Low-risk chest pain in the Clinical Decision Unit: serial troponin pathway and safe disposition
Read the station brief carefully before entering the room. Work through the history, interpret the results provided, then explain your management plan and disposition decision clearly to the patient. Use the time windows printed on each section heading to pace yourself.
Learning points and differential overview
This station tests the candidate's ability to take a focused history in a patient with low-risk chest pain, correctly apply a high-sensitivity troponin pathway, make a safe disposition decision, and communicate that plan clearly. The candidate is expected to own the disposition decision as the senior decision-maker on shift.
Key learning points
- A high-sensitivity troponin (hs-cTnI or hs-cTnT) 0/1h or 0/2h pathway can safely rule in or rule out NSTEMI in low-to-intermediate risk presentations; a rise or fall of greater than a defined delta (assay-specific) is required for rule-in, not simply an elevated absolute value.
- HEART score (History, ECG, Age, Risk factors, Troponin) stratifies chest pain into low, intermediate and high risk; a score of 0 to 3 supports discharge with outpatient follow-up in the absence of a delta rise.
- Low-risk features supporting discharge include: atypical history, normal or non-specifically abnormal ECG, age under 65, fewer than two major cardiovascular risk factors, and a negative serial troponin with no significant delta.
- Patients discharged after a negative troponin pathway should be given clear written safety-netting: return immediately if chest pain recurs, and ensure rapid-access chest pain clinic (RACPC) referral within 72 hours for exercise testing or CT coronary angiography.
- The consultant must explicitly document the disposition reasoning, including that the troponin pathway was completed correctly and that the clinical picture supports a low-risk label -- this is a governance requirement.
- Musculoskeletal and gastrointestinal causes (costochondritis, reflux oesophagitis) are common mimics of cardiac chest pain and should be considered once ACS is excluded.
- Safe discharge after a negative pathway does not exclude all cardiac pathology; stable coronary artery disease and valvular disease are detected at RACPC, not in the ED.
- Do not conflate a negative troponin result with exclusion of unstable angina -- unstable angina produces no troponin rise; clinical risk stratification and RACPC remain essential.
Key differentials to consider
- NSTEMI -- central or left-sided chest tightness, radiation to arm or jaw, diaphoresis, troponin rise with delta on serial testing, ECG ST depression or T-wave inversion
- Unstable angina -- identical presentation to NSTEMI but troponin remains negative; excluded only by clinical risk stratification and RACPC review, not solely by troponin
- Pulmonary embolism -- pleuritic or positional pain, hypoxia, tachycardia, risk factors; Wells score then D-dimer or CTPA to confirm or exclude
- Aortic dissection -- tearing interscapular pain, pulse or blood pressure differential between arms, widened mediastinum on chest X-ray; CT aortogram to confirm
- Musculoskeletal chest pain -- sharp, positional, reproduced by chest wall palpation, no ECG or troponin change; diagnosis of exclusion
- Gastrointestinal cause (reflux or oesophageal spasm) -- burning retrosternal discomfort, association with food or posture, relieved by antacids, normal investigations
Station instructions
You are the emergency medicine consultant on duty. Adeyinka Solaru, a 48-year-old man, was triaged four hours ago with a two-hour episode of central chest tightness that has now resolved. He is in the Clinical Decision Unit. Observations: HR 78, BP 138/84, RR 14, SpO2 98% on air, temperature 36.7 degrees C. The initial ECG and first troponin result are available. Your task is to take a focused history, review the results provided, and determine a safe disposition with an explanation of your plan to the patient. You have 8 minutes.
0:00-0:30 Introduction and consent
Dr Weiming Fong: Hello Mr Solaru, I am Dr Weiming Fong, the emergency medicine consultant on duty today. I would like to talk with you about what brought you in -- is that alright?
0:30-2:30 Focused history of the chest pain
Dr Weiming Fong: Can you describe what the pain felt like -- where it was and what sort of sensation it was?
Dr Weiming Fong: How long did it last, and was there anything that brought it on or made it better?
Dr Weiming Fong: Did you notice any breathlessness, sweating, palpitations, or did you feel like you might faint?
Dr Weiming Fong: Is the pain completely gone now, and have you had anything like this before?
2:30-4:00 Risk factors, relevant background and red flag negatives
Dr Weiming Fong: Do you have any heart problems, high blood pressure, high cholesterol, or diabetes that you know of?
Dr Weiming Fong: Do you smoke, and is there a family history of heart attacks, particularly in a first-degree relative under 65?
Dr Weiming Fong: Are there any medications you take regularly, and do you have any allergies?
4:00-4:30 Working diagnosis stated and results reviewed
Dr Weiming Fong: Thank you, that is very helpful. Based on what you have told me, my main concern is that this could be a cardiac cause -- either angina or a small heart attack -- so I want to go through the results we have for you now.
Results (for candidates who ask)
Click to reveal ECG
ECG report: Sinus rhythm at 76 beats per minute. Normal axis. PR interval 164 ms. No ST elevation. No ST depression. No T-wave inversion. No left bundle branch block. QTc 420 ms. Normal ECG.
Click to reveal blood results
• hs-cTnI at 2 hours: 8 ng/L (delta +2 ng/L -- below the assay-specific delta threshold of 6 ng/L for rule-in)
• Hb 151 g/L
• WBC 7.4 x10^9/L
• Creatinine 84 micromol/L
• eGFR greater than 90 mL/min/1.73m2
• Random glucose 5.8 mmol/L
• Total cholesterol 5.9 mmol/L
Chest X-ray: No cardiomegaly. No pulmonary oedema. No pleural effusion. No pneumothorax. Mediastinum normal width. Bony thorax intact.
