Chest pain in a 58-year-old with normal ECG
Mr. David Chen, 58, presents to a suburban general practice at 9:20 am with 45 minutes of central chest pressure that began while gardening. The pain radiates to his left jaw and is associated with nausea and sweating. He took two sublingual glyceryl trinitrate tablets over 15 minutes with only slight relief. Past history: hypertension, type 2 diabetes for 8 years, 20 pack-year smoking history (quit 3 years ago), father had a myocardial infarction at 62. Observations: BP 158/94, HR 92 regular, RR 20, SpO2 96% on room air, temperature 36.7°C. A 12-lead ECG performed at 9:25 shows no ST elevation and no ST depression; it is technically adequate. The nearest emergency department is 25 minutes by ambulance. The practice has aspirin 300 mg, oxygen, and a defibrillator, but no troponin testing.
1. Formulate your working diagnosis and immediate management plan. Justify why a normal ECG does not change your disposition.
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Working diagnosis: Acute coronary syndrome (ACS) - most likely non-ST-elevation ACS given ongoing ischaemic-sounding pain at rest with diaphoresis and nausea in a patient with multiple risk factors. Differential includes unstable angina, NSTEMI, aortic dissection (less likely given character, but must be considered), pulmonary embolism, and oesophageal spasm; the clinical picture strongly favours ACS.
Why the ECG does not reassure: A single normal ECG has limited sensitivity for ACS, particularly NSTEMI and unstable angina. Up to a substantial minority of patients with confirmed myocardial infarction have a non-diagnostic initial tracing. Ongoing pain at rest lasting more than 20 minutes, diaphoresis, and a high pretest probability (diabetes, hypertension, smoking, family history) mean the post-test probability remains high even with a normal ECG. Serial ECGs and troponin are required; neither is available here.
Immediate plan:
- Call an ambulance for urgent transfer to the emergency department - do not allow self-transport.
- Give aspirin 300 mg chewed immediately (unless true allergy), plus sublingual GTN for ongoing pain if BP tolerates.
- Continuous cardiac monitoring and defibrillator availability while awaiting transport; IV access if feasible.
- Oxygen only if SpO2 falls below 90–92%; current saturation does not warrant routine oxygen.
- Document serial observations and repeat ECG if pain changes.
- Communicate the pretest probability and ongoing pain clearly in the referral so the ED does not deprioritise him on the basis of the normal ECG.
Reasoning: The decision hinges on disposition, not on ruling out ACS in the practice. The safe judgement is to treat as suspected ACS and transfer, accepting that many such patients are ultimately ruled out - the cost of a missed ACS is far higher.
2. The patient says he feels better and asks to go home to "sleep it off" and see you tomorrow. How do you counsel him and manage this refusal?
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Assess capacity first. Mr. Chen is alert and oriented; capacity requires understanding, retention, weighing, and communication of a decision. He appears to have capacity, so his refusal must be respected, but it must be an informed refusal.
Counsel using plain, specific language:
- Explain that his symptoms are consistent with a heart attack or threatened heart attack, and that feeling better does not mean the danger has passed - pain can settle and then recur, and the first hours carry the highest risk of dangerous rhythm disturbance.
- State the concrete risks: cardiac arrest, permanent heart muscle damage, heart failure, and death. Avoid vague warnings.
- Explain that the ECG being normal does not exclude the diagnosis and that blood tests and monitoring available only at hospital are needed.
- Offer to speak with a family member if he wishes, and address practical barriers (transport, dependents, work) - these often drive refusal more than the clinical facts.
Manage the refusal:
- Document the discussion, his capacity, the risks explained, and his decision in detail.
- Give aspirin 300 mg now and arrange the safest possible pathway: strongly recommend ambulance; if he insists on leaving, arrange immediate review, provide written safety-net advice (call 000 for recurrent or worsening chest pain, breathlessness, collapse), and ensure he is not alone.
- Consider a follow-up call and notify his usual GP.
- If he deteriorates or loses capacity, act in his best interests and arrange emergency transfer.
Reasoning: The exam tests whether you can balance autonomy with harm minimisation, document rigorously, and avoid both paternalistic coercion and negligent acquiescence.