From the Guidelines
A patient with jaw pain during activity and negative troponins should still be admitted for observation and further evaluation. Despite the negative troponin, this presentation raises concern for potential unstable angina, which is part of the acute coronary syndrome spectrum, as suggested by the 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes 1. The patient should undergo serial cardiac biomarker testing (troponins at 0,3, and 6 hours), continuous cardiac monitoring, and a thorough cardiac workup including ECG and possibly stress testing or coronary angiography depending on risk stratification.
According to the guideline, it is reasonable to observe patients with symptoms consistent with ACS without objective evidence of myocardial ischemia (nonischemic initial ECG and normal cardiac troponin) in a chest pain unit or telemetry unit with serial ECGs and cardiac troponin at 3- to 6-hour intervals (Level of Evidence: B) 1. Additionally, for patients with possible ACS who have normal serial ECGs and cardiac troponins, it is reasonable to have a treadmill ECG or stress myocardial perfusion imaging before discharge or within 72 hours after discharge (Level of Evidence: B) 1.
While in the hospital, the patient should receive standard ACS therapy including aspirin, consideration of a P2Y12 inhibitor, and anticoagulation, as well as a statin, as these interventions can help prevent adverse outcomes in patients with unstable angina. Jaw pain with activity is a classic angina equivalent that suggests cardiac ischemia, even when initial troponins are negative, as troponin elevation may be delayed or absent in unstable angina. The rationale for admission is that unstable angina can progress to myocardial infarction, and early intervention can prevent adverse outcomes, thus prioritizing morbidity, mortality, and quality of life.
Key considerations for the patient's management include:
- Serial troponin testing at 0,3, and 6 hours
- Continuous cardiac monitoring
- Thorough cardiac workup including ECG and possibly stress testing or coronary angiography
- Standard ACS therapy including aspirin, a P2Y12 inhibitor, anticoagulation, and a statin
- Risk stratification to guide further management and potential interventions.
From the Research
Patient Assessment
- The patient presents with jaw pain that worsens with activity and has negative tropisms.
- There is no clear indication of a specific disease or condition that would require immediate admission.
Diagnostic Considerations
- According to 2, evidence-based diagnosis involves using medical tests to guide treatment decisions, considering the costs and risks of testing, and avoiding over-diagnosis and over-treatment.
- However, the provided studies do not offer specific guidance on diagnosing or managing jaw pain with activity and negative tropisms.
Pain Management
- 3 suggests that pharmacologic management of acute pain should be tailored to each patient, with acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line treatment options for mild to moderate pain.
- However, the patient's specific condition and the need for admission are not addressed in this study.
Screening and Diagnosis
- 4 emphasizes the importance of evidence-based screening for disease, considering factors such as sensitivity, specificity, and disease prevalence.
- 5 discusses the challenges of communicating medical terms and diagnoses between patients and clinicians, highlighting the need for clear explanations and accurate interpretations.
Treatment and Monitoring
- 6 investigates the safety of ibuprofen as an analgesic during cardiac surgery recovery, finding no significant difference in rates of myocardial infarction, sternal healing, or gastrointestinal complications compared to an oxycodone-based regimen.
- However, this study does not directly relate to the patient's jaw pain and activity level, and the decision to admit the patient should be based on a comprehensive assessment of their condition.