Explaining diagnosis and ED plan
Dr Weiming Fong: Mr Solaru, I can reassure you that your ECG -- the heart tracing -- is completely normal, and the two blood tests we use to detect heart muscle damage have both come back negative, with no significant rise between them.
Dr Weiming Fong: It means we have not found evidence of a heart attack today, which is very good news. However, your history -- the tightness, the radiation to your arm, brought on by exertion -- means we cannot completely rule out a problem with the blood supply to your heart without further investigation.
Dr Weiming Fong: I am going to discharge you today, but I am referring you urgently to the rapid-access chest pain clinic, which you should be seen at within 72 hours. They will arrange a further test -- likely a heart scan or an exercise test -- to look at the arteries supplying your heart.
Dr Weiming Fong: Yes, the clinic will contact you directly, and I will make sure the referral is sent today before you leave. In the meantime, I want you to continue your regular medications as normal.
Dr Weiming Fong: If the chest tightness comes back at rest, lasts more than a few minutes, or is accompanied by sweating or breathlessness, you must come straight back to the emergency department or call 999 -- do not wait.
Dr Weiming Fong: I will give you a written discharge summary that sets all of this out, including the symptoms that should bring you back. Do you have any questions before we finalise the plan?
Self assessment and examiner scoring
Select 0, 1 or 2 for each item and click Calculate. Total is out of 20.
Examiner checklist (reference)
- Introduces themselves by name and grade as the emergency medicine consultant on duty and obtains consent to proceed
- Establishes the exertional onset, central tight character, left arm radiation and spontaneous resolution of the chest pain
- Asks directly about associated symptoms: breathlessness, diaphoresis and pre-syncope
- Identifies the relevant cardiovascular risk profile: hypertension, hypercholesterolaemia, ex-smoking and first-degree family history of premature ischaemic heart disease
- Asks about current medications and allergies
- States a working diagnosis of suspected cardiac chest pain and mentions an earlier similar episode as relevant
- Correctly interprets the ECG as normal with no ischaemic features
- Correctly interprets the serial hs-cTnI results as below the 99th percentile with a non-significant delta, and labels the pathway as negative
- Makes a clear disposition decision to discharge and refers to the rapid-access chest pain clinic within 72 hours, explicitly acknowledging that a negative troponin does not exclude stable coronary artery disease
- Gives specific safety-netting: instructs the patient to return immediately or call 999 if chest pain recurs at rest, is prolonged or is accompanied by breathlessness or sweating, and offers written discharge advice
Actor brief
Patient name: Adeyinka Solaru
Age: 48 years
Background: You are Adeyinka Solaru, a 48-year-old Nigerian-British man who works as a project manager. You are generally fit but have been told you have raised blood pressure and high cholesterol. You have been sitting in the Clinical Decision Unit for about four hours and are anxious but composed.
Opening line: Yes, of course, doctor. Thank you for coming to see me.
Presenting illness: About six hours ago you developed a tight, heavy sensation in the centre of your chest while walking up two flights of stairs at your office. The feeling spread a little down your left arm. You were mildly short of breath and noticed you were sweating. The discomfort lasted roughly two hours and eased off completely once you sat and rested. You have no pain at all now.
Red flag negatives: You did not feel faint or lose consciousness. You did not have palpitations or a racing heart. You have no cough, no leg swelling, and no recent long-haul travel. The pain was not sharp or tearing. It was not made worse by breathing in or by pressing on your chest.
Past medical history: You had a similar but milder episode about three months ago when climbing stairs. You dismissed it at the time. You have no previous heart disease, no stroke, no diabetes, and no previous admissions to hospital.
Drug history: Amlodipine 5 mg once daily. Atorvastatin 20 mg at night. No other medications. No allergies.
Social history: You gave up cigarettes five years ago after smoking for about 15 years. You drink alcohol occasionally, perhaps two or three units per week. You are married with two children. You are physically active enough to walk and occasionally cycle.
Family history: Your father had a heart attack at the age of 58. Your mother has type 2 diabetes. No other relevant family history.
Ideas: You are worried that you may have had a small heart attack and are concerned about what it means for your job and your family.
Concerns: Your biggest concern is that the doctor will send you home without a clear answer and that something serious will happen at home.
Expectations: You want a clear explanation of what the results mean and an honest answer about whether your heart is at risk. You also want to know what you should do if it happens again.
Behaviour during station: You are calm and cooperative but visibly anxious. You make good eye contact and ask sensible questions. If the doctor explains things clearly you visibly relax. If they are vague or seem to be rushing you, you ask follow-up questions such as 'But how can you be sure it is not my heart?'
Information to give only if asked directly:
- If asked about the previous similar episode three months ago: 'It was milder, lasted maybe 20 minutes, I just thought it was stress and did not see anyone about it.'
- If asked whether the pain is positional or reproduced by pressing: 'No, pressing on my chest does not bring it on at all.'
- If asked about recent flights or immobility: 'No, nothing like that recently.'
- If asked about recreational drugs or cocaine: 'No, never.'
- If asked about the cholesterol medication: 'Yes I take a tablet at night for cholesterol, atorvastatin the pharmacist calls it.'
Emotional mark points: If the doctor acknowledges your anxiety and explains the results clearly, you respond with visible relief and gratitude. If the doctor uses jargon without explanation, you appear confused and ask 'What does that mean exactly?'
