A 48-Year-Old Female with Episodic Chest Discomfort

HPI: The patient is a 48-year-old female with episodic chest discomfort over the last 3 days. She describes the discomfort as a substernal “ache” with intermittent radiation to the left shoulder, with associated shortness of breath, occurring primarily at rest and not exacerbated with physical exertion or eating. She has had multiple episodes lasting between 5 and20 minutes with spontaneous relief; however, the episode prior to presentation was particularly intense, lasting 60 minutes, prompting the ED visit. Upon presentation to the ED, she was symptom-free; the onset of the last episode was 3 hours prior to presentation.

Risk factors: Hypertension, tobacco use, father had an MI at age 54

PE: VS BP 130/80 mmHg, HR 82 bpm, RR 12
Normal cardiac and lung exam
ECG: Sinus, without ST-T wave  changes
cTnI: <0.04 ng/ml (Siemens cTnI-ultra) at presentation and 3 hours

The patient was moved to the chest pain observation unit after the first cTnI value, with subsequent stress testing prior to being discharged ordered.

When can the patient proceed to stress testing?

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