reproduce pain; tenderness suggests costochondritis (43% of chest pain after cardiac exclusion). 2
• Consider outpatient stress testing or coronary CT angiography within 72 hours given age, hypertension, and persistent symptoms. 1, 2

5. Critical Pitfalls to Avoid

• Do NOT rely on cyclobenzaprine response to differentiate musculoskeletal from cardiac pain—muscle relaxers do not exclude ACS. 1

• Do NOT assume sharp pain is benign: Sharp or pleuritic pain is present in 13–22% of patients with acute myocardial ischemia. 1

• Do NOT dismiss pain that radiates to the back: This is a classic pattern for both ACS and aortic dissection. 1

• Do NOT delay cardiac work-up for H. pylori testing: Gastrointestinal symptoms can coexist with ACS, and epigastric discomfort may represent an anginal equivalent. 1

• Do NOT assume omeprazole will worsen hypertension acutely: While there is a possible association between omeprazole and hypertension in pharmacovigilance data, this is not an immediate concern compared to ruling out ACS. 4

6. Addressing the H. Pylori Breath Test

• Omeprazole reduces H. pylori urease activity and can cause false-negative urea breath tests, especially at doses ≥40 mg/day for ≥5 days. 5, 6

• Discontinue omeprazole for 2 weeks before performing the H. pylori breath test to avoid false-negative results. 5

• If cardiac work-up is negative, resume omeprazole and reschedule the breath test after the appropriate washout period. 5, 7

7. Disposition Decision

• If troponins remain normal at 6 hours AND ECG is non-ischemic AND pain is reproducible with palpation: Diagnose costochondritis, continue cyclobenzaprine and diclofenac, and arrange outpatient stress testing within 72 hours. 2

• If any high-risk features emerge (hemodynamic instability, ongoing pain, ECG changes, elevated troponin): Transport urgently to the emergency department by EMS—do not delay for office-based testing. 1, 2

• If pain worsens, becomes associated with diaphoresis, dyspnea, nausea, or syncope: Call 9-1-1 immediately—these are high-risk features for ACS. 1

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Bottom line: This patient's sharp chest and back pain in the setting of hypertension and age 52 years mandates immediate ECG and troponin measurement to exclude ACS before attributing symptoms to musculoskeletal causes. Sharp pain does not rule out myocardial ischemia, and radiation to the back is a recognized pattern of both ACS and aortic dissection. 1, 2