A 39-year-old man comes to the emergency department due to an episode of chest pain. He says, "I had dinner and 2 hours later started to get this discomfort in the middle of the chest. It felt dull and annoying." The pain lasted for 2 hours, waxed and waned in intensity, and did not radiate. The patient did not have any back pain, dyspnea, palpitations, or lightheadedness, and has never had similar pain episodes. After the pain subsided, his wife insisted that he go to the emergency department. Currently, he has no pain or discomfort and wants to return home. The patient does have occasional heartburn and takes over-the-counter antacids. Medical history is otherwise unremarkable. The patient has smoked a pack of cigarettes a day for the past 10 years. He does not drink alcohol or use illicit drugs. He has no known medication allergies. His father died suddenly in his sleep at age 55. His older brother is healthy. Blood pressure is 138/86 mm Hg and pulse is 89/min and regular. BMI is 28 kg/m². There are no heart murmurs or additional sounds. No carotid bruits are heard. Abdominal examination is unremarkable. ECG shows normal sinus rhythm with nonspecific T-wave changes in leads II and III. Chest x-ray is normal. Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: Although this patient is relatively young, his risk factors for coronary artery disease (CAD) (eg, active smoking, possible family history), typical chest pain in terms of location, and inferior lead T-wave abnormalities on ECG raise reasonable suspicion for acute coronary syndrome (ACS). Patients with suspected ACS should be given aspirin 325 mg (if not already administered) and can be given sublingual nitroglycerin if experiencing active chest pain. Further evaluation should consist of troponin I levels and, in the setting of ongoing chest pain, serial ECGs approximately every 30 minutes. The general recommendation is the collection of at least 2 troponin levels 3 hours apart, keeping in mind that levels may require up to 6-12 hours from the onset of symptoms to become detectable. typical chest pain Patients with significantly elevated troponin levels are diagnosed with non-ST elevation myocardial infarction, and those with negative troponin levels but ongoing chest pain and/or evolving ischemic ECG changes may be diagnosed with unstable angina. Patients with negative troponin levels and no other clinical suggestion of ACS can be discharged with a diagnosis of noncardiac chest pain or undergo stress testing for further evaluation. (Choice A) A negative D-dimer test is effective in ruling out pulmonary embolism in patients with a low pretest probability of the diagnosis; however, this patient's clinical presentation does not raise concern for pulmonary embolism. (Choice C) A treadmill exercise test is appropriate for further diagnosis and risk stratification in patients with negative troponin levels but with moderate probability of clinically significant CAD. However, stress testing should not be performed until ACS has been ruled out. (Choice D) Discharging this patient with lansoprazole under the assumption that his chest pain is due to gastroesophageal reflux disease is not appropriate. The presentation raises reasonable suspicion for ACS and evaluation with troponin levels is needed. (Choice E) Coronary angiography is appropriate for patients with ST-elevation myocardial infarction or other ACS and intermediate or high Thrombolysis in Myocardial Infarction (TIMI) risk score; however, the most appropriate next step for this patient is collection of troponin levels to either diagnose or rule out ACS. risk score Educational objective: Initial history and ECG are often insufficient to diagnose or rule out acute coronary syndrome (ACS) in patients with acute chest pain. Such patients should be evaluated with troponin levels and serial ECGs to evaluate for ACS and determine appropriate management. References: Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. (http://www.ncbi.nlm.nih.gov/pubmed/20660809)

A 39-Year-Old Man Comes to the Emergency Department Due to an Episode