Diagnostic Approach to Chest Pain with Negative Troponin and Normal ECG

Initial Risk Stratification

The American College of Cardiology recommends that patients with normal ECG and negative troponin are generally at low risk, but require serial evaluation 1, 2
The European Heart Journal suggests repeating troponin at 3-6 hours after symptom onset to detect a characteristic rising/falling pattern of acute myocardial injury 2, 1, 3
The American College of Cardiology advises repeating ECG at 15-30 minute intervals during the first hour if symptoms persist or recur 1
Consideration of posterior leads (V7-V9) is recommended, as a normal ECG can mask left circumflex or right coronary occlusion 1

The American College of Cardiology states that 1-6% of patients with acute coronary syndrome present with a normal ECG at admission 1
The European Heart Journal notes that troponin can be negative in the early hours (blind window) 4, 5
The American College of Cardiology recommends continuing surveillance if there is a high clinical suspicion, even with initial negative troponin 2, 1

The American College of Cardiology suggests that aortic dissection can present with initially negative troponin and requires CT thorax with contrast for exclusion 1
The Journal of the American College of Radiology states that CT thorax angiography is the examination of choice to rule out dissection and pulmonary embolism 6, 1
The European Heart Journal notes that pulmonary embolism can cause chest pain with negative troponin and should be excluded by CT angiography 1

The European Heart Journal states that gastroesophageal reflux disease (GERD) is a common cause of chest pain mimicking angina 7
The American College of Cardiology notes that esophageal spasm can be clinically indistinguishable from angina 1
The European Heart Journal suggests that peptic ulcer and pancreatitis can radiate to the thorax 7

The European Heart Journal states that costochondritis is characterized by reproducible pain on palpation 7
The American College of Cardiology notes that Tietze syndrome is an inflammation of the costal cartilages 3
The European Heart Journal suggests that parietal pain is exacerbated by movement 7

For low-risk patients (normal ECG, negative troponin, no symptom recurrence), the American College of Cardiology recommends repeating troponin at 6-12 hours and considering exercise testing before discharge or in the following days to evaluate the probability and severity of coronary artery disease 2, 7
For intermediate/high-risk patients despite negative troponin, the American College of Cardiology advises continuing surveillance beyond 6 hours, especially in patients with diabetes, recurrent ischemia, or a history of coronary artery disease 1, 7