Chest Pain: Tools to Improve Your In-office Evaluation
WHAT TO DO WHEN THE DIAGNOSIS REMAINS UNCLEAR
When your initial evaluation and diagnostic testing yield no clear diagnosis, appropriate follow-up is vital because in the year after primary care patients first develop chest pain, they are 1.5 to 3 times more likely than the general population to be diagnosed with musculoskeletal, GI, psychological, or respiratory problems, nearly five times as likely to be diagnosed with heart failure, and nearly 15 times as likely to be diagnosed with coronary heart disease.27,28
Consider ordering exercise or chemical stress testing within three to seven days for a patient with chest pain that suggests ACS but who has normal results on ECG and biomarker testing.8 Interestingly, though, in a study of 4,181 patients in an ED chest pain unit who had two sets of normal serum troponins during a six-hour period followed by exercise or chemical stress testing, only 470 patients (11%) had abnormal stress test results and only 37 (.9%) had obstructive CAD that would have potentially benefited from revascularization.29 Thus, testing troponin levels twice in six hours is a reasonable alternative to stress testing for a primary care patient with chest pain; stress testing would be unnecessary if both troponin values were normal.
CASE OUTCOME
Based on her current chest pain symptoms, Ms. Z.’s MHS is a reassuringly low 1, so CAD is unlikely. However, she scores 5 on the Dammen panic disorder screen. Due to her financial concerns, you decide to forgo stress testing and instead draw a serum troponin now, with plans to repeat later in the afternoon at your clinic lab if the initial result is normal. You encourage her to try a high-dose PPI for two weeks to determine whether GERD may be contributing to her symptoms, and offer to help her explore counseling options to address her emotional stressors.
REFERENCES
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