Patient 56 year oldcame with chest pain radiating to left shoulder and back with trop i negative and echo normal

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Clinical Assessment: 56M with Chest Pain + Left Shoulder + Back Radiation, Troponin I Negative, Echo Normal

Immediate Priority: Rule Out Aortic Dissection

This presentation MUST trigger an aortic dissection workup first. Back radiation in a middle-aged patient with chest pain is a classic red flag. The negative troponin and normal echo do not rule it out.

Key dissection data from Symptom to Diagnosis, 4th Ed.:

Finding	Prevalence in Dissection
Severe/worst-ever pain	90%
Abrupt onset	85%
Chest pain	79%
Back pain	47%
Normal chest film	11%
Normal mediastinal contour	17%

The aorta appears normal on chest film in ~40% of dissections. A normal echo does NOT rule out dissection (transthoracic echo has limited sensitivity).

Aortic Dissection Risk Stratification (ADD-RS / 3-predictor rule):

Score 1 point each for:

Aortic-type pain - abrupt onset, tearing, ripping character
Mediastinal or aortic widening on CXR
Pulse or BP differential between arms

0 points + D-dimer < 500 ng/mL = dissection essentially ruled out (LR- 0.08)
1+ points = CT aortogram is mandatory

This patient needs an immediate D-dimer and/or CTA chest/abdomen unless clinically very low risk.

Systematic Differential Diagnosis

Based on the full presentation (chest pain + left shoulder + back radiation, troponin I negative x1, normal TTE):

1. Cardiovascular - Must Not Miss

Diagnosis	Key Points
Aortic dissection	Back radiation is the hallmark. Type A: ascending + possible AR, tamponade. Type B: descending only, managed medically. 35% mortality for type A.
NSTEMI (not yet excluded)	A single troponin I is NOT sufficient to rule out ACS. Serial troponins at 0h and 3h (or 0h/1h with high-sensitivity troponin) are required. Echo may be normal in early or small territory ischemia.
Unstable angina	Troponin-negative ACS is possible; requires stress testing or early invasive strategy depending on risk.
Prinzmetal/vasospastic angina	Coronary spasm; can present with radiation; normal troponin between episodes.
Pericarditis	Pleuritic component typical; look for positional features, friction rub, saddle-shaped ST elevation on ECG.
Pulmonary embolism	Can radiate to shoulder; check Wells score, D-dimer, CTPA if suspected.

2. Non-Cardiovascular

Diagnosis	Key Clue
Esophageal spasm / GERD	Can mimic angina perfectly; may respond to nitroglycerin - do NOT use as a diagnostic test
Musculoskeletal (costochondritis, cervical radiculopathy)	Reproducible with palpation; exacerbated by movement
Biliary colic / cholecystitis	Right shoulder more typical; check LFTs, RUQ US
Pleuritis / pneumonia	Respiratory character; check CXR
Peptic ulcer / pancreatitis	Back radiation possible; check amylase/lipase

Immediate Workup Plan

Step 1 - Before anything else:

12-lead ECG (has this been done? Look for ST changes, T-wave inversions, saddle-shaped ST in pericarditis, new Q waves)
Serial troponin I at 3 hours from first draw (or 0h/1h if high-sensitivity assay available) - one negative troponin is insufficient
D-dimer to risk-stratify for dissection and PE
CXR - mediastinal width, aortic contour, pulmonary infiltrates, pneumothorax

Step 2 - Risk score the ACS component:

Using the HEART Score (from Rosen's Emergency Medicine):

Component	This patient
History	Radiating chest pain = at least 1-2 points
ECG	Need result
Age 56	1 point (45-64 range)
Risk factors	Need to assess (HTN, DM, smoking, family history)
Troponin	0 points if negative

HEART 0-3: low risk, possible early discharge after serial troponins
HEART 4-6: moderate risk, observation + further evaluation
HEART 7-10: urgent/emergent intervention

Step 3 - Based on D-dimer and clinical assessment:

If ADD-RS ≥ 1 or D-dimer elevated: CT aortogram (sensitivity and specificity >95% for dissection)
If dissection ruled out and HEART moderate-high: coronary angiography or stress testing
If HEART low risk: stress test before discharge

Key Clinical Pearls

"Back radiation" is the most important feature here - always raises dissection until proven otherwise. Hypertension is present in 72-75% of dissection patients.
One negative troponin does not rule out ACS. The negative predictive value of a single troponin depends heavily on timing from symptom onset.
Normal echo does not exclude:
- Aortic dissection (TTE has ~60-85% sensitivity; TEE or CTA needed)
- Coronary artery disease / unstable angina
- Pulmonary embolism
The pain quality matters:
- Tearing/ripping + abrupt onset = dissection until proven otherwise
- Pressure/squeezing + exertion = ACS pattern
- Pleuritic (worse with inspiration/lying flat) = pericarditis or PE
- Positional relief (sitting forward) = pericarditis
Check blood pressure in both arms - asymmetry (>20 mmHg difference) strongly suggests dissection.

Summary Algorithm

Chest pain + back radiation + Trop I neg + Echo normal
         |
         v
CHECK: Aortic-type pain? Mediastinal widening? BP asymmetry?
         |
    Yes to any ─────────────────────> CT Aortogram URGENT
         |
         No
         |
         v
D-dimer + Serial Troponins (3h) + ECG
         |
    D-dimer elevated ─────────────> CTA (dissection / PE)
         |
    D-dimer low, 2nd Trop negative
         |
         v
HEART Score → Stress test or Angiography

Sources: Symptom to Diagnosis: An Evidence-Based Guide, 4th Ed. | Rosen's Emergency Medicine | The Washington Manual of Medical Therapeutics | Recent review: Bellolio F, et al. "Evaluating patients with chest pain in the emergency department." BMJ 2025 [PMID: 40154972]

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