A 49-year-old male with hypertension, diabetes, and smoking reports two weeks of intermittent chest pressure that worsens with activity and improves with rest. Currently, he is asymptomatic with no pain at rest. An ECG is described in the case. What is the next best step in management?

• A. Refer to ED
• B. Refer to cardiology for outpatient testing
• C. Start a beta-blocker and arrange follow-up
• D. Schedule a treadmill stress test in clinic

Answer: (A)

Exertional chest pain in a middle-aged patient with several risk factors for coronary artery disease should trigger urgent evaluation for acute coronary syndrome. Even though the pain is now absent, this pattern plus the risk factors means ACS could be evolving, and the ECG described in the case likely raises concern for ischemia. The safest next step is referral to the emergency department so he can have rapid, serial ECGs and troponin testing, along with ACS protocol and monitoring. This approach allows immediate ruling in or out of unstable angina or NSTEMI and prevents delays that could occur with outpatient testing or starting therapy without a full ACS work-up. If ACS is ruled out, management then focuses on risk reduction and planning appropriate outpatient testing.