November 2022
A healthy 34-year-old male with no family history of early CAD or stroke presents to your urgent care center with 2 days of “nagging,” dull, left-sided chest pain that he describes as located just lateral to the sternum. It is not pleuritic, exertional, or positional, but it seems to bother him more at night. He rates the pain as 4/10, but there are times of day that he does not notice it at all. There is no dyspnea or nausea. He drinks alcohol socially in low amounts and does not smoke or use illicit drugs. He denies any recent change in activity or exercise pattern, and he recalls no recent injury or illness.
Vital signs are normal, with blood pressure of 133/74 mm Hg and heart rate of 72 beats/min. He has an unremarkable physical examination, with no reproducible chest wall tenderness to palpation. A 12-lead ECG shows normal sinus rhythm, and no ST/T wave abnormalities are evident. Your interpretation of his chest x-ray is normal. The patient would like to avoid an ED visit if at all possible.
Which of the following options is most appropriate in this case?
A. Discharge him with a working diagnosis of musculoskeletal chest pain, prescribe NSAIDs and ask him to follow up with his primary care provider in 2 weeks if he is not improving.
B. This case is highly concerning for ACS. Administer aspirin and summon EMS to the clinic for immediate transfer to the ED. Even when the initial ECG is normal, young patients can still have ACS.
C. Chest pain that is worse at night in a patient with a normal ECG is pathognomonic for GERD. Begin antacids with primary care provider follow-up as needed.
D. Discuss with the patient that you are unsure what is causing his chest pain. Apply the Marburg Heart Score and let the patient know that his score of 1 puts him in a low-risk category with about a 3% risk of CAD. Engage the patient in shared decision making, and if he is comfortable with this level of risk, he can go home with prompt primary care provider follow-up and strict return-to-care instructions.
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Answer: D. It is inappropriate to close this case with a diagnosis that does not clinically fit, as options A and C suggest. A normal ECG does not diagnose GERD; it is diagnosed via endoscopy, pH monitoring, or advanced imaging. This patient is at low risk of ACS, and while answer B is the most conservative choice and carries virtually zero medicolegal risk, applying this strategy with all adult chest pain patients will lead to unnecessary transfers and testing, increased costs to the patient and system, and increased ED overcrowding. Option D is preferable because it avoids premature diagnostic closure, appropriately applies an outpatient chest pain risk-stratification tool, and involves the patient in an honest process of shared decision making.
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Last Updated on January 26, 2023
