Harbor Macros: Chest Pain
Low Risk
This patient presents with chest pain that is very unlikely angina or acute coronary syndrome. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. Based on their history, EKG (which showed no evidence of ischemia or infarction) and imaging, in addition to the patient's physical exam, I see no evidence at this time for a malignant etiology for the patient's chest pain. There is no acute evidence for pulmonary embolus, acute myocardial infarction, pneumothorax, Boerhaeve syndrome, cardiac tamponade, thoracic artery dissection, or any other emergent cardiac, pulmonary or aortic pathology. Given the low pre-test probability for cardiac etiology of chest pain and the absence of any sign of ischemia or infarction, discharge for outpatient follow-up and further evaluation is reasonable.
I have explained to the patient that even though a cardiac problem is very unlikely, follow-up and further testing is required to reduce further the already small uncertainty that exists. Other life-threatening diagnoses have been considered. The patient understands the need to return immediately if their symptoms worsen or they develop any new symptoms, and not to engage in any significant exertional activity until follow-up is obtained.
Negative Troponin
The patient presented with chest pain of uncertain etiology. Based on their history, lab analysis, EKG (which showed no evidence of ischemia or infarction), and imaging, in addition to the patient's physical exam, I see no evidence at this time for a malignant etiology for the patient's chest pain. There is no acute evidence for pulmonary embolus, acute myocardial infarction, pneumothorax, esophageal rupture, cardiac tamponade, thoracic artery dissection, or any other emergent cardiac, pulmonary or aortic pathology at this time.
[Based on the nature and long duration of the patient's pain, paucity of EKG findings, and normal cardiac enzymatic blood analysis, acute coronary syndrome is exceedingly unlikely. It is highly likely that cardiac enzymes would be abnormal in chest pain of this duration if their chest pain was attributable to ACS.] [The patient also has very low risk for coronary artery disease based on their risk factor profile with no substantial risk factors (Age>65, >3 CAD risk factors -- family history of CAD, hypertension, hypercholesterolemia, diabetes, or current smoker, known CAD as defined by >50% stenosis, aspirin use in the past 7 days, severe angina – having more than 2 episodes in the past 24 hours, ST changes >0.5mm, or positive cardiac biomarker).]
This patient may require cardiac stress testing on an outpatient basis and arrangements for this may be made during their follow-up visit with their primary care physician. The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an emergency department workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing, or persistent symptoms should prompt an immediate call or follow up with their primary physician or the emergency department immediately. The importance of close follow up was also discussed with the patient.