Diagnostic Approach to Chest Pain with Negative Stress Test

Introduction to Diagnostic Considerations

• The European Society of Cardiology recommends considering multiple cardiac and non-cardiac diagnoses in patients with chest pain and a negative stress test, as the test may miss up to 30-50% of underlying pathologies 1, 2

Cardiac Causes to Consider

• The American Heart Association suggests that chest pain with radiation to the left shoulder, occurring at rest and with exertion, remains highly suspicious for acute coronary syndrome (ACS) despite a negative stress test 3, 4
• The European Society of Cardiology notes that smoking and sedentary lifestyle are major risk factors that increase the pre-test probability of coronary artery disease 2, 3
• The American College of Cardiology recommends considering dyspnea as a frequent symptom of ACS, particularly in patients with risk factors 1, 4

Pulmonary Causes to Consider

• The American Thoracic Society states that a classic presentation of pulmonary embolism includes chest pain with dyspnea, particularly in a sedentary smoker 1, 5, 6
• The European Respiratory Society notes that tachycardia and dyspnea are present in >90% of patients with pulmonary embolism 5, 6
• The American College of Chest Physicians recommends considering pneumothorax in patients with unilateral chest pain and dyspnea 5, 6

Gastrointestinal Causes to Consider

• The American College of Gastroenterology suggests that gastroesophageal reflux disease (GERD) can mimic angina perfectly with radiation 7
• The American Gastroenterological Association notes that GERD can cause chest pain described as compression or burning, lasting several minutes 7

Diagnostic Evaluation

• The American College of Cardiology recommends immediate evaluation with ECG, troponin, and chest radiograph in patients with suspected ACS or pulmonary embolism 5, 6, 9
• The European Society of Cardiology suggests considering echocardiography, coronary computed tomography angiography (CCTA), or myocardial perfusion scan if initial evaluation is negative 3, 5, 8

Secondary Evaluation

• The American College of Gastroenterology recommends considering upper endoscopy or a therapeutic trial of proton pump inhibitors if GERD is suspected 7
• The American Psychiatric Association suggests referring patients to a cognitive-behavioral therapist if all organic causes are excluded 8